PERRY: BREAST TUMOUR SEX CHROMATIN 73 1

below 150mg., but the safety of operation was difficult to ensure below 800-1000 mg. Marchetta, Krause, and Sako (1963) noted that after ‘total’thyroid- ectomy for carcinoma the postoperative scintigram after a few months showed a radioactive iodine uptake of 20-25 per cent.

Thus neither knowledge of the technique used by different authors, nor remnant size, nor operative histo- logy, contains the whole secret of the development of hypothyroidism. I n our series it only occurred in the toxic gland and in other series only significantly in the toxic gland.

Some other factor in addition, found for practical purposes only in the toxic group, must be necessary to produce this liability to myxoedema. Such a factor might be the continuation of the auto-immune process which caused the disease. While LATS is one of the few immunoglobulins to stimulate cells it might well later destroy or exhaust the gland. I t appears to cause the type of thyrotoxicosis associated with focal thyroiditis (Mason, 1967) and with a tendency towards under-function without antibody formation-Category I of Hargreaves and Garner (1968). Anderson (1964) thought that this picture was in part due to a delayed hypersensitivity process. A genetic component in its aetiology is indicated by the high incidence of myxoedema and Hashimoto’s disease in the relatives of those suffering from thyrotoxicosis. Spontaneous myxoedema can also develop.

There are thus many factors, other than operation, capable of producing hypothyroidism after operation. I t is probable that if the remnant is above 8 C.C. hypo- thyroidism is not due to the operation per se and should not be labelled postoperative, as it is due to the nature of the disease or other iatrogenic interven- tion. Indeed, thyroidectomy can not only control thyrotoxicosis but even alter and improve the toxic histological appearances of the gland remnant, especi- ally after the first year (Curran, Eckhert, and Wilson, 1958).

Recovery from any transient hypothyroidism fol- lowing operation is generally thought to have taken place within 6 months. Therefore, whatever the individual cause in these high probability cases

outlined above, the tendency towards under-function should be assessed by postoperative scan outline and 1311 uptake measurements after I and 6 months. If both are down or the I3lI uptake is markedly down thyroxine should be given to anticipate the appear- ance of myxoedema.

Neither a single postoperative I3lI uptake nor an assessment of the percentage uptake per C.C. of resi- dual tissue gave any worth-while guide to subsequent thyroid status. However, a weight-gain of 6.35 kg. above that lost in the preoperative toxic phase in the presence of careful dietary habits might be con- sidered a useful clinical hint of incipient hypo- thyroidism.

Acknowledgements.-We should like to thank in particular Mr. C. W. Mullet, physicist, the Royal Hospital, for his helpful advice; Miss P. A. Carring- ton, of the Radioactive Isotope Department, for her meticulous care and interest with the scans and uptake measurements; and Mr. R. Paton, of the Photographic Department, for the illustrations.

REFERENCES ANDERSON, J. R. (1964), in Recent Advances in Clinical

Pathology (ed. DYKE, S . C.), p. 345. London: Churchill. ARTACAVEYTIA, D., DE GROSSI, O., GOTTA, H., and

PECORINI, V. (1965), Rev. din. esp., 98, 266. CURRAN, R. C., ECKHERT, H., and WILSON, G. M. (1999,

J . Path. Bact., 06, 541. GREEN, R. (195o),J. Endocr., 7 , I. HARGREAVES, A. W., and GARNER, A. (1968), Br. 3. Surg.,

MARCHETTA, F. C., KRAUSE, L., and SAKO, K. (1963),

MASON, A. S. (1967), J . clin. Path., 20, 379. MURLEY, R. S., and RIGG, B. M. (1968), Br. J. Surg., 55,

SZILAGYI, D. E., BARRETT, J. L., and PREUSE, L. E.

TAYLOR, G. W., and PAINTER, N. S. (1962), Lancet, I,

TAYLOR, S . (1966), Recent Advances in Surgery, 6th ed.,

THOMSON, J. A. (1966), Lancet, 2, 308. WIENER, J. D., and ROOS, P. (1968), Br. wed. J., 2, 312.

55, 543.

Surgery Gynec. Obstet., 116, 647.

757,

(1955)~ J. clin. Endocr. Metab. 15, 1409.

287.

p. 395. London: Churchill.

EVALUATION OF BREAST TUMOUR SEX CHROMATI” (BARR BODY) AS AN INDEX OF SURVIVAL AND

RESPONSE TO PITUITARY ABLATION BY MICHAEL PERRY*

DEPARTMENT OF SURGERY, ROYAL POSTGRADUATE MEDICAL SCHOOL, LONDON

SUMMARY I n a retrospective study of 36 patients with advanced

breast cancer relationships were found between the tumour Barr body count and the response to pituitary ablation and the length of survival. High tumour Barr body counts were associated with long survival after treatment, and low counts with short survival

* Present address : Surgical Professorial Unit, St. Bar- tholomew’s Hospital, London, E.C.I.

(Pio.001). High counts were also associated with a good response to pituitary ablation, and low counts with a poor response (P<o.or). The tumour Barr body count gave possibly better prediction than urinary steroid measurement.

A BARR body is defined (Fig. I) as a female cellular sex chromatin marker, I p in diameter and located against the inner surface of the nuclear membrane

732 BRIT. J. SURG., 1972, Vol. 59, No. 9, SEPTEMBER

envelope (Barr and Bertram, 1949). Any living chromatin counts and in older women with low nucleated cell may be used in the examination for counts. These results do not confirm the hypothesis sex chromatin, but in practice cells with clear nuclei that the sex chromatin complement of the tumour obtained from easily accessible sites are used. indicates oestrogen dependence. No comparison has

Barr bodies may be identified in about 50 per cent been published of the value of the tumour Barr of normal female cells. This is also the case for most body with that of the urinary steroid estima- tumours, in that the tumour Barr body count is tion in predicting survival or response to treat-

ment.

PATIENTS AND METHODS Thirty-six mammary cancers were studied, selected

at random from routine surgical slides stained with haematoxylin and eosin. Most of the sections were taken from drill biopsy specimens and thus were unsuitable for accurate interpretation of tissue

70

60

50 - * - F- 40 z 3 0

2- 0

0 m

7 x

CL < m

ti 30

20

-

-

-

-

-

-

lo t:.

. . (36 1

.L

..I

....

FIG. I.-TWO cells with Barr bodies demonstrated (arrowed) in mammary cancer. ( x goo.)

equivalent to the normal count for that patient (Sohval and Gaines, 1955; Tavares, 1955). However, Kimel (1957) found that breast cancer was an exception to this rule. He studied IOO cells in a tumour and counted the number containing Barr bodies. In his study of 91 mammary cancers Kimel found that 66 per cent of the tumours had counts of less than 40 and that 53 per cent had counts of less than 30. In normal tissues, however, the lowest sex chromatin count observed was 40. Only 34 per cent of the tumours studied had counts in the normal range of 40 or more.

Bohle, Burger, Fischbach, and Schooli-Tubingen (1965) summarized 10 reports from the German literature on studies of sex chromatin in cases of breast cancer. They concluded that low tumour sex chromatin counts were associated with lowered re- sponsiveness to hormones and that these tumours were more malignant than those with high counts. Shirley (1967) confirmed these findings. In a retro- spective study from the Massachusetts General Hos- pital he found that hormonal therapy was most likely to be successful in patients with normal sex chromatin in their tumours. In addition he found that the response to hormonal therapy was extremely poor in women under the age of 50 years with high sex

" 4 8 12 16 20 24 28 >30

S U R V I V 4 L i M O N T H S !

FIG. 2.-Relationship of mammary cancer Barr body count to survival time of patient.

differentiation. Approximately IOO cells were counted on each slide and the number of cells containing Barr bodies was expressed as a percentage of the total number of cells counted. Slides were only included in the study if the sections were evenly stained and the cells clearly defined.

Twenty-six of the patients had their urinary steroids measured. The ratio of the 17-oxogenic steroids to the combined excretion of androsterone and aetio- cholone ( I I-deoxy-17-oxosteroids) has been found to be a good index of response to endocrine therapy (Fotherby, Sellwood, and Burn, 1970). A value of 9 for the ratio provided a fair degree of discrimination between those who responded and those who did not, the proportion of responders being three times greater in those with a low ratio than in those with a high one.

RESULTS Relationship of Mammary Cancer Barr Body

Count to Survival Time of Patient.-In Fig. 2 there appear to be two populations: one with low counts and a short survival, and the other with high counts and a longer survival. Many of the patients shown as having survived more than 30 months are, in fact, still alive. All the patients in Fig. 2 and

PERRY: BREAST TUMOUR SEX CHROMATIN 73 3

subsequent figures had advanced disease and were treated by endocrine therapy.

Comparison of Barr Body Count and Steroid Ratio in Relation to Response to Pituitary Ablation (Fig. 3).-The high tumour Barr body count was associated with a good response to pituitary ablation whereas the low count was not (P(o.01).

Similarly, patients with low steroid ratios were found to respond to pituitary ablation significantly better than patients with higher ones (P<0.05).

Comparison of Barr Body Count and Steroid Ratio in Relation to Survival Time (Fig. 4).- Patients who survived up to 12 months after treat- ment have been compared with those who survived

e I- z 3 0 0

>- n 0 m

(22. lx -=c m

s;2 I- z 3 0 V > 0 m (22. lx

M

n

a

BARR B-ODY ~~~ COUNT p < 0.01

loo[ 80

. .... 0. 6ol t-43

20 t w 0.b ....

0 No n

Responders Responders

60

45 0

I- -

s 30 n

0 - 5 15

STEROID R A T I O

p < 0.05

.

. .

H . . . 2

Non Responders Responders

FIG. 3.-Comparison of Barr body count and steroid ratio in relation to response to pituitary ablation.

BARR BODY COUNT -___.

p < 0.001

loo[ 80

6ot . 4oc

. . ...... H .... . .

...... 0

1 - 1 2 > 30

60

45 0

+ - a CL 30 n

0 -

15 $ 9

0

STEROID RATIO

~ ( 0 . 0 4

.

.

.

. . .

1-12 > 30

S U R V I V A L T I M E ( M o n t h s ) FIG. 4.-Comparison of Barr body count and steroid ratio in relation to survival time.

734 BRIT. J. SURG., 1972, Vol. 59, No. 9, SEPTEMBER

w

2 40

more than 30 months in respect of the Barr body count and of the steroid ratio. The mean Barr body count was higher (Pco.001) and the mean ratio lower (P<0.04) in those who survived the longer time.

Relationship between Barr Body Count and Steroid Ratio in Patients who underwent Pituitary Ablation.-Twenty-two of the patients who underwent pituitary ablation had both the tumour Barr body count and the urinary steroid ratio

RESPONSE TO PITUITARY ABLATI0N:BARR BODY COUNllSTEROlO RATIO

0 Responders 1131 . Non Responderrl91

I

I I I I I I

10 20 30 40 50

S T E R O I D R A T I O

FIG. s.-Relationship between Barr body count and steroid ratio in patients who underwent pituitary ablation.

Table I.-RELATION OF BARR BODY COUNT AND STEROID RATIO TO RESPONSE TO PITUITARY ABLATION (see also Fig. 5 )

Steroid ratio alone

Barr body count alone

Steroid ratio and Barr

< 9 > 9

> 40 < 40

body count <9 and ;'40 > 9 and <40

RATIO OF RESPONDERS TO

NON-RESPONDERS

11 : 14 2 : 8

9 : I 2 4 : I 0

8 : 9 I : 5

PERCENTAGE

79 25

75 40

89 20

measured. Simple inspection of the data suggested that a level of 40 per cent for the Barr body count (like that of 9 for the steroid ratio) provided a fairly good discrimination between those who responded and those who did not. The relative values of these two factors in relation to response are shown in Fig. 5 and Table I . Although the numbers are small, the data suggest that the steroid ratio and the Barr body count together may provide a better prognostic index of the response to therapy than either alone.

DISCUSSION This study suggests that the simple method of

counting the numbers of cells containing Barr bodies in the mammary cancer is significantly related to both the length of survival of the patient and her

response to pituitary ablation and that it may there- fore be of prognostic value.

The tumour Barr body count has been criticized on the grounds that it is merely a reflection of the degree of differentiation of the tumour, normal counts being associated with well-differentiated turnouts and low ones with poorly differentiated tumours. In the present study the pathologist was able to assess the degree of differentiation in only 14 of the 36 patients. All 14 patients had advanced disease of the breast and were not treated by mastectomy, the tumour material being taken by drill biopsy. How- ever, it is interesting to note that in 9 out of the 14 specimens the count correlated well with the degree of differentiation of the tumour but that in 5 it did not. Conclusions cannot be drawn from such small numbers.

There is disagreement in the literature about the relationship of the tumour Barr body count and the degree of dissemination of the cancer. Kimel (1957) presented evidence that turnours with high counts were more likely to metastasize than those with low counts, whereas Bohle and others (1965) found that lower counts were associated with a shorter survival time-a finding in agreement with our results.

The comparison of the tumour Barr body count with the urinary steroid ratio is an interesting one. Both estimations agree with regard to prediction of survival and the response to pituitary ablation, but it may be that the tumour Barr body count provides better discrimination. When the two estimations are compared in Figs. 3 and 4 with respect to response to treatment and survival, the Barr body count shows a greater difference between the means and a higher level of statistical significance in both groups.

A good correlation might be expected between the tumour Barr body count and the urinary steroid ratio in view of their similar predictions concerning re- sponse to pituitary ablation and to survival of the patient. However, this is not the case (Fig. 5). It may be, as suggested already, that the two estimations together provide a better discriminant than either alone, but the attraction of the Barr body count is that it is simple and can be used in any hospital.

Acknowledgements.-I am indebted to Mr. J. Ian Burn and Professor R. B. Welbourn for permis- sion to study patients under their care and for their help in the preparation of this paper. I am grateful to Mr. Cedric Richmond for technical help and to Miss Diane Lippiatt for secretarial assistance.

REFERENCES BARR, M. L., and BERTRAM, E. C. (1949), Nature, Lond.,

BOHLE, A., BURGER, E., FISCHBACH, H., and SCHOOLI-

FOTHERBY. K. A.. SELLWOOD, R. A.. and BURN, 1. I.

163, 676.

TUBINGEN, A. (1965), Arch. klin. Chir., 313, 392. . _ ~ ~ ~~~

(1970), Br. J . shrg., 57, 859. KIMEL, V. M. (1957), Cancer, Phil., 10, 922. SHIRLEY, R. L. (1967)~ Surgery Gynec. Obstet., 125, 737. SOHVAL, A. R., and GAINES, J . A, (I955), Cancer, Phil., 8,

TAVARES, A. S. (1955), Lancet, I , 948. 896.