579
clear. We report a case of intrauterine pregnancy after an otherwise successful TCER. A 39-year-old European woman was admitted in December, 1989, for an elective TCER. She had a 4-year history of menorrhagia and postcoital and intermenstrual bleeding. She had dilatation and curettage in 1985 and again in 1988, both with negative results. She had been taking a progestagen-only contraceptive pill before being started on danazol six weeks preoperatively. Her obstetric history included two normal
deliveries. A TCER with a modified urological resectoscope was done on Dec 18, 1989. She had an anteverted uterus of normal size with a regular endometrial cavity and normal adnexae. The procedure was uncomplicated and she was discharged home the next day. Histopathological examination revealed several glands deep in the myometrium that were suggestive of adenomyosis. At follow-up four and eight months later she remained well and amenorrhoeic. On Aug 21,1990 (8 months postoperatively), she was admitted as an emergency with severe pain in the right iliac fossa of two days’ duration. Laparoscopy demonstrated an oedematous, enlarged right tube adherent to the right ovary and endometriotic deposits on the left uterosacral ligament. A right salpingo-oophorectomy was done. She proved to have acute salpingitis. Her recovery was uneventful and she was discharged home on oral antibiotics. Endocervical cultures were reported positive for Bacteroidesfragilis. On June 14,1991 (18 months post-operatively), she was referred to the gynaecology clinic by her general practitioner. She had noted symptoms of pregnancy and a positive pregnancy test was reported; she had continued to be amenorrhoeic. The uterus was enlarged, consistent with 12 weeks’ gestation. A vaginal termination of pregnancy and laparoscopic sterilisation were done on June 20. Evacuation was by a size 12 suction curette followed by sharp curettage. A 27 mm embryo was retrieved. Hysteroscopy showed the implantation site to be located in the right horn of the uterus; the lower uterine cavity was partly occluded with adhesions. At laparoscopy the left tube and ovary were normal; endometriosis was noted in the pouch of Douglas. A single Filshie clip was applied to the left tube. We are unaware of other reports of pregnancy after TCER. Although this patient was told of the risk of pregnancy after this procedure, we were surprised that this could occur after such a long period of amenorrhoea. A tubal occlusive procedure has been suggested immediately before TCER to keep the absorption of irrigant to a minimum.3This case demonstrates two further advantages of this suggestion-the prevention of pregnancy and possibly of pelvic inflammatory disease.
J. M. MONGELLI A. J. EVANS
Royal Victoria Hospital, Bournemouth BH1 4JG, UK
40% of these newborn babies will show signs of intrauterine malnutrition;2 these differences in fetal size and growth have been discussed in detail by Altman and Hytten.4 However, although the perinatal outcome in the short term is related to the occurrence of fetal growth retardation, in the long-term these individuals might be affected by conditions such as hypertension and ischaemic heart disease. These conditions may well be a function of fetal (and placental) size alone.5,6 Thus, the use of aspirin in pregnancy might prevent the onset of serious diseases in adulthood. Hopefully, Uzan et al have planned long-term follow-up of the children delivered during their study. Rosie
Maternity Hospital, Cambridge CB2 2SW, UK
TOBY N. FAY
LO, Searls DT, Brazie JV. Neonatal mortality rate: relationship to birth weight and gestational age. J Pediatr 1972; 81: 814-22. 2. Fay TN, Patodi M, Crocker SG. Antenatal prediction of ’small-for-dates’ babies: what proportion are growth retarded? J Obstet Gynecol 1991; 11: 237-40. 3. Keen DV, Pearse RG. Birthweight between 14 and 42 weeks’ gestation. Arch Dis Child 1. Lubcheno
1985; 60: 440-46. 4. Altman DG, Hytten FE. Intrauterine growth retardation: let’s be clear about it. Br J Obstet Gynaecol 1989; 96: 1127-28. 5. Barker DJP, Winter PD, Osmond C, Margetts B, Simmonds SJ. Weight in infancy and death from ischaemic heart disease. Lancet 1989; ii: 577-80. 6. Barker DJP, Bull AR, Osmond C, Simmonds SJ. Fetal and placental size and risk of hypertension in adult life. Br Med J 1990; 301: 259-62.
Natural killer cell activity and immunotherapy for recurrent spontaneous abortion SiR,—Women with recurrent spontaneous abortion have been treated by immunisation with the husband’s peripheral blood mononuclear cells (PBMC) and cells from unrelated donors. We have also obtained successful results with the husband’s PBMC.1 Many large granular lymphocytes have been detected in the uterus,’!2 but the role of these cells is unknown. We have investigated natural killer (NK) cell activities in patients before and after
immunotherapy. Patients who had more than three successive unexplained abortions during the early stages of pregnancy were selected for immunotherapy. PBMCs isolated from the patients’ husbands were frozen and stored in liquid nitrogen. NK activity was assessed in samples taken before and after immunotherapy by cytolysis ofK562 with the carboxy-fluorescein diacetate (C-FDA) method.3 All 5 patients in whom NK activity decreased after immunotherapy became pregnant and had healthy babies (figure). By contrast, 3 patients in whom NK activity greatly increased after immunotherapy had not become pregnant more than 12 months later. Of 4 patients with little change in NK activity, 2 had a successful outcome, 1 aborted, and 1 did not conceive. Changes in NK activity differed between those who conceived (n 7) and those who did not (4) (Welch test, p < 0-05); NK activity in peripheral blood before immunotherapy was higher in patients who conceived, and differed significantly between the two groups (Welch, p < 001). De Fougerolles and Baines4 showed in the mouse that the abortion rate was related to NK cell activity. These data suggest that =
1. DeCherney AH, Polan ML. Hysteroscopic resection of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol 1983; 61: 392-97. 2. Boto TCA, Fowler CG. Sugrical alternatives to hysterectomy for intractable menorrhagia. Br J Hosp Med 1990; 44: 93-99. 3. Goldrath MH, Fuller TA, Segal S. Laser vaporisation of endometrium for the treatment of menorrhagia. Am J Obstet Gynecol 1981; 140: 14-19.
Low-dose aspirin
during
pregnancy
SIR,-Dr Uzan and colleagues (June 15, p 1427) show in a well-controlled study that low-dose aspirin can significantly increase birthweight in high-risk pregnancies. However, they define fetal growth retardation with a cut-off below the tenth centile from birthweight nomograms developed in Colorado in the early 1970s.1 This definition is flawed for several reasons. First, these reference data were established before the introduction of routine determination of gestational age by ultrasound scanning in the second trimester. Accurate dating of pregnancies has been shown to alter significantly birthweight centile estimations.2.3 Second, birthweights derived from Colorado bear little relation to those in France because of differences in the two populations. Third, this definition for fetal growth retardation, that relates to fetal size alone, will incorporate both genetically small normal babies and pathologically malnourished infants. It has been shown that about
Changes in NK activity after immunotherapy with husbands’ PBMCs in unexplained recurrent abortion.
580
are cytotoxic effector cells against trophoblast in early pregnancy. Our data show that changes of NK activities are related
NK cells
outcome after immunotherapy. NK activity before might be important in decisions about immunotherapy for patients with unexplained recurrent spontaneous abortion. In those with low pretreatment NK, activity factors other than NK activity may contribute to abortion, or abortion may be due to different factors in these patients and those with high NK activity. Finally, we are concerned about the patients in whom NK activity was raised by immunotherapy but who had not conceived more than a year after immunotherapy, and believe that further investigation is necessary.
clinical
to
treatment
This work
was
supported by
a
Grant-in-Aid from the Ministry of
Education, Science, and Culture of Japan.
RYUJI MAKIDA Departments of Transfusion Medicine and Immunohaematology, and Obstetrics and Gynaecology, Faculty of Medicine, University of Tokyo, Tokyo 113, Japan
MUTSUHIKO MINAMI MASARU TAKAMIZAWA TAKEO JUJI TOMOYUKI FUJII MASAYUKI MIZUNO
Fujii T, Takamizawa M, Juji T, Kawana T, Mizuno M. Outcome of pregnancy after injection of mononuclear cells. Am J Obstet Gynecol 1988; 158: 1015-16. 2. King A, Loke YW. Uterine large granular lymphocytes: a possible role in embryonic implantation. Am J Obstet Gynecol 1990; 162: 308-10. 3. Bumig JW. Carboxy-fluorescein fluorochromasia assay: I non-radioactively labeled 1.
4. De
cell-mediated lympholysis. J Immunol Methods 1980; 33: 33-44. Fougerolles AR, Baines MG. Modulation of the natural killer cell activity in pregnant mice alters spontaneous abortion rate. J Reprod Immunol 1987; 11: 147-53.
Helix pomatia in breast
cancer
SIR,-Dr Brooks and Dr Leathern (July 13, p 71) report that staining of primary breast cancers for Helix pomatia (HPA) is an "excellent predictor of long-term patient prognosis" and that it is a "possible staging adjunct in patients apparently lymph-node negative". We have done a pilot study on 363 primary breast cancers taken at random from the files of the International (Ludwig) Breast Cancer Study Group Trial V conducted between 1981 and 1985. Details of this trial have been published elsewhere.1,2 All cases were stained immunocytochemically with the lectin and specificity was confirmed by absorption with the appropriate sugar. Scoring, as described by Brooks and Leathem, was done by two pathologists. All samples were coded and the results sent to the Biostatistics Center, Dana Farber Cancer Institute, where the clinical correlations were studied. A detailed analysis has been done but what follows is limited to the questions raised by Brooks and Leathem’s paper. There was a weak correlation between HPA binding and lymph node involvement. In contrast to the findings of Brooks and Leathern only 70% of node-positive cases were positively stained, making HPA binding a poor predictor of lymph node staging in our material:
Disease-free survival (DFS) was the same for HPA non-stainers for HPA stainers (6-year DFS 56% [SE 5] and 56% [3], respectively). We evaluated DFS and overall survival according to lymph node status and HPA binding. While lymph node status was significant, as expected, HPA binding had no predictive value: as
*p< 0 0001 for node+ vs node - (univariate analysis by log-rank test) tNo significant differences for HPA- vs HPA+ by umvanate analysis or by multivarite analyses based on Cox model with lymph node status (N -, 1-3N +, > 3N +), H PA, grade, and tumour size
37% of node-negative patients received no chemotherapy and 63 % received one cycle of perioperative chemotherapy. Among the
node-positive patients, 67% received six or seven cycles of chemotherapy and 33% received one cycle of perioperative chemotherapy. Thus, in contrast to Brooks and Leathem, we can find no evidence that HPA staining is of value as a prognostic marker. In our cases lymph node status was determined pathologically after total mastectomy with complete axillary clearance, and an average of 14 nodes
were
examined per
case.
It is difficult
to
draw direct
comparisons with the Brooks study since no details are provided on how lymph node status was assessed. Treatment may affect outcome and information on this is not provided by Brooks and T eathem Section of Cell Biology and Experimental Pathology, Institute of Cancer Research, Haddow Laboratories, Sutton, Surrey SM2 5NG, UK
International
Breast Cancer
(Ludwig) Study Group (IBCSG),
Boston, Massachusetts, USA and Bern, Switzerland
C. W. TAYLOR R. ANBAZHAGAN H. JAYATILAKE A. ADAMS B. A. GUSTERSON K. PRICE R. D. GELBER A.
GOLDHIRSCH,
behalf of pathologists and participants of the IBCSG
on
Ludwig Breast Cancer Study Group. Combination adjuvant chemotherapy for node-positive breast cancer: inadequacy of a single perioperative cycle. N Engl J Med 1988, 319: 677-83. 2. Ludwig Breast Cancer Study Group. Prolonged disease-free survival after one course of perioperative adjuvant chemotherapy for node negative breast cancer. N Engl J 1.
Med 1989; 320: 491-96.
***This letter has been shown to Dr Brooks and Dr Leathern, whose reply to it and a previous letter follows.-ED. L. SIR,-Mr Galea and colleagues (Aug 10, p 392) and Dr Taylor et al raise questions that seem to relate directly to our methodology. Our earlier observation1 that binding of Helix pomatia lectin (HPA) to primary breast cancers was associated with shorter survival was followed by three publications confirming our results with an indirect antibody, an avidin-biotin, and a fluorescein method.2-4 Of six different methods we tried on cancers with long versus short survival, we found that an indirect antibody method gave staining results that most closely reflected survival. We described earlier how various methods to detect lectin binding to tissue sections could give different results.5,6Last year we tried to develop a simple staining and scoring system to detect HPA binding to breast cancer sections. We chose a direct HPAperoxidase conjugate (Sigma) to stain our series and obtained clean staining that was straightforward to interpret as positive or negative. In parallel we used an indirect antibody method. Comparing results with survival showed a trong correlation with prognosis by the indirect method (p < 0-00001) but only a weak correlation by the direct method (p < 0-03), and we stopped using this direct method. We were surprised by this difference. The earlier HPA results of the Nottingham group in 1987,z with an indirect antibody method, showed a close association between HPA binding and survival (p < 0-001) but the group’s recent results (Aug 10) with a direct conjugate show no significant differences between stainers and non-stainers. This is in accord with the results of our direct conjugate staining method. We have discussed this with them and agree that "the most probable explanation must lie in the difference between the staining method and the source of HPA. Although, as Galea et al mention, many of our lectins and conjugates have been home-made; both the native and conjugated HPA described here have been obtained from Sigma. Our rabbit polyclonal antiserum reacts with all HPA sources we have tested. We are evaluating a monoclonal antibody to HPA that is directed against an epitope seemingly distinct from the binding site and produces good staining, but we do not yet know how the results compare with tumour behaviour. Taylor et al do not show that HPA has a predictive value for node status or prognosis, but the methodology is not explained. To compare results from different centres the basic methodology must be the same, and polyclonal rabbit antiserum is available from us and others to centres wishing to test this out. There are several explanations for the differences noted that relate to the binding of a lectin. First, the binding of lectins, just as that of antibodies and other
clear. We report a case of intrauterine pregnancy after an otherwise successful TCER. A 39-year-old European woman was admitted in December, 1989, for an elective TCER. She had a 4-year history of menorrhagia and postcoital and intermenstrual bleeding. She had dilatation and curettage in 1985 and again in 1988, both with negative results. She had been taking a progestagen-only contraceptive pill before being started on danazol six weeks preoperatively. Her obstetric history included two normal
deliveries. A TCER with a modified urological resectoscope was done on Dec 18, 1989. She had an anteverted uterus of normal size with a regular endometrial cavity and normal adnexae. The procedure was uncomplicated and she was discharged home the next day. Histopathological examination revealed several glands deep in the myometrium that were suggestive of adenomyosis. At follow-up four and eight months later she remained well and amenorrhoeic. On Aug 21,1990 (8 months postoperatively), she was admitted as an emergency with severe pain in the right iliac fossa of two days’ duration. Laparoscopy demonstrated an oedematous, enlarged right tube adherent to the right ovary and endometriotic deposits on the left uterosacral ligament. A right salpingo-oophorectomy was done. She proved to have acute salpingitis. Her recovery was uneventful and she was discharged home on oral antibiotics. Endocervical cultures were reported positive for Bacteroidesfragilis. On June 14,1991 (18 months post-operatively), she was referred to the gynaecology clinic by her general practitioner. She had noted symptoms of pregnancy and a positive pregnancy test was reported; she had continued to be amenorrhoeic. The uterus was enlarged, consistent with 12 weeks’ gestation. A vaginal termination of pregnancy and laparoscopic sterilisation were done on June 20. Evacuation was by a size 12 suction curette followed by sharp curettage. A 27 mm embryo was retrieved. Hysteroscopy showed the implantation site to be located in the right horn of the uterus; the lower uterine cavity was partly occluded with adhesions. At laparoscopy the left tube and ovary were normal; endometriosis was noted in the pouch of Douglas. A single Filshie clip was applied to the left tube. We are unaware of other reports of pregnancy after TCER. Although this patient was told of the risk of pregnancy after this procedure, we were surprised that this could occur after such a long period of amenorrhoea. A tubal occlusive procedure has been suggested immediately before TCER to keep the absorption of irrigant to a minimum.3This case demonstrates two further advantages of this suggestion-the prevention of pregnancy and possibly of pelvic inflammatory disease.
J. M. MONGELLI A. J. EVANS
Royal Victoria Hospital, Bournemouth BH1 4JG, UK
40% of these newborn babies will show signs of intrauterine malnutrition;2 these differences in fetal size and growth have been discussed in detail by Altman and Hytten.4 However, although the perinatal outcome in the short term is related to the occurrence of fetal growth retardation, in the long-term these individuals might be affected by conditions such as hypertension and ischaemic heart disease. These conditions may well be a function of fetal (and placental) size alone.5,6 Thus, the use of aspirin in pregnancy might prevent the onset of serious diseases in adulthood. Hopefully, Uzan et al have planned long-term follow-up of the children delivered during their study. Rosie
Maternity Hospital, Cambridge CB2 2SW, UK
TOBY N. FAY
LO, Searls DT, Brazie JV. Neonatal mortality rate: relationship to birth weight and gestational age. J Pediatr 1972; 81: 814-22. 2. Fay TN, Patodi M, Crocker SG. Antenatal prediction of ’small-for-dates’ babies: what proportion are growth retarded? J Obstet Gynecol 1991; 11: 237-40. 3. Keen DV, Pearse RG. Birthweight between 14 and 42 weeks’ gestation. Arch Dis Child 1. Lubcheno
1985; 60: 440-46. 4. Altman DG, Hytten FE. Intrauterine growth retardation: let’s be clear about it. Br J Obstet Gynaecol 1989; 96: 1127-28. 5. Barker DJP, Winter PD, Osmond C, Margetts B, Simmonds SJ. Weight in infancy and death from ischaemic heart disease. Lancet 1989; ii: 577-80. 6. Barker DJP, Bull AR, Osmond C, Simmonds SJ. Fetal and placental size and risk of hypertension in adult life. Br Med J 1990; 301: 259-62.
Natural killer cell activity and immunotherapy for recurrent spontaneous abortion SiR,—Women with recurrent spontaneous abortion have been treated by immunisation with the husband’s peripheral blood mononuclear cells (PBMC) and cells from unrelated donors. We have also obtained successful results with the husband’s PBMC.1 Many large granular lymphocytes have been detected in the uterus,’!2 but the role of these cells is unknown. We have investigated natural killer (NK) cell activities in patients before and after
immunotherapy. Patients who had more than three successive unexplained abortions during the early stages of pregnancy were selected for immunotherapy. PBMCs isolated from the patients’ husbands were frozen and stored in liquid nitrogen. NK activity was assessed in samples taken before and after immunotherapy by cytolysis ofK562 with the carboxy-fluorescein diacetate (C-FDA) method.3 All 5 patients in whom NK activity decreased after immunotherapy became pregnant and had healthy babies (figure). By contrast, 3 patients in whom NK activity greatly increased after immunotherapy had not become pregnant more than 12 months later. Of 4 patients with little change in NK activity, 2 had a successful outcome, 1 aborted, and 1 did not conceive. Changes in NK activity differed between those who conceived (n 7) and those who did not (4) (Welch test, p < 0-05); NK activity in peripheral blood before immunotherapy was higher in patients who conceived, and differed significantly between the two groups (Welch, p < 001). De Fougerolles and Baines4 showed in the mouse that the abortion rate was related to NK cell activity. These data suggest that =
1. DeCherney AH, Polan ML. Hysteroscopic resection of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol 1983; 61: 392-97. 2. Boto TCA, Fowler CG. Sugrical alternatives to hysterectomy for intractable menorrhagia. Br J Hosp Med 1990; 44: 93-99. 3. Goldrath MH, Fuller TA, Segal S. Laser vaporisation of endometrium for the treatment of menorrhagia. Am J Obstet Gynecol 1981; 140: 14-19.
Low-dose aspirin
during
pregnancy
SIR,-Dr Uzan and colleagues (June 15, p 1427) show in a well-controlled study that low-dose aspirin can significantly increase birthweight in high-risk pregnancies. However, they define fetal growth retardation with a cut-off below the tenth centile from birthweight nomograms developed in Colorado in the early 1970s.1 This definition is flawed for several reasons. First, these reference data were established before the introduction of routine determination of gestational age by ultrasound scanning in the second trimester. Accurate dating of pregnancies has been shown to alter significantly birthweight centile estimations.2.3 Second, birthweights derived from Colorado bear little relation to those in France because of differences in the two populations. Third, this definition for fetal growth retardation, that relates to fetal size alone, will incorporate both genetically small normal babies and pathologically malnourished infants. It has been shown that about
Changes in NK activity after immunotherapy with husbands’ PBMCs in unexplained recurrent abortion.
580
are cytotoxic effector cells against trophoblast in early pregnancy. Our data show that changes of NK activities are related
NK cells
outcome after immunotherapy. NK activity before might be important in decisions about immunotherapy for patients with unexplained recurrent spontaneous abortion. In those with low pretreatment NK, activity factors other than NK activity may contribute to abortion, or abortion may be due to different factors in these patients and those with high NK activity. Finally, we are concerned about the patients in whom NK activity was raised by immunotherapy but who had not conceived more than a year after immunotherapy, and believe that further investigation is necessary.
clinical
to
treatment
This work
was
supported by
a
Grant-in-Aid from the Ministry of
Education, Science, and Culture of Japan.
RYUJI MAKIDA Departments of Transfusion Medicine and Immunohaematology, and Obstetrics and Gynaecology, Faculty of Medicine, University of Tokyo, Tokyo 113, Japan
MUTSUHIKO MINAMI MASARU TAKAMIZAWA TAKEO JUJI TOMOYUKI FUJII MASAYUKI MIZUNO
Fujii T, Takamizawa M, Juji T, Kawana T, Mizuno M. Outcome of pregnancy after injection of mononuclear cells. Am J Obstet Gynecol 1988; 158: 1015-16. 2. King A, Loke YW. Uterine large granular lymphocytes: a possible role in embryonic implantation. Am J Obstet Gynecol 1990; 162: 308-10. 3. Bumig JW. Carboxy-fluorescein fluorochromasia assay: I non-radioactively labeled 1.
4. De
cell-mediated lympholysis. J Immunol Methods 1980; 33: 33-44. Fougerolles AR, Baines MG. Modulation of the natural killer cell activity in pregnant mice alters spontaneous abortion rate. J Reprod Immunol 1987; 11: 147-53.
Helix pomatia in breast
cancer
SIR,-Dr Brooks and Dr Leathern (July 13, p 71) report that staining of primary breast cancers for Helix pomatia (HPA) is an "excellent predictor of long-term patient prognosis" and that it is a "possible staging adjunct in patients apparently lymph-node negative". We have done a pilot study on 363 primary breast cancers taken at random from the files of the International (Ludwig) Breast Cancer Study Group Trial V conducted between 1981 and 1985. Details of this trial have been published elsewhere.1,2 All cases were stained immunocytochemically with the lectin and specificity was confirmed by absorption with the appropriate sugar. Scoring, as described by Brooks and Leathem, was done by two pathologists. All samples were coded and the results sent to the Biostatistics Center, Dana Farber Cancer Institute, where the clinical correlations were studied. A detailed analysis has been done but what follows is limited to the questions raised by Brooks and Leathem’s paper. There was a weak correlation between HPA binding and lymph node involvement. In contrast to the findings of Brooks and Leathern only 70% of node-positive cases were positively stained, making HPA binding a poor predictor of lymph node staging in our material:
Disease-free survival (DFS) was the same for HPA non-stainers for HPA stainers (6-year DFS 56% [SE 5] and 56% [3], respectively). We evaluated DFS and overall survival according to lymph node status and HPA binding. While lymph node status was significant, as expected, HPA binding had no predictive value: as
*p< 0 0001 for node+ vs node - (univariate analysis by log-rank test) tNo significant differences for HPA- vs HPA+ by umvanate analysis or by multivarite analyses based on Cox model with lymph node status (N -, 1-3N +, > 3N +), H PA, grade, and tumour size
37% of node-negative patients received no chemotherapy and 63 % received one cycle of perioperative chemotherapy. Among the
node-positive patients, 67% received six or seven cycles of chemotherapy and 33% received one cycle of perioperative chemotherapy. Thus, in contrast to Brooks and Leathem, we can find no evidence that HPA staining is of value as a prognostic marker. In our cases lymph node status was determined pathologically after total mastectomy with complete axillary clearance, and an average of 14 nodes
were
examined per
case.
It is difficult
to
draw direct
comparisons with the Brooks study since no details are provided on how lymph node status was assessed. Treatment may affect outcome and information on this is not provided by Brooks and T eathem Section of Cell Biology and Experimental Pathology, Institute of Cancer Research, Haddow Laboratories, Sutton, Surrey SM2 5NG, UK
International
Breast Cancer
(Ludwig) Study Group (IBCSG),
Boston, Massachusetts, USA and Bern, Switzerland
C. W. TAYLOR R. ANBAZHAGAN H. JAYATILAKE A. ADAMS B. A. GUSTERSON K. PRICE R. D. GELBER A.
GOLDHIRSCH,
behalf of pathologists and participants of the IBCSG
on
Ludwig Breast Cancer Study Group. Combination adjuvant chemotherapy for node-positive breast cancer: inadequacy of a single perioperative cycle. N Engl J Med 1988, 319: 677-83. 2. Ludwig Breast Cancer Study Group. Prolonged disease-free survival after one course of perioperative adjuvant chemotherapy for node negative breast cancer. N Engl J 1.
Med 1989; 320: 491-96.
***This letter has been shown to Dr Brooks and Dr Leathern, whose reply to it and a previous letter follows.-ED. L. SIR,-Mr Galea and colleagues (Aug 10, p 392) and Dr Taylor et al raise questions that seem to relate directly to our methodology. Our earlier observation1 that binding of Helix pomatia lectin (HPA) to primary breast cancers was associated with shorter survival was followed by three publications confirming our results with an indirect antibody, an avidin-biotin, and a fluorescein method.2-4 Of six different methods we tried on cancers with long versus short survival, we found that an indirect antibody method gave staining results that most closely reflected survival. We described earlier how various methods to detect lectin binding to tissue sections could give different results.5,6Last year we tried to develop a simple staining and scoring system to detect HPA binding to breast cancer sections. We chose a direct HPAperoxidase conjugate (Sigma) to stain our series and obtained clean staining that was straightforward to interpret as positive or negative. In parallel we used an indirect antibody method. Comparing results with survival showed a trong correlation with prognosis by the indirect method (p < 0-00001) but only a weak correlation by the direct method (p < 0-03), and we stopped using this direct method. We were surprised by this difference. The earlier HPA results of the Nottingham group in 1987,z with an indirect antibody method, showed a close association between HPA binding and survival (p < 0-001) but the group’s recent results (Aug 10) with a direct conjugate show no significant differences between stainers and non-stainers. This is in accord with the results of our direct conjugate staining method. We have discussed this with them and agree that "the most probable explanation must lie in the difference between the staining method and the source of HPA. Although, as Galea et al mention, many of our lectins and conjugates have been home-made; both the native and conjugated HPA described here have been obtained from Sigma. Our rabbit polyclonal antiserum reacts with all HPA sources we have tested. We are evaluating a monoclonal antibody to HPA that is directed against an epitope seemingly distinct from the binding site and produces good staining, but we do not yet know how the results compare with tumour behaviour. Taylor et al do not show that HPA has a predictive value for node status or prognosis, but the methodology is not explained. To compare results from different centres the basic methodology must be the same, and polyclonal rabbit antiserum is available from us and others to centres wishing to test this out. There are several explanations for the differences noted that relate to the binding of a lectin. First, the binding of lectins, just as that of antibodies and other
