VOL XV, NO 2, SUPPL 1
`
`///
`
`APRIL 1988
`
`Lflminars in
`
` “151% Life i.
`
`EDITOR-IN-CHIEF ‘
`
`John W. Yarbro, MD, PhD
`
`ASSOCIATE EDITORS
`
`Richard S. Bornstein, MD
`
`Michael]. Mastrangelo, MD
`
`Advances in the Management
`of Hormone-Responsive Diseases
`
`Contributors
`
`C. Kent Osborne
`0 Gary M. Clark
`Scot M. Sedlacek I Kathryn B. Horwitz
`- Meryl Gale
`William L. McGuire
`0 Philip Bonomi
`0 Patricia Johnson
`Jamie Von Roenn
`I Kenning Anderson
`Janet Wolter
`0 Steven Economou
`- H. Muss
`0 W. Black
`M. Cooper
`0 N. Simon Tchekmedyian
`0 Nancy Tait
`Jeffrey Abrams
`0
`Joseph Aisner
`I M. Steven Piver
`Jack Geller
`0
`Jerry Albert
`0 Amy Vik
`0 P.M.Venner
`P.G.Klotz
`0 L.H.Klotz
`0 DJ. Stewart
`0 LR. Davis
`W.L.Orovan 0 E.W. Ramsey
`0 Howard Parnes
`Melvin Novak 0 Anne W. Hamburger
`I Gary B. Gordon
`Lisa M. Shantz
`0 Kelly A. O’Donnell
`
`Genentech 2122
`
`Hospira v. Genentech
`|PR2017-00737
`
`Genentech 2122
`Hospira v. Genentech
`IPR2017-00737
`
`1
`
`

`

`Seminars in Oncology
`
`
`
`Seminars in Oncology (ISSN 0093-7754) is published bimonthly by Grune & Stratton, Inc., The
`Curtis Center,
`Independence Square West, Philadelphia, PA 19106-3399. Months of issue are
`February, April, June, August, October, and December. Second class postage paid at Duluth, MN, and
`at additional mailing ofiices.
`POSTMASTER: Send change of address to Seminars in Oncology, c/o Grune & Stratton, Inc., PO
`Box 6280, Duluth, MN 55806.
`Editorial correspondence should be addressed to John W. Yarbro, MD, PhD, School of Medicine,
`University of Missouri at Columbia, Columbia, MO 65212.
`Business correspondence (subscriptions, change of address) should be addressed to the Publisher,
`Grune & Stratton, Inc., PO Box 6280, Duluth, MN 55806.
`Change ofaddress notices, including both the old and new addresses ofthe subscriber, should be sent
`to the Publisher at least one month in advance.
`Customer Service: 1-800-654-2452.
`Subscription rates: one volume of six issues, $78.00 in the United States and Canada; elsewhere,
`$116.00. Libraries and institutions: $105.00 in the United States and Canada; elsewhere, $116.00.
`Single copies, $28.00 in the United States and Canada; elsewhere, $30.00. Students, fellows, interns,
`and residents in the United States, Canada, and Australia may subscribe at a discount rate of $45.00 per
`year (a letter giving qualifying data must accompany order). Subscriptions are accepted on a calendar
`year basis. Prices are subject to change. Current prices are in effect for back volumes and back issues.
`Single issues, both current and back, exist in limited quantities and are offered for sale subject to
`availability. Journal orders are payable in advance. Checks should be sent to Grune & Stratton, Inc., PO
`Box 6209, Duluth, MN 55806.
`The appearance of the code at the bottom of the first page of an article in this journal indicates the
`copyright owner’s consent that copies of the article may be made for personal or internal use, or for the
`personal or internal use of specific clients. This consent is given on the condition, however, that the copier
`pay the stated per-copy fee through the Copyright Clearance Center, Inc. for copying beyond that
`permitted by Sections 107 or 108 of the US Copyright Law. This consent does not extend to other kinds
`of copying, such as copying for general distribution, for advertising or promotional purposes, for creating
`new collective works, or for resale. Absence of the code indicates that the material may not be processed
`through the Copyright Clearance Center, Inc.
`Advertising representative: Cunningham Associates, PO Box 308, Park Ridge, NJ 07656, telephone
`(201) 767-4170.
`Agents for Great Britain: Grune & Stratton Limited, 24-28 Oval Rd, London NW1 7DX, England.
`Agents for Australia and New Zealand: Grune & Stratton Australia, PO Box 300, North Ryde, NSW
`2113, Australia. Publication of an advertisement in Seminars in Oncology does not imply endorsement
`of its claims by the Edit0r(s) or Publisher of thejournal.
`Every effort has been made to check generic and trade names, and to verify drug doses. The ultimate
`responsibility, however, lies with the prescribing physician. Please convey any errors to the Editors.
`
`
`© 1988, Grune & Stratton, Inc.
`
`Philadelphia, PA
`
`Harcourt Brace Jommom'ch, Inc.
`
`
`
`2
`
`

`

`This material may be protected by Copyright law (Title 17 U.S. Code)
`
`3
`
`

`

`PROGNOSTIC FACTORS lN BREAST CANCER
`
`21
`
`DFS probability
`
`-0 Cid-10 :>20
`1:11—3 mn—zo
`
`Positive
`nodes
`
`
`
`Time (yr)
`
`ods, only the number of positive nodes and PgR
`retained their significance. These findings con-
`tinue to hold after a median of 114 months of
`
`follow-up (Table 1).
`
`PROLIFERATIVE RATE BY THYMIDINE
`LABELING INDEX
`
`While receptor status is an important prognos-
`tic variable,
`it alone cannot account for
`the
`
`varied course seen in breast cancer patients.
`Classic pathologic features importing more
`aggressive behavior to a malignancy are a high
`mitotic rate and nuclear anaplastic features.
`Because these characteristics are very difficult to
`quantify reproducibly among different patholo—
`gists, many investigators have utilized the thy-
`midine labeling index (TLI) and aneuploidy (de-
`gree of abnormal DNA content) as equivalent
`properties.
`The TLI is based on incubating fresh, viable
`tumor specimens with tritiated thymidine, a pre-
`cursor that incorporates specifically into DNA if
`the cells are synthesizing DNA. This enables the
`identification of S—phase cells through the use of
`autoradiography. The exposure time is 1
`to 2
`weeks, and the TLI is obtained by counting 3,000
`to 10,000 cells from different specimens of the
`same tumor. The constraints imposed by the
`need for fresh tissue, by the delay in obtaining
`results from autoradiography, and by the tedium
`involved in cell counting are the main disadvan-
`tages of the procedure.
`Several independent groups have related TLI
`and the probability of relapse in breast cancer.
`Tubiana et al17 prospectively measured the TLI
`in 128 patients with subsequent follow-up of at
`least 10 years. Patients with low TLI had longer
`
`(DFS) by axillary
`Fig 1. Disease—free survival
`node status. DFS calculated from date of diagnosis
`of primary breast cancer. Number of patients with 0
`positive nodes (N = 3,103); with one to three posi—
`tive nodes (N = 1.414); with three to ten positive
`nodes (N = 835); with 11
`to 20 positive nodes
`(N = 386); with >20 positive nodes
`(N = 170).
`Median follow—up, 40 months.
`
`showed that ER positivity predicts for longer
`DFS and overall survival regardless of the axilw
`lary nodal status (Fig 2).
`Crowe et al10 reported results from a prospec—
`tive, multi-institutional trial in which 510 stage I
`(node—negative) patients were followed after
`mastectomy without adjuvant therapy. With a
`median follow-up of 51 months, patients with
`ER-negative tumors had significantly higher
`recurrence rates and shorter survival. Among
`other factors analyzed, only tumor size was pre-
`dictive for recurrence and survival. Although
`findings did not reach statistical significance,
`premenopausal patients appeared to experience
`recurrence more rapidly than postmenopausal
`patients. Valagussa et
`all4 reported similar
`results based on 464 node-negative patients, with
`median follow-up of 5 years, but statistical sig-
`nificance was found only among premenopausal
`women. These findings led to an adjuvant trial in
`stage I, ER-negative patients, whose preliminary
`results, with median follow-up of 23 months,
`Showed higher recurrence rates and shorter sur-
`vival in the no—treatment arm.15
`
`(PgRs)
`in progesterone receptors
`Interest
`arose at a time when investigators were looking
`for other factors, in addition to ER, to correlate
`
`with response to endocrine therapy. PgR seemed
`ideal, since estrogen stimulates its production in
`normal reproductive tissue and also in human
`breast cancer cell lines. The prognostic impor-
`tance of PgR was demonstrated in a study of
`stage 11 patients receiving adjuvant therapy.16 By
`univariate analyses, the number of positive axil-
`lary nodes, size of the primary tumor, ER, and
`PgR all were significant predictors of DFS.
`However, when analyzed by multivariate meth-
`
`4
`
`

`

`22
`
`DFS probability
`
`
`
`:Negative nodes, ER+
`:Negatlve nodes, EH-
`EPositive nodes. ER+
`- Positive nodes, ER-
`
`Tlme (yr)
`
`CLARK AND MCGUIRE
`
`Fig 2. Disease—free survival (DFS)'by axillary
`node and estrogen receptor
`(ER) status. ER+
`defined as 23 fmol/mg protein. Number of patients
`with negative nodes, ER+ (N = 2,089); with nega—
`tive nodes. ER— (N = 751); with positive nodes,
`ER+ (N = 670); with positive nodes, ER—
`(N = 1,837). Median follow-up, 40 months.
`
`relapse—free and overall survival. A multivariate
`analysis of the prognostic factors showed that
`TLI was a better indicator than the size of the
`
`tumor, number of involved nodes, or histologic
`grading. Similar results were shown by Meyer et
`al,18 who analyzed TLI in 227 patients with
`primary breast cancer. In this study, patients
`with low TLI had a probability of relapse of 20%
`at 4 years, in contrast to 52% for patients with
`high TLI. In addition, there was an association
`between high TLI, younger age, and poor prog-
`nostic histologic features. The probability of
`relapse was significantly related to TLI indepen-
`dent of axillary node status, ER content, or
`menopausal status. These findings confirmed
`those of Gentili and colleagues19 in 127 stage I
`patients. Not only did they show that the proba-
`bility of relapse was higher in patients whose
`tumors had high TLI but also that the prolifera-
`tive rate was different according to menopausal
`status. The premenopausal group had higher
`TLIs than the postmenopausal group, but in each
`group the proliferative rate predicted for higher
`relapse rate.
`A consistent
`
`inverse relationship has been
`
`found between steroid receptors and TLI such
`that tumors with high TLI tend to be receptor
`negative.”23 Of particular interest has been the
`identification of prognostic factors for node—
`negative patients. Silvestrini et a122 analyzed ER,
`tumor size, and TLI in 215 patients with node-
`negative breast cancer and found that TLI was
`the most
`important variable for predicting
`relapse-free and overall survival. Meyer and col—
`leagues23 also studied the relationship between
`ER, PgR, and TLI and reported that PgR was
`the most important factor in predicting relapse in
`a group of 130 stage I patients.
`
`PROLIFERATIVE RATE AND PLOIDY
`BY FLOW CYTOMETRY
`
`a new
`is
`DNA flow cytometry (FCM)
`approach for measuring proliferative rate by
`identifying S-phase cells with the use of DNA—
`specific fluorescent stains. After preparation of a
`single cell suspension from the specimen,
`the
`DNA content of 100,000 cells can be measured
`by FCM in a few minutes, and the fraction of
`cells in S-phase (SPF) can be calculated. An
`important advantage of this technique over TLI
`
`Table 1. Cleveland/San Antonio Update of Stage ll Breast Cancer
`
`Published DFS
`Updated DFS
`Overall Survival
`
`<.0001
`<.OOO1
`No. of positive nodes
`<.0001
`<.OOO1
`<.OOO1
`Logarithm (PgR)
`<.0001
`.30
`.54
`Size of primary tumor
`.11
`.69
`.13
`Logarithm (ER)
`.26
`.77
`.44
`Treatment
`.56
`.27
`.07
`Menopausal status
`.94
`
`NOTES: All patients (N = 189) were clinically stage II, had radical or modified radical mastectomy, and received adjuvant chemotherapy
`+/~ adjuvant hormonal therapy. These are updated multivariate analyses based on median follow—up of 114 months for patients still
`alive.
`Abbreviations: DFS, disease—free survival; PgR, progesterone receptor; ER, estrogen receptor.
`
`5
`
`

`

`PROGNOSTIC FACTORS IN BREAST CANCER
`
`23
`
`is that the analysis can be performed on frozen
`specimens after acetic acid fixation or on fixed
`paraffin-embedded blocks of
`tumor
`tissue.
`McDivitt et alz‘1 demonstrated a good correlation
`between S-phase as determined by TLI and by
`FCM. This finding paved the way to using FCM
`as the method of choice to study tumor kinet-
`ics.”
`
`FCM also offers the advantage of determining
`cell populations with abnormal DNA content
`(aneuploidy). Even though most aneuploid cells
`contain excess DNA, aneuploidy also refers to
`cells that have less than the diploid amount of
`DNA. The DNA index is a quantitative reflec-
`tion of the degree of aneuploidy and can be
`calculated from DNA histograms.
`Using FCM, it has been shown that the major-
`ity of tumors have aneuploid DNA populations.
`Hedley and associates26 analyzed DNA content
`in 165 patients with stage II breast cancer.
`Aneuploid tumors had more extensive axillary
`node involvement, but there was no correlation
`with menopausal or ER status. At a median
`follow-up of 3.5 years, 44% of patients with
`aneuploid tumors v 23% of those with diploid
`tumors had relapsed. Coulson and colleagues27
`divided aneuploid tumors into subgroups and
`showed the best prognosis for patients with
`diploid tumors and a particularly bad outcome
`for those with tumors that were hypodiploid,
`multiploid, or hypertetraploid.
`Moran et a]28 observed that aneuploid tumors
`were more likely to be ER/PgR negative and to
`have a higher SPF. In addition, well-differen-
`tiated tumors were more likely to be diploid and
`to exhibit a lower SPF than poorly differentiated
`tumors. This correlation persisted when patients
`were stratified according to number of involved
`axillary nodes.
`Dressler et al29 confirmed these data in more
`
`than 1,000 patients in whom receptors, prolifera—
`tive rate, and ploidy status were measured in
`frozen breast tumors. Aneuploid tumors exhib—
`ited a higher SPF, with a median of 10.3% v 2.6%
`for diploid tumors. ER/PgR-positive tumors
`were less likely to be aneuploid and had lower
`SPF than receptor-negative patients. Premeno—
`pausal women had higher SPF than postmeno-
`pausal women, although no difference in ploidy
`was seen.
`.
`
`In a retrospective study of 346 node-negative
`
`patients followed for a median of 45 months,
`Dressler et al30 found that patients with diploid
`tumors had longer DFS than patients with aneu—
`ploid tumors. Among patients with diploid
`tumors, SPF provided additional prognostic
`information: Those with low SPF had longer
`DFS than patients with high SPF. However,
`among patients with aneuploid tumors, time to
`relapse was independent of SPF.
`
`ONCOGENE AMPLIFICATION
`
`Altered cellular proto-oncogenes have been
`implicated in the pathogenesis of certain animal
`and human malignant tumors, although the data
`are still mostly indirect. Data from animal mod-
`els and cell
`lines include sequence homology
`between human proto-oncogenes and viral onco—
`genes of transforming viruses that are tumori-
`genic in some species, and transfection studies
`showing the transforming potential of proto-
`oncogenes in NIH 3T3 cells and primary embryo
`fibroblasts. Data from human tumors include
`
`increased amplification and/or expression of
`proto—oncogenes in some human tumors and
`localization of proto—oncogenes at or near the site
`of specific tumor—associated chromosomal trans-
`locations.”33 There is a belief that oncogenes
`code for proteins associated with cellular growth
`and differentiation. In fact, three of the known
`cellular oncogenes encode molecules related to
`cellular growth factors or their receptors.
`Several studies have found increased gene
`amplification and/ or expression or gene deletion
`in breast cancer. Specifically, c-myc, c-erb-B-2,
`or int-2 is amplified in 16% to 32% of breast
`cancer.”36 Theillet and colleagues37 found
`increased expression of Ha-ras-l
`in 16 of 22
`tumors. In addition, 27% had an allelic fragment
`loss, which was associated with high histologic
`grade, ER negativity, and the presence of metas-
`tasis.
`
`a138 examined the HER—2/neu
`Slamon et
`oncogene and breast cancer. This oncogene is a
`member of the erb—B-like oncogene family,
`is
`related to the epidermal growth factor receptor,
`and codes for a protein with a cellular receptor
`function. This oncogene was amplified several-
`fold in 30% of primary breast tumors. Amplifica-
`tion of HER-Z/neu was a significant predictor of
`time to relapse and overall survival in 86 patients
`with stage II breast cancer. When adjustments
`
`6
`
`

`

`24
`
`CLARK AND MCGUIRE
`
`were made for other known prognostic factors by
`multivariate analysis, HER—Z/neu amplification
`retained its prognostic significance. These results
`suggest a role for this oncogene in the biology
`and / or pathogenesis of breast cancer.
`
`CONCLUSIONS
`
`Breast cancer remains a significant health
`problem worldwide and a challenge to oncolo-
`gists. Aside from the cost
`in terms of human
`lives, it causes an immense amount of suffering
`and despair in women. There have been efforts
`by the medical community to facilitate early
`diagnosis and improve therapy. Even though
`adjuvant therapy is accepted as standard care in
`primary breast cancer, neither the particular
`therapeutic modalities involved nor the specific
`subset of women to whom adjuvant
`therapy
`should be directed is well defined. Prognostic
`factors can enable physicians to identify those
`breast cancer patients at higher risk of recur—
`rence who could benefit from additional therapy
`and also can provide stratification factors to
`evaluate such therapy in clinical trials.
`We have identified several
`independent but
`
`interrelated factors that predict for relapse and
`survival
`in breast cancer. This information is
`obtained readily at the time the tumor is resected
`and the axillary nodes dissected. The specimen
`initially is evaluated for its histologic diagnosis,
`subclassification, and grading, and the axillary
`nodal status is determined. At the same time,
`part of the tumor sample is sent for hormone
`receptors (ER, PgR), and its proliferative rate
`and degree of aneuploidy are analyzed by flow
`cytometry. All of this information is available
`within a short period of time so that the clinician
`and the patient may plan appropriate therapy
`according to the patient’s overall prognosis. Still,
`the picture is not totally clear, since the relative
`contribution of the different prognostic factors
`must be defined for the individual patient.
`Finally,
`the roles of oncogenes and growth
`factors in the pathogenesis of breast cancer are
`beginning to be elucidated. It
`is particularly
`encouraging that some oncogenes are signifi—
`cantly correlated with recurrence and survival in
`breast cancer, since this provides an important
`link between the molecular level and the clinical
`
`biologic behavior of the tumor.
`
`REFERENCES
`
`1. Fisher B, Ravdin RG, Ausman RK, et al: Surgical
`adjuvant chemotherapy in cancer of the breast: Results of a
`decade of cooperative investigation. Ann Surg 168:337-356,
`1968
`2. Harris JR, Hellman S, Canellos GP, et al: Cancer:
`Principles and practice of oncology, in DeVita VT Jr, Hell-
`man S, Rosenberg SA (eds): Cancer of the Breast, ed 2.
`Philadelphia, Lippincott, 1985, p 1125
`3. Fisher B, Bauer M, Wickerham DL, et al: Relation of
`number of positive axillary nodes to the prognosis of patients
`with primary breast cancer. Cancer 542:1551-1557, 1983
`4. Oxley DK: Hormone receptors in breast cancer: Ana-
`lytical accuracy of contemporary assays. Arch Pathol Lab
`Med 108:20-23, 1984
`5. Knight WA 111, Livingston RB, Gregory EJ, et al:
`Estrogen receptor as an independent prognostic factor for
`early recurrence in breast cancer. Cancer Res 37:4669-4671,
`1977
`
`6. Maynard PV, Blarney RW, Elston CW, et al: Estrogen
`receptor assay in primary breast cancer and early recurrence
`of the disease. Cancer Res 38:4292-4295, 1978
`7. Pinchon MF, Pallud M, Brunet M, et al: Relationship
`of presence of progesterone receptors to prognosis in early
`breast cancer. Cancer Res 40:3357-3360, 1980
`8. Cooke T, George WD, Grifliths K: Possible tests for
`selection of adjuvant systemic therapy in early cancer of the
`breast. Br J Surg 67:747-750, 1980
`9. Godolphin W, Elwood JM, Spinelli JJ: Estrogen recep-
`tor quantification and staging as complementary prognostic
`
`indicators in breast cancer: A study of 583 patients. Eur J
`Cancer Clin Onc01282677-683, 1981
`10. Crowe JP, Hubay CA, Pearson OH, et al: Estrogen
`receptor status as a prognostic indicator for stage I breast
`cancer patients. Breast Cancer Res Treat 2:171-176, 1982
`11. Mason BH, Holdaway IM, Mullins PR, et al: Proges-
`terone and estrogen receptors as prognostic variables in
`breast cancer. Cancer Res 43:2985-2990, 1983
`12. Hilf R, Feldstein ML, Gibson SL, et al: The relative
`importance of estrogen receptor analysis as a prognostic
`factor for recurrence or response to chemotherapy in women
`with breast cancer. Cancer 45:1993-2000, 1980
`13. Howat JM, Harris M, Swindell R, et al: The etTect of
`oestrogen and progesterone receptors on recurrence and
`survival in patients with carcinoma of the breast. Br J Cancer
`51:263-270, 1985
`14. Valagussa P, Bignami P, Buzzoni R, et al: Are
`estrogen receptors (ER) alone a reliable prognostic factor in
`node negative (N-) breast cancer? Proc Am Soc Clin Oncol
`3:130, 1984 (abstr)
`'
`15. Bonadonna G, Zambetti M, Valagussa P, et a1: Adju-
`vant CMF in node negative breast cancer. Proc Am Soc Clin
`Oncol 5:74, 1986 (abstr)
`16. Clark GM, McGuire WL, Hubay CA, et al: Proges-
`terone receptors as a prognostic factor in stage 11 breast
`cancer. N Engl J Med 309:1343—1347, 1983
`17. Tubiana M, Pejovic MH, Chavaudra N, et al: The
`long-term prognostic significance of the thymidine labelling
`index in breast cancer. Int J Cancer 33:441-445, 1984
`
`7
`
`

`

`PHOGNOSTE FACTORSIN BREAST CANCER
`
`25
`
`18. Meyer JS, Friedman E, McCrate MM, et al: Predic-
`tion of early course of breast carcinoma by thymidine label-
`ing. Cancer 51:1879-1886, 1983
`19. Gentili C, Sanfilippo O, Silvestrini R: Cell prolifera-
`tion and its relationship to clinical features and relapse in
`breast cancers. Cancer 38:974-979, 1981
`20. Meyer .18, Rao BR, Stevens SC, et al: Low incidence
`of estrogen receptor in breast carcinomas with rapid rates of
`cellular replication. Cancer 40:2290-2298, 1977
`21. Bertuzzi A, Daidone MG, Di Fronzo G, et al: Rela-
`tionship among estrogen receptors, proliferative activity and
`menopausal status in breast cancer. Breast Cancer Res Treat
`1:253-262, 1981
`22. Silvestrini R, Daidone MG, Di Fronzo G, et al:
`Prognostic implication of labelling index versus estrogen
`receptors and tumor size in node-negative breast cancer.
`Breast Cancer Res Treat 7:161—169, 1986
`23. Meyer JS, McDivitt RW, Stone KR, et a1: Practical
`breast carcinoma cell kinetics: Review and update. Breast
`Cancer Res Treat 4279-88, 1984
`
`24. McDivitt RW, Stone KR, Craig RB, et al: A compari—
`son of human breast cancer cell kinetics measured by flow
`cytometry and thymidine labeling. Lab Invest 52:287, 1985
`25. McGuire WL, Dressler LG: Emerging impact of flow
`cytometry in predicting recurrence and survival in breast
`cancer patients. J Natl Cancer Inst 75:405-410, 1985
`26. Hedley DW, Rugg CA, Taylor
`IW:
`Influence of
`cellular DNA content on disease-free survival of stage 11
`breast cancer patients. Cancer Res 44:5395-5398, 1984
`27. Coulson PB, Thornthwaite JT, Wooley TW: Prognos—
`tic indicators including DNA histogram type, receptor con-
`tent, and staging related to human breast cancer survival.
`Cancer Res 44:4187-4196, 1984
`
`28. Moran RE, Black MM, Alpert L, et al: Correlation of
`cell cycle kinetics, hormone receptors, histopathology, and
`nodal status in human breast cancer. Cancer 54:1586-1590,
`1984
`
`29. Dressler LG, Seamer LG, Owens MA, et al: DNA
`flow cytometry and prognostic factors in 1331 frozen breast
`cancer specimens. Cancer 61:420-427, 1988
`30. Dressler L, Clark G, Owens M, et al: DNA flow
`cytometry predicts for relapse in node negative breast cancer
`patients. Proc Am Soc Clin Oncol 6:57, 1987 (abstr)
`31. Slamon DJ, de Kermion JB, Verma IM, et al: Expres—
`sion of cellular oncogenes in human malignancies. Science
`224:256-262, 1984
`32. Duesberg PH: Activated proto-oncogenes: Sufficient
`or necessary for cancer? Science 228:669-677, 1985
`33. Verma RS: Oncogenetics, a new emerging field of
`cancer. M01 Gen Genet 205:385-389, 1986
`34. Hynes NE, Kozma S, Redmond S, et al: Oncogenes
`and human breast cancer. Proc Int Assoc Breast Cancer Res
`A-O4, 1987
`35. Ali IU, Lidereau R, Theillet C, et a1: Reduction to
`homozygosity of genes on chromosome II in human breast
`neoplasia. Science 238:185—188, 1987
`36. Kouyoumdjian JC, Feuilhade F, Dupre G, et al:
`Multiple oncogenes transcription in normal, benign and
`malignant human breast tissue. Proc Int Assoc Breast Cancer
`Res E—04, 1987
`37. Theillet C, Lidereau R, Escott C, et al: Loss of a
`c-H-ras-l allele and aggressive human primary breast carci-
`nomas. Cancer Res 46:4776-4781, 1986
`38. Slamon D], Clark GM, Wong SG, et al: Human
`breast cancer: Correlation of relapse and survival with ampli-
`fication of the HER—2/neu oncogene. Science 235:177-182,
`1987
`
`8
`
`