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PURPOSE: To determine the mammographic features of locally advanced breast carcinoma treated with neoadjuvant chemotherapy and to evaluate the accuracy of mammography in the prediction of residual carcinoma. MATERIALS AND METHODS: Of 90 women treated with hormonally synchronized cytotoxic therapy before mastectomy or lumpectomy for advanced breast carcinoma, 56 were selected because they had undergone mammography before and after neo-adjuvant therapy. Mammographic and clinical opinion on the presence of residual disease was compared with histologic results. RESULTS: Fifty-four (96%) of 56 women had a complete (n = 34 [61%]) or partial (n = 20 [36%]) clinical response. Thirteen (23%) of 56 women had no residual tumor. Sensitivity of mammography in the prediction of residual carcinoma was greater than that of clinical examination (79% vs 49%), but specificity was lower (77% vs 92%). In 24 women with inflammatory carcinoma, sensitivity of mammography was 78% while that of clinical examination was 39%; specificity was equal (83%). CONCLUSION: Mammography was more sensitive than clinical examination in the prediction of residual carcinoma; it was not accurate enough to obviate surgical biopsy.

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The University of Michigan Breast Care Center (BCC) was established in 1985 to provide comprehensive, multidisciplinary diagnosis and treatment of benign and malignant breast disease. This work presents an overview of our experience in the BCC and assesses the clinical, academic, financial, and educational effectiveness of the program. A database was used to generate a list of all patients seen in the BCC between February 1, 1985 and December 31, 1991. Participating departments provided information regarding outpatient, inpatient, clinical and consultative activities, and referral patterns attributable to BCC endeavors. BCC educational and academic activities were reviewed and profiled. Clinical information was culled from the BCC database, hospital records, and the hospital tumor registry. The BCC has resulted in a fivefold increase in breast care related activity at the University of Michigan Medical Center. Over half of the patients treated in the BCC with primary operable breast cancer receive breast-conserving therapy. The BCC performs a unique educational function, providing the primary breast care experience for house staff as well as one third of the third year medical school class. The BCC supports over 20 clinical research protocols, and patient enrollment in clinical trials has increased dramatically since 1985. The BCC also provides support to basic science researchers receiving over 2.5 million dollars in peer reviewed direct cost support. These data suggest that a multidisciplinary approach to patient care as embodied by the BCC can be clinically, financially, and academically superior and productive. This model warrants further investigation not only in the field of breast care, but also in other clinical situations that require multidisciplinary input and therapy.

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Aclarubicin is an anthracycline antibiotic that differs from doxorubicin in its structure, mechanism of action, and preclinical toxicity profile, especially its reduced cardiotoxicity. We therefore conducted a side-by-side in vivo and in vitro trial of this agent in metastatic breast-cancer patients and their biopsied tumor specimens, respectively. Aclarubicin (100 mg/m2) was given by intravenous infusion every 3 weeks to 22 patients with objectively measurable metastatic breast cancer, 15 of whom had not previously received doxorubicin. The dose-limiting toxicity consisted primarily of leukopenia and severe nausea and vomiting. No objective response was observed in the 19 evaluable patients. After disease progression, 10 of the 15 doxorubicin-naive patients were treated with doxorubicin; 6 patients achieved a partial response, including 4 who responded to doxorubicin alone and 2 who responded to doxorubicin in combination with thiotepa and vinblastine. Tumor specimens were obtained from 14 of the 22 patients prior to the start of therapy and were tested for in vitro sensitivity to aclarubicin and doxorubicin using a soft agar colony-forming assay. Adequate colony growth occurred in 9 of 14 cultured tumor specimens. All 9 specimens, including 3 obtained from doxorubicin-naive patients, demonstrated in vitro resistance to aclarubicin. In all, 1 of 3 specimens taken from doxorubicin-naive patients demonstrated in vitro sensitivity to doxorubicin, whereas 6 tumor specimens obtained from patients who had undergone prior doxorubicin therapy demonstrated in vitro resistance. The patient whose tumor demonstrated in vitro doxorubicin sensitivity responded to a doxorubicin regimen after failing aclarubicin treatment; in vitro doxorubicin resistance correlated with clinical resistance in all cases. We conclude that aclarubicin is inactive in metastatic breast cancer at the dose and schedule used. Side-by-side in vivo and in vitro trials are feasible and could be useful in the development of investigational agents with activity greater than that of aclarubicin and, particularly, in the evaluation of analogs of clinically active drugs.

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We present a series of patients who developed cellulitis following axillary lymph node dissection for carcinoma of the breast. Bacterial cultures were not helpful in making a diagnosis for the majority of the cases. The clinical scenario of upper extremity cellulitis after axillary dissection mimics the presentation of cellulitis in the lower extremity. Until diagnostic methods or treatment advances can eliminate the indications for axillary lymphadenectomy, many women treated for breast cancer will be at long-term risk for the development of cellulitis due to localized immune impairment. Patient and physician awareness of this syndrome is the best available tool to prevent secondary exacerbation of lymphedema. Prompt treatment with appropriate antibiotics appears universally successful. Antistreptococcal antibiotics should not be withheld pending results of blood or tissue cultures, since in only a few cases will a pathogen be isolated. Although there are no studies confirming the concept, it is likely that appropriate treatment for lymphedema may reduce the risk of infection.

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OBJECTIVE: Reports of pharmacy research using crossover designs were reviewed to determine if the studies adequately consider interaction effects and use appropriate statistical analyses. DATA SOURCES: All crossover studies published in DICP, The Annals of Pharmacotherapy during 1988 and 1989 were analyzed. STUDY SELECTION: Reports of crossover studies were included only if at least two treatments were applied in a different order to two or more groups of subjects. DATA EXTRACTION: The principal characteristics of crossover studies and the critical design variables were listed and each study analyzed according to these variables. The critical design variables included consideration of period, sequence, and carryover effects as well as the presentation of data by groups and the use of multivariate statistical analysis. The analysis was conducted independently by each author and conflicts were discussed until consensus was obtained. RESULTS: A total of 11 crossover studies were identified: 6 were bioavailability trials, 3 were treatment comparisons, and 2 had multiple objectives. The possibility of period, sequence, or carryover effects was less with bioavailability studies than with treatment comparisons. Only 1 study presented data by group and only 4 studies used multivariate analysis. CONCLUSIONS: The crossover design appears more appropriate for bioavailability trials than for treatment trials in pharmacy research. Analysis of data from crossover designs could be improved by presenting the data for each treatment group and using multivariate statistical analysis.

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A 49-year-old patient with breast cancer had a leiomyoma that rapidly enlarged shortly after she started therapy with tamoxifen. Exploratory laparotomy was necessary to confirm the diagnosis. The rapid growth may have resulted from the estrogen agonist properties of tamoxifen or alternatively by ovarian stimulation resulting in endogenous estrogen production.

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Of the remote effects of cancer on the neurologic system, paraneoplastic cerebellar degeneration (PCD), characterized by global cerebellar dysfunction, is second only to paraneoplastic neuropathies in frequency. Recent evidence, including the finding of anti-Purkinje cell (now termed anti-Yo) antibodies directed against specific protein antigens shared by Purkinje's and tumor cells, supports an autoimmune etiology for this disorder. Increasingly, a link between breast cancer and PCD is being recognized. The authors report a case, as well as a comprehensive overview, of 62 women with breast cancer and PCD, identified through a Medline (National Library of Medicine, Washington, DC) computer search (1966 to 1991) and comprehensive reference follow-up of the medical literature. The current understanding of the pathophysiology of PCD, with particular emphasis upon those features both salient and unique to breast cancer, is discussed. Whereas PCD will affect only a small number of patients with breast cancer, recognition of this syndrome is important. Anti-Purkinje cell (anti-Yo) antibody titers are now commercially available through several reference laboratories, and a serum anti-Purkinje cell antibody titer will assist in establishing the diagnosis. Presence of consistent symptoms and elevated titers of anti-Yo antibodies should prompt a search for an otherwise occult, and potentially treatable, malignancy. Only therapy initiated early in the patient's course appears to be of benefit. Finally, investigations into the pathogenesis of this syndrome may shed further light upon other diseases presumed secondary to autoimmune dysfunction.

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A new human plasma cell line, UMJF-2, has been derived from the bone marrow of a patient with multiple myeloma. Morphological studies disclosed large nucleoli, moderate numbers of mitochondria, and scant endoplasmic reticulum consistent with a plasmablastic morphology. The cells have immunologic characteristics of early plasma cells, including intense expression of cytoplasmic IgG-lambda and weaker, but discernible, expression of surface IgG-lambda. Cell surface antigens defined by the monoclonal antibodies OKT10 (CD38) and PCA-1, characteristic of mature plasma cells, and B1 (CD20), B4 (CD19), and I-2 (HLA-DR), characteristic of earlier stages of B-lymphocyte differentiation, are present on UMJF-2 cells. Cytogenetic studies reveal the presence of trisomy 12. UMJF-2 does not contain the Epstein-Barr virus by Southern blot analysis. Tissue culture media conditioned by these cells contains a soluble immunosuppressive factor, capable of inhibiting pokeweed mitogen induced IgM secretion by normal human B-lymphocytes. UMJF-2 provides a model for the study of the pathogenesis of polyclonal hypogammaglobulinemia in human multiple myeloma.

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The authors assessed whether breast cancers can be detected by means of positron emission tomography (PET) with the positron-emitter-labeled glucose analogue 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG). In 12 patients with primary and/or metastatic breast cancer, PET images of F-18 distribution in vivo were obtained approximately 1 hour after intravenous injection of 10 mCi of FDG. Scan findings were correlated with other imaging data and physical examination and biopsy results. Ten of 10 primary breast cancers were imaged by means of FDG PET with a tumor:background FDG uptake ratio of 8.1 (median). Ten of 10 bone metastases were imaged with a tumor:normal bone uptake ratio of 6.05 (median). Five of five known soft-tissue metastases and four previously unsuspected nodal lesions were found with PET. No false-positive foci of FDG uptake were demonstrated. In two cases with negative mammograms due to dense breast parenchyma, FDG PET clearly delineated the primary tumors. These preliminary data demonstrate the feasibility and substantial potential of PET scanning with FDG to detect and localize both primary and metastatic breast cancers.

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von Willebrand disease (vWD), the most common inherited bleeding disorder in humans, results from abnormalities in the plasma clotting protein von Willebrand factor (vWF). Severe (type III) vWD is autosomal recessive in inheritance and is associated with extremely low or undetectable vWF levels. We report a method designed to distinguish mRNA expression from the two vWF alleles by PCR analysis of peripheral blood platelet RNA using DNA sequence polymorphisms located within exons of the vWF gene. This approach was applied to a severe-vWD pedigree in which three of eight siblings are affected and the parents and additional siblings are clinically normal. Each parent was shown to carry a vWF allele that is silent at the mRNA level. Family members inheriting both abnormal alleles are affected with severe vWD, whereas individuals with only one abnormal allele are asymptomatic. The maternal and paternal silent alleles are identical at two coding sequence polymorphisms as well as an intron 40 variable number tandem repeat, suggesting a possible common origin. Given the frequencies of the two exon polymorphisms reported here, this analysis should be applicable to approximately 70% of type I and type III vWD patients. This comparative DNA and RNA PCR-restriction fragment length polymorphism approach may also prove useful in identifying defects at the level of gene expression associated with other genetic disorders.

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We have found a single 4p+ chromosomal abnormality, 46,XX, -4, +der(4)t(3;4)(q13.3;p16), in a patient with an unusual B cell leukemia of mature phenotype characterized by a high white cell count, tartrate-resistant acid phosphatase-positive malignant cells, splenic white pulp proliferation, and a serum IgM monoclonal gammopathy. The malignant cells were characterized by surface expression of CD19 (B4), CD20 (B1), IgM, IgD, kappa, and HLA-DR. They were weakly positive for CD21 (B2) and negative for CD25 (interleukin-2 receptor). The malignant cells also showed clonal rearrangement of the immunoglobulin heavy chain and kappa light chain genes. A cell line, designated HCLW-3B, was derived from unstimulated peripheral blood obtained during the leukemic phase and was found to contain the same 4p+ chromosomal abnormality as well as genomic sequences of the Epstein-Barr virus nuclear antigen. A somatic cell hybrid constructed from HCLW-3B containing the derivative chromosome 4 was used to confirm that chromosome 3q was the source of the translocated material. The availability of a cell line which is clonally derived from the patient's circulating leukemia cells should permit further characterization of this translocation at the molecular level.

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The growth of human mammary cells may be regulated by a balance between growth stimulatory and growth inhibitory pathways. Polypeptides of 47 and 65 kilodaltons (mammastatin) were isolated from conditioned medium of normal human mammary cells. Monoclonal antibodies against mammastatin were generated that blocked its activity and were used for purification and further characterization of the protein. Mammastatin inhibited the growth of 5 transformed human mammary cell lines, but had no effect on the growth of 11 transformed human cell lines derived from nonmammary tissues. Mammastatin appeared to be a heat-labile protein distinct from transforming growth factor-beta (TGF-beta). By immunoperoxidase staining it was detected in cultured normal human mammary cells, but was decreased in transformed mammary cells.

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In order to provide evidence for an association of cell surface laminin with the cytoskeleton, we have examined the detergent extractability of cell surface laminin on murine fibrosarcoma cells. We utilized indirect immunofluorescence with affinity-purified anti-laminin antibodies to determine the distribution, mobility and detergent extractability of laminin bound to the cell surface. We demonstrate that antibody induces clustering of cell surface laminin rendering it resistant to detergent extraction. At low receptor occupancy, approx. 80% of cell surface laminin is detergent-extractable. If cell surface laminin is induced to cluster with anti-laminin antibody, IB4 isolectin from Bandeiraea simplicifolia or by high receptor occupancy, then it is rendered resistant to detergent extraction. This process is temperature-sensitive and inhibited by cytochalasin D (CD). On the basis of these findings, we propose a model in which laminin anchored in the basement membrane in vivo affects the cellular cytoskeleton by facilitating the clustering of cell surface transmembrane laminin receptors which are able to interact with cellular actin.

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