995
LYMPH-NODE BIOPSY DURING SIMPLE MASTECTOMY A. A. SHIVAS ELIZABETH L. M. CANT A. P. M. FORREST
Departments of Clinical Surgery and Pathology,
University of Edinburgh The distribution of pectoral (external mammary) nodes identified during the removed with the axillary tail of the and operation breast was studied in 45 patients treated by simple (total) mastectomy. Up to 13 nodes may lie within the axillary tail, and these are continuous with the pectoral nodes. Lymph-nodes were identified in 90% of patients treated by simple (total) mastectomy without dissection of the axilla. Sum ary
tail postoperatively; and "pectoral nodes" as those selected peroperatively by the surgeon (fig. 1). Methods
Simple mastectomy was performed in 45 patients with early breast cancer. Our technique for this procedure is described elsewhere.5 It includes careful definition and dissection of the axillary tail of the breast from between the pectoralis major muscle in front and the latissimus dorsi behind, and its removal with the breast up to the point where it blends with the axillary fat-i.e., at the level of the third rib. This is facilitated by removing the
Introduction WE have suggested that a rational policy for the local management of primary breast cancer is simple mastectomy with pectoral-node biopsy, followed by immediate postoperative radiotherapy only in those cases in which involvement of these nodes is proved histologically. Since these nodes can be identified without dissecting the axilla, the morbidity of either unnecessary axillary dissection or radical radiotherapy is avoided. We reported a controlled randomised study which was designed to assess this policy of treatment in Cardiff and St. Mary’s Hospital.’ This is now also the basic procedure used in the current Edinburgh breast cancer trials, which include the administration of additional systemic therapy to those with histologically involved pectoral lymph-nodes.3.4t We have been uncertain as to the true distribution of these pectoral nodes. Initially we believed that be near to the top of the best identified they could excised breast specimen, but later axillary tail of the we advised that the surgeon should identify a node or nodes of this group during his dissection of the axillary tail, particularly at the point of separation from the axillary fat. The study we now report was undertaken to determine the best method of accurate sampling of these nodes. It suggests that a careful search of the excised axillary tail and a careful search by the surgeon peroperatively are both essential steps for complete sampling. For clarity, we have defined " axillary-tail nodes " as those identified in the axillary
9. Schaffner, W., Melly, M. A., Hash, J. H., Koenig, M. G. J. biol. Med. 1967, 39, 215. 10. Tan, J. S., Watanakunakorn, C., Phair, J. P. J. Lab. clin. Med. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
1971, 78, 316. Holmes, B., Quie, P. G., Windhorst, D. B., Good, R. A. Lancet, 1966, i, 1225. Windhorst, D. B., Page, A. R., Holmes, B., Quie, P. G., Good, R. A. J. clin. Invest. 1967, 47, 1026. Biggar, W. D., Buron, S., Holmes, B. J. Pediat. (in the press). Holmes, B., Good, R. A. J. reticul. Soc. 1972, 12, 216. Strauss, R. R., Paul, B. B., Sbarra, A. J. J. Bact. 1968, 96, 1982. Stossel, T. P. New Engl. J. Med. 1974, 290, 717. Quie, P. G. in Current Problems in Pediatrics, vol. XI, no. 11, p. 1. Chicago, 1972. Baehner, R. L. J. Pediat. 1974, 84, 317. Elsbach, P. New Engl. J. Med. 1973, 289, 846. Najjar, V. A., Constantopoulos, A. J. reticul. Soc. 1972, 12, 197.
Fig. 1-Position of axillary-tail and pectoral lymph-nodes. breast from the medial to lateral side. Separation of the tail from the axillary fat pad is facilitated by grasping it and feeling between finger and thumb the point at which the nodular breast fat merges into the much finer and smoother axillary fat lobules. After removal of the breast, the axillary tail was detached and the cut end marked with a suture. It was spread on a cork board and palpated on the flat. Palpable nodes were removed and their site marked on a sketch plan. The axillary tail was then sliced and any further nodes removed and also marked on the plan. Each node was fixed in 10% formol saline solution, embedded in paraffin, and sectioned. These nodes are termed " axillary-tail nodes ". Several sections were taken from each half of the node and stained with haematoxylin and eosin. When examination of these initial sections was negative, serial 1/10 sections were cut from the nodes, stained, and examined for foci of tumour. In all cases, sections were taken to confirm the presence of breast parenchyma in the axillarytail specimens. In 38 cases, at operation the surgeon also attempted to identify a node or nodes separate from the axillary tail These usually lay at the junction of the axillary tail and the axillary fat, and towards its medial aspect. A node was defined in 29 cases; 2 of these on section proved to be only fat. These nodes have been termed " pectoral
Results
Total Yield of Nodes from Axillary Tail Nodes were identified within the breast of the axillary tail in 32 (71 %) of the 45
parenchyma cases.
The
996
Fig. 2-Positive nodes (black) found by axillary-tail dissection.
Fig. 3-Correlation of positive pectoral node biopsy results with positive axillary-tail nodes.
number of nodes varied from one to thirteen, and on average was 5. In 14 cases, one or more nodes
The correlation between preoperative palpability and pectoral-node involvement is given in table 111. Impalpable nodes were involved in 20% of cases.
in the axillary tail contained metastases. In general the pattern of involvement was from below upwards. In those cases in which only some nodes were positive, these generally were situated in the lower part of the tail, those in the upper part being normal
(fig. 2). The preoperative palpability of axillary nodes is correlated with the histology of axillary-tail nodes in table i. Histologically involved nodes were found in cases with palpable nodes. only The nodes in the axillary tail often lay in association with an obvious vein which ran through the tail and entered the axilla. This presumably is the main venous drainage of the axillary tail of the breast.
Pectoral-node Involvement in Relation
Total Series Taking into account both methods of sampling, nodes were identified for histological examination in 41 of the total 45 cases, in 7 of which no attempt was made to define a pectoral node, and in 34 (i.e., over TABLE III-PALPABILITY RELATED TO METASTATIC INVOLVEMENT OF PECTORAL NODES SELECTED BY SURGEON
to
Axillary-tail Findings In 27 (71 %) of 38 cases a lymph-node was correctly identified by the surgeon, and separately sectioned as a pectoral node. Thirteen of these nodes contained
TABLE
IV-NODE INVOLVEMENT IN TOTAL SERIES RELATED TO PALPABILITY AND TO SITE OF BREAST TUMOUR
metastatic tumour. The relation between these nodes and those within the axillary tail of the same patients is given in table 11. Those instances in which a node was sought but not found are included as negative. Axillary-tail nodes were not found in 4 of the 5 patients whose pectoral nodes were positive and axillary-tail nodes negative (fig. 3). TABLE
I—PALPABILITY AND METASTATIC INVOLVEMENT OF AXILLARY-TAIL NODES
TABLE II-PECTORAL-NODE INVOLVEMENT RELATED TO STATE OF AXILLARY-TAIL NODES
90 %) of the 38 cases in which both methods were always used. There was histological involvement of nodes in 19 of the 45, and 18 of the 38 patients, respectively. In the latter group, 5 were positive by examination of the axillary-tail alone, 5 by examination of the pectoral nodes (selected by the surgeon) alone, and 8 by both. The relation of nodal involvement in the total series to the preoperative palpability of the axillary nodes, and the site of the tumour, is noted in table IV. This indicates that 15 % of patients with impalpable axillary nodes had proved involvement, that 36 % of patients with palpable nodes did not have involvement, and that tumours in the medial half of the breast were less likely to metastasise to the pectoral and axillarytail nodes than those which were situated laterally. The only medial tumour which was associated with positive nodes was locally advanced; so also were 3 of the 4 central tumours.
997
Discussion first suggested that the treatment of breast cancer might be planned according to the histological state of those lymph-nodes which can be defined during a simple mastectomy and without dissecting the axilla, we were unaware of the number of nodes which were present within the axillary tail of the breast. Anatomical texts do not describe the axillary tail as containing a chain of lymphatic tissue associated with a main vein. Such texts generally suggest that the pectoral (or external mammary) nodes lie in the anteromedial angle of the axilla in relation to the lateral thoracic vessels, at around the level of the third rib. It is now clear that these particular nodes are only the uppermost of a group of lymph-nodes which run within the substance of the axillary tail of the breast, and are only part of its lymphatic drainage system. In only one case (no. 13) did the pectoral node defined by the surgeon peroperatively contain tumour in the presence of identified, but uninvolved, nodes in the axillary tail. Spread to the uppermost nodes of this group by routes other than through the axillary tail is evidently rare. Our study demonstrates that if one is accurately to sample nodes during a simple mastectomy, without dissecting the axilla, it is insufficient either to define and select a node during the operation, or to rely on the examination of the excised axillary tail of the breast. Either method alone resulted in a yield of nodes in 71 % of cases, but both together yielded 90 %. So far the evidence we have suggests that the determination of node status by sampling of those nodes defined during a simple mastectomy is as accurate as that based on the routine examination In the Cardiff/ of radical mastectomy specimens. St. Mary’s trial in which pectoral nodes were obtained at the discretion of the surgeon, and were taken either from the axillary tail or sampled during the operation, the frequency of involvement was not different from that assessed from the specimens obtained from those control patients treated by radical mastectomy. Further, the frequency of subsequent growth in the axillary nodes of those patients who, on the basis of negative pectoral-node histology, received no treatment other than a simple mastectomy has indicated a true false-negative rate of only 7 %. We cannot yet assess this from the current study. The relation between preoperative palpability of axillary nodes and the histological findings confirms the known inaccuracy of the former. Nevertheless involved axillary-tail nodes were found only in cases which had palpable axillary nodes. This suggests that those nodes most readily palpable clinically may be lying within the axillary ’tail itself. Since careful dissection of the axillary tail is not part of the routine pathological examination of mastectomy specimens, this could account for some of the discrepancies between palpability and involvement. Unless the axillary tail is carefully dissected, policies of treatment based on the number of involved nodes defined in mastectomy specimens are highly suspect.
When
we
Conclusion This study indicates that for a full and accurate assessment of pectoral (external-mammary) node
involvement during a simple mastectomy there must be (i) a careful and complete dissection of the axillary tail of the breast as part of the operation of simple mastectomy; (ii) a careful search by the surgeon for those nodes of the pectoral group which lie outside the substance of the axillary tail, particularly at its upper part; and (iii) a careful search of the axillary tail after its removal, both by palpation and by careful dissection. It is apparent that the nodes which lie in the axillary tail of the breast are continuous with those defined anatomically as the pectoral group, and form the main lymphatic pathway from the breast to the axilla. We thank Mr I. B. Macleod, Mr T. Hamilton, and Mr Ian Wallace for their cooperation in providing some of the mastectomy specimens studied; Prof. A. R. Currie for his support; and Miss Anne McNeil for the illustration. Requests for reprints should be addressed to A. P. M. F. REFERENCES 1. 2.
3.
4.
5.
Forrest, A. P. M., Gleave, E. N., Roberts, M. M., Henk, J. M., Gravelle, I. H. Proc. R. Soc. Med. 1970, 63, 107. Roberts, M. M., Forrest, A. P. M., Blumgart, L. H., Campbell, H., Davies, M., Gleave, E. N., Henk, J. M., Kunkler, P. B., Shields, R., Hulbert, M., Jamieson, C. W., Sellwood, R. A. Lancet, 1973, i, 1073. Forrest, A. P. M., Roberts, M. M., Preece, P., Henk, J. M., Campbell, H., Hughes, L. E., Desai, S., Hulbert, M. Br. J. Surg. 1974, 61, 766. Co-ordinating Committee: Edinburgh Primary Breast Trials. Unpublished. Forrest, A. P. M., Cant, E. L. M. Br. J. Surg. (in the press).
ANTIBODY TO CULTURED HUMAN INSULINOMA CELLS IN INSULIN-DEPENDENT DIABETES NOEL KEITH MACLAREN
SHIH-WEN HUANG
Department of Pediatrics, Divisions of Endocrinology/ Metabolism, and Immunology/Allergy, University of Maryland School of Medicine, Baltimore, Maryland 21201, U.S.A.
JØRGEN FOGH Memorial Sloan-Kettering Cancer Center, New York, N.Y. 10021 to live tissuecultured human-insulinoma cells were identified in 34 out of 39 insulin-dependent diabetic patients by an indirect immunofluorescent technique. The antibodies were unrelated to insulin therapy since 8 of 9 sera obtained before insulin-replacement treatment were antibody positive and the test results were not influenced by prior addition of porcine insulin to The antibodies were of the IgM and IgG sera. classes. The findings suggest that autoimmune mechanisms are important in the pathogenesis of most cases of insulin-requiring diabetes.
Sum ary
Circulating antibodies
Introduction THERE is considerable interest in the pathogenesis of insulin-dependent diabetes (I.D.D.), with reports that support both viral and autoimmune oetiologies. The pancreatic islets of Langerhans may be infiltrated with lymphocytes if the pancreas is examined early
LYMPH-NODE BIOPSY DURING SIMPLE MASTECTOMY A. A. SHIVAS ELIZABETH L. M. CANT A. P. M. FORREST
Departments of Clinical Surgery and Pathology,
University of Edinburgh The distribution of pectoral (external mammary) nodes identified during the removed with the axillary tail of the and operation breast was studied in 45 patients treated by simple (total) mastectomy. Up to 13 nodes may lie within the axillary tail, and these are continuous with the pectoral nodes. Lymph-nodes were identified in 90% of patients treated by simple (total) mastectomy without dissection of the axilla. Sum ary
tail postoperatively; and "pectoral nodes" as those selected peroperatively by the surgeon (fig. 1). Methods
Simple mastectomy was performed in 45 patients with early breast cancer. Our technique for this procedure is described elsewhere.5 It includes careful definition and dissection of the axillary tail of the breast from between the pectoralis major muscle in front and the latissimus dorsi behind, and its removal with the breast up to the point where it blends with the axillary fat-i.e., at the level of the third rib. This is facilitated by removing the
Introduction WE have suggested that a rational policy for the local management of primary breast cancer is simple mastectomy with pectoral-node biopsy, followed by immediate postoperative radiotherapy only in those cases in which involvement of these nodes is proved histologically. Since these nodes can be identified without dissecting the axilla, the morbidity of either unnecessary axillary dissection or radical radiotherapy is avoided. We reported a controlled randomised study which was designed to assess this policy of treatment in Cardiff and St. Mary’s Hospital.’ This is now also the basic procedure used in the current Edinburgh breast cancer trials, which include the administration of additional systemic therapy to those with histologically involved pectoral lymph-nodes.3.4t We have been uncertain as to the true distribution of these pectoral nodes. Initially we believed that be near to the top of the best identified they could excised breast specimen, but later axillary tail of the we advised that the surgeon should identify a node or nodes of this group during his dissection of the axillary tail, particularly at the point of separation from the axillary fat. The study we now report was undertaken to determine the best method of accurate sampling of these nodes. It suggests that a careful search of the excised axillary tail and a careful search by the surgeon peroperatively are both essential steps for complete sampling. For clarity, we have defined " axillary-tail nodes " as those identified in the axillary
9. Schaffner, W., Melly, M. A., Hash, J. H., Koenig, M. G. J. biol. Med. 1967, 39, 215. 10. Tan, J. S., Watanakunakorn, C., Phair, J. P. J. Lab. clin. Med. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
1971, 78, 316. Holmes, B., Quie, P. G., Windhorst, D. B., Good, R. A. Lancet, 1966, i, 1225. Windhorst, D. B., Page, A. R., Holmes, B., Quie, P. G., Good, R. A. J. clin. Invest. 1967, 47, 1026. Biggar, W. D., Buron, S., Holmes, B. J. Pediat. (in the press). Holmes, B., Good, R. A. J. reticul. Soc. 1972, 12, 216. Strauss, R. R., Paul, B. B., Sbarra, A. J. J. Bact. 1968, 96, 1982. Stossel, T. P. New Engl. J. Med. 1974, 290, 717. Quie, P. G. in Current Problems in Pediatrics, vol. XI, no. 11, p. 1. Chicago, 1972. Baehner, R. L. J. Pediat. 1974, 84, 317. Elsbach, P. New Engl. J. Med. 1973, 289, 846. Najjar, V. A., Constantopoulos, A. J. reticul. Soc. 1972, 12, 197.
Fig. 1-Position of axillary-tail and pectoral lymph-nodes. breast from the medial to lateral side. Separation of the tail from the axillary fat pad is facilitated by grasping it and feeling between finger and thumb the point at which the nodular breast fat merges into the much finer and smoother axillary fat lobules. After removal of the breast, the axillary tail was detached and the cut end marked with a suture. It was spread on a cork board and palpated on the flat. Palpable nodes were removed and their site marked on a sketch plan. The axillary tail was then sliced and any further nodes removed and also marked on the plan. Each node was fixed in 10% formol saline solution, embedded in paraffin, and sectioned. These nodes are termed " axillary-tail nodes ". Several sections were taken from each half of the node and stained with haematoxylin and eosin. When examination of these initial sections was negative, serial 1/10 sections were cut from the nodes, stained, and examined for foci of tumour. In all cases, sections were taken to confirm the presence of breast parenchyma in the axillarytail specimens. In 38 cases, at operation the surgeon also attempted to identify a node or nodes separate from the axillary tail These usually lay at the junction of the axillary tail and the axillary fat, and towards its medial aspect. A node was defined in 29 cases; 2 of these on section proved to be only fat. These nodes have been termed " pectoral
Results
Total Yield of Nodes from Axillary Tail Nodes were identified within the breast of the axillary tail in 32 (71 %) of the 45
parenchyma cases.
The
996
Fig. 2-Positive nodes (black) found by axillary-tail dissection.
Fig. 3-Correlation of positive pectoral node biopsy results with positive axillary-tail nodes.
number of nodes varied from one to thirteen, and on average was 5. In 14 cases, one or more nodes
The correlation between preoperative palpability and pectoral-node involvement is given in table 111. Impalpable nodes were involved in 20% of cases.
in the axillary tail contained metastases. In general the pattern of involvement was from below upwards. In those cases in which only some nodes were positive, these generally were situated in the lower part of the tail, those in the upper part being normal
(fig. 2). The preoperative palpability of axillary nodes is correlated with the histology of axillary-tail nodes in table i. Histologically involved nodes were found in cases with palpable nodes. only The nodes in the axillary tail often lay in association with an obvious vein which ran through the tail and entered the axilla. This presumably is the main venous drainage of the axillary tail of the breast.
Pectoral-node Involvement in Relation
Total Series Taking into account both methods of sampling, nodes were identified for histological examination in 41 of the total 45 cases, in 7 of which no attempt was made to define a pectoral node, and in 34 (i.e., over TABLE III-PALPABILITY RELATED TO METASTATIC INVOLVEMENT OF PECTORAL NODES SELECTED BY SURGEON
to
Axillary-tail Findings In 27 (71 %) of 38 cases a lymph-node was correctly identified by the surgeon, and separately sectioned as a pectoral node. Thirteen of these nodes contained
TABLE
IV-NODE INVOLVEMENT IN TOTAL SERIES RELATED TO PALPABILITY AND TO SITE OF BREAST TUMOUR
metastatic tumour. The relation between these nodes and those within the axillary tail of the same patients is given in table 11. Those instances in which a node was sought but not found are included as negative. Axillary-tail nodes were not found in 4 of the 5 patients whose pectoral nodes were positive and axillary-tail nodes negative (fig. 3). TABLE
I—PALPABILITY AND METASTATIC INVOLVEMENT OF AXILLARY-TAIL NODES
TABLE II-PECTORAL-NODE INVOLVEMENT RELATED TO STATE OF AXILLARY-TAIL NODES
90 %) of the 38 cases in which both methods were always used. There was histological involvement of nodes in 19 of the 45, and 18 of the 38 patients, respectively. In the latter group, 5 were positive by examination of the axillary-tail alone, 5 by examination of the pectoral nodes (selected by the surgeon) alone, and 8 by both. The relation of nodal involvement in the total series to the preoperative palpability of the axillary nodes, and the site of the tumour, is noted in table IV. This indicates that 15 % of patients with impalpable axillary nodes had proved involvement, that 36 % of patients with palpable nodes did not have involvement, and that tumours in the medial half of the breast were less likely to metastasise to the pectoral and axillarytail nodes than those which were situated laterally. The only medial tumour which was associated with positive nodes was locally advanced; so also were 3 of the 4 central tumours.
997
Discussion first suggested that the treatment of breast cancer might be planned according to the histological state of those lymph-nodes which can be defined during a simple mastectomy and without dissecting the axilla, we were unaware of the number of nodes which were present within the axillary tail of the breast. Anatomical texts do not describe the axillary tail as containing a chain of lymphatic tissue associated with a main vein. Such texts generally suggest that the pectoral (or external mammary) nodes lie in the anteromedial angle of the axilla in relation to the lateral thoracic vessels, at around the level of the third rib. It is now clear that these particular nodes are only the uppermost of a group of lymph-nodes which run within the substance of the axillary tail of the breast, and are only part of its lymphatic drainage system. In only one case (no. 13) did the pectoral node defined by the surgeon peroperatively contain tumour in the presence of identified, but uninvolved, nodes in the axillary tail. Spread to the uppermost nodes of this group by routes other than through the axillary tail is evidently rare. Our study demonstrates that if one is accurately to sample nodes during a simple mastectomy, without dissecting the axilla, it is insufficient either to define and select a node during the operation, or to rely on the examination of the excised axillary tail of the breast. Either method alone resulted in a yield of nodes in 71 % of cases, but both together yielded 90 %. So far the evidence we have suggests that the determination of node status by sampling of those nodes defined during a simple mastectomy is as accurate as that based on the routine examination In the Cardiff/ of radical mastectomy specimens. St. Mary’s trial in which pectoral nodes were obtained at the discretion of the surgeon, and were taken either from the axillary tail or sampled during the operation, the frequency of involvement was not different from that assessed from the specimens obtained from those control patients treated by radical mastectomy. Further, the frequency of subsequent growth in the axillary nodes of those patients who, on the basis of negative pectoral-node histology, received no treatment other than a simple mastectomy has indicated a true false-negative rate of only 7 %. We cannot yet assess this from the current study. The relation between preoperative palpability of axillary nodes and the histological findings confirms the known inaccuracy of the former. Nevertheless involved axillary-tail nodes were found only in cases which had palpable axillary nodes. This suggests that those nodes most readily palpable clinically may be lying within the axillary ’tail itself. Since careful dissection of the axillary tail is not part of the routine pathological examination of mastectomy specimens, this could account for some of the discrepancies between palpability and involvement. Unless the axillary tail is carefully dissected, policies of treatment based on the number of involved nodes defined in mastectomy specimens are highly suspect.
When
we
Conclusion This study indicates that for a full and accurate assessment of pectoral (external-mammary) node
involvement during a simple mastectomy there must be (i) a careful and complete dissection of the axillary tail of the breast as part of the operation of simple mastectomy; (ii) a careful search by the surgeon for those nodes of the pectoral group which lie outside the substance of the axillary tail, particularly at its upper part; and (iii) a careful search of the axillary tail after its removal, both by palpation and by careful dissection. It is apparent that the nodes which lie in the axillary tail of the breast are continuous with those defined anatomically as the pectoral group, and form the main lymphatic pathway from the breast to the axilla. We thank Mr I. B. Macleod, Mr T. Hamilton, and Mr Ian Wallace for their cooperation in providing some of the mastectomy specimens studied; Prof. A. R. Currie for his support; and Miss Anne McNeil for the illustration. Requests for reprints should be addressed to A. P. M. F. REFERENCES 1. 2.
3.
4.
5.
Forrest, A. P. M., Gleave, E. N., Roberts, M. M., Henk, J. M., Gravelle, I. H. Proc. R. Soc. Med. 1970, 63, 107. Roberts, M. M., Forrest, A. P. M., Blumgart, L. H., Campbell, H., Davies, M., Gleave, E. N., Henk, J. M., Kunkler, P. B., Shields, R., Hulbert, M., Jamieson, C. W., Sellwood, R. A. Lancet, 1973, i, 1073. Forrest, A. P. M., Roberts, M. M., Preece, P., Henk, J. M., Campbell, H., Hughes, L. E., Desai, S., Hulbert, M. Br. J. Surg. 1974, 61, 766. Co-ordinating Committee: Edinburgh Primary Breast Trials. Unpublished. Forrest, A. P. M., Cant, E. L. M. Br. J. Surg. (in the press).
ANTIBODY TO CULTURED HUMAN INSULINOMA CELLS IN INSULIN-DEPENDENT DIABETES NOEL KEITH MACLAREN
SHIH-WEN HUANG
Department of Pediatrics, Divisions of Endocrinology/ Metabolism, and Immunology/Allergy, University of Maryland School of Medicine, Baltimore, Maryland 21201, U.S.A.
JØRGEN FOGH Memorial Sloan-Kettering Cancer Center, New York, N.Y. 10021 to live tissuecultured human-insulinoma cells were identified in 34 out of 39 insulin-dependent diabetic patients by an indirect immunofluorescent technique. The antibodies were unrelated to insulin therapy since 8 of 9 sera obtained before insulin-replacement treatment were antibody positive and the test results were not influenced by prior addition of porcine insulin to The antibodies were of the IgM and IgG sera. classes. The findings suggest that autoimmune mechanisms are important in the pathogenesis of most cases of insulin-requiring diabetes.
Sum ary
Circulating antibodies
Introduction THERE is considerable interest in the pathogenesis of insulin-dependent diabetes (I.D.D.), with reports that support both viral and autoimmune oetiologies. The pancreatic islets of Langerhans may be infiltrated with lymphocytes if the pancreas is examined early
