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General Methods and Overviews,
Lung Carcinoma and Prostate Carcinoma
Methods of Cancer Diagnosis, Therapy, and Prognosis

Volume 2

For other titles published in this series, go to

www.springer.com/series/8172
Methods of Cancer Diagnosis,
Therapy, and Prognosis

Volume 2

General Methods and Overviews,

Lung Carcinoma and Prostate
Carcinoma
Edited by

M.A. Hayat
Department of Biological Sciences,
Kean University, Union, NJ, USA
Editor
M.A. Hayat
Department of Biological Sciences
Kean University
Union, NJ
USA

ISBN 978-1-4020-8441-6 e-ISBN 978-1-4020-8442-3

Library of Congress Control Number: 2008930172

© 2008 Springer Science + Business Media B.V.

No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic,
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New technology, for better or for worse, will be used, as that is our nature.
Lewis Thomas

You have been given the key that opens the gates of heaven; the same key opens the
gates of hell.
Writing at the entrance to a Buddhist temple
Authors and Co-Authors of Volume 2

Naglaa F. Abbas Florence Arnold

Medical Division, National Research Saskatoon Cancer Center, University
Center, Al-Tahrir Street, Dokki Giza, of Saskatchewan, 20 Campus Drive,
Egypt University of Saskatchewan, Saskatoon,
SK, Canada S7N 4H4
Imran Ahmad
Saskatoon Cancer Center, University Armando Bartolazzi
of Saskatchewan, 20 Campus Drive, Department of Oncology-Pathology,
University of Saskatchewan, Cellular and Molecular Pathology,
Saskatoon, SK, Canada S7N 4H4 Cancer Center Karolinska, CCK R8:04
E-mail: [email protected] Karolinska Hospital, 17176
Stockholm, Sweden
Shahid Ahmed E-mail: [email protected]
Saskatoon Cancer Center, University
of Saskatchewan, 20 Campus Drive, Susana Benlloch
University of Saskatchewan, Research Unit, Alicante University
Saskatoon, SK, Canada S7N 4H4 General Hospital, Avda Pintor Baeza
12, Alicante 03010, Spain
Annette Altmann E-mail: [email protected]
Clinical Cooperation Unit Nuclear
Medicine, German Cancer Research Heinrich Bulzebruck
Center, Im Neuenheimer Feld 280, IT-Abteilung der Thoraxklinik am
FRG-69120 Heidelberg, Germany Universitatsklinikum, Heidelburg,
E-mail: [email protected] Amalienstrasse 5, D-69126
Heidelberg, Germany
Samuel G. Armato III
Department of Radiology- MC 2026, Loren E. Clarke
The University of Chicago, 5841 Penn State Milton S. Hershey Medical
S. Maryland Ave., Chicago, IL 60637 Center-M.C. H179, P. O. Box 850, 500
E-mail: [email protected] University Drive, Hershey, PA 17033

vii
viii Authors and Co-Authors of Volume 2

Philip Clewer Henndrik Dienemann

Medical Physics and Bioengineering, Chirurgische Abteilung der Thoraxklinik
Southampton General Hospital, Tremona am Universitatsklinikum, Heidelburg,
Road Southampton, SO16 6YD, Amalienstrasse 5, D-69126 Heidelberg,
United Kingdom Germany
E-mail: [email protected]
David Dingli
Gaetano Compagnone Harvard University, Program for
Department of Medical Physics, Evolutionary Dynamics, One Brattle Sq.
S. Orsola-Malpighi Hospital, Azienda Suite 6, Cambridge, MA 02138
Ospedaliero-Universitaria di Bologna, E-mail: [email protected]
Via Massarenti, 9 40138 Bologna, Italy
E-mail: [email protected]. Vikram S. Dogra
unibo.it University of Rochester, School of
Medicine, Department of Imaging
Leslie C. Costello Sciences, 601 Elmwood Avenue,
Department of Biomedical Sciences, Box 648, Rochester, NY 14642
Dental School and the Greenbaum E-mail: vikram_dogra@urmc.
Cancer Center, University of Maryland, rochester.edu
650 West Baltimore, MD 21201
E-mail: [email protected] Nadia G. EL-Hefnawy
Pathology Department, Faculty of
Juanita Crook Medicine, Ain-Shams University,
University of Toronto/Princess Margaret Cairo, Egypt
Hospital, 610 University Avenue,
Toronto M5G 2M9 Sonia L. El-Sharkawy
E-mail: [email protected] Medical Division, National Research
Center, Al-Tahrir Street, Dokki Giza,
Gabriel D. Dakubo Egypt
Genesis Genomics, Inc., 290 Munro E-mail: [email protected]
Street, Ste. 1000, Thunder Bay,
ON P7A 7T1, Canada Renty B. Franklin
E-mail: Gabriel.dakubo Department of Biomedical Sciences,
@genesisgenomics.com Dental School and the Greenbaum
Cancer Center, University of
Marco Das Maryland, 650 West Baltimore,
Hochschule Aachen University, MD 21201
Rheinisch-Westfalische Technische,
Department of Diagnostic Radiology, José Marcelo Galbis-Caravajal
Pauwelsstrasse 30, Aachen 52074, Medical Oncology, Alicante University
Germany General Hospital, Avda Pintor Baeza
E-mail: [email protected] 12, Alicante 03010, Spain
Authors and Co-Authors of Volume 2 ix

Christian Görg Kristie Harding

Department of Internal Medicine, Saskatoon Cancer Center, University
Philipps-University Marburg, of Saskatchewan, 20 Campus Drive,
Baldingerstraße, D-35033 Marburg, University of Saskatchewan, Saskatoon,
Germany SK, Canada S7N 4H4
E-mail: Christian.Goerg@med.
uni-marburg.de M.A. Hayat
Kean University, 1000 Morris Avenue,
Peter Grandics Union, NJ 07083
A-D Research Foundation, 5922 E-mail: [email protected]
Farnsworth Ct., Carlsbad,
CA 92008 Rui Henrique
E-mail: [email protected] Department of Pathology, Portugese
Oncology Institute – Porto, Rua
Cesare Gridelli Dr. Antonio, Bernardino de Almeida,
Division of Medical Oncology, 4200-072 Porto, Portugal
S.G. Moscati Hospital, Contreds
Amorette, 83100 Avellino, Kenzo Hiroshima
Italy Kenzo Hiroshima, Department of
E-mail: [email protected] Diagnostic Pathology, Graduate
School of Medicine, Chiba University,
Olli H.J. Grohn 1-8-1 Inohana, Chuo-ku, Chiba 260-8670,
Department of Biochemistry, Japan
University of Cambridge, Old E-mail: [email protected]
Addenbrookes Site, 80 Tennis Court
Road, CB2 1GA Cambridge, Angelique Holland
United Kingdom Department of Internal Medicine,
Philipps-University Marburg,
S.J. Gwyther Baldingerstraße, D-35033 Marburg,
East Surrey Healthcare NHS Trust, Germany
Redhill, Canda Avenue, Surrey,
United Kingdom John P. Jakupciak
E-mail: [email protected] National Institute of Standards and
Technology, Biochemical Science
Uwe Haberkorn Division, Gaithersburg, MD 20899
Clinical Cooperation Unit Nuclear
Medicine,German Cancer Research Samer Kalakish
Center, Im Neuenheimer Feld 280, Comprehensive Cancer Center, Wake
FRG-69120 Heidelberg, Germany Forest University, School of Medicine,
Winston Salem, NC 27157
Kamal Haider E-mail: [email protected]
Saskatoon Cancer Center, University
of Saskatchewan, 20 Campus Drive,
University of Saskatchewan, Saskatoon,
SK, Canada S7N 4H4
x Authors and Co-Authors of Volume 2

Mikko I. Kettunen Bartomeu Massutí

Department of Biochemistry, University Thoracic Surgery, Hospital de La Ribera,
of Cambridge, Old Addenbrookes Alzira, Valencia, Spain
Site, 80 Tennis Court Road, CB2 1GA
Cambridge, United Kingdom Luca Moscetti
E-mail: [email protected] Medical Oncology Department,
Centreal Hospital of Outcome, Research
Katsuyuki Kiura Network for Evaluation of Treatment,
Department of Respiratory Medicine, Results in Oncology, Belcolle-ASL di
Okayama University Hospital, Graduate Viterbo, Strada Sammartinese snc,
School of Medicine, Okayama 01100 Viterbo, Italy
700-8558, Japan E-mail: [email protected]
Shan Lu Fabrizio Nelli
Department of Pathology, University of Medical Oncology Department,
Cincinnati, College of Medicine, 231 Centreal Hospital of Outcome, Research
Albert Sabin Way, Cincinnati, Network for Evaluation of Treatment,
OH 45267 Results in Oncology, Belcolle-ASL di
E-mail: [email protected] Viterbo, Strada Sammartinese
snc, 01100 Viterbo, Italy
Charles M. Ludgate
Radiation Oncology Program, Brad H. Nelson
BC Cancer Agency - Vancouver Island Trev and Joyce Deeley Research Centre,
Centre, 2410 Lee Ave., Victoria, BC Cancer Agency – Vancouver Island
BC, Canada, V8R 6V5 Centre, 2410 Lee Ave., Victoria, BC,
Canada, V8R 6V5
Edmond S.K. Ma E-mail: [email protected]
Division of Molecular Pathology,
Department of Pathology and Cancer Nancy J. Nesslinger
Genetics Center, Hong Kong Sanatorium Trev and Joyce Deeley Research Centre,
and Hospital, 2 Village Road, Happy BC Cancer Agency – Vancouver Island
Valley, Hong Kong Centre, 2410 Lee Ave., Victoria, BC,
E-mail: [email protected] Canada, V8R 6V5
Paolo Maione Hiroaki Nomori
Division of Medical Oncology, Department of Thoracic Surgery,
S.G. Moscati Hospital, Contreds Graduate School of Medicine,
Amorette, 83100 Avellino, Italy Kumamoto University, 1-1-1 Honjo,
Kumamoto 860-8556,
Stephen Man Japan
Department of Medical Biochemistry E-mail: [email protected]
and Immunology, Health Park, Cardiff,
CF14 4XN, School of Medicine,
Cardiff University, U.K
Authors and Co-Authors of Volume 2 xi

Jorge M. Pacheco Franclim R. Ribeiro

Harvard University, Program for Department of Genetics, Portuguese
Evolutionary Dynamics, One Brattle Sq., Oncology Institute - Porto, Portugal Rua
Suite 6, Cambridge, MA 02138 Dr. Antonio Bernardino de Almeida,
Porto, 4200-072, Portugal
Howard H. Pai E-mail: [email protected]
Radiation Oncology Program, BC
Cancer Agency - Vancouver Island Amer Sami
Centre, 2410 Lee Ave., Victoria, Saskatoon Cancer Center, University
BC, Canada, V8R 6V5 of Saskatchewan, 20 Campus Drive,
University of Saskatchewan, Saskatoon,
Klaus Pantel SK, Canada S7N 4H4
Institute of Tumor Biology, University
Medical Center, Hamburg-Eppendorf, Heidi Schwarzenbach
Martinistrasse 52, D-20246 Hamburg, Institute of Tumor Biology, University
Germany Medical Center, Hamburg-Eppendorf,
E-mail: [email protected] Martinistrasse 52, D-20246 Hamburg,
Germany
Ryan L. Parr
Genesis Genomics, Inc., 290 Munro Yoshihiko Segawa
Street, Ste. 1000, Thunder Bay, Department of Medicine and
ON P7A 7T1, Canada Thoracic Oncology, National Hospital
Organization, Shikoku Cancer Center,
Joachim Pfannschmidt 160 Kou-Minami-Umemoto-cho,
Chirurgische Abteilung der Thoraxklinik Matsuyama, Ehime 791-0288, Japan
am Universitatsklinikum, Heidelburg, E-mail: [email protected]
Amalienstrasse 5, D-69126 Heidelberg,
Germany William F. Sensakovic
E-mail: joachim.pfannschmidt Department of Radiology- MC 2026,
@thoraxklinik-heidelberg.de The University of Chicago, 5841
S. Maryland Ave., Chicago, IL 60637
David Popkin
Saskatoon Cancer Center, University Rabia K. Shahid
of Saskatchewan, 20 Campus Drive, Saskatoon Cancer Center, University
University of Saskatchewan, Saskatoon, of Saskatchewan, 20 Campus Drive,
SK, Canada S7N 4H4 University of Saskatchewan, Saskatoon,
SK, Canada S7N 4H4
Garth Powis
Department of Experimental Rolf I. Skotheim
Therapeutics, University of Texas, M.D. Department of Cancer Prevention,
Anderson Cancer Center, 1400 Holcombe Institute for Cancer Research,
Blvd., FC6. 3044, Unit 422, Houston, Rikshospitalet-Radiumhospitalet
TX 77030 Medical Center, NO-0310 Oslo,
E-mail: [email protected] Norway
xii Authors and Co-Authors of Volume 2

Zsuzsanna Tabi Sarah J. Welsh

Department of Oncology and Palliative University of Oxford, Harris Manchester
Medicine, Velindre Hospital, Whitchurch, College, Manchester Road, Oxford,
CF14 2TL Cardiff, United Kingdom OX1 3 TD, UK
E-mail: [email protected].
nhs.uk Chris L.P. Wong
Division of Molecular Pathology,
Nagio Takigawa Department of Pathology and Cancer
Department of Respiratory Medicine, Genetics Center, Hong Kong Sanatorium
Okayama University Hospital, Graduate and Hospital, 2 Village Road, Happy
School of Medicine, Okayama 700-8558, Valley, Hong Kong
Japan
E-mail: [email protected] Sunil Yadav
Saskatoon Cancer Center, University
Manuel R. Teixeira of Saskatchewan, 20 Campus Drive,
Department of Genetics, Portuguese University of Saskatchewan, Saskatoon,
Oncology Institute - Porto, Portugal Rua SK, Canada, S7N 4H4
Dr. Antonio Bernardino de Almeida,
Porto, 4200-072, Portugal Dani S. Zander
Penn State Milton S. Hershey Medical
Franck Toledo Center-M.C. H179, P. O. Box 850,
Institut Curie, Centre de Recherche, 500 University Drive, Hershey,
UMR CNRS 7147, 26 rue d’Ulm 75248, PA 17033
Cedex 05 Paris, France E-mail: [email protected]
E-mail: [email protected]
Pat Zanzonico
Frank M. Torti Room Z 2002 (Zuckerman Research
Comprehensive Cancer Center, Wake Center), Memorial Sloan-Kettering
Forest University, School of Medicine, Cancer Center, 1275 York Avenue,
Winston-Salem, NC 27157 New York, NY 10021
E-mail: [email protected]
Ahmet T. Turgut
Department of Radiology, Ankara
Training and Research Hospital,
25. Cadde 362. Sokak Hüner Sitesi
No: 18/30 Karakusunlar, Ankara,
TR-06530 Turkey
Preface

Cancer is the leading cause of death, in the number of older cancer patients is
after cardiovascular diseases, in the expected. Approximately, 77% of all types
United States. A total of ∼ 1,399,790 new of cancers are diagnosed in persons of 55
cancer cases and ∼ 564,830 deaths were years and older. It was estimated that one-
reported in the year 2006 in the country. third of the 559,650 cancer deaths in 2007
Approximately, one in every two men and in the United States were related to over-
one in every three women in the country weight or obesity, physical inactivity, and
will have some type of cancer during nutrition, and thus could also be prevented
their lifetime. Healthcare costs exceed (Am. Cancer Society, 2007). However,
1.7 trillion dollars per year in the United in developed countries, including United
States, which is ∼ 15% of the country’s States, the average person of 65 years can
gross domestic product. expect to live another 15 years in a fairly
Tobacco use is the most serious prevent- good health. Persons of 75 or 85 years old
able cause of cancer. Tobacco use causes have an average expectancy of 10 and 6
cancer of the lung, throat, mouth, pancreas, years, respectively.
urinary bladder, stomach, liver, kidney, and During the last three decades, intensive
other types. Passive smoking causes lung clinical research has resulted in reduced
cancer. In 2007, ∼ 168,000 cancer deaths cancer incidence, side effects of treat-
were expected to be caused by tobacco use ments, and death rates and increased sur-
(Am. Cancer Society, 2007). vival rates. As a result, there are ∼ ten
The most important risk factor for the million cancer survivors in the United
development of cancer is increasing age. States; some of them are cancer-free,
This factor and epidemiologic shifts have while others may still have cancer and
resulted in a marked increase in the number may be undergoing treatment.
of older patients with cancer. This fact It is recognized that scientific journals
will result in marked increased burden of facilitate exchange of information, result-
cancer to the world, including the United ing in rapid progress. In this endeavor, the
States. The fastest-growing segment of the main role of scientific books is to present
United States population comprises per- information in more detail after careful,
sons of 65 years and older, and an increase additional evaluation of the investigational

xiii
xiv Preface

results, especially those of new or rela- various imaging modalities, and tumor
tively new methods, and their potential markers. Treatments such as chemother-
side-effects. apy, radiation, chemoradiation, hormonal
Although subjects of diagnosis, therapy therapy, immunotherapy, and surgery; and
assessment, and prognosis of various types prognosis. The side effects of the treat-
of cancers, cancer recurrence, and resist- ments are also pointed out. Both primary
ance to chemotherapy are scattered in a and secondary cancers, and risk of cancer
vast number of journals and books, there survivors developing other cancers are
is need of combining these subjects in explained. An attempt is also made to
single volumes. An attempt has been made translate molecular genetics into clini-
to accomplish this goal in these volumes. cal practice. Evidence-based therapy is
A constructive evaluation of commonly included.
used methods for elucidating primary and Role of metabolism in malignancy
secondary cancer initiation, progression, and cancer stem cells are discussed in
relapse, and metastasis is presented. detail. Methods of cancer diagnosis dis-
In the era of cost-effectiveness, my opin- cussed include various modalities of
ion may be a minority prospective, but it imaging (e.g., MRI, PET, Whole-Body
needs to be recognized that the potential PET, Multidetector-Row Computed
for false-positive or false-negative inter- Tomography, Transcutaneous Contrast-
pretation on the basis of a single labora- Enhanced Sonography, and Transrectal
tory test in clinical pathology does exist. Sonography), and Histology and Immuno-
Interobservor or intraobservor variability histochemistry. Other methodologies, such
in the interpretation of results in pathology as Array-Based Comparative Genomic
is not uncommon. Interpretive differences Hybridization and Polymerase Chain
often are related to the relative importance Reaction Analysis, are also included.
of criteria being used. Prognostic biological markers such as
Generally, no test always performs per- mitochondrial mutations and circulat-
fectly. Although there is no perfect remedy ing DNA in blood for prostate cancer
to this problem, standardized classifica- are described. Treatment of NSCLC with
tions with written definitions and guide- docetaxel, platinum-based chemotherapy,
lines will help. Standardization of methods and gefitinib is discussed. Chemotherapy
to achieve objectivity is imperative in this with vinorelbine, doxorubicin, and pred-
effort. The validity of a test should be nisone, and radiotherapy for prostate
based on the objective interpretation of the cancer are discussed. Overexposure of
photomicrographs or tomographic images. patients to radiology is included.
The interpretation of the results should be Each chapter is written by distinguished,
explicit rather than implicit. To achieve practicing clinicians/surgeons/oncologists.
accurate diagnosis, and correct prognosis, Their practical experience highlights their
the use of molecular criteria is important. writings, which should build and further
Indeed, molecular medicine has arrived. the endeavors of the readers. This volume
This volume discusses in detail all aspects was written by 75 scientists representing
of lung cancer and prostate cancer, includ- 14 countries. It is my hope that these
ing diagnosis using molecular genetics, handbooks would assist in more complete
Preface xv

understanding of at least some of the theoretical information. It is my hope that

globally-encountered cancer problems. the book will be published expeditiously.
Successful cancer treatment, cure, and I am thankful to the Board of Trustees,
prevention are areas of immediate concern Dr. Dawood Farahi, and Dr. Kristie Reilly
of and demand by the public. for recognizing the importance of schol-
I am grateful to the contributors for their arship in an institution of higher edu-
promptness in accepting my suggestions, cation and providing the resources for
and appreciate their dedication and hard completing this important project. I am
work in sharing their invaluable knowledge thankful to Ayesha Muzaffar and Lina
with the readers. Each chapter provides Builes for their expert help in preparing
unique individual, practical knowledge this volume.
based on the expertise and practical expe-
rience of the authors. The chapters contain M.A. Hayat
the most up-to-date practical as well as February 2008
Contents

Authors and Co-Authors of Volume 2 .................................................................. vii

Preface ..................................................................................................................... xiii

Contents of Volume 1 ............................................................................................. xxxiii

Part I General Methods and Overviews

1. Metabolic Transformations of Malignant Cells: An Overview................... 3
Leslie C. Costello and Renty B. Franklin
Introduction .................................................................................................... 3
Axioms of Relationships of Cellular Activity, Cellular Metabolism,
and Malignancy .......................................................................................... 3
Defining a Malignant Cell: A Parasitic Existence ......................................... 4
The In Situ Environment of the Malignant Cell Dictates its Metabolism ...... 5
Tumor Cell Proliferation and Involved Metabolic Pathways
for its Achievement .................................................................................... 6
The Coupling of Glycolysis via Citrate to De Novo
Lipogenesis/Cholesterogenesis .................................................................. 7
The Operation of the Krebs Cycle in Tumor Cells ........................................ 9
Glutaminolysis as an Alternative or Additional Pathway in Tumor Cells ..... 9
The Application of Molecular Genetics and Proteomics to Tumor Cell
Intermediary Metabolism ........................................................................... 10
References ...................................................................................................... 15

2. Detection of Recurrent Cancer by Radiological Imaging ........................... 17

S.J. Gwyther
Introduction .................................................................................................... 17
Lung Cancer ............................................................................................... 22
Breast Cancer ............................................................................................. 24

xvii
xviii Contents

Colorectal Cancer....................................................................................... 25
Lymphomas ................................................................................................ 27
Pancreatic Cancer....................................................................................... 27
Prostate Cancer .......................................................................................... 28
Esophageal Cancer ..................................................................................... 29
Melanoma .................................................................................................. 29
Gynecological Cancers .............................................................................. 29
Ovarian Cancer....................................................................................... 29
Endometrial Cancer ................................................................................ 31
Cervical Cancer ...................................................................................... 31
Head and Neck Cancers ............................................................................. 32
Thyroid Cancer .......................................................................................... 33
Renal and Bladder Tumors ........................................................................ 33
Primary Intracranial Tumors ...................................................................... 34
Conclusions ................................................................................................ 34
References ...................................................................................................... 35

3. Tumor Gene Therapy: Magnetic Resonance Imaging

and Magnetic Resonance Spectroscopy .................................................... 39
Mikko I. Kettunen and Olli H.J. Gröhn
Introduction .................................................................................................... 39
Tumor Gene Therapy ..................................................................................... 39
Magnetic Resonance Imaging ........................................................................ 40
Endogenous Magnetic Resonance Imaging Contrast ................................ 41
Exogenous Contrast Agents ....................................................................... 42
Magnetic Resonance Spectroscopy................................................................ 43
Detection of Transgene Delivery and Expression Using Magnetic
Resonance Imaging and Spectroscopy....................................................... 44
Detection of Gene Therapy Response Using Magnetic
Resonance Imaging and Spectroscopy....................................................... 46
Volumetric Imaging ................................................................................... 46
Endogenous Contrasts................................................................................ 46
Sodium Magnetic Resonance Imaging ...................................................... 48
Molecular Imaging ..................................................................................... 48
Magnetic Resonance Spectroscopy of Metabolic Alterations ................... 49
Summary ........................................................................................................ 51
References ...................................................................................................... 52

4. Assessment of Gene Transfer: Magnetic Resonance Imaging

and Nuclear Medicine Techniques............................................................. 55
Annette Altmann and Uwe Haberkorn
Introduction .................................................................................................... 55
Molecular Imaging Modalities for Gene Expression ................................. 57
Molecular Imaging of Suicide Gene Transfer and Therapeutic Effects .... 58
Contents xix

Molecular Imaging of Suicide Gene Therapy by the Uptake

of Specific Substrates ............................................................................. 63
Noninvasive Imaging of Reporter Gene Transfer ...................................... 65
References ...................................................................................................... 69

5. Role of TP53 Mutations in Cancer (An Overview) ...................................... 75

Franck Toledo
Introduction .................................................................................................... 75
Impact of TP53 Mutations on P53 Transactivation Capacity ........................ 75
Other Effects of TP53 Mutations ................................................................... 79
TP53 Mutations and the Etiology of Human Cancers ................................... 81
Prognostic and Predictive Value of TP53 Mutations ..................................... 83
Correction of P53 Pathway in Tumors ........................................................... 84
Future Perspectives ........................................................................................ 87
References ...................................................................................................... 90

6. Personalized Medicine for Cancer................................................................. 93

Sarah J. Welsh and Garth Powis
Introduction .................................................................................................... 93
Why Is Personalized Medicine Important in Cancer? ............................... 94
To What Extent Is Cancer Medicine Already Personalized? ..................... 94
The Future of Personalized Medicine in Cancer........................................ 99
The Challenges for Achieving Personalized Medicine .............................. 102
References ...................................................................................................... 105

7. Radiation Doses to Patients Using Computed Radiography,

Direct Digital Radiography, and Screen-Film Radiography................... 109
Gaetano Compagnone
Introduction .................................................................................................... 109
Radiation Quantities Used in Patient Dosimetry ........................................... 109
Conventional Screen-Film Systems ............................................................... 112
Patient Dose and Image Quality with Conventional Screen-Film Systems ... 115
Computed Radiography ................................................................................. 117
Patient Dose and Image Quality with Computed Radiography ..................... 119
Direct Digital Radiography ............................................................................ 122
Patient Dose and Image Quality with Direct Digital Radiography................ 124
Conclusions .................................................................................................... 126
References ...................................................................................................... 127

8. Cancer Vaccines and Immune Monitoring (An Overview) ......................... 129

Zsuzsanna Tabi and Stephen Man
Introduction .................................................................................................... 129
Prophylactic Cancer Vaccines ........................................................................ 130
xx Contents

Vaccines to Prevent HPV Infection and Cervical Cancer .............................. 130

Vaccines to Prevent Hepatitis B Infection and Liver Cancer ......................... 133
Prophylactic Vaccines Against HBV ......................................................... 133
Vaccines to Prevent Hepatitis C Infection and Liver Cancer ......................... 133
Other Viruses Associated with Cancer .......................................................... 134
Therapeutic Cancer Vaccines ......................................................................... 134
Dendritic Cell Vaccines.................................................................................. 134
Exogenously Loaded Antigen .................................................................... 136
Endogenously Synthesized Antigens ......................................................... 137
Adoptive T Cell Transfer ............................................................................... 138
Peptide- and Protein-Based Vaccines, Adjuvants ........................................... 140
Recombinant Viral Vector-Vaccines .............................................................. 141
Nonspecific Immune Stimulants – Immune Response Modifiers .................. 141
Adjuvants ................................................................................................... 141
Cytokines, Chemokines ............................................................................. 142
Ligands/Antibodies .................................................................................... 142
Combination of Cancer Vaccines with Chemo- and Radiotherapy ............... 143
Combined Chemoimmunotherapy ............................................................. 143
Combined Radio-Immunotherapy ............................................................. 145
Monitoring Immune Responses ..................................................................... 146
Proliferation Assays ....................................................................................... 146
Cytotoxicity Assays ....................................................................................... 147
Cytokine Secretion Assays ............................................................................ 149
Tetramers.................................................................................................... 152
Standardization .............................................................................................. 153
Summary ........................................................................................................ 154
Conclusion and Outlook ................................................................................ 155
References ...................................................................................................... 156

9. New Insights into the Role of Infection, Immunity and Apoptosis

in the Genesis of the Cancer Stem Cell ..................................................... 161
Peter Grandics
Introduction .................................................................................................... 161
The Exterior Cell Surface Layer (Cell Coat) ............................................. 162
Activation of Coagulation .......................................................................... 163
Infection and Inflammation ........................................................................ 165
Infection, Autoimmunity, and Cancer ........................................................ 167
Defective Apoptosis ................................................................................... 168
Discussion and Therapeutic Implications .................................................. 170
Summary ........................................................................................................ 175
References ...................................................................................................... 175
Contents xxi

10. Successful Cancer Treatment: Eradication of Cancer Stem Cells ............ 179
David Dingli and Jorge M. Pacheco
Introduction .................................................................................................. 179
Tissue Organization and Stem Cells ............................................................ 179
Evidence for Cancer Stem Cells .................................................................. 180
Origin of Cancer Stem Cells ........................................................................ 181
Stochastic Dynamics of Cancer Stem Cells ................................................. 182
Markers of Cancer Stem Cells ..................................................................... 184
Treating Cancer Stem Cells ......................................................................... 185
Problems with Targeting Cancer Stem Cells ........................................... 186
Overcoming Drug Resistance .................................................................. 186
Evidence for Effective Anti-Cancer Stem Cell Therapy.......................... 187
The Future ................................................................................................ 188
References .................................................................................................... 188

11. Overexposure of Patients to Ionizing Radiation: An Overview................. 193

Philip Clewer
Introduction .................................................................................................. 193
Justification and Optimization ..................................................................... 193
Unintended Exposures ................................................................................. 194
Overexposure in Radiology ......................................................................... 195
Overexposure in Nuclear Medicine ............................................................. 196
Overexposure in Radiotherapy..................................................................... 196
At What Level Should We Be Concerned About Overexposures? .............. 197
References .................................................................................................... 200

Part II Lung Cancer

12. Lung Carcinoma ............................................................................................ 203
M.A. Hayat
Introduction .................................................................................................. 203
References .................................................................................................... 206

13. Extra-Pulmonary Small Cell Cancer: Diagnosis, Treatment,

and Prognosis ............................................................................................. 207
Rabia K. Shahid, Kamal Haider, Amer Sami, Imran Ahmad,
Florence Arnold, Sunil Yadav, Kristie Harding, David Popkin,
and Shahid Ahmed
Introduction .................................................................................................. 207
Epidemiology ............................................................................................... 208
Pathology ..................................................................................................... 208
Histogenesis ............................................................................................. 208
xxii Contents

Light Microscopic Features ..................................................................... 208

Immunophenohistochemistry................................................................... 209
Electron Microscopy ................................................................................ 209
Cytogenetics............................................................................................. 209
Clinical Features .......................................................................................... 209
Differential Diagnosis .................................................................................. 209
Staging ......................................................................................................... 210
Management................................................................................................. 210
Limited Stage Disease.............................................................................. 211
Extensive Stage Disease........................................................................... 211
Prognosis ...................................................................................................... 211
Genitourinary Tract ...................................................................................... 212
Urinary Bladder ....................................................................................... 212
Prostate..................................................................................................... 212
Gynaecological Sites.................................................................................... 213
Cervix....................................................................................................... 213
Endometrium............................................................................................ 213
Gastrointestinal Tract ................................................................................... 213
Esophagus ................................................................................................ 213
Colon and Rectum.................................................................................... 214
Head and Neck Region ................................................................................ 214
Larynx ...................................................................................................... 214
Salivary Glands ........................................................................................ 215
Breast ........................................................................................................... 215
Unknown Primary Sites ............................................................................... 215
Summary ...................................................................................................... 215
References .................................................................................................... 216

14. Magnetic Resonance Imaging of the Lung: Automated

Segmentation Methods .............................................................................. 219
William F. Sensakovic and Samuel G. Armato III
Introduction .................................................................................................. 219
Thoracic Magnetic Resonance Imaging and Acquisition Artifacts ............. 220
Automated Segmentation Methods .............................................................. 221
Thresholding, Shape Descriptors, and Morphological Operators ................ 221
Model-Based Segmentation ......................................................................... 226
Parametric Active Contours ......................................................................... 228
Neural Network/Active Contour Combination ............................................ 231
References .................................................................................................... 234

15. Peripheral Lung Lesions: Diagnosis Using Transcutaneous

Contrast-Enhanced Sonography .............................................................. 235
Christian Görg and Angelique Holland
Introduction .................................................................................................. 235
Pathophysiologic Basics of Pulmonary Vascularity..................................... 236
Contents xxiii

General Considerations of Contrast-Enhanced Sonography........................ 236

Clinical Data of Contrast-Enhanced Sonography ........................................ 237
Pleurisy .................................................................................................... 237
Pulmonary Embolism............................................................................... 237
Pleural Based Pulmonary Nodules........................................................... 239
Pneumonia................................................................................................ 240
Atelectasis ................................................................................................ 242
Primary Lung Tumors .............................................................................. 242
References .................................................................................................... 244

16. Small Pulmonary Nodules: Detection Using Multidetector-Row

Computed Tomography ............................................................................. 247
Marco Das
Pulmonary .................................................................................................... 247
The Pulmonary Nodule ................................................................................ 247
Differential Diagnosis of Pulmonary Nodules ............................................. 247
Granuloma, Harmatomas ......................................................................... 247
Lung Cancer ............................................................................................. 248
Metastasis................................................................................................. 249
Rare Differential Diagnosis ..................................................................... 249
Multidetector-Row Computed Tomography for Pulmonary Nodules.......... 249
Technique ................................................................................................. 249
Low-Dose Computed Tomography .......................................................... 250
Contrast-Enhanced Computed Tomography ............................................ 250
Dynamic Computed Tomography ............................................................ 251
Diagnostic Workup ...................................................................................... 251
Detection of Pulmonary Nodules ............................................................. 251
Nodule Density ........................................................................................ 252
Nodule Size .............................................................................................. 252
Nodule Growth......................................................................................... 253
Recommended Workup Algorithms......................................................... 253
Lung Cancer Screening ................................................................................ 254
Advanced Diagnosis of Pulmonary Nodules ............................................... 255
Computer Aided Detection ...................................................................... 256
Computer Aided Volumetry ..................................................................... 257
References .................................................................................................... 258

17. Secondary Primary Cancer Following Chemoradiation

for Non-Small-Cell Lung Cancer.............................................................. 261
Nagio Takigawa, Yoshihiko Segawa, and Katsuyuki Kiura
Introduction .................................................................................................. 261
Methods........................................................................................................ 261
Results .......................................................................................................... 262
xxiv Contents

Discussion .................................................................................................... 264

References .................................................................................................... 265

18. Advanced Non-Small Cell Lung Cancer: Second-Line Treatment

with Docetaxel ............................................................................................ 269
Cesare Gridelli and Paolo Maione
Introduction .................................................................................................. 269
Second-Line Treatment ................................................................................ 269
Docetaxel Versus Best Supportive Care in the Second-Line Treatment ...... 270
Docetaxel Versus Other Chemotherapeutic Agents in the
Second-Line Treatment ............................................................................ 271
Docetaxel Given Every 3 Weeks Compared with Weekly Schedule ........... 273
Docetaxel Versus Targeted Therapies in the Second-Line Treatment ......... 275
Ongoing Studies on Docetaxel..................................................................... 277
References .................................................................................................... 277

19. Non-Small Cell Lung Cancer with Brain Metastases:

Platinum-Based Chemotherapy................................................................ 281
Fabrizio Nelli and Luca Moscetti
Epidemiology ............................................................................................... 281
Prognosis and Treatment Options ................................................................ 281
Shifting the Paradigm of the Blood-Brain Barrier ....................................... 282
Role of Chemotherapy ................................................................................. 283
Platinum-Based Chemotherapy: Phase II Trials .......................................... 284
Platinum-Based Chemotherapy: Phase III Trials ......................................... 285
References .................................................................................................... 287

20. Non-Small Cell Lung Carcinoma: EGFR Gene Mutations

and Response to Gefitinib.......................................................................... 291
Armando Bartolazzi
Introduction .................................................................................................. 291
Epidermal Growth Factor Receptor and Downstream Signaling ................. 292
Epidermal Growth Factor Receptor Molecular Targeted Therapy
for Non-Small Cell Lung Carcinomas ..................................................... 294
Epidermal Growth Factor Receptor Mutations and Their Clinical
Relevance ................................................................................................. 296
Oncogene Addiction and Gefitinib Response .............................................. 298
Non-Small Cell Lung Carcinoma Sensitivity to Epidermal
Growth Factor Receptor Targeted Therapy, and Mechanisms
of Resistance ............................................................................................ 299
Irreversible Epidermal Growth Factor Inhibitors and Combinatorial
Approaches with Other Targeted Therapies............................................. 301
Future Advances .......................................................................................... 302
References .................................................................................................... 303
Contents xxv

21. Advanced Non-Small Cell Lung Carcinoma: Acquired

Resistance to Gefitinib ............................................................................... 307
Katsuyuki Kiura, Nagio Takigawa, and Yoshihiko Segawa
Introduction .................................................................................................. 307
Discovery of Somatic EGFR-TK Mutations ............................................ 307
Resistance to Gefitinib ............................................................................. 308
Primary Resistance................................................................................... 309
RAS ...................................................................................................... 309
Other Mechanisms ............................................................................... 309
Acquired Resistance................................................................................. 309
Mutation of Threonine 790 to Methionine in EGFR ........................... 309
MET Amplification .............................................................................. 311
Clinical Factors Affecting Acquired Resistance to Gefitinib............... 312
Overcoming Acquired Resistance to Gefitinib ........................................ 312
References .................................................................................................... 313

22. Prognostic Significance of [18F]-Fluorodeoxyglucose Uptake

on Positron Emission Tomography in Patients with Pathological
Stage I Lung Adenocarcinoma ................................................................. 317
Hiroaki Nomori
Introduction .................................................................................................. 317
Patients and Methods ................................................................................... 317
PET Data Analysis ................................................................................... 318
Follow-up and Assessment of Tumor Recurrence ................................... 318
Statistical Analysis ................................................................................... 318
Results .......................................................................................................... 319
Univariate Analysis .................................................................................. 319
Multivariate Analysis ............................................................................... 320
Discussion .................................................................................................... 320
References .................................................................................................... 322

23. Non-Small Cell Lung Cancer: Prognosis Using the TNM

Staging System ........................................................................................... 323
Joachim Pfannschmidt, Heinrich Bulzebruck, and Hendrik Dienemann
Introduction .................................................................................................. 323
History of TNM ........................................................................................... 323
TNM Descriptors ......................................................................................... 324
Staging Procedures....................................................................................... 326
Stage Grouping in NSCLC .......................................................................... 328
Prognostic Implications of TNM Classification and Stage in NSCLC ........ 329
Stage IA and IB............................................................................................ 329
Stage IIA and IIB ......................................................................................... 330
Stage IIIA and IIIB ...................................................................................... 331
xxvi Contents

Stage IV ....................................................................................................... 332

Stage Reporting: Future Perspective ............................................................ 333
References .................................................................................................... 334

24. Differentiation Between Malignant and Benign Pleural Effusions:

Methylation Specific Polymerase Chain Reaction Analysis ................... 337
Susana Benlloch, José Marcelo Galbis-Caravajal, and Bartomeu Massutí
Introduction .................................................................................................. 337
Materials and Methods................................................................................. 339
Patients ..................................................................................................... 339
Collection and Processing of Pleural Fluid Samples and DNA
Extraction ............................................................................................. 339
Methylation-Specific Polymerase Chain Reaction (MSP) ....................... 340
Statistical Analysis ............................................................................... 340
Results .......................................................................................................... 341
Discussion .................................................................................................... 342
References .................................................................................................... 345

25. Pathological Distinction of Pulmonary Large Cell Neuroendocrine

Carcinoma from Small-Cell Lung Carcinoma Using
Immunohistochemistry .............................................................................. 349
Kenzo Hiroshima
Introduction .................................................................................................. 349
Small-Cell Lung Carcinoma ........................................................................ 350
Clinical Presentation ................................................................................ 350
Pathologic Features .................................................................................. 350
Large Cell Neuroendocrine Carcinoma ....................................................... 352
Clinical Presentation ................................................................................ 352
Pathologic Features .................................................................................. 352
Morphometry ............................................................................................... 353
Molecular Biology ....................................................................................... 354
Immunohistochemistry ................................................................................ 354
CD56 ........................................................................................................ 355
hASH1...................................................................................................... 355
TTF-1 ....................................................................................................... 356
Cytokeratins ............................................................................................. 356
p53, Rb, Bcl-2 .......................................................................................... 357
CD117 ...................................................................................................... 357
Differential Diagnosis .................................................................................. 357
References .................................................................................................... 359
Contents xxvii

26. Differentiation Between Pleuropulmonary Desmoid Tumors

and Solitary Fibrous Tumors: Role of Histology and
Immunohistochemistry .............................................................................. 363
Dani S. Zander and Loren E. Clarke
Introduction .................................................................................................. 363
Gross and Microscopic Pathology ............................................................... 363
Gross Features.......................................................................................... 363
Microscopic Features ............................................................................... 364
Immunohistochemistry ................................................................................ 366
Conventional Antibodies.......................................................................... 366
β-Catenin and Cyclin D1 ......................................................................... 368
References .................................................................................................... 369

27. Non-Small Cell Lung Cancer with Brain Metastasis: Role

of Epidermal Growth Factor Receptor Gene Mutation ......................... 371
Edmond S.K. Ma and Chris L.P. Wong
Introduction .................................................................................................. 371
Histopathological Correlation .................................................................. 371
Epidermal Growth Factor Receptor Gene Mutation ................................ 372
Epidermal Growth Factor Receptor Gene Amplification ........................ 373
Materials ...................................................................................................... 373
Methods........................................................................................................ 375
Tissue Preparation .................................................................................... 375
EGFR Gene PCR Amplification and Sequencing Analysis..................... 376
Fluorescence In-Situ Hybridization Detection of EGFR Gene
Amplification and Loss of Heterozygosity .......................................... 377
MLPA Detection of EGFR Gene Copy Number Changes ....................... 379
Results and Discussion ................................................................................ 380
Spectrum of EGFR Mutations in Hong Kong Chinese Patients
with NSCLC......................................................................................... 380
Role of EGFR Gene Mutation in Brain Metastases from NSCLC .......... 380
Molecular Genetic Study of NSCLC with Brain Metastasis ................... 382
Gefitinib Response of Brain Metastases from NSCLC............................ 383
References .................................................................................................... 385

Part III Prostate Cancer

28. Prostate Carcinoma ....................................................................................... 391
M.A. Hayat
Introduction .................................................................................................. 391
Prostate Specific Antigen ......................................................................... 392
References .................................................................................................... 395
xxviii Contents

29. The Role of Intermediary Metabolism and Molecular Genetics

in Prostate Cancer...................................................................................... 397
Renty B. Franklin and Leslie C. Costello
Introduction .................................................................................................. 397
Citrate Production and the Human Prostate Gland ...................................... 398
Citrate Metabolism in Normal Prostate Epithelial Cells.............................. 399
M-Aconitase and Zinc in Citrate Production ............................................... 399
Glucose Utilization for Net Citrate Production ........................................... 400
Aspartate as the Source of Oxalacetate for Citrate Production.................... 402
The Bioenergetics of Net Citrate Production ............................................... 402
The Citrate Relationship in Prostate Cancer ................................................ 403
The Genetic/Metabolic Transformation in Malignant Cells ........................ 404
Is Zinc a Tumor Suppressor in Prostate Cancer? ......................................... 405
Is Zip1 a Tumor Suppressor Gene in Prostate Cancer?................................ 406
Citrate Metabolism and De Novo Lipogenesis ............................................ 406
The Concept of “Metabolic” Genes ............................................................. 408
The Clinical Application of Prostate Cancer Metabolism ........................... 409
References .................................................................................................... 411

30. Array-Based Comparative Genomic Hybridization in

Prostate Cancer: Research and Clinical Applications ............................ 415
Franclim R. Ribeiro, Rolf I. Skotheim, Rui Henrique,
and Manuel R. Teixeira
Introduction .................................................................................................. 415
The Methodology ......................................................................................... 415
Platforms and Methodologies .................................................................. 416
Scoring Approaches and Common Pitfalls .............................................. 418
Technical Limitations of Prostate Cancer Sampling .................................... 419
Genomic Data on Prostate Cancer ............................................................... 420
Genomic Hotspots in Prostate Cancer ................................................. 423
Recurrent Copy Number Gains and Candidate Oncogenes ......................... 423
Recurrent Copy Number Losses and Putative Tumor
Suppressor Genes ..................................................................................... 423
Fusion Genes – Newly Discovered Players ................................................. 424
Complementary Technologies ................................................................. 425
Conclusions and Future Perspectives ........................................................... 426
References .................................................................................................... 426

31. Prostate Cancer: Role of Vav3 Overexpression in Development

and Progression .......................................................................................... 431
Shan Lu
Introduction .................................................................................................. 431
Multiple Functions of Vav Family Proteins ................................................. 431
Vav3 is Overexpressed in Human Prostate Cancer and Stimulates
Growth of Prostate Cancer Cells...................................................................... 432
Contents xxix

Vav3 Overexpression Enhances AR Transactivation Activity ...................... 433

The Potential Impact of Vav3 on Nongenomic Androgen
Receptor Activity ..................................................................................... 433
Vav3 Signaling in Prostate Cancer ............................................................... 435
The Role of Vav3 in Prostate Cancer Biology ............................................. 436
References .................................................................................................... 438

32. Prostate Cancer: Detection and Monitoring Using Mitochondrial

Mutations as a Biomarker ......................................................................... 441
Gabriel D. Dakubo, Ryan L. Parr, and John P. Jakupciak
Introduction .................................................................................................. 441
Mitochondrial Genetics................................................................................ 442
Mitochondrial Bioenergetics ........................................................................ 444
Mitochondrial Oncology .............................................................................. 446
Unique Prostate Epithelial Cell Metabolism................................................ 447
Mitochondrial DNA Mutations in Prostate Cancer...................................... 448
Sample Preparation for Mitochondrial DNA Mutation Analysis
in Prostate Cancer ........................................................................................ 451
Analysis of Mitochondrial DNA Point Mutations in Prostate Cancer ......... 452
Microarray Resequencing of Mitochondrial DNA .................................. 453
Denaturing High-Performance Liquid Chromatography ......................... 455
Pyrosequencing ........................................................................................ 456
Other Emerging Sequencing Technologies .............................................. 458
Real Time PCR Analysis of Mitochondrial DNA in Prostate Cancer ......... 458
Quality Assurance Issues to Be Considered in Mitochondrial DNA
Analysis.................................................................................................... 461
References .................................................................................................... 463

33. Prognostic Markers in Prostatic Carcinoma ............................................... 465

Sonia L. El-Sharkawy, Naglaa F. Abbas, and Nadia G. EL-Hefnawy
Introduction .................................................................................................. 465
Materials and Methods................................................................................. 467
Results and Discussion ................................................................................ 470
References .................................................................................................... 477

34. Prostate Cancer: Detection of Free Tumor-Specific DNA in Blood

and Bone Marrow ...................................................................................... 481
Heidi Schwarzenbach and Klaus Pantel
Introduction .................................................................................................. 481
Genetics and Epigenetics of Prostate Tumors.............................................. 482
Limitations of Using Tumor Tissues for Genetic and
Epigenetic Analyses ................................................................................. 482
History of Detection Circulating DNA in Blood ......................................... 483
Elevated Levels of Cell-Free Nucleic Acids in Prostate Cancer Patients .... 484
xxx Contents

Plasma-Based Microsatellite Analysis......................................................... 486

Plasma-Based Single Nucleotide Polymorphism Analysis.......................... 489
PCR-Based Fluorescence Microsatellite and SNP Technique Using
Blood and Bone Marrow DNA ................................................................ 490
Limitations of the Blood-Based LOH Analysis ........................................... 490
Technical Considerations of the Plasma-Based Analyses ........................... 492
Plasma-Based Epigenetic Analysis .............................................................. 493
DNA Methylation Analysis by the Sodium Bisulfite Technique ................. 494
References .................................................................................................... 495

35. Prostate Carcinoma: Evaluation Using Transrectal Sonography ............. 499

Ahmet T. Turgut and Vikram S. Dogra
Introduction .................................................................................................. 495
Prostate Carcinoma Diagnosis ..................................................................... 500
Transrectal Ultrasonography Using Assessment of Prostate Cancer ........... 501
Anatomy....................................................................................................... 501
Physics ......................................................................................................... 501
Sonographic Anatomy ................................................................................. 501
Techniques ................................................................................................... 502
Gray Scale Ultrasound ................................................................................. 503
Color Doppler Ultrasound............................................................................ 507
Power Doppler Ultrasound........................................................................... 509
Contrast-Enhanced Ultrasound Imaging ...................................................... 510
Elastography ................................................................................................ 512
Transrectal Ultrasound-Guided Prostate Biopsy.......................................... 513
Repeat Biopsies............................................................................................ 514
Complications .............................................................................................. 515
Pain or Discomfort ....................................................................................... 515
Anesthesia .................................................................................................... 516
Therapeutic Applications of Transrectal Ultrasound for Prostate Cancer ... 517
Transrectal Ultrasound in the Evaluation of Local Recurrence
After Radical Prostatectomy .................................................................... 517
References .................................................................................................... 518

36. Prostate Cancer: 16b-[18F]Fluoro-5α-Dihydrotesterone(FDHT)

Whole-Body Positron Emission Tomography.......................................... 521
Pat Zanzonico
Introduction .................................................................................................. 521
The Potential Role of Androgen-Receptor Imaging in Prostate Cancer ...... 521
Positron Emission Tomography ................................................................... 522
Pre-Clinical Studies of Androgen Receptor Radioligands........................... 523
Clinical Studies of 16β-[18F]Fluoro-5α-Dihydrotesterone .......................... 525
Radiation Dosimetry of 16β-[18F]Fluoro-5α-Dihydrotesterone .................. 528
References .................................................................................................... 528
Contents xxxi

37. Effects of Standard Treatments on the Immune Response

to Prostate Cancer...................................................................................... 531
Nancy J. Nesslinger, Howard H. Pai, Charles M. Ludgate, and
Brad H. Nelson
Introduction .................................................................................................. 531
Methodology ................................................................................................ 536
Western Blotting Assay............................................................................ 536
Materials for Cell Culture .................................................................... 536
Materials for Protein Lysate Preparation and Quantification............... 536
Materials for Western Blotting Assay .................................................. 536
Protocol for Cell Culture, Protein Lysate Preparation
and Quantification ............................................................................ 537
Protocol for Western Blotting .............................................................. 538
SEREX Screening .................................................................................... 538
Materials for cDNA Library Construction ........................................... 539
Materials for SEREX Screening .......................................................... 539
Protocol for cDNA Library Construction ............................................ 540
Protocol for Pre-Clearing Serum Samples ........................................... 541
Protocol for SEREX Screening............................................................ 542
Protocol for Analyzing SEREX Antigen Arrays ................................. 543
Protocol for Purifying Phage Clones ................................................... 544
Results and Discussion ................................................................................ 545
References .................................................................................................... 551

38. Vinorelbine, Doxorubicin, and Prednisone

in Hormone Refractory Prostate Cancer ................................................. 557
Samer Kalakish and Frank M. Torti
Introduction .................................................................................................. 557
Eligibility ..................................................................................................... 558
Treatment Plan ............................................................................................. 559
Evaluation .................................................................................................... 559
Statistical Analysis ....................................................................................... 560
Results .......................................................................................................... 560
Discussion .................................................................................................... 561
References .................................................................................................... 562

39. Locally Advanced Prostate Cancer Biochemical Recurrence

after Radiotherapy: Use of Cyclic Androgen Withdrawal Therapy ........ 565
Juanita Crook
Introduction .................................................................................................. 565
Laboratory Basis for Human Studies ........................................................... 566
Mechanisms of Progression to Androgen Independence ............................. 567
Clonal Selection ....................................................................................... 567
Molecular Adaptation .............................................................................. 567
xxxii Contents

Rationale for Intermittent Administration of Androgen Suppression

in Clinical Practice ................................................................................... 567
Phase II Clinical Studies .............................................................................. 568
The Canadian Prospective Trial ............................................................... 569
The Ottawa Phase II Intermittent Androgen Suppression Experience .... 570
Side Effects of Treatment......................................................................... 571
Bone Density............................................................................................ 572
Phase III Clinical Studies ............................................................................. 572
Is There an Accepted Standard Regimen of Intermittent Androgen
Suppression? ............................................................................................ 573
Summary and Conclusions .......................................................................... 574
References .................................................................................................... 575

Index ...................................................................................................................... 579

Contents of Volume 1

1. Breast Cancer: An Introduction

2. Breast Cancer: Computer-Aided Detection

3. Sebaceous Carcinoma of the Breast: Clinicopathologic Features

4. Breast Cancer: Detection by In-Vivo Imaging of Angiogenesis

5. Breast and Prostate Biopsies: Use of Optimized High-Throughput

MicroRNA Expression for Diagnosis (Methodology)

6. Familial Breast Cancer: Detection of Prevalent High-Risk

Epithelial Lesions

7. Differentiation Between Benign and Malignant Papillary

Lesions of Breast: Excisional Biopsy or Stereotactic
Vacuum-Assisted Biopsy (Methodology)

8. Multicentric Breast Cancer: Sentinel Node Biopsy

as a Diagnostic Tool

9. Breast Cancer Recurrence: Role of Serum Tumor

Markers CEA and CA 15-3

10. Breast Cancer Patients Before, During or After Treatment:

Circulating Tumor Cells in Peripheral Blood Detected
by Multigene Real-Time Reverse Transcriptase-Polymerase
Chain Reaction

11. Breast Cancer Patients: Diagnostic Epigenetic

Markers in Blood

xxxiii
xxxiv Contents of Volume 1

12. Breast Cancer Patients: Detection of Circulating Cancer

Cell-Related mRNA Markers with Membrane Array Method

13. Prediction of Metastasis and Recurrence of Breast Carcinoma:

Detection of Survivin-Expressing Circulating Cancer Cells

14. Node-Negative Breast Cancer: Predictive and Prognostic

Value of Peripheral Blood Cytokeratin-19 mRNA-Positive Cells

15. Breast and Colon Carcinomas: Detection with Plasma

CRIPTO-1

16. Breast Cancer Risk in Women with Abnormal Cytology

in Nipple Aspirate Fluid

17. Tissue Microarrays: Construction and Utilization

for Biomarker Studies

18. Systematic Validation of Breast Cancer Biomarkers

Using Tissue Microarrays: From Construction
to Image Analysis

19. Phyllodes Tumors of the Breast: The Role

of Immunohistochemistry in Diagnosis

20. Phyllodes Tumor of the Breast: Prognostic Assessment

Using Immunohistochemistry

21. Metaplastic Breast Carcinoma: Detection Using

Histology and Immunohistochemistry

22. Invasive Breast Cancer: Overexpression of HER-2 Determined

by Immunohistochemistry and Multiplex Ligation-Dependent
Probe Amplification

23. Operable Breast Cancer: Neoadjuvant Treatment

(Methodology)

24. Chemotherapy for Breast Cancer

25. Locally Advanced Breast Cancer: Role of Chemotherapy

in Improving Prognosis

26. Relevance of Dose-Intensity for Adjuvant Treatment

of Breast Cancer
Contents of Volume 1 xxxv

27. Advanced Breast Cancer: Treatment with Docetaxel/Epirubicin

28. Systemic Therapy for Breast Cancer: Using Toxicity

Data to Inform Decisions

29. Chemotherapy for Metastatic Breast Cancer Patients

Who Received Adjuvant Anthracyclines (An Overview)

30. Estrogen Receptor-Negative and HER-2/neu-Positive

Locally Advanced Breast Carcinoma: Therapy with
Paclitaxel and Granulocyte-Colony Stimulating Factor

31. Breast Cancer: Side Effects of Tamoxifen and Anastrozole

32. Breast Cancer: Expression of HER-2 and Epidermal

Growth Factor Receptor as Clinical Markers for Response
to Targeted Therapy

33. Young Breast Cancer Patients Undergoing

Breast-Conserving Therapy: Role of BRCA1 and BRCA2

34. Radiation Therapy for Older Women with Early Breast Cancer

35. Acute Side Effects of Radiotherapy in Breast Cancer

Patients: Role of DNA-Repair and Cell Cycle Control Genes
18
36. F-Fluorodeoxyglucose/Positron Emission Tomography
in Primary Breast Cancer: Factors Responsible for
False-Negative Results

37. Sentinel Lymph Node Surgery During Prophylactic

Mastectomy (Methodology)

38. Breast Conservation Surgery: Methods

39. Lymph Node-Negative Breast Carcinoma:

Assessment of HER-2/neu Gene Status as Prognostic Value

40. Multifocal or Multicentric Breast Cancer:

Understanding Its Impact on Management
and Treatment Outcomes

41. Are Breast Cancer Survivors at Risk for Developing

Other Cancers?
xxxvi Contents of Volume 1

42. Distant Metastasis in Elderly Patients with

Breast Cancer: Prognosis with Nodal Status

43. Concomitant Use of Tamoxifen with Radiotherapy

Enhances Subcutaneous Breast Fibrosis in
Hypersensitive Patients

44. Malignant Phyllodes Tumor of the Breast:

Is Adjuvant Radiotherapy Necessary?

45. Locally Advanced Breast Cancer: Multidrug Resistance

46. Breast Cancer: Diagnosis of Recurrence

Using 18 F-Fluorodeoxyglucose-Positron Emission
Tomography/Computed Tomography

47. Role of Sentinel Lymph Node Biopsy in Ductal

Carcinoma In Situ: Diagnosis and Methodology

48. Breast Conservation Treatment of Early Stage Breast

Carcinoma: Risk of Cardiac Mortality

Index
1
Metabolic Transformations of Malignant
Cells: An Overview
Leslie C. Costello and Renty B. Franklin

pled with molecular technology; none of

INTRODUCTION
which existed during the days of the out-
It is generally considered that the hallmark standing biochemists and mitochondriacs
studies of Otto Warburg and colleagues of earlier times.
reported in 1926 (Warburg et al., 1926) The following overview will present
sparked the era of tumor cell metabolism. some important considerations that relate
From that time until around 1980, and espe- to the intermediary energy metabolic
cially from 1940–1970, studies of interme- requirements of tumor cells. However,
diary metabolism of normal and malignant one must also recognize that differing
cells were dominant areas of research and metabolic pathways exist for different
graduate and post-graduate training in bio- malignant cells in situ; therefore, gener-
medical sciences. Pursuant to ~ 1980, the alizations of metabolic transformations are
advent, development, and subsequent dom- not likely to be uniformly applicable to all
inance of molecular genetics, proteomics, malignant cells. Also, as authors, we take
and molecular technology in clinical and license to present some concepts of malig-
experimental biomedical application was nancy that might be challenged by others.
accompanied by the nearly complete sub- Nevertheless, this presentation will serve
mersion of interest and training in areas as “food for thought” that might stimulate
of intermediary metabolism and tumor interest and further studies in the exciting
cell metabolism. (The contemporary con- field of metabolism of malignancy.
sequences of this transition are discussed
in a following section.) Now a resurging
interest in intermediary metabolism along AXIOMS OF RELATIONSHIPS
with the development of metabolomics in OF CELLULAR ACTIVITY,
relation to cancer and other diseases has CELLULAR METABOLISM,
emerged. This provides a timely reason AND MALIGNANCY
to revisit some of the important issues of
tumor cell metabolism with a perspec- The following are important generaliza-
tive of the contemporary associations of tions that we consider to be axiomatic and
genomics/proteomics/metabolomics, cou- applicable to all cells.

3
4 L.C. Costello and R.B. Franklin

1. The existing cellular intermediary the bioenergetic/synthetic requirements

metabolism of a cell provides the bioen- of malignancy.
ergetic/synthetic/catabolic requirements 6. In the absence of the metabolic trans-
that are essential for the manifestation formation, the neoplastic cell will not
of the cell’s current activities (function, progress to complete malignancy. Con-
growth, and proliferation). versely, the metabolic transformation, in
2. When the activity of a cell changes, the absence of the genetic transforma-
its metabolism must also be adjusted tion to a neoplastic malignant cell, will
consistent with any newly estab- not cause malignancy.
lished bioenergetic/synthetic/catabolic 7. Common to all malignant cells is the
requirements. metabolic requirement for de novo
3. Malignant cells exhibit a parasitic exist- lipogenesis/cholesterogenesis for mem-
ence. They have no specialized function braneogenesis that is essential for their
other than the activities essential for proliferative existence.
their generational propagation (growth These axioms define a relationship (rep-
and proliferation), which occur at the resented in Figure 1.1) that we propose is
expense of their host. applicable to all malignancies.
4. Malignant cells are derived from nor-
mal cells that have undergone a genetic
transformation to a neoplastic cell phe- DEFINING A MALIGNANT
notype that is endowed with malignant CELL: A PARASITIC
potential. EXISTENCE
5. Manifestation of the malignant poten-
tial of the neoplastic cell necessitates An understanding of the “purpose” of the
alterations in its metabolism (i.e., a existence of a cell at any point in time in its
metabolic transformation) to provide life provides information of the requirement

Figure 1.1. The role of altered intermediary metabolism in the process of the development of malignancy.
Malignancy begins with the genetic transformation of a normal cell to a neoplastic malignant phenotype.
The neoplastic cell undergoes genetic expression changes involved in the metabolic transformation from
the normal cell metabolism of A→B→C to the malignant cell metabolism of X→Y→Z to fulfill the
energetic and synthetic metabolic requirements of malignancy. The neoplastic cell can then fulfill its
malignant potential
1. Metabolic Transformations of Malignant Cells: An Overview 5

for and role of its intermediary metabolism.

Most notable is the influence of the
Malignant cells are “parasitic” cells. They
availability of oxygen and micronutrients
exist for one purpose, that is, to grow and
derived from circulation. The former is of
to proliferate to ensure their generational
paramount importance in relation to the
propagation. They do so at the expense and
intermediary metabolism of the malig-
destruction of the host. These are the crite-
nant cell. The initiation of the malignant
ria that define a parasitic life-style. Except
cell activity is followed by growth and
for the relevance to clinical identification,
proliferation that results in an increasing
it is an error (in our view) to consider or to
mass of malignant cells. This subjects
describe tumor cells as “dedifferentiated”
the population of malignant cells to dif-
or “undifferentiated” cells. To do so places
ferent gradients of oxygen ranging from
tumor cells in the same category as normal
normoxia through hypoxia toward anoxia.
undifferentiated cells (e.g., stem cells, basal
One can visualize a solid ball of cells
cells, mesenchyme cells and others that we
in which the outside layer of cells is in
will refer to collectively as “stem” cells).
apposition to the air, and each inner layer
Stem cells, like tumor cells, also exist to
of cells progressively is more distant from
grow and proliferate, but they do so forthe air. Thus, the intermediary metabo-
the purpose of differentiating into special-
lism of the malignant cells comprising the
ized cells that perform specific functions.
tumor mass cannot be expected to be uni-
Stem cells proliferate to maintain a con-
form at any one time, and the intermedi-
tinual population of cells for further dif-
ary metabolism of the malignant cells can
ferentiation. However, unlike the parasitic
be expected to change as the availability
tumor cells, these cells grow/proliferate
of oxygen changes. As the environment
in harmony with the host tissue, i.e., they
becomes more hypoxic leading to anoxia,
exhibit a symbiotic life-style. In this sense
the continued malignant proliferation and
these are “sane” cells, while tumor cells are
other activities will become compromised
“insane” cells. The malignant cells exhibit
and ultimately arrested. This is due to the
two essential activities for their progres-
inability of the major population of malig-
sion and propagation: (1) growth and pro-
nant cells to derive their metabolic bioen-
liferation; (2) invasion and motility. The
ergetic and biosynthetic requirements. The
latter are life-cycle activities in support of
lack of available oxygen and nutrients,
the former. The intermediary metabolism such as glucose, from circulation prevents
of the malignant cells must provide the the malignancy from progressing. This is
bioenergetic and synthetic requirements best illustrated by the requirements for
for these activities. lipogenesis/cholesterogenesis and even the
accelerated glycolysis, neither of which
can be sustained under such conditions.
THE IN SITU ENVIRONMENT One must not forget that the “waste prod-
OF THE MALIGNANT CELL ucts” of the metabolism of the malignant
DICTATES ITS METABOLISM cells also need to be eliminated, which
also requires the availability of circulation.
Especially for solid tumors, the malig- In other words, a refurbished perfusate is
nant cells are subjected to a changing an essential environmental condition for
environment as they grow and progress. tumor progression. Indeed, the successful
6 L.C. Costello and R.B. Franklin

evolution of malignant cells has resulted ments of cell proliferation. For this
from adaptive capabilities to confront and reason, we will focus our discussion on
to overcome this adversity. For example, such requirements, with recognition that
they upregulate hypoxia inducible factor many other areas of intermediary metabo-
and stimulate angiogenesis to create the lism are critical to the development and
circulation and environment that allows propagation of tumor cells. A hallmark
their further progression. metabolic activity of proliferating cells
Therefore, the cycle of malignancy is the pathway to de novo lipogenesis/
involves periods of growth and prolifera- cholesterogenesis that is essential for the
tion and periods of arrest to “refuel” the membraneogenesis requirement of cell
environment; all of which accommodate the growth and proliferation. (While we focus
metabolic requirements of the malignant on this, one must also be cognizant that
cells. To optimize their parasitic existence, protein and polysaccharide synthesis are
some malignant cells will vacate the pri- also involved.) Therefore, a major meta-
mary site of their development and seek bolic transformation in malignancy is the
other host tissue sites to invade and continue “switch” from the functional metabolism
their parasitic existence. Thus, the capability of their parental normal cell to the de novo
and stages of metastasis are invoked. The lipogenesis/cholesterogenesis requirement
vascularization and distant tissue site inva- of the tumor cell.
sion provide different environmental condi- The purpose of this overview presenta-
tions that likely affect the metabolism of the tion is not to detail the pathway(s) to de
metastatic cells. Very little is known con- novo lipogenesis/cholesterogenesis, but to
cerning the in situ metabolic relationships highlight some relationships for considera-
of these cells. The understanding of all of tion. De novo lipogenesis/cholesterogene-
these relationships (and other relationships sis begins with the availability of cytosolic
not described herein) dictate that any studies acetyl CoA (acetyl coenzyme A), the com-
of tumor cell metabolism must be extrapo- mon carbon skeleton for fatty acid synthe-
lated and related to the realities of the in situ sis (lipogenesis) and lanesterol synthesis
environment of the malignant cells. (cholesterogenesis). Therefore, tumor cells
must direct their attention to providing a
source and pathway for cytosolic acetyl
CoA synthesis. In mammalian cells, the
TUMOR CELL PROLIFERATION major source of cytosolic acetyl CoA is
AND INVOLVED METABOLIC derived from the mitochondrial production
PATHWAYS FOR ITS of citrate (Figure 1.2), which is exported
ACHIEVEMENT into the cytosol via a mitochondrial citrate
transporter protein (CTP). Normally, in
The propagation of a cell-type requires its most mammalian cells CTP expression is
ability for cell proliferation. This is the low, so that citrate is retained predomi-
dominant activity of parasitic cells. To nantly within the mitochondria mainly to
achieve this, the intermediary metabolism be oxidized via the Krebs cycle for energy
of the malignant cell is dominated by production and also to provide intermedi-
the bioenergetic and biosynthetic require- ates for associated metabolic pathways.
1. Metabolic Transformations of Malignant Cells: An Overview 7

Figure 1.2. The glucose-citrate pathway to de novo lipogenesis/cholesterogenesis in malignant cells.

Glucose is utilized for the mitochondrial synthesis and production of citrate. Citrate transporter protein
is up-regulated, which permits the export of some citrate to the cytosol while some citrate is oxidized via
the Krebs cycle. The cytosolic citrate is converted to acetyl CoA for lipogenesis/cholesterogenesis

Tumor cells exhibit an upregulation of cells. As shown in Figure 1.2, it takes a

CTP which permits an increased export prolific amount of glucose conversion
of citrate to cytosol where it is converted to fulfill the lipogenic/cholesterogenic
by ATP citrate lyase to acetyl CoA + requirements of growing/proliferating
oxalacetate. Therefore, in the absence of tumor cells. This brings us to the consid-
alternative sources of cytosolic acetyl CoA, eration of the “hallmark” characterization
proliferating tumor cells must direct their of tumor cell metabolism as being a trans-
metabolism to optimize the mitochondrial formation to “high aerobic glycolysis”; a
production of citrate. characterization that has dominated the
studies of tumor cell metabolism both
directly and indirectly. In its strictly
THE COUPLING OF defined metabolic end-point, which is
GLYCOLYSIS VIA CITRATE lactic acid, a high aerobic glycolysis
TO DE NOVO LIPOGENESIS/ would be inconsistent with the require-
CHOLESTEROGENESIS ments for proliferating tumor cells, unless
an alternative pathway to mitochondrial
Glycolysis is coupled with de novo lipo- citrate synthesis exists (described below).
genesis/cholesterogenesis because glu- In the absence of alternative sources,
cose generally provides the carbon source the ‘high aerobic glycolysis” could pro-
for acetyl CoA production in most tumor vide energy for sustaining the cells in
cells and other lipogenic/cholesterogenic a non-proliferating condition, which is
8 L.C. Costello and R.B. Franklin

an energy-inefficient process that pro- To establish the operation of this path-

duces only 2 mols ATP/mol glucose way of glucose utilization in cells, one
under anaerobic (anoxic) conditions; or must conduct a stoichiometric analysis
possibly 8 mols ATP/mol glucose under of the utilization of glucose and its major
aerobic conditions if NADH is shut- products. Typically, in anaerobic glycolysis
tled to mitochondria for re-oxidation to essentially all of the glucose utilized will
NAD. This is contrasted with the genera- be balanced by the production of lactate
tion of 38 mols ATP/mol glucose that is + pyruvate (assuming minimal accumula-
completely oxidized. This inefficiency is tion of other glycolytic intermediates).
somewhat compensated by the rapidity of However, the utilization of glucose under
glycolysis and by the large host plasma aerobic conditions will likely result in the
pool of glucose that is available to the oxidation of pyruvate which can lead to
parasitic tumor cells.. On the other hand, citrate production. In this case, the level of
an “accelerated aerobic glycolysis” is lactate + pyruvate will be significantly less
likely to exist for the increased produc- than the glucose utilized. One must then
tion of lactate → pyruvate → citrate as the incorporate the analysis of CO2 production
end-point in the following pathway: and citrate levels. Since some portion of
GLUC 2 PYR + 8ATP the latter will be swept into the lipogenic/
2 02 2 0AA cholesterogenic pathway, the incorpora-
2 LACT ACCOA 2 CIT + 2 CO2 + 6 ATP
tion of citrate into this pathway must be
This pathway requires oxygen and results considered. In a practical sense, one can
in the production of citrate along with 14 use fluoroacetate to inhibit m-aconitase
ATP molecules/glucose. activity and citrate oxidation. Then the
Then, the increased availability of a sum of lactate, pyruvate, CO2, and citrate
mitochondrial pool of citrate will pro- should approximate the glucose utilized.
vide for an increased export of citrate for If it does not, then the incorporation of
cytosolic acetyl CoA production along citrate into lipogenesis/cholesterogenesis
with the continued oxidation of citrate must be pursued. The use of ATP citrate
via the Krebs cycle for energy produc- lyase inhibitor such as hydroxycitrate can
tion (Figure 1.2). Consequently, those also be incorporated, in which case most of
tumor cells in situ that are exposed to the citrate that is produced will be accumu-
physiological anoxia (i.e., insufficient lated. One must be cautious in using inhibi-
oxygen availability to sustain aerobic oxi- tors to ensure that appropriate and effective
dative metabolism) cannot proliferate and concentrations are employed. These are
are in an arrested/dormant state. Neither representative of some of the types of
anoxic glycolysis that produces only lac- metabolic studies that must be employed.
tic acid nor normoxic glycolysis that The important point to be recognized is
completely oxidizes glucose, regardless that simply accounting for “most” (what-
of the bioenergetic consequences of each, ever that means) of the glucose utilized
is compatible with the de novo lipogenic/ as residing in the accumulation of lactate
cholesterogenic requirements of tumor does not negate the role of glucose as the
cells, unless an alternative pathway exists precursor for citrate production leading to
(presented below). lipogenesis/cholesterogenesis.
1. Metabolic Transformations of Malignant Cells: An Overview 9

in the presence of a sufficient intramito-

THE OPERATION OF THE chondial pool of citrate that would support
KREBS CYCLE IN TUMOR high citrate export, m-aconitase activity and
CELLS citrate oxidation will prevail. Therefore,
m-aconitase activity must be decreased
The preceding discussion raises the impor- and become rate-limiting in the tumor
tant issue regarding the operation of the cells if citrate oxidation is truncated while
Krebs cycle in tumor cells. Most studies high citrate export occurs. In our view, it is
indicate that the enzymes and reactions plausible to expect that the upregulation of
of the Krebs cycle remain operational CTP in tumor cells will provide for export
in tumor cells. An important issue is the of citrate concurrently with citrate oxida-
concept of a “truncated Krebs cycle” in tion as long as the source of citrate produc-
tumor cells (Parlo and Coleman, 1986), tion for increased citrate utilization exists
which suggests that an increased rapid (Figure 1.2).
export of citrate, due to the upregulation of
CTP (Parlo and Coleman, 1984), depletes
citrate availability for oxidation by the
Krebs cycle. A contemporary understand- GLUTAMINOLYSIS
ing of the m-aconitase reaction makes this AS AN ALTERNATIVE
concept untenable. It is well established OR ADDITIONAL PATHWAY
that the Krebs cycle downstream reac- IN TUMOR CELLS
tions from isocitrate to oxalacetate are
operational in tumor cells (Costello and Although a high rate of glycolysis has been
Franklin, 2005). However, the critical reac- presented as a prominent pathway in issues
tion is m-aconitase, about which little is of altered intermediary metabolism in tumor
known in tumor cells. Studies of hepatoma cells, increased glutaminolysis is also asso-
cells indicate the existence of a complete ciated with tumor cell metabolism. Mazurek
Krebs cycle including citrate oxidation et al. (1999) concluded, “… that a special
(Kelleher et al., 1987; Dietzen and Davis, metabolic feature (increased glycolysis
1993); while another study (Hernanz and and glutaminolysis) is a general charac-
de la Fuente, 1988) reports that the Krebs teristic of tumor cells…” Moreadith and
cycle is truncated. In malignant prostate Lehninger (1984) observed, “In fact, many
cells, m-aconitase activity and a functional malignant cell lines, as well as some normal
Krebs cycle exist (Costello and Franklin, cells, do not have an absolute requirement
2001, 2006; Costello et al., 2005; Singh for glucose per se…” They further stated,
et al., 2006). The important consideration “The two major products of the [gluta-
is that under conditions of the presence of mate oxidation] pathway described here,
uninhibited m-aconitase and downstream citrate and alanine, have important roles
oxidation, it is not possible for the rate of in tumor metabolism. Citrate is required
citrate export to deplete the citrate pool as the major source of cytosolic acetyl-
so that no citrate oxidation would occur. coA for fatty acid and cholesterol biosyn-
The kinetic relationships of citrate export thesis.” McKeehan (1982) proposed the
versus m-aconitase activity dictate that, utilization of glutaminolysis as a source
10 L.C. Costello and R.B. Franklin

of pyruvate in tumor cells. The follow- not manifested in altered and impaired
ing is a modified representation of the cellular and metabolic function. We
pathway of glutaminolysis through citrate mentioned in the Introduction that, pursu-
to lipogenesis in the absence of glucose ant to ∼ 1980, molecular genetics, pro-
utilization or in tumor cells that exhibit a teomics, and molecular technology have
high aerobic glycolysis: become contemporary focal and dominant
GLUT aKG MAL OAA ACCOA PYR MAL LIPOG.
areas of biomedical research, training, and
CIT OAA + ACCOA teaching. These technologies now provide
potential new approaches to the study
These descriptions are presented as illus-
of the cellular intermediary metabolism
trations of the energetic/synthetic meta-
of tumor cells, which will provide new
bolic alterations and requirements that
insights and revelations concerning the
are implicated in the development and
metabolic relationships and transforma-
progression of malignant cells. While we
tions in malignancy. These developments
emphasize the generalized requirement
provide for an exciting and revealing era
of de novo lipogenesis/cholesterogenesis
of rejuvenated interest in intermediary
and the bioenergetic requirement of all
metabolism to address the critical issues,
tumor cells for their proliferation; no
“What are the essential adaptive meta-
“universal” metabolic pathway for all
bolic requirements of malignant cells, and
tumor cells to achieve this end exists. The
how is the altered metabolism achieved?”
metabolism of each “species” of tumor
However, this molecular biology/molecu-
cell in relation to its true environment
lar technology dominance and empha-
must be established. A “one-size fits all”
sis (perhaps over-emphasis) has created
pathway is not applicable to tumor cell
problems and issues that did not exist
metabolism.
in the past. Simultaneously, the train-
ing of young investigators with a focus
and expertise in biochemistry, intermedi-
THE APPLICATION OF ary metabolism, enzymology, and enzyme
MOLECULAR GENETICS AND kinetics during the past 25 years has been
PROTEOMICS TO TUMOR widely diminished or eliminated from the
CELL INTERMEDIARY didactic, methodology, and seminar compo-
METABOLISM nents of pre- and post-doctoral training
programs.
In view of the current issues that arise In prior times, the study of cellular
from the contemporary application of intermediary metabolism was conducted
molecular technology/genomics/proteom- by those who were trained in the princi-
ics to studies of intermediary metabo- ples and methodology of biochemistry,
lism, we must add the 8th axiom to the enzymology, cellular physiology, meta-
preceding list of seven axioms: Genetic bolic pathways, and related areas. As
transformations and proteomic altera- the molecular biology era evolved, this
tions will have little relevancy to tumor generation became trained in the develop-
metabolism and other disease processes ing areas of molecular genetics, proteom-
if the genetic/proteomic alterations are ics, and molecular technology. With this
1. Metabolic Transformations of Malignant Cells: An Overview 11

capability, these researchers identified the metabolic pathways. This is the evolving
pathways of metabolism and the activities dominant group in contemporary biomedi-
of the enzymes involved through the appli- cal research associated with intermediary
cation of substrate analysis and enzyme metabolism.
kinetic studies. To state that this was One must recognize that intermediary
difficult, tedious, and time-consuming work metabolism reactions and pathways are
is a gross understatement. For this group governed by regulatory enzymes. The rate
of investigators, the developing molecular of an enzymatic reaction is the product of the
approaches were added to their fundamen- level and the specific activity of the enzyme.
tal strength in biochemistry and metabo- The level of the enzyme is established by its
lism. The view of this generation is that the gene expression and its subsequent biosynthe-
cellular enzyme activities and operation of sis to its active form. The specific activity
pathways are the critical events that need of the enzyme is dependent upon the
to be established. The role of gene expres- enzyme kinetic properties, cellular envi-
sion and enzyme protein biosynthesis are ronmental conditions of the reaction (such
viewed as critical tools to understanding as pH, ionic conditions, product inhibi-
the factors that are associated with altera- tion, and substrate concentration), enzyme
tions of cellular metabolism. They fully activation-deactivation reactions and other
understand that molecular genetics and conditions. One cannot presume that
proteomics cannot identify the operation altered expression and biosynthesis of an
of cellular pathways of metabolism and/or enzyme is manifested by a correspond-
specific enzyme activities, and can only ing change in the reaction rate within the
be established by the traditional methods cell. Conversely, one cannot presume that
of substrate analysis and enzyme kinetics. the absence of a change in the expres-
This group of researchers is a generation sion and level of an enzyme provides
that is reaching extinction. evidence that the specific enzyme activity
This group is being replaced by the alteration is not associated with a cellular
younger generation of researchers who metabolic change. This is exemplified by
have been trained in the events of molecular our identification that m-aconitase expres-
genetics and proteomics that are associated sion and level are unchanged in malignant
with the expression and biosynthesis of vs nonmalignant glandular epithelial cells
proteins, including enzymes. The princi- (Costello and Franklin, 2006; Costello
ples of molecular genetics and proteomics et al., 2005; Singh et al., 2006). However,
are then applied similarly and generally to the enzyme activity is markedly inhibited
proteins, among which enzymes of inter- by zinc in normal prostate epithelial cells,
mediary metabolism are included. These which results in inhibition of citrate oxida-
molecular events are then extrapolated to tion and truncation of the Krebs cycle. In
cellular metabolic events. The weakness contrast, the malignant cells do not accu-
of this group is the absence of training in mulate zinc so that m-aconitase activity
and understanding of the principles of bio- is not inhibited, and these cells oxidize
chemistry and enzymology, the factors that citrate via a functional Krebs cycle. This is
affect cellular enzyme activity, and the rela- a major and critical metabolic transforma-
tionships of sequential enzyme activities in tion that is essential for the development
12 L.C. Costello and R.B. Franklin

and progression of prostate malignancy. Enzyme activities 1,2,4 are in excess, and
Genetic and proteomic studies in the absence enzyme 3 is rate limiting. The product of
of metabolism studies would have lead to an the pathway ‘E’ is low despite the fact
erroneous conclusion regarding a major fac- that enzyme 4 is in excess. Reaction 4 is
tor for this important metabolic transforma- low because the substrate D concentra-
tion. The employment of gene and protein tion is lower than the Km for the reaction
microarrays would dismiss m-aconitase as an 4 enzyme. Therefore, the up regulation of
essential factor in prostate malignancy! enzyme 4 gene expression will have little,
The contemporary literature contains if any, effect on increasing the pathway for
numerous instances in which gene expres- conversion of substrate ‘A’ to product ‘E’.
sion studies (e.g., RT-PCR) and protein abun- Moreover, the accumulation of intermediate
dance studies (e.g., Western blot analysis) C could induce a product inhibition of reac-
have lead to conclusions that the changes in tion 2, which would then decrease product
the expression and level of specific enzymes C, even if enzyme 2 is in excess. In such an
are evidence of corresponding changes in example, the identification of altered expres-
the cellular enzyme activity and associated sion of metabolic genes and of changes in
pathway. Conversely, the absence of changes the level of the corresponding enzymes does
in expression has lead to conclusions that not establish changes in the cellular activity
the enzyme-associated activity and pathway of the enzyme or the associated metabolic
are not involved in altered metabolism in pathway. Conversely, the identification of
a tumor cell or a disease process. Notably altered enzyme activity of metabolic path-
absent from such reports are the essential ways does not identify the factors and cause
cellular metabolic studies that are required of the altered metabolism. This is when
to determine the relationship of genetic/ the genetic/proteomic approach becomes a
proteomic observations to the cellular met- critical tool for understanding mechanisms
abolic events. Such circumstances reveal of regulation of cellular metabolism.
the absence of an essential understanding One must also recognize an important
of fundamental cellular metabolic relation- distinction between regulatory enzymes
ships. The only circumstance in which a of intermediary metabolism and other
genetic/proteomic alteration can be directly enzymes/proteins. We classify genes that
related to a corresponding cellular enzyme are involved in the expression of enzymes
effect is the complete down regulation of the of intermediary metabolism as “metabolic”
gene with the absence of the enzyme, so that genes to differentiate from the genes that
cellular enzyme activity cannot exist. are involved in the expression of other pro-
In any series of reactions that comprises teins such as structural/skeletal proteins
a metabolic pathway, the activity rate of the and secretory/digestive enzymes. The lat-
pathway is governed by the slowest reaction ter group can be classified as “abundant”
within the pathway (the ‘master reaction’). proteins that require increased expression
The following exemplifies a sequence of level over a many-fold range. Enzymes
enzymes comprising a metabolic pathway of intermediary metabolism are not abun-
leading to the following product: dant proteins and exist in micro-abundant
levels. In many instances the alterations
in the level of regulatory enzymes of
1. Metabolic Transformations of Malignant Cells: An Overview 13

intermediary metabolism in the range of be identified, i.e., the geneticist approach

1–2 fold will exhibit significant changes and the biochemist approach (Figure 1.3).
in the cellular enzyme activity. In fact,
it makes no sense for such regulatory 1. The “Geneticist” Approach: This approach
enzymes to be increased several-fold above (Figure 1.3) focuses initially on the iden-
the level required for its cellular maximal tification of changes in gene expression
activity. by microarray analysis (step A) and/or
Consequently, the statistical require- specific gene expression analysis (step
ments of microarray analysis or gene B). If a “significant” difference in a
expression changes will tend to elimi- gene expression is revealed, studies
nate small, but metabolically important, proceed to the proteomic identification
changes in the expression of “metabolic” of corresponding changes in the rela-
genes. The statistical parameters applied tive level of the enzyme protein (step
to microarrays and to RT-PCR for identifi- C). Very often demonstrable alterations
cation of significant changes in the expres- in the gene expression and the relative
sion of a gene are of serious consequence protein level become presumptive evi-
for “metabolic genes.” The statistical strin- dence of a corresponding change in the
gency that is applied to the analysis of typ- cellular enzyme activity and associated
ical microarray data is somewhat arbitrary pathway of metabolism. This presump-
and designed to separate signal from noise. tion leads to the geneticist approach
In order to reduce the rate at which signifi- ending at step C, and eliminates the
cant differences in expression are falsely most critical step D. If step D were to
identified, the threshold for designating reveal an alteration in the cellular spe-
differences as being significant is often set cific enzyme activity and/or the associ-
higher (e.g., 2-fold or greater) than might ated pathway due to the cellular kinetic
be expected for significant functional dif- conditions, the geneticist approach in
ferences in metabolic enzyme activity. the absence of step D would have elic-
Thus, the potential for “false-negative” ited a “false-positive” interpretation.
results is more probable for metabolic Conversely, if steps A and/or B and/or
genes than for other genes. C reveal no significant change in the
If we apply the aforementioned condi- expression of a gene, the presumption is
tions and principles to the relationship made that its associated enzyme and/or
between gene expression and intermediary metabolic pathway is not involved in a
metabolism, two distinct approaches can metabolic transformation, and step D

Figure 1.3. The geneticist and biochemist approaches to establishing cellular enzyme activities and associ-
ated metabolic pathways in tumor cells
14 L.C. Costello and R.B. Franklin

is eliminated. However, further study (steps C and B), and define a critical role
that involves step D could reveal cellu- of altered gene expression in the metabolic
lar changes in the enzyme activity and transformation. Conversely, the enzyme
associated pathway. Thus, a false-nega- kinetic change might not be mimicked
tive result would have been reported. by genetic/proteomic changes. Then one
2. The “Biochemist” Approach: This must consider alternative reasons for the
approach (Figure 1.3) first seeks to iden- change in Vmax as described above. There
tify the alteration in the cellular inter- are other scenarios that exist. However,
mediary metabolism (step A) such as the “biochemist” approach is essentially
a change in the specific enzyme activ- devoid of potential false-positive and false-
ity and/or the operation of a metabolic negative results relative to defining the
pathway. If an alteration in the cellu- involvement of specific enzymes in met-
lar enzyme activity and/or associated abolic transformations. The application
metabolic pathway is not identified, its of genetic/proteomic studies is essential
involvement in a metabolic transforma- for the elucidation of the mechanisms of
tion is unlikely. The need to proceed with altered enzyme activity and the regulation
genetic and proteomic studies (steps B of metabolic transformations.
and C), seemingly becomes unnecessary. These relationships are also applicable
However, pursuant genetic/proteomic to mutations in the mitochondrial (mt)
studies might reveal altered expression DNA genome. Mutated mtDNA is a com-
and level of the enzyme. Then an impor- mon occurrence in malignant cells in situ.
tant issue is revealed. “What are the cel- For example, mutations in the cytochrome
lular conditions that prevent the change c oxidase subunit (COX1 gene) have been
in the activity of the altered enzyme widely reported in malignant prostate cells.
level?” This would dictate the need for However, important information concern-
further investigation. ing the effects of specific mutations on
the mitochondrial cytochrome c oxidase
Alternatively, Step A might reveal a activity and terminal oxidation often does
cellular alteration in the enzyme activity not exist. Mutations that do not have any
and associated metabolic pathway. Then, metabolic implications become irrelevant.
the issue becomes the identification of These issues in the marriage of molecu-
the mechanism of altered enzyme and lar genetics/proteomics with cellular inter-
metabolic activity. The application of the mediary metabolism raise the important
contemporary molecular tools of proteom- question, “What should be done to alle-
ics and gene expression are then applied, viate the problems?” Hopefully, aware-
with biochemical examination of cellular ness of these issues and principles by
conditions that can alter the activity of an the contemporary biomedical researchers
enzyme. For example, a kinetic change in will provide some immediate resolution
the enzyme Vmax with no change in the in forthcoming studies and reports. The
substrate Km value would suggest that more permanent and meaningful resolu-
the level of enzyme is altered. This could tion resides in the pre-and post-doctoral
correlate with a corresponding change in training programs. Cellular biochemistry,
the gene expression and/or protein level intermediary metabolism, enzyme kinetics,
1. Metabolic Transformations of Malignant Cells: An Overview 15

and enzymology must be reinstituted into and experimental studies in which tumor
the didactic and seminar components of cell metabolism will be an indispensable
training of biomedical researchers; particu- and critically important component in the
larly in the molecular genetics training pro- effort to eliminate cancer as a significant
grams. Practical laboratory training and human disease.
experience in the biochemical/metabolic
methodologies along with the molecu-
lar technology methodologies would be Acknowledgement. The cited studies of
extremely beneficial for those involved in LCC and RBF described in this review were
studies of the regulation of cellular inter- supported in part by NIH grants CA71207,
mediary metabolism of tumor cells and CA21097, CA79903. and CA93443.
other diseases. Such programs would pro-
vide the most capable generation of bio- REFERENCES
medical scientists to address and resolve
the critical issues of altered intermediary Costello, L.C., and Franklin, R.B. 2001. The inter-
mediary metabolism of the prostate: A key to
metabolism in malignancy and in other understanding the pathogenesis and progression
areas of biology and medicine. of prostate malignancy. Oncology 59: 269–282.
In conclusion, a new era of tumor cell Costello, L.C., and Franklin, R.B. 2005. “Why
metabolism is evolving. Critical issues of Do Tumor Cells Glycolyze?”: From glyco-
the role of altered intermediary metabo- lysis through citrate to lipogenesis. Mol. Cell.
lism in the development and progression Biochem. 280: 1–8.
Costello, L.C., and Franklin, R.B. 2006. The clini-
of malignancy can now be addressed. cal relevance of the metabolism of prostate can-
The factors and mechanisms involved in cer; zinc and tumor suppression: connecting the
the regulation and alteration of interme- dots. Mol. Cancer 5: 17.
diary metabolism in malignant cells can Costello, L.C., Feng, P., and Franklin, R.B. 2005.
be addressed. This new frontier of can- Mitochondrial function, zinc, and intermediary
cer research (and other diseases) requires metabolism relationships in normal prostate and
prostate cancer. Mitochondrion 5: 143–153.
the appropriate marriage of genetics/pro- Dietzen, D.J., and Davis, E.J. 1993. Oxidation of
teomics/molecular technology with the pyruvate, malate, citrate, and cytosolic reducing
principles and methodology of enzyme equivalents by AS-30D hepatoma mitochondria.
relationships and intermediary metabo- Arch. Biochem. Biophys. 305: 91–102.
lism. A hybrid of the geneticist approach Hernanz, A., and de la Fuente, M. 1988. Characterization
and the biochemist approach is essential. of aconitate hydratase from mitochondria and cyto-
plasm of ascites tumor cells. Biochem. Cell Biol.
New insights into the importance and 66: 792–795.
mechanism of the metabolic transforma- Kelleher, J.K., Bryan, B.M. 3rd, Mallet, R.T.,
tions required for the development and Holleran, A.L., Murphy, A.N., and Fiskum, G.
progression of malignancy altered are at 1987. Analysis of tricarboxylic acid-cycle
hand. The understanding of the genetic/ metabolism of hepatoma cells by comparison of
molecular/metabolic basis of malignancy 14CO2 ratios. Biochem. J. 246: 633–639.
Mazurek, S., Eigenbrodt, E., Failing, K., and
is critical to the issues of diagnosis, Steinberg, P. 1999. Alterations in the glycolytic
treatment, and prevention of the vari- and glutaminolytic pathways after malignant
ous types of cancers. This provides for an transformation of rat liver oval cells. J. Cell.
exciting and revealing future for clinical Physiol. 181: 136–146.
16 L.C. Costello and R.B. Franklin

McKeehan, W.L. 1982. Glycolysis, glutaminolysis and cholesterol and the suppressed evolution of
cell proliferation. Cell Biol. Int. Rep. 6: 635–650. pyruvate-generated CO2 in tumors: further evi-
Moreadith, R.W., and Lehninger, A.L. 1984. The dence for a persistent truncated Krebs cycle in
pathways of glutamate and glutamine oxida- hepatomas. Biochim. Biophys. Acta 886: 169–176.
tion by tumor cell mitochondria. Role of mito- Singh, K.K., Desouki, M.M., Franklin, R.B., and
chondrial NAD(P)+-dependent malic enzyme. J. Costello, L.C. 2006. Mitochondrial aconitase
Biol. Chem. 259: 6215–6221. and citrate metabolism in malignant and non-
Parlo, R.A., and Coleman, P.S. 1984. Enhanced rate malignant human prostate tissues. Mol. Cancer
of citrate export from cholesterol-rich hepatoma 5: 14, 4.
mitochondria. J. Biol. Chem. 259: 997–1003. Warburg, O., Wind, F., and Negelein E. 1926. Uber
Parlo, R.A., and Coleman, P.S. 1986. Continuous den Stoffwechsel von Tumoren im Korper. Klin.
pyruvate carbon flux to newly synthesized Woch. 5: 829–832.
2
Detection of Recurrent Cancer
by Radiological Imaging
S.J. Gwyther

INTRODUCTION of long term survival is early detection of

disease when a curative procedure can be
Diagnosis of cancer is often viewed by the undertaken, usually by complete surgical
general population as a life changing event excision, though curative chemotherapy
that will inevitably lead to an early death and/or radiotherapy are effective in some
after treatment with unpleasant and nox- situations such as early stage Hodgkin’s
ious side effects. Whilst there have been lymphoma and seminoma of the testis.
improvements in treatment and prolonged Those who die of their disease or as a
survival in many types of cancers in recent result of their disease can be divided into
years, cancer has remained common. It two groups. Firstly, those patients who
has been estimated that one in three peo- always have evidence of disease from the
ple develop some form of cancer at some time of diagnosis. When conventional treat-
point during their life and one in four will ment strategies fail they may enter clinical
die as a result of it (Seddon and Workman, trials using new agents or combinations
2003). The overall number of patients and are likely to achieve, at best, a partial
will inevitably rise as the overall world response to treatment, defined as a prede-
population not only increases in number termined reduction in tumor bulk, usually
but becomes more aged. This is borne out based on the reduction in size of well-
by the fact that in the year 2000 ~10 mil- defined lesions seen on anatomical imaging.
lion new cases of cancer were diagnosed The most common imaging modality used
worldwide, and this number is expected is computerised tomography (CT), though
to rise to 15 million by the year 2020 magnetic resonance imaging (MRI) is also
(Stewart and Kleihuer, 2003). Table 2.1 used but in specific anatomical sites, such
gives the estimated figures for the number as the diagnosis of spinal cord compression.
of patients who will develop the major can- Should the disease relentlessly continue to
cers and Table 2.2 the estimated number progress during treatment, the patient is
of patients who will die of various cancers defined as having progressive disease and
in the United States during 2006 (NCI, the ineffective treatment is withdrawn.
Common Cancer types, 2006; American The second group comprises those
Cancer Society, 2006). The best chance patients who have been treated by curative

17
Other documents randomly have
different content
The work of the peace party was first felt in the August elections of
1863. The governor, though a true and loyal man, was elected with
the help of a disaffected party, and a disaffected element was
elected to the legislature and to Congress. Six members of Congress
from Alabama were said to be “unionists,” that is, in favor of ending
the war at once and returning to the Union.[321] A Confederate
official who had wide opportunities for observation reported that the
district (Talladega) in which he was stationed had been carried by
the peace party under circumstances that indicated treasonable
influence. Unknown men were elected to the legislature and to other
offices by a secret order which, he stated, had for its object the
encouragement of desertion, the protection of deserters, and
resistance to the conscription laws. Some men of influence and
position belonged to it, and the leaders were believed to be in
communication with the enemy. The entire organization was not
disloyal, but he feared that the controlling element was faithless.
The election had been determined largely by the votes of stragglers
and deserters and of paroled Vicksburg soldiers who, it was found
later, had been “contaminated” by contact with the western soldiers
of Grant’s army.[322] By this he evidently meant that the soldiers had
been initiated into the “Peace Society.”
A few months later the “Peace Society” appeared among the soldiers
of General Clanton’s brigade stationed at Pollard, in Conecuh County.
Some of the soldiers had served in the army of Tennessee, and had
there been initiated into this secret society. Clanton, who was
strongly disliked by General Bragg and not loved by General Polk,
had much trouble with them because he asserted that the order
appeared first in Bragg’s army and spread from thence. Later
developments showed that he was correct.[323] It was in December,
1863, that the operations of the order among the soldiers were
exposed. A number of soldiers at Pollard determined to lay down
their arms on Christmas Day, as the only means of ending the war.
These troops, for the most part, were lately recruited from the
poorer classes of southwest Alabama by a popular leader and had
never seen active service. They were stationed near their homes and
were exposed to home influences. Upon them and their families the
pressure of the war had been heavy.[324] Many of them were exempt
from service but had joined because of Clanton’s personal popularity,
because they feared that later they might become liable to service,
and because they were promised special privileges in the way of
furloughs and stations near their homes. To this unpromising
material had been added conscripts and substitutes in whom the
fires of patriotism burned low, and who entered the service very
reluctantly. With them were a few veteran soldiers, and in command
were veteran officers. A secret society was formed among the
discontented, with all the usual accompaniment of signs, passwords,
grips, oaths, and obligations. Some bound themselves by solemn
oaths never to fight the enemy, to desert, and to encourage
desertion—all this in order to break down the Confederacy. General
Maury, in command at Mobile, concluded after investigation that the
society had originated with the enemy and had entered the southern
army at Cumberland Gap.[325]
In regard to the discontent among the soldiers, Colonel Swanson of
the Fifty-ninth and Sixty-first Alabama[326] regiments (consolidated)
stated that there was a general disposition on the part of the poorer
classes, substitutes, and foreigners to accept terms and stop the
war. They had nothing anyway, so there was nothing to fight for,
they said. There was no general matured plan, and no leader,
Colonel Swanson thought.[327] Major Cunningham of the Fifty-
seventh Alabama Regiment[328] reported that there had been
considerable manifestation of revolutionary spirit on account of the
tax-in-kind law and the impressment system, and that there was
much reckless talk, even among good men, of protecting their
families from the injustice of the government, even if they had to lay
down their arms and go home.[329] General Clanton said that the
society had existed in Hilliard’s Legion and Gracie’s brigade, and that
few men, he was sure, joined it for treasonable purposes.[330] Before
the appointed time—Christmas Day—sixty or seventy members of
the order mutinied and the whole design was exposed. Seventy
members were arrested and sent to Mobile for trial by court-martial.
[331] There is no record of the action of the court. The purged
regiments were then ordered to the front and obeyed without a
single desertion. Bolling Hall’s battalion, which was sent to the
Western army for having in it such a society, made a splendid record
at Chickamauga and in other battles, and came out of the
Chickamauga fight with eighty-two bullet-holes in its colors.[332]
During the summer and fall of 1863 and in 1864 the Confederate
officials in north Alabama often reported that they had found certain
traces of secret organizations which were hostile to the Confederate
government. The Provost-Marshal’s Department in 1863 obtained
information of the existence of a secret society between the lines in
Alabama and Tennessee, the object of which was to encourage
desertion.
Confederate soldiers at home on furlough joined the organization
and made known its object to the Confederate authorities. The
members were pledged not to assist the Confederacy in any way, to
encourage desertion of the north Alabama soldiers, and to work for
a revolution in the state government. Stringent oaths were taken by
the members, a code of signals, and passwords was used, and a
well-organized society was formed. The bulk of the membership
consisted of tories and deserters, with a few discontented
Confederates. Their society gave information to the Federals in north
Alabama and Tennessee and had agents far within the Confederate
lines, organizing discontent. General Clanton early in 1864
endeavored to break up the organization in north Alabama and
made a number of arrests, but failed to crush the order.
In middle Alabama, about the same time (the spring of 1864), the
workings of a treasonable secret society were brought to light.
Colonel Jefferson Falkner of the Eighth Confederate Infantry
overheard a conversation between two malcontents and began to
investigate. He found that in the central counties a secret society
was working to break down the Confederate government and bring
about peace. The plans were not perfected, but some were in favor
of returning to the Union on the Arkansas or Sebastian platform,[333]
others wanted to send to Washington and make terms, and still
others were in favor of unconditional submission. As to methods, the
malcontents meant to secure control of the state administration,
either by revolution or by elections in the summer of 1865, then they
would negotiate with the United States and end the war. The society
had agents in both the Western army and the Army of Northern
Virginia, tampering with the soldiers and endeavoring to carry the
organization into the Federal army. The leaders in the movement
hoped to organize into one party all who were discontented with the
administration. If successful in this, they would be strong enough
either to overthrow the state government, which was supported only
by home guards, or by obstruction to force the state government to
make peace. The oaths, passwords, and signals of this society were
similar to those of the north Alabama organization, with which it was
in communication. Conscript officers, county officials, medical
boards, and members of the legislature were members of the order.
If a deserter were arrested, some member released him; the
members claimed that the society caused the loss of the battle of
Missionary Ridge and the surrender at Vicksburg.
The strength of the so-called Peace Society lay in Alabama, Georgia,
Tennessee, and North Carolina. The organizers were called
Eminents. They gave the “degree” to (that is, initiated) those whom
they considered proper persons. No records were kept; the members
did not know one another except by recognition through signals.
They received directions from the Eminents, who accommodated
their instructions to the person initiated. An ignorant but loyal person
was told that the object of the order was to secure a change of
administration; the disloyal were told that the purpose was to
encourage desertion and mutiny in the army, to injure loyal citizens,
and to overthrow the state and Confederate governments. Owing to
the non-intercourse between members there were many in the order
who never knew the real objects of the leaders or Eminents, who
intended to use the organization to further their designs in 1865.
The swift collapse of the Confederacy in the spring of 1865
anticipated the work of the secret societies. The anti-Confederate
element was, however, left somewhat organized through the work of
the order.[334]

Reconstruction Sentiment
Besides the open obstruction of politicians, officials, and legislature,
and the secret opposition of the peace societies, there was a third
movement for reconstruction. This movement took place in that part
of Alabama held by the Federal armies, and the reconstruction
meetings were encouraged by the Union army officers. The leaders
were D. C. Humphreys and Jeremiah Clemens, whose defection has
been noted before. A more substantial element than the tories and
deserters supported this movement—the dissatisfied property
holders who were afraid of confiscation. Several Confederate officers
were drawn into the movement later.[335]
Early in 1864, Humphreys[336] issued an elaborate address
renouncing his errors. There was no hope, he told his fellow-citizens,
that foreign powers would intervene. Slavery as a permanent
institution must be given up. Law and order must be enforced and
constitutional authority reëstablished. Slavery was the cause of
revolution, and as an institution was at an end. With slavery
abolished, there was, therefore, no reason why the war should not
end. The right to regulate the labor question would be secured to
the state by the United States government. At present labor was
destroyed, and in order to regulate labor, there must be peace. The
address was printed and distributed throughout the state with the
assistance of the Federal officials. A number of the packages of
these addresses was seized by some women and thrown into the
Tennessee River.[337] Jeremiah Clemens, who had deserted in 1862,
issued an address to the people of the South advocating the election
of Lincoln as President.[338] March 5, 1864, a reconstruction
meeting, thinly attended, was held in Huntsville under the protection
of the Union troops. Clemens presided. Resolutions were passed
denying the legality of secession because the ordinance had not
been submitted to the people for their ratification or rejection.
Professions of devotion and loyalty to the United States were made
by Clemens, the late major-general of Alabama militia and
secessionist of 1861.[339] A week later the same party met again. No
young men were present, for they were in the army. All were men
over forty-five, concerned for their property. Clemens spoke,
denouncing the “twenty-negro” law. The Gilchrist story was here
originated by Clemens and told for the first time. The story was that
J. G. Gilchrist of Montgomery County went to the Secretary of War,
Mr. Walker, and urged him to begin hostilities by firing on Fort
Sumter, saying, “You must sprinkle blood in the face of the people of
Alabama or the state will be back into the Union within ten days.” In
closing, Clemens said, “Thank God, there is now no prospect of the
Confederacy succeeding.”
D. C. Humphreys then proposed his plan: slavery was dead, but by
submitting to Federal authority gradual emancipation could be
secured, and also such guarantees as to the future status of the
negro as would relieve the people from social, economic, and
political dangers. He expressed entire confidence in the conservatism
of the northern people, and asserted that if only the ordinance of
secession were revoked, the southern people would have as long a
time as they pleased to get rid of the institution of slavery. In case of
return to the Union the people would have political coöperation to
enable them to secure control of negro labor. “There is really no
difference, in my opinion,” he said, “whether we hold them as slaves
or obtain their labor by some other method. Of course, we prefer the
old method. But that is not the question.” He announced the
defection from the Confederacy of Vice-President Stephens, and
bitterly denounced Ben Butler, Davis, and Slidell, to whose intrigues
he attributed the present troubles. Resolutions were proposed by
him and adopted, acknowledging the hopelessness of secession and
advising a return to the Union. Longer war, it was declared, would be
dangerous to the liberties of the people, and the restoration of civil
government was necessary. The governor was asked to call a
convention for the purpose of reuniting Alabama to the Union. It was
not expected, it was stated, that the governor would do this; but his
refusal would be an excuse for the independent action of north
Alabama and a movement toward setting up a new state
government. Busteed could then come down and hold a “bloody
assize, trying traitors and bushwhackers.”[340]
In the early winter of 1864-1865, the northern newspaper
correspondents in the South[341] began to write of the organization
of a strong peace party called the “State Rights party,” in Georgia,
Alabama, and Mississippi. The leaders were in communication with
the Washington authorities. They claimed that each state had the
right to negotiate for itself terms of reconstruction. The plan was to
secure control of the state administration and then apply for
readmission to the Union. The destruction of Hood’s army removed
the fear of the soldier element. Several thousand of Hood’s suffering
and dispirited soldiers took the oath of allegiance to the United
States, or dispersed to their homes. Early in 1865 peace meetings
were held in Georgia, Alabama, and Mississippi, within the
Confederate lines; commissioners were sent to Washington; and the
tories and deserters organized. A delegation waited on Governor
Watts to ask him to negotiate for the return of the state to the
Union, but did not get, nor did they expect, a favorable answer from
him. The peace party expected to gain the August elections and
elect as governor J. C. Bradley of Huntsville, or M. J. Bulger of
Tallapoosa.[342] The plan, then, was not to wait for the inauguration
in November, but to have the newly elected administration take
charge at once. It was continually reported that General P. D. Roddy
was to head the movement.[343]
There is no doubt that during the winter of 1864-1865 some kind of
negotiation was going on with the Federal authorities. J. J. Giers,
who was a brother-in-law of State Senator Patton,[344] was in
constant communication with General Grant. In one of his reports to
Grant he stated that Roddy and another Confederate general had
sent Major McGaughey, Roddy’s brother-in-law, to meet Giers near
Moulton, in Lawrence County, to learn what terms could be obtained
for the readmission of Alabama. Major McGaughey said that the
people considered that affairs were hopeless and wanted peace. If
the terms were favorable, steps would be taken to induce Governor
Watts to accept them. If Watts should refuse, a civil and military
movement would be begun to organize a state government for
Alabama which would include three-fourths of the state. The plan, it
was stated, was indorsed by the leading public men. The peace
leaders wanted Grant, or the Washington administration, to
announce at once a policy of gradual emancipation in order to
reassure those afraid of outright abolition, and to “disintegrate the
rebel soldiery” of north Alabama, which they said was never strongly
devoted to the Confederacy. It was asserted that all the counties
north of the cotton belt and those in the southeast were ready for a
movement toward reconstruction. Giers stated that approaches were
then being made to Governor Watts. Andrew Johnson, the newly
elected Vice-President, vouched for the good character of Giers.[345]
Ten days later Giers wrote Grant that on account of the rumors of
the submission of various Confederate generals he had caused to be
published a contradiction of the report of the agreement with the
Confederate leaders. He further stated that one of Roddy’s officers,
Lieutenant W. Alexander, had released a number of Federal prisoners
without parole or exchange, according to agreement.[346] In several
instances, in the spring of 1865, subordinate Confederate
commanders proposed a truce, and after Lee’s surrender and
Wilson’s raid this was a general practice. During the months of April
and May, there was a combined movement of citizens and soldiers in
a number of counties in north Alabama to reorganize civil
government according to a plan furnished by General Thomas, Giers
being the intermediary.[347] On May 1 General Steele of the second
army of invasion was informed at Montgomery by J. J. Seibels, L. E.
Parsons, and J. C. Bradley—all well-known obstructionists—that two-
thirds of the people of Alabama would take up arms to put down the
“rebels.”[348] Colonel Seibels alone of that gallant company had ever
taken up arms for any cause. The other two and their kind may have
been, and doubtless often were, warlike in their conversation, but
they never drew steel to support their convictions.
It is quite likely that the strength of the disaffection, especially in
north and east Alabama, was exaggerated by the reports of both
Union and Confederate authorities. There never had been during the
war much loyalty, in the proper sense of the word, to the United
States. There was much pure indifference on the part of some
people who desired the strongest side to win as soon as possible
and leave them in safety. There was much discontent on the part of
others who had supported the Confederacy for a while, but who, for
various reasons, had fallen away from the cause and now wanted
peace and reunion. There was a very large element of outright
lawlessness in the opposition to the Confederate government. The
lowest class of men on both sides or of no side united to plunder
that defenceless land between the two armies. This class wanted no
peace, for on disorder they thrived. For years after the war ended
they gave trouble to Federal and state authorities. The discontent
was actively manifested by civilians, deserters, “mossbacks,” “bomb-
proofs,” and “feather beds.” These had never strongly supported the
Confederacy. It was largely a timid, stay-at-home crowd, with a few
able but erratic leaders. The soldiers may have been dissatisfied,—
many of them were,—and many of them left the army in the spring
of 1865 to go home and plant crops for the relief of their suffering
families. Many of them in the dark days after Nashville and Franklin
took the oath of allegiance and went home, sure that the war was
ended and the cause was lost. Yet these were not the ones found in
such organizations as the Peace Society. That was largely made up
of people whom the true soldier despised as worthless. There were
few soldiers in the peace movement and these only at the last.
The peace party, however, was strong in one way. All were voters
and, being at home, could vote. The soldiers in the army had no
voice in the elections. The malcontents, had they possessed courage
and good leaders, could have controlled the state after the summer
of 1864. The able men in the movement were not those who
inspired confidence in their followers. There were no troops in the
state to keep them down, and the only check seems to have been
their fear of the soldiers, who were fighting at the front, in the
armies of Lee and Johnston, of Wheeler and Hood and Taylor. They
were certainly afraid of the vengeance of these soldiers.[349] It was
much better that the war resulted in the complete destruction of the
southern cause, leaving no questions for future controversy, such as
would have arisen had the peace party succeeded in its plans.

CHAPTER IV

ECONOMIC AND SOCIAL CONDITIONS

Sec. 1. Industrial Development during the War

Early in the war the blockade of the southern ports became so
effective that the southern states were shut off from their usual
sources of supply by sea. Trade through the lines between the
United States and the Confederate States was forbidden, and
Alabama, owing to its central location, suffered more from the
blockade than any other state. For three years the Federal lines
touched the northern part of the state only, and, as no railroads
connected north and south Alabama, contraband trade was difficult
in that direction. Mobile, the only port of the state, was closely
blockaded by a strong Federal fleet. The railroad communications
with other states were poor, and the Confederate government
usually kept the railroads busy in the public service. Consequently,
the people of Alabama were forced to develop certain industries in
order to secure the necessaries of life. But outside these the
industrial development was naturally in the direction of the
production of materials of war.
 Military Industries
During the first two years of the war volunteers were much more
plentiful than equipment. The arms seized at Mount Vernon and
other arsenals in Alabama were old flint-locks altered for the use of
percussion caps and were almost worthless, being valued at $2
apiece. These were afterwards transferred to the Confederate
States, which returned but few of them to arm the Alabama troops.
[350] Late in 1860 a few thousand old muskets were purchased by
the state from the arsenal at Baton Rouge, Louisiana, for $2.50
each. A few Mississippi rifles were also secured, and with these the
Second Alabama Infantry was armed. These rifles, however, required
a special kind of ammunition, and this made them almost worthless.
Other arms were found to be useless for the same reason. Both
cavalry and infantry regiments went to the front armed with single
and double barrelled shot-guns, squirrel rifles, muskets, flint-locks,
and old pistols. No ammunition could be supplied for such a
miscellaneous collection. Many regiments had to wait for months
before arms could be obtained. Before October, 1861, several
thousand men had left Alabama unarmed, and several thousand
more, also unarmed, were left waiting in the state camps.[351] In
1861 the state legislature bought a thousand pikes and a hundred
bowie-knives to arm the Forty-eighth Militia Regiment, which was
defending Mobile. The sum of $250,000 was appropriated to lend to
those who would manufacture firearms for the government.[352] In
1863 the Confederate Congress authorized the enlistment of
companies armed with pikes who should take the places of men
armed with firearms when the latter were dead or absent.[353]
Private arms—muskets, rifles, pistols, shot-guns, carbines—were
called for and purchased from the owners when not donated.[354] An
offer was made to advance fifty per cent of the amount necessary to
set up machinery for the manufacture of small arms.[355] Old
Spanish flint-lock muskets were brought in from Cuba through the
blockade, altered, and placed in the hands of the troops.[356]
 Larger Image

In 1862 a small-arms factory was established at Tallassee which

employed 150 men and turned out about 150 carbines a week. At
the end of 1864 it had produced only 6000.[357] At Montgomery the
Alabama Arms Manufacturing Company had the best machinery in
the Confederacy for making Enfield rifles. At Selma were the state
and Confederate arsenals, a navy-yard, and naval foundry with
machinery of English make, of the newest and most complete
pattern. It had been brought through the blockade from Europe and
set up at Selma because that seemed to be a place safe from
invasion and from the raids of the enemy. Here the vessels for the
defence of Mobile were built, heavy ordnance was cast, with shot
and shell, and plating for men-of-war. The armored ram Tennessee,
famous in the fight in Mobile Bay, the gunboats Morgan, Selma, and
Gaines were all built at the Selma navy-yard—guns, armor, and
everything being manufactured on the spot. When the Tennessee
surrendered, after a terrible battle, its armor had not been
penetrated by a single shot or shell. The best cannon in America
were cast at the works in Selma. The naval foundry employed 3000
men, the other works as many more. Half the cannon and two-thirds
of the fixed ammunition used during the last two years of the war
were made at these foundries and factories. The foundry destroyed
by Wilson was pronounced by experts to be the best in existence. It
could turn out at short notice a fifteen-inch Brooks or a mountain
howitzer. Swords, rifles, muskets, pistols, caps, were manufactured
in great quantities. There were more than a hundred buildings,
which covered fifty acres; and after Wilson’s destructive work,
Truman, the war correspondent, said that they presented the
greatest mass of ruins he had ever seen.[358] There was a navy-yard
on the Tombigbee, in Clarke County, near the Sunflower Bend.
Several small vessels had been completed and several war vessels,
probably gunboats, were in process of construction here when the
war ended; both vessels and machinery were destroyed by order of
the Confederate authorities.[359]
Gunpowder was scarce throughout the war, and nitre or saltpetre, its
principal ingredient, was not to be purchased from abroad. A powder
mill was established at Cahaba,[360] but the ingredients were lacking.
Charcoal for gunpowder was made from willow, dogwood, and
similar woods. The nitre on hand was soon exhausted, and it was
sought for in the caves of the limestone region of Alabama and
Tennessee. In north Alabama there were many of these large caves.
The earth in them was dug up and put in hoppers and water poured
over it to leach out the nitre. The lye was caught (just as for making
soft soap from lye ashes), boiled down, and then dried in the
sunshine.[361] The earth in cellars and under old houses was scraped
up and leached for the nitre in it. In 1862 a corps of officers under
the title of the Nitre and Mining Bureau[362] was organized by the
War Department to work the nitre caves of north Alabama which lay
in the doubtful region between the Union and the Confederate lines,
and which were often raided by the enemy. The men were subjected
to military discipline and were under the absolute command of the
superintendent, who often called them out to repulse Federal
raiders. As much as possible in this department, as in the others,
exempts and negroes were used for laborers. For clerical work those
disabled for active service were appointed, and instructions were
issued that employment should be given to needy refugee women.
[363] These important nitre works were repeatedly destroyed by the
Federals, who killed or captured many of the employees.[364] In the
district of upper Alabama, under the command of Captain William
Gabbitt, whose headquarters were at Blue Mountain (now Anniston),
most of the work was done in the limestone caves of the mountain
region.[365] Several hundred men—whites and negroes—were
employed in extracting the nitre from the cave earth. To the end of
September, 1864, this district had produced 222,665 pounds of nitre
at a cost of $237,977.17, war prices.[366]
The supply from the caves proved insufficient, and artificial nitre
beds or nitraries were prepared in the cities of south and central
Alabama. It was necessary to have them near large towns, in order
to obtain a plentiful supply of animal matter and potash, and the
necessary labor. Efforts were also made to induce planters in marl or
limestone counties to work plantation earth.[367] Under the
supervision of Professor W. H. C. Price, nitraries were established at
Selma, Mobile, Talladega, Tuscaloosa, and Montgomery. Negro labor
was used almost entirely, each negro having charge of one small
nitre bed. To October, 1864, the nitraries of south Alabama produced
34,716 pounds at a cost of $26,171.14, which was somewhat
cheaper than the nitre from the caves. From these nitraries better
results were obtained than from the French, Swedish, and Russian
nitraries which served as models. The Confederate nitre beds were
from sixteen to twenty-seven months old in October, 1864, and
hence not at their best producing stage. Yet, allowing for the
difference in age, they gave better results, as they produced from
2.57 to 3.3 ounces of nitre per cubic foot, while the average
European nitraries at four years of age gave 4 ounces per cubic foot.
Earth from under old houses and from cellars produced from 2 to 4
ounces to the cubic foot. Nitre caves produced from 6 to 12 ounces
per cubic foot. Most of the nitre thus obtained was made into
powder at the mills in Selma. There were some private
manufacturers of nitre, and to encourage these the Confederate
Congress authorized the advance to makers of fifty per cent of the
cost of the necessary machinery.[368]
The state legislature appropriated $30,000 to encourage the
manufacture and preparation of powder, saltpetre (nitre), sulphur,
and lead. Little of the last article was found in Alabama.[369] Some of
the powder works were in operation as early as 1861, and in that
year the War Department gave Dr. Ullman of Tallapoosa a contract to
supply 1000 to 1500 pounds of sulphur a day.[370]
The Confederate Nitre and Mining Bureau had charge of the
production of iron in Alabama for the use of the Confederacy. The
mines were principally in the hilly region south of the Tennessee
River, where several furnaces and iron works were already
established before the war. Two or three new companies, with
capital of $1,000,000 each, had bought mineral lands and had
commenced operations when the war broke out. The Confederate
government bought the property or gave the companies financial
assistance. The iron district was often raided by the Federals, who
blew up the furnaces and wrecked the iron works.[371] The Irondale
works, near Elyton, were begun in 1862, and made much iron, but
they also were destroyed in 1864 by the Federals.[372] Other large
iron furnaces, with their forges, foundries, and rolling-mills, were
destroyed by Rousseau’s raid in 1864. The government employed
several hundred conscripts and several thousand negroes in the
mines and rolling-mills. It also offered fifty per cent of the cost of
equipment to encourage the opening of new mines by private
owners.[373] There is record of only about 15,000 tons of Alabama
iron being mined by the Confederacy, but probably there was much
more.[374] The iron was sent to Selma, Montgomery, and other
places for manufacture. The ordnance cast in Selma was of Alabama
iron; and after the war, when the United States sold the ruins of the
arsenal, the big guns were cut up and sent to Philadelphia. Here the
fine quality of the iron attracted the attention of experts and led to
the development by northern capital of the iron industry in north
Alabama.
The Confederate government encouraged the building and extension
of railroads, and paid large sums to them for the transportation of
troops, munitions of war, and military supplies.[375] Several lines of
road within the state were made military roads, and the government
extended their lines, built bridges and cars, and kept the lines in
repair.[376] In 1862 $150,000 was advanced to the Alabama and
Mississippi Railway Company, to complete the line between Selma
and Meridian,[377] and the duty on iron needed for the road was
remitted.[378] On June 25 of this year this road was seized by the
military authorities in order to finish it,[379] and because of the lack
of iron D. H. Kenny was directed (July 21, 1863) to impress the iron
and rolling stock belonging to the Alabama and Florida Railway, the
Gainesville Branch of the Mobile and Ohio, the Cahaba, Marion, and
Greensborough Railroad, and the Uniontown and Newberne
Railroad. The Alabama and Mississippi road was a very important
line, since it tapped the supply districts of Mississippi and the Black
Belt of Alabama. There were many difficulties in the way of the
builders. In 1862 the locomotives were wearing out and no iron was
to be obtained. In the fall of the same year the planters withdrew
their negroes who were working on the road, and left the bridges
half finished. But finally, in December, 1862, the road was
completed.[380] In the fall of 1862 a road between Blue Mountain,
Alabama, and Rome, Georgia, was planned, and $1,122,480.92 was
appropriated by the Confederate Congress, a mortgage being taken
as security.[381] This road was graded and some bridges built and
iron laid, but was not in running order before the end of the war.
Telegraph lines, which had been few before the war, were now
placed along each railroad, and several cross-country lines were put
up. The first important new line was along the Mobile and Ohio
Railroad, from Mobile to Meridian.[382]

Private Manufacturing Enterprises

Both the state and the Confederate government encouraged
manufactures by favorable legislation. The Confederate government
was always ready to advance half of the cost of the machinery and
to take goods in payment. A law of Alabama in 1861 secured the
rights of inventors and authors. All patents under the United States
laws prior to January 11, 1861, were to hold good under the state
laws, and the United States patent and copyright laws were adopted
for Alabama.[383] Later, jurisdiction over patents, inventions, and
copyrights was transferred to the Confederate government. A bonus
of five and ten cents apiece on all cotton and wool cards made in
Alabama was offered by the legislature in December, 1861.[384] All
employees in iron mills, in foundries, and in factories supplying the
state or Confederate governments with arms, clothing, cloth, and
the like were declared by the state exempt from military duty.
Factories were soon in operation all over the state, especially in
central Alabama. In all places where there were government
factories there also were found factories conducted by private
individuals. In 1861 there were factories at Tallassee, Autaugaville,
and Prattville, with 23,000 spindles and 800 employees, which could
make 5000 yards of good tent cloth a day.[385] And other cotton mills
were established in north Alabama as early as 1861.[386] The
Federals burned these buildings and destroyed the machinery in
1862 and 1863. There was the most “unsparing hostility displayed
by the northern armies to this branch of industry. They destroyed
instantly every cotton factory within their reach.”[387]
At Tuscaloosa were cotton and shoe factories, tanneries, and an iron
foundry. A large cotton factory was established in Bibb County, and
at Gainesville there were workshops and machine-shops. In addition
to the government works, Selma had machine-shops, car shops, iron
mills, and foundries, cotton, wool, and harness factories, conducted
by private individuals. There were cotton and woollen factories at
Prattville and Autaugaville, and at Montgomery were car shops,
harness shops, iron mills, foundries, and machine-shops. The best
tent cloth and uniform cloth was made at the factories of Tallassee.
The state itself began the manufacture of shoes, salt, clothing,
whiskey, alcohol, army supplies, and supplies for the destitute.[388]
Extensive manufacturing establishments of various kinds in Madison,
Lauderdale, Tuscumbia, Bibb, Autauga, Coosa, and Tallapoosa
counties were destroyed during the war by the Federals. There were
iron works in Bibb, Shelby, Calhoun, and Jefferson counties, and in
1864 there were a dozen large furnaces with rolling-mills and
foundries in the state.[389] However, in that year the governor
complained that though Alabama had immense quantities of iron
ore, even the planters in the iron country were unable to get
sufficient iron to make and mend agricultural implements, since all
iron that was mined was used for purposes of the Confederacy.[390]
The best and strongest cast iron used by the Confederacy was made
at Selma and at Briarfield. The cotton factories and tanneries in the
Tennessee valley were destroyed in 1862 by the Federal troops.[391]

Salt Making
Salt was one of the first necessaries of life which became scarce on
account of the blockade. The Adjutant and Inspector-General of
Alabama stated, March 20, 1862, that the Confederacy needed
6,000,000 bushels of salt, and that only an enormous price would
force the people to make it. In Montgomery salt was then very
scarce, bringing $20 per sack, and speculators were using every trick
and fraud in order to control the supply.[392] The poor people
especially soon felt the want of it, and in November, 1861, the
legislature passed an act to encourage the manufacture of salt at the
state reservation in Clarke County.[393] The state government even
began to make salt at these salt springs. At the Upper Works, near
Old St. Stephens, 600 men and 120 teams were employed at 30
furnaces, which were kept going all the time, the production
amounting to 600 bushels a day. These works were in operation
from 1862 to 1865. The Lower Works, near Sunflower Bend on the
Tombigbee River, for four years employed 400 men with 80 teams at
20 furnaces. The production here was about 400 bushels a day. The
Central Works, near Salt Mountain, were under private management,
and, it is said, were much more successful than the works under
state management.[394] The price of salt at the works ranged from
$2.50 to $7 a bushel in gold, or from $3 to $40 in currency. From
1861 to 1865, 500,000 bushels of good salt were produced each
year.
To obtain the salt water, wells were bored to depths ranging from 60
to 100 feet,—one well, however, was 600 feet deep,—while in the
bottom or swamp lands brine was sometimes found at a depth of 8
feet. The water at first rose to the surface and overflowed about 30
gallons a minute in some wells, but as more wells were sunk the
brine ceased to flow out and had to be pumped about 16 feet by
steam or horse power. It was boiled in large iron kettles like those
then used in syrup making and which are still seen in remote
districts in the South. Seven or eight kettles of water would make
one kettle of salt. This was about the same percentage that was
obtained at the Onondaga (New York) salt springs. About the same
boiling was required as in making syrup from sugar-cane juice. The
wells were scattered for miles over the country and thousands of
men were employed. For three years more than 6000 men, white
and black, were employed at the salt works of Clarke County, from
2000 to 3000 working at the Upper Works alone. All were not at
work at the furnaces, but hundreds were engaged in cutting and
hauling wood for fuel, and in sacking and barrelling salt. It is said
that in the woods the blows of no single axe nor the sound of any
single falling tree could be distinguished; the sound was simply
continuous. Nine or ten square miles of pine timber were cleared for
fuel.
The salt was sent down the Tombigbee to Mobile or conveyed in
wagons into the interior of Alabama, Mississippi, and Georgia. These
wagons were so numerous that for miles from the various works it
was difficult to cross the road. The whole place had the appearance
of a manufacturing city. These works had been in operation to some
extent since 1809. The wells were exhausted from 1865 to 1870,
when they began flowing again.
Besides the smaller works and large private works there were
hundreds of smaller establishments. When salt was needed on a
plantation in the Black Belt, the overseer would take hands, with
pots and kettles, and go to the salt wells, camp out for several
weeks, and make enough salt for the year’s supply. All private
makers had to give a certain amount to the state.[395] People from
the interior of the state and from southeast Alabama went to the
Florida coast and made salt by boiling the sea water. The state had
salt works at Saltville, Virginia, but found it difficult to get
transportation for the product. Salt was given to the poor people by
the state, or sold to them at a moderate price. The legislature
authorized the governor to take possession of all salt when
necessary for public use, paying the owners a just compensation;
$150,000 was appropriated for this purpose in 1861, and in 1862 it
was made a penal offence to send salt out of the state.[396] A Salt
Commission was appointed to look after the salt works owned by the
state in Louisiana. A private salt maker in Clarke County made a
contract to deliver two-fifths of his product to the state at the cost of
manufacture, and the state purchased some salt from the Louisiana
saltbeds.[397] As salt became scarcer the people took the brine in old
pork and beef barrels and boiled it down. The soil under old smoke-
houses was dug up, put in hoppers, and bleached like ashes, and
the brine boiled down and dried in the sunshine.[398]
At Bon Secour Bay, near Mobile, there were salt works consisting of
fifteen houses, capable of making seventy-five bushels per day from
the sea-water. In 1864 these were burned by the Federals, who
often destroyed the salt works along the Florida coast.[399] At
Saltmarsh, ten miles west of Selma, there were works which
furnished much of the salt used in Mississippi, central Alabama, and
east Georgia during the years 1862, 1863, and 1864. Wells were dug
to the depth of twelve or fifteen feet, when salt water was struck.
The wells were then curbed, furnaces of lime rock were built, and
upon them large kettles were placed. The water was pumped from
the wells and run into the kettles through troughs, then boiled down,
and the moisture evaporated by the sun. The fires were kept up day
and night. A large number of blacks and whites were employed at
these wells, and, as salt makers were exempt from military duty, the
work was quite popular.[400]
Besides the industries above mentioned there were many minor
enterprises. Household manufactures were universal. The more
important companies were chartered by the legislature. The acts of
the war period show that in 1861 there were incorporated six
insurance companies and the charters of others were amended to
suit the changed conditions; three railroad companies were
incorporated, and aid was granted to others for building purposes.
Roads carrying troops and munitions free were exempted from
taxation. Two mining and manufacturing companies were
incorporated, four iron and coal companies, one ore foundry, an
express company,[401] a salt manufacturing company, a chemical
manufacturing company, a coal and leather company, and a wine
and fruit company. In 1862 the legislature incorporated four iron and
foundry companies, a railroad company, the Southern Express
Company, a gas-light company, six coal and iron companies, a
rolling-mill, and an oil company, and amended the charters of four
railroad companies and two insurance companies. In 1864 two
railroad companies were given permission to manufacture alcohol
and lubricating oil, and the Citronelle Wine, Fruit, and Nursery
Company was incorporated. Various other manufacturing companies
—of drugs, barrels, and pottery—were established.
Besides salt the state made alcohol and whiskey for the poor. Every
man who had a more than usual regard for his comfort and wanted
to keep out of the army had a tannery in his back yard, and made a
few shoes or some harness for the Confederacy, thus securing
exemption.
Governor Moore, in his message to the legislature on October 28,
1861, said: “Mechanical arts and industrial pursuits, hitherto
practically unknown to our people, are already in operation. The
clink of the hammer and the busy hum of the workshop are
beginning to be heard throughout our land. Our manufactories are
rapidly increasing and the inconvenience which would result from
the continuance of the war and the closing of our ports for years
would be more than compensated by forcing us to the development
of our abundant resources, and the tone and the temper it would
give to our national character. Under such circumstances the return
of peace would find us a self-reliant and truly independent
people.”[402] And had the war ended early in 1864, the state would
have been well provided with manufactures.
The raids through the state in 1864 and 1865 destroyed most of the
manufacturing establishments. The rest, whether owned by the
government or private persons, were seized by the Federal troops at
the surrender and were dismantled.[403]

Sec. 2. Confederate Finance in Alabama

Banks and Banking
In a circular letter dated December 4, 1860, and addressed to the
banks, Governor Moore announced that should the state secede
from the Union, as seemed probable, $1,000,000 in specie, or its
equivalent, would be needed by the administration. The state bonds
could not be sold in the North nor in Europe, except at a ruinous
discount, and a tax on the people at this time would be inexpedient.
Therefore he recommended that the banks hold their specie.
Otherwise there would be a run on the banks, and should an extra
session of the legislature be called to authorize the banks to suspend
specie payments, such action would produce a run and thus defeat
the object. He requested the banks to suspend specie payments,
trusting to the convention to legalize this action.[404] The governor
then issued an address to the people stating his reasons for such a
step. It was done, he said, at the request and by the advice of many
citizens whose opinions were entitled to respect and consideration.
Such a course, they thought, would relieve the banks from a run
during the cotton season, would enable them to aid the state, would
do away with the expense of a special session of the legislature,
would prevent the sale of state bonds at a great sacrifice, and would
prevent extra taxation of the people in time of financial crisis.[405]
Three banks—the Central, Eastern, and Commercial—suspended at
the governor’s request and made a loan to the state of $200,000 in
coin. Their suspension was legalized later by an ordinance of the
convention. The Bank of Mobile, the Northern Bank, and the
Southern Bank refused to suspend, though they announced that the
state should have their full support. The legislature passed an act in
February, 1861, authorizing the suspension on condition that the
banks subscribe for ten year state bonds at their par value. The
bonds were to stand as capital, and the bills issued by the banks
upon these bonds were to be receivable in payment of taxes. The
amount which each bank was to pay into the treasury for the bonds
was fixed, and no interest was to be paid by the state on these
bonds until specie payments were resumed. All the banks suspended
under these acts, and thus the government secured most of the coin
in the state.[406] In October, 1861, before all the banks had
suspended, state bonds at par to the amount of $975,066.68 had
been sold—all but $28,500 to the banks. By early acts specie
payments were to be resumed in May, 1862, but in December, 1861,
the suspension was continued until one year after the conclusion of
peace with the United States. By this law the banks were to receive
at par the Confederate treasury notes in payment of debts, their
notes being good for public dues. The banks were further required
to make a loan to the state of $200,000 to pay its quota of the
Confederate war tax of August 16, 1861. So the privilege of
suspension was worth paying for.[407]
The banking law was revised by the convention so that a bank might
deposit with the state comptroller stocks of the Confederate States
or of Alabama, receiving in return notes countersigned by the
comptroller amounting to twice the market value of the bonds
deposited. If a bank had in deposit with the comptroller under the
old law any stocks of the United States, they could be withdrawn
upon the deposit of an equal amount of Confederate stocks or bonds
of the state. The same ordinance provided that none except citizens
of Alabama and members of state corporations might engage in the
banking business under this law. But no rights under the old law
were to be affected. It was further provided that subsequent
legislation might require any “free” bank to reduce its circulation to
an amount not exceeding the market value of the bonds deposited
with the comptroller. The notes thus retired were to be cancelled by
the comptroller.[408] The suspension of specie payments was
followed by an increase of banking business; note issues were
enlarged; eleven new banks were chartered,[409] and none wound
up affairs. They paid dividends regularly of from 6 to 10 per cent in
coin, in Confederate notes, or in both. Speculation in government
funds was quite profitable to the banks.

Issues of Bonds and Notes

The convention authorized the general assembly of the state to issue
bonds to such amounts and in such sums as seemed best, thus
giving the assembly practically unlimited discretion. But it was
provided that money must not be borrowed except for purposes of
military defence, unless by a two-thirds vote of the members elected
to each house; and the faith and credit of the state was pledged for
the punctual payment of the principal and interest.[410]
The legislature hastened to avail itself of this permission. In 1861 a
bond issue of $2,000,000 for defence, and not liable to taxation, was
authorized at one time; at another, $385,000 for defence, besides an
issue of $1,000,000 in treasury notes receivable for taxes. Of the
first issue authorized, only $1,759,500 were ever issued. Opposition
to taxation caused the state to take up the war tax of $2,000,000
(August 19, 1861), and for this purpose $1,700,000 in bonds was
issued, the banks supplying the remainder. There was a relaxation in
taxation during the war; paper money was easily printed, and the
people were opposed to heavy taxes.[411]
In 1862 bonds to the amount of $2,000,000 were issued for the
benefit of the indigent. The governor was given unlimited authority
to issue bonds and notes, receivable for taxes, to “repair the
treasury,” and $2,085,000 in bonds were issued under this permit.
These bonds drew interest at 6 per cent, ran for twenty years, and
sold at a premium of from 50 per cent to 100 per cent. Bonds were
used both for civil and for military purposes, but chiefly for the
support of the destitute. Treasury notes to the amount of
$3,500,000 were issued, drawing interest at 5 per cent, and
receivable for taxes. The Confederate Congress came to the aid of
Alabama with a grant of $1,200,000 for the defence of Mobile.[412]
In 1863 notes and bonds for $4,000,000 were issued for the benefit
of indigent families of soldiers, and $1,500,000 for defence; $90,000
in bonds was paid for the steamer Florida, which was later turned
over to the Confederate government.[413] In 1864 $7,000,000 was
appropriated for the support of indigent families of soldiers, and an
unlimited issue of bonds and notes was authorized.[414] In 1862 the
Alabama legislature proposed that each state should guarantee the
debt of the Confederate States in proportion to its representation in
Congress. This measure was opposed by the other states and failed.
[415] A year later a resolution of the legislature declared that the
people of Alabama would cheerfully submit to any tax, not too
oppressive in amount or unequal in operation, laid by the
Confederate government for the purpose of reducing the volume of
currency and appreciating its value. The assembly also signified its
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