The requirements of a specialist Breast Centre

INTRODUCTION

In recognition of the advances and evidence based changes in clinical practice that have occurred in recent years and taking into account the knowledge and experience accumulated through the voluntary breast unit certification programme, Eusoma has produced this up-dated and revised guidelines on the requirements of a Specialist Breast Centre (BC).

METHODS

The content of these guidelines is based on evidence from the recent relevant peer reviewed literature and the consensus of a multidisciplinary team of European experts. The guidelines define the requirements for each breast service and for the specialists who work in specialist Breast Centres.

RESULTS

The guidelines identify the minimum requirements needed to set up a BC, these being an integrated Breast Centre, dealing with a sufficient number of cases to allow effective working and continuing expertise, dedicated specialists working with a multidisciplinary approach, providing all services throughout the patients pathway and data collection and audit. It is essential that the BC also guarantees the continuity of care for patients with advanced (metastatic) disease offering treatments according to multidisciplinary competencies and a high quality palliative care service. The BC must ensure that comprehensive support and expertise may be needed, not only through the core BC team, but also ensure that all other medical and paramedical expertise that may be necessary depending on the individual case are freely available, referring the patient to the specific care provider depending on the problem.

CONCLUSIONS

Applying minimum requirements and quality indicators is essential to improve organisation, performance and outcome in breast care. Efficacy and compliance have to be constantly monitored to evaluate the quality of patient care and to allow appropriate corrective actions leading to improvements in patient care.

[Quality of conventional PAP smears. Quality assessment and motivation for improvement]

The success of cytology in screening programs for cervical cancer is highly dependent on the smear quality. Interdisciplinary projects which evaluate the smear quality and the results of collection devices could be helpful for an improvement and a successful example for quality improvement is presented here. An average of 83% technically adequate and representative smears was documented for 12 million conventional PAP smears; however only an average of 68% technically adequate and representative smears was found for the group of least successful smear takers of all laboratories. This indicates a potential for improvement. Following an interdisciplinary project on smear quality improvement the average rate of representative smears increased from 69 to 83% and in another project this rate remained stable at 86%. Based on 158,411 conventional smears, representative smears were achieved in 92% using Cervex-Brush®, 86% using Szalay Spatula and 82% Cytobrush methods. The combinations of Cytobrush with the Ayre wooden spatula, cotton wool swab or Szalay Spatula achieved 97%, 94% and 92% representative smears, respectively.

An automated approach for three-dimensional quantification of fibrillar structures in optically cleared soft biological tissues

We present a novel approach allowing for a simple, fast and automated morphological analysis of three-dimensional image stacks (z-stacks) featuring fibrillar structures from optically cleared soft biological tissues. Five non-atherosclerotic tissue samples from human abdominal aortas were used to outline the multi-purpose methodology, applicable to various tissue types. It yields a three-dimensional orientational distribution of relative amplitudes, representing the original collagen fibre morphology, identifies regions of isotropy where no preferred fibre orientations are observed and determines structural parameters throughout anisotropic regions for the analysis and numerical modelling of biomechanical quantities such as stress and strain. Our method combines optical tissue clearing with second-harmonic generation imaging, Fourier-based image analysis and maximum-likelihood estimation for distribution fitting. With a new sample preparation method for arteries, we present, for the first time to our knowledge, a continuous three-dimensional distribution of collagen fibres throughout the entire thickness of the aortic wall, revealing novel structural and organizational insights into the three arterial layers.

International multicenter tool to predict the risk of nonsentinel node metastases in breast cancer

BACKGROUND

Axillary treatment of breast cancer patients is undergoing a paradigm shift, as completion axillary lymph node dissections (ALNDs) are being questioned in the treatment of patients with tumor-positive sentinel nodes. This study aims to develop a novel multi-institutional predictive tool to calculate patient-specific risk of residual axillary disease after tumor-positive sentinel node biopsy.

METHODS

Breast cancer patients with a tumor-positive sentinel node and a completion ALND from five European centers formed the original patient series (N = 1000). Statistically significant variables predicting nonsentinel node involvement were identified in logistic regression analysis. A multivariable predictive model was developed and validated by area under the receiver operating characteristics curve (AUC), first internally in 500 additional patients and then externally in 1068 patients from other centers. All statistical tests were two-sided.

RESULTS

Nine tumor- and sentinel node-specific variables were identified as statistically significant factors predicting nonsentinel node involvement in logistic regression analysis. A resulting predictive model applied to the internal validation series resulted in an AUC of 0.714 (95% confidence interval [CI] = 0.665 to 0.763). For the external validation series, the AUC was 0.719 (95% CI = 0.689 to 0.750). The model was well calibrated in the external validation series.

CONCLUSIONS

We present a novel, international, multicenter, predictive tool to assess the risk of additional axillary metastases after tumor-positive sentinel node biopsy in breast cancer. The predictive model performed well in internal and external validation but needs to be further studied in each center before application to clinical use.

Analysis of functional germline polymorphisms for prediction of response to anthracycline-based neoadjuvant chemotherapy in breast cancer

To elucidate the role of predictive factors on individual's drug response, based on genetic variation, we examined the association between eight germline polymorphisms in genes involved in protection against oxidative stress, apoptosis, oncogenic transformation, proliferation, immune response and DNA repair (TP53, NQO1, IL6, TLR4 and XRCC1) and the pathological response to anthracycline-based neoadjuvant chemotherapy in 70 patients with breast cancer. The DNA was genotyped for eight polymorphisms in five genes (TP53, NQO1, IL6, TLR4 and XRCC1) by 5'-exonuclease (TaqMan™) technology. Fisher's exact test was used to evaluate the association between genotype, clinicopathological parameters and pathological response. A good pathological response, defined as a pathological complete response or residual isolated invasive tumor cells, was found significantly more frequently for estrogen (ER) and progesterone receptor (PR) negative breast carcinomas compared to ER and PR positive and ER or PR positive carcinomas, respectively (43.5 vs. 37.5 and 10.3 %, p = 0.006), and was significantly associated with high tumor grade (G3) (p = 0.002). A non-significant trend towards a good pathological response was shown in patients carrying the Arg/Arg or Arg/Pro TP53 codon 72 gene variant compared to those harboring the Pro/Pro variant (17.6 or 37.9 % vs. 0; p = 0.071). No association was found between NQO1 Pro187Ser, IL6 -174G>C, TLR4 Asp299Gly and Thr399Ile, and XRCC1 Arg194Trp, Arg399Gln and Arg280His and pathological response. The present study shows hormone receptor status and tumor grade as predictors for pathological response to neoadjuvant anthracycline-based chemotherapy. Among various functional germline polymorphisms, a potential predictive value was only found for the TP53 Arg72Pro gene variant.

Progression of genomic signatures in local and metastatic estrogen receptor-positive (ER+) breast cancer: Relevance to palliative treatment

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Background: Biological progression of ER+ breast cancer accelerates clinical progression and resistance to treatments. Methods: One laboratory used Affymetrix U133A gene expression microarrays to profile 588 biopsy samples from patients with ER+ breast cancer: 74 AJCC Stage I, 155 Stage IIA, 105 Stage IIB, 127 Stage III, 127 Stage IV (27 at presentation, 100 relapsed). We evaluated stage dependence of ER [ESR1, PGR, sensitivity to endocrine therapy (SET) index], proliferation [MKI67, AURKA, genomic grade index (GGI)], invasion [PLAU (uPA)], PI3-kinase (PIK3CA-GS), VEGF, genomic subtype [PAM50, 3-gene classifier (ESR1, ERBB2, AURKA)], and housekeeper control genes. Significance was evaluated through ordinal median regression (P < 0.002, for multiple testing) after adjusting for staging method (clinical or pathologic). Exploratory Cox regression analyses of progression-free survival (PFS) and overall survival (OS) were performed when treatment was hormonal therapy (HT, N=58) or chemotherapy (CT, N=27) after biopsy of metastatic ER+ breast cancer (MBC). Results: Stage progression was associated with reduced SET index and increased proliferation (GGI, MKI67, AURKA) and metabolism (GAPDH). These changes occurred between Stages IIB and III, and Stages III and IV. Luminal B and proliferation subtypes were more prevalent in Stage IV and less in Stage I. Interestingly, invasion (PLAU) genes were lower in MBC. Only SET index demonstrated a significant interaction with treatment (HT or CT) for MBC (PFS: p=0.018). SET was predictive of PFS and OS following HT, as a continuous score (PFS: HR=0.69, 95%CI 0.49 to 0.97, p=0.035; OS: HR=0.61, 95%CI 0.40 to 0.94, p=0.025) or dichotomized at median value (PFS: HR=0.43, 95%CI 0.24 to 0.76, p=0.003; OS: HR=0.37, 95%CI 0.18 to 0.77, p=0.006). Genomic subtype was prognostic for PFS irrespective of treatment type. High PIK3CA-GS expression predicted OS in the HT subset. Conclusions: Stage progression was associated with decreased ER-related transcription (SET) and increased proliferation, grade, higher risk subtype, and metabolism. In MBC samples, only SET index was predictive of PFS and OS with palliative hormonal therapy.

Layer-specific damage experiments and modeling of human thoracic and abdominal aortas with non-atherosclerotic intimal thickening

Many treatments for cardiovascular diseases include an endovascular insertion of stents or stent grafts into arteries, a procedure which may cause high tissue stresses and even damage in the arterial wall. In order to study such problems by using finite element methods, both appropriate constitutive models and experimental data on human tissue samples are required. Layer-specific experimental data for human tissue tested up to the supra-physiological loading range are rare in the literature. In this study, intact and layer-separated experimental data from uniaxial extension tests are presented for human thoracic and abdominal aortas with non-atherosclerotic intimal thickening undergoing supra-physiological loading. A novel pseudo-elastic damage model, proposed to describe discontinuous softening in aortic arterial tissues, is fit to the obtained experimental data. Fitting of the model with and without consideration of damage accumulation in the non-collagenous matrix material reveals that tissue damage is primarily related to the collagen fiber fabric. By employing the fit model, the effect of aortic tissue pre-conditioning on the material parameters from the resulting data fits is evaluated. Histological examination of the collagen fibers under different applied stretches is used to gain more insights into the structural changes of the tissue under supra-physiological loading.

P5-11-15: Should HER-2 Score 0/1+ Breast Cancer Cases Be Retested by In-Situ Hybridisation? Results of a Multicenter Retesting Study

Background: HER-2 status is vital for selection of appropriate therapy for breast cancer patients. Accuracy of immunohistochemistry (IHC) varies with a major problem of false negative testing. To assess the false negative rate retesting by in situ hybridisation was performed on a group of primary breast cancers in which according to guidelines routine retesting is not recommended.

Material and Methods: 570 breast cancers from 5 pathology departments scored 0/1+ by IHC (HercepTest or 4B5-antibody) were retested by HER2−Dual-SISH (BDISH) in a central laboratory. CAP/ASCO guidelines were applied. Cases showing ratios in the amplified or equivocal range by BDISH were further analysed by fluorescence in situ hybridisation (FISH) using Pathvysion® and ZytoLight® and retested centrally by IHC using 4B5 antibody (Ventana).

Results: 25/570 cases (4.38%) were amplified by BDISH, the majority with low level amplification (ratios ≤ 3.26). Only two cases showed high level ratios (6.35 and 6.48). 17/570 cases (2.98%) showed ratios by BDISH in the equivocal range (1.8 — 2.2). 24 amplified and 17 equivocal cases underwent further retesting. In one case no tumor tissue was available for further testing.

On further testing 17/24 (71%) BDISH-amplified cases showed IHC scores 2+/3+ and 7/24 (29%) cases showed IHC scores 0/1+. Subsequently 3/13 score 2+ cases were amplified by Pathvysion® and 9/13 by ZytoLight®. 3/4 score 3+ cases were amplified by both FISH assays. In case of amplification ratios of BDISH and both FISH assays appeared to be in the same range. Only 2/17 BDISH-equivocal carcinomas were confirmed equivocal by Pathvysion® and 6/17 were confirmed equivocal by ZytoLight®. All other BDISH-equivocal cases were non-amplified by both FISH assays. Discrepant results between different methods could partly be caused by interobserver variability. This question is currently under investigation. Overall, after multistep retesting amplification occurred in only 17 cases (2.98%).

Discussion: Amplification is rare in immunohistochemically HER-2 negative breast carcinomas and occurred predominantly at low level in our study. Low level amplification seemed to be diagnosed more frequently by BDISH compared with FISH. Since clinical data demonstrate a benefit of therapy even in carcinomas with low level amplification the identification of these carcinomas might be of interest.

Conflicts of Interest: The study was supported by Roche Austria GmbH.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-11-15.

Determination of the layer-specific distributed collagen fibre orientations in human thoracic and abdominal aortas and common iliac arteries

The established method of polarized microscopy in combination with a universal stage is used to determine the layer-specific distributed collagen fibre orientations in 11 human non-atherosclerotic thoracic and abdominal aortas and common iliac arteries (63 ± 15.3 years, mean ± s.d.). A dispersion model is used to quantify over 37 000 recorded fibre angles from tissue samples. The study resulted in distinct fibre families, fibre directions, dispersion and thickness data for each layer and all vessels investigated. Two fibre families were present for the intima, media and adventitia in the aortas, with often a third and sometimes a fourth family in the intima in the respective axial and circumferential directions. In all aortas, the two families were almost symmetrically arranged with respect to the cylinder axis, closer to the axial direction in the adventitia, closer to the circumferential direction in the media and in between in the intima. The same trend was found for the intima and adventitia of the common iliac arteries; however, there was only one preferred fibre alignment present in the media. In all locations and layers, the observed fibre orientations were always in the tangential plane of the walls, with no radial components and very small dispersion through the wall thickness. A wider range of in-plane fibre orientations was present in the intima than in the media and adventitia. The mean total wall thickness for the aortas and the common iliac artery was 1.39 and 1.05 mm, respectively. For the aortas, a slight thickening of the intima and a thinning of the media in increasingly distal regions were observed. A clear intimal thickening was present distal to the branching of the celiac arteries. All data, except for the media of the common iliac arteries, showed two prominent collagen fibre families for all layers so that two-fibre family models seem most appropriate.

Cloning and characterisation of GIRK1 variants resulting from alternative RNA editing of the KCNJ3 gene transcript in a human breast cancer cell line

The aim of this study was to investigate the impact of increased mRNA levels encoding GIRK1 in breast tumours on GIRK protein expression. mRNA levels encoding hGIRK1 and hGIRK4 in the MCF7, MCF10A and MDA-MB-453 breast cancer cell lines were assessed and the corresponding proteins detected using Western blots. cDNAs encoding for four hGIRK1 splice variants (hGIRK1a, 1c, 1d and 1e) were cloned from the MCF7 cell line. Subcellular localisation of fluorescence labelled hGIRK1a-e and hGIRK4 and of endogenous GIRK1 and GIRK4 subunits was monitored in the MCF7 cell line. All hGIRK1 splice variants and hGIRK4 were predominantly located within the endoplasmic reticulum. Heterologous expression in Xenopus laevis oocytes and two electrode voltage clamp experiments together with confocal microscopy were performed. Only the hGIRK1a subunit was able to form functional GIRK channels in connection with hGIRK4. The other splice variants are expressed, but exert a dominant negative effect on heterooligomeric channel function. Hence, alternative splicing of the KCNJ3 gene transcript in the MCF7 cell line leads to a family of mRNA's, encoding truncated versions of the hGIRK1 protein. The very high abundance of mRNA's encoding GIRK1 together with the presence of GIRK1 protein suggests a pathophysiological role in breast cancer.

Genomic index of sensitivity to endocrine therapy for breast cancer

PURPOSE

We hypothesize that measurement of gene expression related to estrogen receptor α (ER; gene name ESR1) within a breast cancer sample represents intrinsic tumoral sensitivity to adjuvant endocrine therapy.

METHODS

A genomic index for sensitivity to endocrine therapy (SET) index was defined from genes coexpressed with ESR1 in 437 microarray profiles from newly diagnosed breast cancer, unrelated to treatment or outcome. The association of SET index and ESR1 levels with distant relapse risk was evaluated from microarrays of ER-positive breast cancer in two cohorts who received 5 years of tamoxifen alone as adjuvant endocrine therapy (n = 225 and 298, respectively), a cohort who received neoadjuvant chemotherapy followed by tamoxifen and/or aromatase inhibition (n = 122), and two cohorts who received no adjuvant systemic therapy (n = 208 and 133, respectively).

RESULTS

The SET index (165 genes) was significantly associated with distant relapse or death risk in both tamoxifen-treated cohorts (hazard ratio [HR] = 0.70, 95% CI, 0.56 to 0.88, P = .002; and HR = 0.76, 95% CI, 0.63 to 0.93, P = .007) and in the chemo-endocrine-treated cohort (HR = 0.19; 95% CI, 0.05 to 0.69, P = .011) independently from pathologic response to chemotherapy, but was not prognostic in two untreated cohorts. No distant relapse or death was observed after tamoxifen alone if node-negative and high SET or after chemo-endocrine therapy if intermediate or high SET.

CONCLUSION

The SET index of ER-related transcription predicted survival benefit from adjuvant endocrine therapy, not inherent prognosis. Prior chemotherapy seemed to enhance the efficacy of adjuvant endocrine therapy related to SET index.

Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group

The use of breast magnetic resonance imaging (MRI) is rapidly increasing. EUSOMA organised a workshop in Milan on 20-21st October 2008 to evaluate the evidence currently available on clinical value and indications for breast MRI. Twenty-three experts from the disciplines involved in breast disease management - including epidemiologists, geneticists, oncologists, radiologists, radiation oncologists, and surgeons - discussed the evidence for the use of this technology in plenary and focused sessions. This paper presents the consensus reached by this working group. General recommendations, technical requirements, methodology, and interpretation were firstly considered. For the following ten indications, an overview of the evidence, a list of recommendations, and a number of research issues were defined: staging before treatment planning; screening of high-risk women; evaluation of response to neoadjuvant chemotherapy; patients with breast augmentation or reconstruction; occult primary breast cancer; breast cancer recurrence; nipple discharge; characterisation of equivocal findings at conventional imaging; inflammatory breast cancer; and male breast. The working group strongly suggests that all breast cancer specialists cooperate for an optimal clinical use of this emerging technology and for future research, focusing on patient outcome as primary end-point.

Biaxial mechanical properties of intact and layer-dissected human carotid arteries at physiological and supraphysiological loadings

Specimens of intact wall tubes of human common carotid arteries (CCA), internal carotid arteries (ICA) ( n = 11, age 77.6 yr, SD 6.3), and related adventitia and media-intima tubes are mechanically examined. Cyclic, quasi-static extension-inflation tests at different axial stretches are performed on preconditioned tube specimens. Stress-free configurations show significant stress releases in the circumferential direction of the intact CCA and ICA walls and in the axial directions of the intact CCA walls and the CCA and ICA adventitias. All investigated tissues exhibit strong nonlinear, pseudoelastic mechanical behavior with small hysteresis. The “inversion” feature, where the pressure/axial stretch relationship becomes a vertical line, is found only for intact walls. Axial “inversion stretches” are 1.15 (SD 0.06) for CCA and 1.14 (SD 0.06) for ICA, and related external axial forces are 0.43 N (SD 0.15) and 0.30 N (SD 0.22), respectively. Significant negative correlations between age and axial inversion stretches for CCA ( r = −0.67, P = 0.03) and ICA ( r = −0.29, P = 0.04) are identified. Adventitias are very compliant at low pressures, but change into stiff tubes at high pressures. The burst pressure of the adventitia is beyond 250 kPa. A relatively low burst pressure of ∼60 kPa is found in the media-intima tubes, in which the pressure/circumferential stretch relationships are almost independent of the axial stretches. Stress analyses indicate a high degree of material anisotropy for all investigated tissues. High circumferential and axial stresses occur in the media-intima tubes at physiological conditions. The obtained data are intended to serve for an improvement of constitutive laws, determination of constitutive parameters, and enhancing our knowledge of the mechanical functions of arteries and their associated layers in specific pathophysiological and clinical problems, such as hypertension and angioplasty with stenting.

Granular cell tumour of the breast

Granular cell tumour of the breast (GCTB) is a rare tumour which arises from Schwann cells. It is a largely benign tumour but in extremely rare cases can exhibit malignant characteristics. It poses a particular problem as it's characteristics can mimic breast carcinoma clinically, radiologically and macroscopically. This results in the potential misdiagnosis of breast carcinoma and over treatment of patients. Typically GCTBs are benign, solitary lesions but variations include malignant GCTBs, colocalisation with breast malignancies and multicentricity. These tumours can be investigated using mammography, ultrasound and magnetic resonance imaging. However none of these modalities have yet identified any GCTB specific characteristics. On pathological examination they can be identified using both microscopic and immunohistochemical features. The cells have a distinctive granular eosinophilic cytoplasm associated with typical nuclei and abundant lysosomes. Immunohistochemically they are positive for S100 protein, CD68 and neuron specific endolase (NSE). They are treated with wide local excision and while they may reoccur, are associated with a good prognosis.