The expression of gene transcripts of telomere-associated genes in human breast cancer: correlation with clinico-pathological parameters and clinical outcome

BACKGROUND

Telomerase is a ribonucleoprotein enzyme that synthesises telomeres in human germ cells, embryogenesis and in cancer, maintaining chromosomal length, stability and cellular immortality. The hTERT gene is the rate-limiting determinant of telomerase reactivation during immortalization and malignant transformation. Telomeric DNA-binding proteins have been attracting increasing interest due to their essential role in the regulation of telomeric DNA length and in protecting against chromosomal end-to-end fusion. These proteins include hTR, TRF1, TRF2, TANK1, TANK2, POT1, TIN2, EST1, and TEP. This study represents the first comprehensive investigation of the mRNA expression of key telomere-related genes in human breast cancer.

METHODS

One hundred and twenty seven tumour tissues and 33 normal tissues were analyzed. Levels of transcription of hTERT, hTR, TRF1, TRF2, TANK1, TANK2, POT1, TIN2, EST1, and TEP1 were determined using real-time quantitative PCR. The mRNA expression of these genes was normalized against CK19 and was then analyzed against the pathological parameters and clinical outcome over a 10 year follow up period.

RESULTS

The mRNA expressions of hTERT, hTR, TANK1, EST1, and TEP1 were higher in tumour samples compared with normal breast tissue. This reached statistical significance for EST1 when comparing good prognosis tumours with normal breast tissue (means=11013 vs 1160, P=0.05). Both hTERT and TEP1 levels significantly predicted overall survival (P=0.012 and 0.005 respectively) and disease-free survival (P=0.0011 and 0.01 respectively). The mRNA levels of TANK2 and POT1 were lower in malignant tissues compared with non-malignant breast tissues and this difference reached statistical significance when comparing the levels in normal tissues with those in advanced tumours (P=0.0008 and P=0.038 respectively). Their levels fell further with increasing tumour's stage and were higher in tumours from patients who remained disease free compared with those who developed local recurrence or distant metastasis or died from breast cancer.TRF2 showed a trend similar to that of TANK2 and POT1. Furthermore, there was a highly significant correlation between TANK1 expression and that of hTERT, hTR, TRF1, TRF2 and EST1, (r=0.533, 0.586, 0.608, 0.644 and 0.551 respectively, P<0.001).

CONCLUSIONS

Genes encoding telomere-associated proteins display different patterns of mRNA expression in human breast cancer, and in normal breast tissue, suggesting different and sometimes opposing roles in mammary carcinogenesis. hTERT, hTR, TANK1, EST1 and TEP1 seem to be up-regulated, with hTERT and TEP1 correlating with clinical outcome. Conversely, TANK2 and POT1 transcription levels demonstrate a compelling trend to be lower in malignant tissues and lower still in those patients who develop recurrent disease suggesting that TANK2 and POT1 may act as tumour suppressor genes possibly by negatively regulating telomerase activity.

Management of gynaecomastia: an update

Gynaecomastia, a benign enlargement of the male breast as a result of proliferation of the glandular component, is common, being present in 30-50% of healthy men. It may be an incidental finding, an acute unilateral or bilateral tender breast enlargement or a progressive painless enlargement of the male breast. A general medical history and careful physical examination, looking for features suggestive of breast cancer, often suffice for evaluation in patients without symptoms or those with incidentally discovered breast enlargement. If the gynaecomastia is of recent onset, a more detailed evaluation, including selected laboratory tests to search for an underlying cause is necessary. Treatment depends on the cause: an offending drug may need to be withdrawn or alternatively radiation, surgery and/or medical therapy may be necessary. The use of a combination of surgical excision and liposuction through a periareolar incision represents the surgical approach of choice.

HTERT mRNA expression correlates with matrix metalloproteinase-1 and vascular endothelial growth factor expression in human breast cancer: a correlative study using RT-PCR

BACKGROUND

Telomerase activity has been significantly associated with nodal metastasis and cellular proliferation in human breast cancer, indicating that its degree of expression has some form of vital control over the invasive nature of the malignancy concerned. Of the telomerase subunits, the reverse transcriptase (hTERT) is the main determinant of enzyme activity. Vascular endothelial growth factors (VEGF)-C and (VEGF)-D, matrix metalloprotease type 1 (MMP-1) and protease-activated receptors (PARs) have all been linked to promotion of tumour invasiveness and metastatic dissemination. This study aims to examine the association between hTERT transcription and that of VEGF-D, VEGF-C, MMP-1, PAR1a and PAR1b through a correlative analysis of the mRNA transcripts of these genes in human breast cancer.

MATERIALS AND METHODS

Breast cancer tissues (n = 116) and normal tissues (n-31) were collected immediately after surgery and stored at -80 degrees C until use. The level of hTERT transcripts from the prepared DNA from the above samples was determined using real time-quantitative PCR based on the Amplifluor technology. The levels of the transcript were generated from a standard that was simultaneously amplified with the samples. Normalisation against cytokeratin 19 (CK19) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was also carried out.

RESULTS

There was a positive correlation between hTERT mRNA expression (after CK19 normalisation) with both VEGF-D and MMP-1 in human breast cancer. PAR1 was seen to correlate with hTERT (after GAPDH normalisation) with a highly significant correlation with PAR1a alone. However there was no correlation between hTERT transcription and VEGF-C or with PAR1b alone.

CONCLUSION

Our findings suggest that hTERT is a potential up-regulator of MMP-1, PAR1 and VEGF-D expression and this may explain its apparent control over the invasiveness and metastasis of the malignancy concerned.

The potential clinical applications of insulin-like growth factor-1 ligand in human breast cancer

Insulin-like growth factor-1 (IGF-1) has become recognized as a growth factor with pro-mitogenic and antiapoptotic effects on a variety of human cells. This article reviews the potential role of IGF-1 ligand in the clinical management of breast cancer patients. Many studies have shown that IGF-1 acts synergistically with oestrogen to stimulate breast cancer cells. Case-control studies have also demonstrated that premenopausal women with high levels of serum IGF-1 have an increased risk of developing breast cancer later in life. Serum IGF-1 levels can therefore be used as a potential biomarker for predicting breast cancer risk. Furthermore, there is evidence that serum IGF-1 levels can serve as a response biomarker in chemoprevention drug trials. The role of IGF-1 expression in breast cancer tissue as a prognostic marker is not clearly established. Identifying the IGF-1 gene polymorphism can potentially be used in predicting breast cancer risk.

Current management of the axilla in patients with clinically node-negative breast cancer: a nationwide survey of United Kingdom breast surgeons

Background

Precise knowledge of axillary lymph node status is essential in the treatment of operable carcinoma of the breast. For many years, axillary nodal clearance (ANC) has been an integral part of the conventional management of early-stage breast cancer. During the last few decades the trend of these surgical procedures has been one of decreasing invasiveness in order to try and achieve a much lower level of morbidity. To help reach this improved level of treatment the concept of the sentinel lymph node (SLN) was utilized. Recent studies have shown that SNB can provide an accurate assessment of the axillary nodal status in clinically node negative patients, negating the need to remove the majority of the axillary contents and thus reducing morbidity. A recent meta-analysis of all the literature to date appears to reveal that the dual technique (blue dye and technetium-labelled sulfur) is the gold-standard for successful identification of the SLN in the context of early-stage breast cancer. We aim to highlight the on-going wide range of differing methods employed, and compare this to the gold-standard recommended guidelines.

Methods

A questionnaire was devised to provide a snapshot overview of the current management of the axilla in patients with clinically node-negative T1 invasive breast cancer amongst UK beast surgeons in August 2006.

Results

Of the 271 UK surgeons, 74 (27.3%) performed ANC as the initial management of the axilla in patients with clinically node negative T1 invasive breast cancer, 56 (20.7%) used axillary node sampling (not directed by sentinel node mapping) and a total of 141 (52.0%) used the technique of SNB, of which 50 (18.5%) used blue dye alone and 91 (33.6%) used a combination of blue dye and radioisotope.

Conclusion

Despite the obvious advantages, our survey has revealed that the procedure is only used by 52% of British breast surgeons in this subgroup of patients (clinically node negative, tumour equal of smaller than 2 cm) most of whom have no disease within the axilla. The reasons for this include limited hospital resources and lack of surgeons training and accreditation and ARSAC license (nuclear medicine license).

The competent sentinel node: an association with an axillary presentation and an occult or a small primary invasive breast carcinoma

The concept of the sentinel node describes a primary or sentinel lymph node (SLN), which exists and through which tumour cells from a primary tumour in a particular location must first travel to spread to a particular regional lymph node group. In this series we present three patients presenting with a pathological axillary node associated with either an occult or very small primary breast cancer. In each case the primary tumour was found to have metastasised to the palpable node, however despite the significant enlargement of this node, no other axillary nodes were found to be affected on axillary node clearance. This has led us to postulate that the SLN in some cases contains unique characteristics that enable it to prevent further spread of the tumour up the lymphatic chain. Hence the term the competent sentinel node.

hTERT mRNA expression is associated with a poor clinical outcome in human breast cancer

BACKGROUND

Telomerase is a ribonucleoprotein enzyme that synthesises telomeres after cell division and maintains chromosomal length and stability thus leading to cellular immortalisation. hTERT (human telomerase reverse transcriptase) gene is the rate-limiting determinant of telomerase reactivation. The present study aims to quantitatively measure the expression of hTERT mRNA in human breast cancer, examine the association between hTERT and the clinicopathological characteristics of the cancer specimens including the Nottingham Prognostic Index (NPI) and to explore the relationship between hTERT expression and clinical outcome.

MATERIALS AND METHODS

RNA was extracted from 116 breast carcinomas and 31 matched adjacent non-cancerous tissue (ANCT). hTERT mRNA expression was estimated by reverse transcriptase-PCR (RT-PCR) and Taqman methodology.

RESULTS

hTERT mRNA was present in all of the cancerous specimens (mean=0.1701, median=0.0205) and most ANCT specimens with levels being 2.6 times higher in the cancerous tissue than in ANCT (mean=0.156 vs. 0.68, p=0.18). The mean mRNA levels increased with NPI scores (0.0816 for NPI 1, 0.1186 for NPI 2 and 0.68 for NPI 3), however this failed to reach statistical significance (P-values= 0.33 for NPI 1 vs. 2, 0.27for NPI2 vs. 3 and 0.24 for NPI 1 vs. 3). hTERT levels also increased with increasing tumour's grade (mean= 0.0459 for grade 1, 0.111for grade 2, and 0.27 for grade 3) but this trend did not reach a statistical significance. Low levels of hTERT were associated with mucinous carcinoma compared with ductal (p=0.023) and lobular (p=0.021) types. hTERT mRNA levels were higher in patients who had recurrent disease or died from breast cancer compared with those who remained alive without disease after a median follow up of 6 years (p=0.0026).

CONCLUSION

High hTERT mRNA levels are associated with a poor clinical outcome in human breast cancer and should be included as a prognostic marker in future validation studies.

The role of STS and OATP-B mRNA expression in predicting the clinical outcome in human breast cancer

BACKGROUND

Steroid sulfatase (STS) is the enzyme responsible for hydrolysing biologically inactive estrogen sulfates to active estrogens. Therefore it plays a significant role in supporting the growth of hormone-dependent tumours of the breast, endometrium and prostate. OATP-B is a member of a family of membrane transporter proteins that regulates the uptake of steroid sulfates through cell membranes. Our objective was to determine, using quantitative PCRA whether the mRNA expression levels from these genes were positively correlated with clinical outcome in human breast cancer. This is the first study in the literature to examine the relationship between STS and OATP-B in human breast cancer and to investigate the potential prognostic value of OATP-B.

MATERIALS AND METHODS

A total of 153 samples (120 tumour tissues and 33 normal breast tissues) were analysed. The levels of transcription of STS and OATP-B were determined using real-time quantitative PCR and normalized against cytokeratin 19. The levels of expression were analysed against tumour's stage, grade, nodal status, local relapse, distant metastasis, ERalpha, ERbeta and HER1-4 receptor status and survival over a 10 year follow up period.

RESULTS

The levels of STS mRNA were significantly higher in malignant samples (p=0.031) and in node positive disease (p=0.0222). STS mRNA expression increased with increasing tumour grade but this did not reach statistical significance. A significant increase was also noted in levels correlating with tumour stage when stages TNM1 and TNM2, TNM2 and TNM3, and TNM3 and TNM4 (p=0.00001, 0.0017 and 0.02, respectively) were compared. Furthermore, STS expression levels positively correlated with progression of disease, as levels were significantly higher in samples from patients who developed metastasis, local recurrence, or died of breast cancer when compared to those who were disease free for >10 years (p=0.0036). No significant correlation was found between the levels of STS expression and ERalpha/ERbeta/ status. The levels positively correlated with HER1 and HER3 receptors. The levels of mRNA expression of OATP-B were higher in malignant tissue compared to normal tissue; this, however, did not reach statistical significance (p=0.4045). Levels were also higher in node positive disease (p=0.0672). Expression levels increased with increasing tumour grade and this became statistically significant when comparing grade 1 to 2, and grade 2 to 3 (p=0.0271 and 0.0289, respectively). An increase in levels correlating with TNM tumour staging was also observed; this, however, did not reach statistical significance. There was no significant correlation between OATP-B expression levels and clinical progression of breast cancer. No correlation was found between STS and OATP-B expression levels.

CONCLUSION

This study demonstrates a compelling trend for STS transcription levels to be higher in cancer tissues and in patients who developed progressive disease. OATP-B expression levels correlated with the grade and stage of the disease, but not with the clinical outcome. These results suggest that STS mRNA has a significant potential as an important predictor of clinical outcome in patients with breast cancer.

Does the timing of breast cancer surgery in pre-menopausal women affect clinical outcome? An update

There is some evidence that breast cancer surgery during the luteal phase in pre-menopausal women is associated with a better clinical outcome, however the evidence for this is still equivocal.

In this paper, after summarizing the normal physiology of the menstrual cycle, we examine how such an association may occur and provide a comprehensive review of the literature in the area.

Skin-sparing mastectomy and radiotherapy: an update

Despite the lack of randomised controlled trials and paucity of the published data, the current evidence suggests that the post-mastectomy radiation therapy (PMRT) does not represent a contraindication to skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) in the multidisciplinary setting. Although PMRT is associated with a higher incidence of complications, a satisfactory cosmetic outcome can be achieved in most patients. Radiation has a deleterious effect on autologous flap reconstruction that relies on fat for volume replacement such as the deep inferior epi-gastric perforator (DIEP) flap reconstruction and this method of reconstruction should be delayed until RT is completed. Until better methods of RT delivery are developed to minimise complications, women at high risk of requiring PMRT, can be safely offered SSM and IBR with a sub-pectoral saline-filled tissue expander and this can be replaced with a permanent prosthesis or converted into an autologous flap reconstruction after the completion of RT. Any capsule formation can be surgically treated at this stage. This new concept, known as immediate-delayed reconstruction, can avoid the cosmetic and RT delivery problems that can occur after IBR.

Furthermore, prior RT does not represent a contra-indication to SSM and IBR, however it increases the incidence of complications.

Adjuvant endocrine therapy for postmenopausal breast cancer in the era of aromatase inhibitors: an update

There is overwhelming evidence that optimal adjuvant endocrine therapy for hormone sensitive breast cancer in postmenopausal women should include a third generation aromatase inhibitor (AI). On current evidence, adjuvant anstrozole or letrozole should be used upfront in such patients especially in those with high risk disease (node positive and/or tumours > 2 cm). The sequential approach of tamoxifen for 2-3 years followed by exemestane or anastrozole for 2-3 years is a reasonable alternative to 5 years of AI monotherapy in patients with low risk disease (node negative and tumour smaller than 2 cm) especially if the tumour is positive for estrogen and progesterone receptors.Node-positive patients completing 5 years of adjuvant tamoxifen should be offered letrozole for up 48 months. Further research is required to establish the long-term cardiovascular safety of AIs especially that of letrozole and exmestane, the optimal AI to use, duration of AI therapy and whether monotherapy with an AI for 5 years is superior to sequencing an AI after 2-3 years of tamoxifen. The bone mineral density (BMD) should be measured at baseline and monitored during therapy in women being treated with AIs. Anti-osteoporosis agents should such as bisphosphonates should be considered in patients at high risk of bone fractures.

Heterogeneity of ductal carcinoma in situ and its effects on management

Data derived from histopathological analysis, natural history, radiological characteristics, molecular markers, and clinical outcome indicate that ductal carcinoma in situ (DCIS) is a heterogeneous disease, meaning that no one treatment strategy is best, but rather that treatment should be personalised and entail a systematic and rigorous multidisciplinary approach. Many women with DCIS will develop actual invasive carcinoma over time, whereas others-especially those with low-grade cancers-will not. At the moment, identification of patients at low risk of recurrence risk is very difficult (that is, such people for whom further treatment beyond lumpectomy is not needed). In this context, molecular profiling analysis is a promising method to guide management decisions. In this Review, various treatment strategies for DCIS will be reviewed, highlighting the limitations of randomised trials. Furthermore, discussions about the role of sentinel-node biopsy and tamoxifen in disease management; locoregional recurrence; and special clinical scenarios such as recurrent disease, DCIS after thoracic radiotherapy, ductal carcinoma with concurrent lobular carcinoma in situ, and DCIS in elderly people and in men will be presented.

Breast cancer risk in flight attendants: an update

Although further research is required, epidemiological evidence indicates that breast cancer risk is increased by 40% among flight attendants. Female flight attendants and women who fly frequently should be informed of this potential increase in risk and be encouraged to participate in appropriate breast cancer screening programs.

Is it safe to preserve the nipple areola complex during skin-sparing mastectomy for breast cancer?

Skin-sparing mastectomy (SSM) with nipple areola complex (NAC) preservation appears to be oncologically safe, provided the tumor is not close to the nipple and a frozen section protocol for the retroareolar tissue is followed.

The expression of hTR and hTERT in human breast cancer: correlation with clinico-pathological parameters

BACKGROUND

Telomerase is a ribonucleoprotein enzyme that synthesizes telomeres after cell division and maintains chromosomal stability leading to cellular immortalization. Telomerase has been associated with negative prognostic indicators in some studies. The present study aims to detect any association between telomerase sub-units: hTERT and hTR and the prognostic indicators including tumour's size and grade, nodal status and patient's age.

METHODS

Tumour samples from 46 patients with primary invasive breast cancer and 3 patients with benign tumours were collected. RT-PCR analysis was used for the detection of hTR, hTERT, and PGM1 (as a housekeeping) genes expression.

RESULTS

The expression of hTR and hTERT was found in 31(67.4%) and 38 (82.6%) samples respectively. We observed a significant association between hTR gene expression and younger age at diagnosis (p = 0.019) when comparing patients < or = 40 years with those who are older than 40 years. None of the benign tumours expressed hTR gene. However, the expression of hTERT gene was revealed in 2 samples. No significant association between hTR and hTERT expression and tumour's grade, stage and nodal status was seen.

CONCLUSION

The expression of hTR and hTERT seems to be independent of tumour's stage. hTR expression probably plays a greater role in mammary tumourogenesis in younger women (< or = 40 years) and this may have therapeutic implications in the context of hTR targeting strategies.

Does mammary ductoscopy have a role in clinical practice?

BACKGROUND

Mammary ductoscopy (MD) is a newly developed endoscopic technique that allows direct visualisation of the mammary ductal epithelium using sub-millimetre fiberoptic microendoscopes inserted through the ductal opening onto the nipple surface. These scopes also provide working channels for insufflation, irrigation, ductal lavage, and possible therapeutic intervention. MD can be performed under local anaesthesia in the office setting. The objective of this study is to assess the technical feasibility of mammary ductoscopy, and examine its role in guiding ductal excision surgery and the early diagnosis of malignancy.

METHODS

Mammary ductoscopy (MD) was performed using a 1 mm fiberoptic microendoscope (Mastascope TM) in 26 patients (age range: 14-73 years): 13 patients undergoing mastectomy (n = 12) or lumpectomy (n = 1) for ductal carcinoma (including 12 cases of DCIS and one case of infiltrating ductal carcinoma) and 13 patients with pathological nipple discharge (PND) and benign breast imaging and simple discharge cytology. Of the latter group: 10 procedures were performed under local anaesthesia (LA) in the office setting and 3 procedures were carried out under general anaesthesia (GA) to guide duct excision surgery. The ductoscopic appearances in this group were graded between 0 and 5 (D0-D5) according to the degree of suspicion.

RESULTS

Intraoperative MD was accomplished in 11 (84.6%) of 13 patients undergoing surgery for DCIS. MD was unsuccessful in 2 cases: one patient (aged 73 years) had sclerosis of the nipple and one patient had preoperative vital blue injection in the subareolar region as part of the sentinel node biopsy thus resulting in inadequate visualisation. Intraductal pathology was visualised in 8 (80%) of the 10 cases undergoing mastectomy but ductoscopic cytology was positive for malignancy in only 2 cases (sensitivity = 16%, specificity = 100%). In the office setting, MD was accomplished in 9 (90%) out of 10 patients with PND and was well tolerated (mean pain score = 3.8 out of 10: range 0-7). Of these 10 patients; MD was inadequate (D0) in one patient due to complete occlusion of lumen by the lesion, showed a papilloma in 3 patients (D3), duct ectasia (D2) in 3 patients, irregular thickening of the lumen suspicious of DCIS (D4) in one patient and non-specific benign findings (D2) in 2 patients. Three women with benign ductoscopy and ductoscopy-assisted cytology were reassured and treated conservatively. The remaining 7 patients had ductoscopy-guided duct excision which revealed DCIS in one, papilloma in 4 and benign breast disease in 2 patients. Adequate cellular yield was obtained in 7 (70%) out of 10 cases (benign cytology). The three patients who had MD under GA during microdochectomy had benign endoscopic appearances and final histology (one papilloma and 2 cases of duct ectasia).

CONCLUSION

MD is technically feasible in most patients and has a potential in the early detection of breast cancer. The procedure can be performed safely in the office setting and should be considered in all patients presenting with a single duct PND. MD has the potential to reduce the number of duct excision procedures and minimise the extent of surgical resection. Ductoscopic cytology is not sufficiently sensitive for the diagnosis of malignancy and the development of a biopsy tool that obtains tissue under direct visualisation is required.

The association between telomerase activity and expression of its RNA component (hTR) in breast cancer patients: the importance of DNase treatment

Telomerase is a ribonucleoprotein enzyme that compensates for the telomere length shortening which occurs during the cell cycle. Telomerase activity has been detected in most tumours but not in somatic cells. However, hTR; the RNA component of telomerase; has been reported to be universally expressed in both cancerous and non-cancerous tissues. Tumour samples from 50 patients with primary invasive breast cancer were collected. The TRAP assay was used to detect telomerase activity. RT-PCR on cDNA and DNased cDNA samples and control groups was used to detect the expression of hTR, GAPDH and PGM1 genes. Seventy-two percent of samples showed telomerase activity. DNA contamination was detected in 36 (72%) of RNA samples. Without performing DNase treatment, 49 (98%) of all samples showed hTR expression, but with the application of this strategy, hTR expression decreased from 98% to 64%. A significant association (p < 0.001) between hTR expression and telomerase activity was observed. Among the 32 hTR positive samples, 30 had telomerase activity and among the 18 hTR negative samples, telomerase activity was observed in 6 cases. Thus the application of this strategy could provide an applicable tool to use instead of the TRAP assay thus facilitating telomerase research in cancer genetic investigations.

Oncological considerations of skin-sparing mastectomy

Aim

To review evidence concerning the oncological safety of performing skin-sparing mastectomy (SSM) for invasive breast cancer and ductal carcinoma in situ (DCIS). Furthermore, the evidence concerning RT in relation to SSM and the possibility of nipple preservation was considered.

Methods

Literature review facilitated by Medline and PubMed databases.

Findings

Despite the lack of randomised controlled trials, SSM has become an accepted procedure in women undergoing mastectomy and immediate reconstruction for early breast cancer. Compared to non-skin-sparing mastectomy (NSSM), SSM seems to be oncologically safe in patients undergoing mastectomy for invasive tumours smaller than 5 cm, multicentric tumours, DCIS or risk-reduction. However, the technique should be avoided in patients with inflammatory breast cancer or in those with extensive tumour involvement of the skin in view of the high risk of local recurrence. SSM with nipple areola complex (NAC) preservation appears to be oncologically safe, provided the tumour is not close to the nipple and a frozen section protocol for the retro-areolar tissue is followed. Although radiotherapy (RT) does not represent a contraindication to SSM, the latter should be used with caution if postoperative RT is likely, since it detracts from the final cosmetic outcome.

The potential role of dynamic thermal analysis in breast cancer detection

BACKGROUND

It is presently well accepted that the breast exhibits a circadian rhythm reflective of its physiology. There is increasing evidence that rhythms associated with malignant cells proliferation are largely non-circadian. Cancer development appears to generate its own thermal signatures and the complexity of these signatures may be a reflection of its degree of development. The limitations of mammography as a screening modality especially in young women with dense breasts necessitated the development of novel and more effective screening strategies with a high sensitivity and specificity. The aim of this prospective study was to evaluate the feasibility of dynamic thermal analysis (DTA) as a potential breast cancer screening tool.

METHODS

173 women undergoing mammography as part of clinical assessment of their breast symptoms were recruited prior to having a biopsy. Thermal data from the breast surface were collected every five minutes for a period of 48 hours using eight thermal sensors placed on each breast surface [First Warning System (FWS), Lifeline Biotechnologies, Florida, USA]. Thermal data were recorded by microprocessors during the test period and analysed using specially developed statistical software. Temperature points from each contra-lateral sensor are plotted against each other to form a thermal motion picture of a lesion's physiological activity. DTA interpretations [positive (abnormal thermal signature) and negative (normal thermal signature)] were compared with mammography and final histology findings.

RESULTS

118 (68%) of participating patients, were found to have breast cancer on final histology. Mammography was diagnostic of malignancy (M5) in 55 (47%), indeterminate (M3, M4) in 54 (46%) and normal/benign (M1, M2) in 9 (8%) patients. DTA data was available on 160 (92.5%) participants. Using our initial algorithm, DTA was interpreted as positive in 113 patients and negative in 47 patients. Abnormal thermal signatures were found in 76 (72%) out of 105 breast cancer patients and 37 of the 55 benign cases. Then we developed a new algorithm using multiple-layer perception and SoftMax output artificial neural networks (ANN) on a subgroup (n = 38) of recorded files. The sensitivity improved to 76% (16/21) and false positives decreased to 26% (7/27)

CONCLUSION

DTA of the breast is a feasible, non invasive approach that seems to be sensitive for the detection of breast cancer. However, the test has a limited specificity that can be improved further using ANN. Prospective multi-centre trials are required to validate this promising modality as an adjunct to screening mammography especially in young women with dense breasts.

The role of aromatase and 17-β-hydroxysteroid dehydrogenase type 1 mRNA expression in predicting the clinical outcome of human breast cancer

INTRODUCTION

There is substantial evidence that breast cancer tissue contains all the enzymes responsible for the local biosynthesis of estrogens from circulating precursors. The cytochrome P-450 aromatase enzyme complex is responsible for the conversion of C19 androgens to estrogens and 17-beta-hydroxysteroid dehydrogenase (17-I(2)-HSD) type 1 catalyses the inter-conversion of estrone to the biologically more potent estradiol. The gene encoding for the cytochrome P-450 aromatase is known as CYP19 (15q21.2). It is well established that increased exposure to local estrogens is an important risk factor in the genesis and growth of breast cancer. The aim of this study is to investigate the relationship between CYP19 and 17-beta-HSD type 1A mRNA expression and clinico-pathological parameters of human breast cancer.

METHODS

One hundred and twenty seven tumor tissues and 33 normal tissues were analyzed. The levels of transcription of CYP19 and 17-beta-HSD type 1 were determined using real-time quantitative PCR. The mRNA expression was normalized against CK19. Levels of expression were analyzed against tumorâ's stage, grade, nodal status, local relapse, distant metastasis and survival over a 120A months follow up period. In addition, the levels were analyzed against estrogen receptor (ER) and HER1-4 status.

RESULTS

Overall, high tumor levels of mRNA expression of CYP19 and 17-beta-HSD type 1 correlated with poor survival (p=0.0105 and p=0.0182, respectively). Increased levels of CYP19 mRNA expression positively correlated with disease progression as levels were significantly higher in samples of patients who had distant metastasis and local recurrence and/or died of breast related causes when compared to those who were disease free for >10 years (p=0.0015). We also observed higher levels of CYP19 mRNA in tumor samples compared to normal breast tissue. However, this reached statistical significance only when comparing grade 1 tumors with normal tissue (p=0.01). There was no correlation between CYP19á mRNA expression and tumor stage, lymph node status and tumor grade. There was however a trend for a positive correlation between CYP19 and ER mRNA expressions (p=0.06). No significant difference in 17-beta-HSD type 1 expression between normal and cancerous tissues was observed. In tumor samples, we observed an increase in levels correlating with tumor's grade. This correlation was statistically significant when we compared grade 1 with grade 2 and grade 1 with grade 3 (p=0.0031 and 0.0251, respectively).

CONCLUSION

Our study shows that higher levels of the enzymes responsible for the local biosynthesis of estrogens especially aromatase are associated with a poor clinical outcome in patients with breast cancer.

Skin-sparing mastectomy and immediate breast reconstruction: patient satisfaction and clinical outcome

BACKGROUND

Skin-sparing mastectomy (SSM) followed by immediate reconstruction has been advocated as an effective treatment option for patients with early-stage breast carcinoma. It minimizes deformity and improves cosmesis through preservation of the natural skin envelope of the breast. The purpose of this study was to evaluate postoperative morbidity, patients' satisfaction, and oncological safety for SSM and immediate breast reconstruction (IBR) with a latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis in patients with operable breast cancer.

METHODS

Twenty-one consecutive patients with operable breast cancer undergoing 25 SSM and immediate reconstruction with an LD flap plus implant (n = 14) or implant alone (n = 11) were retrospectively studied (from 2001 through 2005). The median patients' age was 44 years (range, 30-68). Patient satisfaction with the outcome of surgery was assessed using a detailed questionnaire including a linear visual analogue scale ranging from 0 (not satisfied) to 10 (most satisfied). Eight of 20 (40%) patients required adjuvant chemotherapy, and only 2 patients required post-mastectomy radiation. Reconstruction of the nipple-areola complex was performed in 7 patients (33%) using the trefoil local flap technique. Contralateral procedures to achieve symmetry were performed in 6 (28%) patients (5 augmentations and 1 reduction mammoplasty).

RESULTS

Histological analysis showed pure ductal carcinoma in situ (DCIS) in 4 patients and invasive carcinoma (+/- DCIS) in 20 cases, of which 5 (25%) were node positive. One prophylactic mastectomy in a BRCA-2 carrier was negative for malignancy. Tumor size ranged from 5 to 90 mm. The surgical margins were clear in all cases. There was no delay in time to commencement of adjuvant therapies. After a mean follow-up period of 13.5 months (range, 5-46 months), none of the patients developed locoregional recurrence. Only 1 patient (5%) developed systemic recurrence (bony metastases). Overall survival was 100%. The incidence of flap necrosis/loss, implant loss, wound infection, or hematoma requiring surgical evacuation was 0%, 0%, 0%, and 0%, respectively. Capsule formation requiring capsulotomy was observed in 3 of 21 patients (14%). The median patient satisfaction score was 10 (range, 6-10).

CONCLUSION

SSM and IBR for operable breast cancer is associated with a high level of patient satisfaction and low morbidity. The procedure seems to be oncologically safe, even in patients with high-risk (T3 or node-positive) carcinoma. The latter needs to be confirmed with greater numbers of patients and longer follow-up.

Screening mammography in women aged 40-49: is it time to change?

There is little doubt that significant benefits can accrue from carrying out screening mammography of women aged 40–49 in the setting of a highly quality assured service delivery. This will best be achieved using digital mammography to maximise detection rates and trained and high volume reading expert radiologists to apply economic cushions of optimising specificity as well as sensitivity in addition to utilising modern and accurate assessment and tissue sampling techniques that have evolved.

The clinical applications of mammary ductoscopy

BACKGROUND

Mammary ductoscopy (MD) is a newly developed endoscopic technique that allows direct visualization and biopsy examination of the mammary ductal epithelium where most cancers originate. The procedure can be performed under local anesthesia in the office setting. This article reviews the rationale, current clinical applications, and limitations of MD.

METHODS

A literature search was performed using Pubmed for indexed articles published over the past 30 years using the key words "mammary ductoscopy," "breast ductoscopy," "ductal lavage," and "nipple aspiration." The most important articles were analyzed and discussed.

RESULTS

MD is a useful diagnostic adjunct in patients with pathologic nipple discharge. Furthermore, it can reduce the number and extent of duct excision surgeries for pathologic nipple discharge. There is a clear need to design prospective clinical trials that evaluate the potential role of MD in breast cancer screening, guiding risk-reducing strategies, and as an adjunct to breast-conservation surgery.

CONCLUSIONS

MD is useful in the management of PND, but its potential role in the early detection or management of breast cancer requires further investigation.

Expression of Com-1/P8 in human breast cancer and its relevance to clinical outcome and ER status

Com-1 is a recently discovered molecule that has putative action on the metastatic nature of cancer cells. The molecular action and clinical implication in cancer and prognosis are yet to be established. The current study examined the role of Com-1 in a cohort of patients with breast cancer, with particular emphasis on its relationship with clinical outcomes and ER status. A panel of human breast cancer cell lines were tested. A cohort of breast cancer tumours (n-120) with matched normal non-neoplastic mammary tissues (n = 32) were used. Expression of Com-1 in cancer cells and mammary tissues were studied using conventional and real-time quantitative PCR. Expression profile was analysed against clinical information including tumour grade, staging, nodal status, ER status and survival of the patients. Statistical analysis was Mann-Whitney U-test and Cox Proportion analysis. Com-1 was expressed in breast cancer cell lines. Com-1 protein staining was primarily found in nucleus of epithelial cells of mammary tissues. Tumour cells in breast tissues exhibited a significant reduction in nuclear staining of Com-1, compared to normal epithelial cells (p = 0.0061). Breast tumour tissues expressed similar levels of Com-1, compared to normal non-neoplastic mammary tissues (p = 0.62). There was, however, a stepwise decrease in tumours from patients with predicted good, moderate, to poor prognosis (using Nottingham Prognostic Index) (166 +/- 135 copies of Com1 transcript, 44.3 +/- 36 and 0.64 +/- 0.24, respectively, p = 0.06 by Kruskal-Wallis test). Likewise, node positive tumours had low levels of Com-1, compared to node negative tumours. Tumours from patients who developed metastasis (11.4 +/- 7 copies of Com1 transcript), had local recurrence (41.5 +/- 3.7 copies of Com1 transcript), or who died of breast cancer (0.058 +/- 0.03 copies of Com1 transcript) had lower levels of Com-1, when compared to tumours from patients who remained disease free (156 +/- 129 copies of Com1 transcript). There was no significant correlation between Com-1 and overall survival or disease free survival. When ER status were taken into consideration, it was demonstrated that low levels of Com-1 in ER-beta positive tumours were highly correlated with shorter overall survival of the patients (p = 0.018) (median follow-up 120 months). Com-1 is a nuclear protein, whose expression is reduced in human breast cancer tissues and cancer cell lines. The loss of Com-1 protein is primarily from the nuclear compartment in cancer cells. The expression levels of Com-1 in breast tumours are correlated with the prognosis of the patients and with the long term overall survival in association with ER status.

Breast papillomas: current management with a focus on a new diagnostic and therapeutic modality

Breast papilloma is a term that describes an intraductal papillary configuration of the mammary epithelium on macroscopic or microscopic examination. It includes solitary intraductal papillomas, multiple papillomas, papillomatosis, and juvenile papillomatosis (JP).

Recent advances in mammary ductoscopy (MD) have raised new possibilities in the diagnosis and treatment of breast papillomas. This technique represents an important diagnostic adjunct in patients with pathological nipple discharge (PND) by allowing direct visualisation and biopsy of intraductal lesions and guiding duct excision surgery.

Treatment of breast papillomas often entails surgical duct excision for symptomatic relief and histopathological examination. Recently, more conservative approach has been adapted. MD-assisted microdochectomy should be considered the procedure of choice for a papilloma-related single duct discharge. Furthermore, there is increasing evidence that MD has the potential to reduce the number of duct excision procedures and minimise the extent of surgical resection. Imaging-guided vacuum-assisted core biopsy can be diagnostic and therapeutic for papillomas seen on mammography and/or ultrasound.

Patients with multiple papillomas do have an increased risk of developing cancer and should be kept under annual review with regular mammography (preferably digital mammography) if treated conservatively. Magnetic resonance (MR) can be also used in surveillance in view of its high sensitivity. Because the risk is small, long term and affects both breasts, long-term follow-up is more appropriate than prophylactic mastectomy. Patients who prove to have solitary duct papilloma have insufficient increase in the risk of subsequent malignancy to justify routine follow-up.

Insulin-like growth factor 1 (IGF-1) and its receptor mRNA levels in breast cancer and adjacent non-neoplastic tissue

Previous studies investigating the insulin-like growth factor 1 receptor (IGF-1R) expression in breast cancer tissue and adjacent non-neoplastic breast tissue (ANCT) have produced conflicting results. The IGF-1 and IGF-1R expression in pairs of breast cancer tissue and ANCT were investigated using RT-PCR and immunohistochemistry. The results of both methods were compared.

MATERIALS AND METHODS

IGF-1 and IGF-1R mRNA from 31 specimen pairs were estimated using RT-PCR. Immunohistochemistry for IGF-1R was carried out on 20 specimen pairs and the strength of staining was scored.

RESULTS

The mean relative IGF-1 mRNA level was lower in the cancerous tissue (mean 0.450 +/- 0.206) than in the ANCT (mean 0.632 +/- 0.384) (paired t-test, p = 0.001). There was no measurable difference in relative IGF-1R mRNA levels in the cancerous tissue (mean 0.146 +/- 0.08) and the ANCT (mean 0.14608 +/- 0.108) (paired t-test, p = 0.807). Using immunohistochemistry, there was no statistical difference (paired t-test, p = 0.910) in IGF-1R staining scores between cancer (mean 1.93) and ANCT (mean 1.90). The comparison between the two methodologies showed no correlation (Pearson's Correlation Coefficient = -0.393).

DISCUSSION

It can be concluded that IGF-1 expression is lower in cancerous tissue, thus supporting a paracrine relationship between cancerous tissue and ANCT, which may be useful in the prevention, diagnosis and treatment of breast cancer. There was no difference in the expression of the IGF-1 receptor in both types of tissue, as proven by RT-PCR and immunohistochemistty. Conflicting results in previous studies may be due to the different methods used to measure IGF-1R expression.

Targeting matrilysin and its impact on tumor growth in vivo: the potential implications in breast cancer therapy

INTRODUCTION

Matrilysin (MMP-7) is a metalloproteinase that is involved in the degradation of extracellular matrix, invasion, and tumor progression. The current study examined if targeting matrilysin using retroviral ribozyme transgenes may have an impact on breast cancer cells and may have clinical implications.

EXPERIMENTAL DESIGN

Retroviral hammerhead ribozyme transgenes were designed to specifically target human matrilysin mRNA. The breast cancer cell MDA-MB-231 was transfected with either a retroviral matrilysin transgene or a control retroviral transgene. Stably transfected cells were tested for their invasiveness and migratory properties in vitro. The cells were also used in creating a tumor model in athymic nude mice in which the growth of tumors and levels of matrilysin were assessed. In addition, levels of both protein and mRNA of matrilysin were investigated in a cohort of human breast tumors.

RESULTS

Expression of matrilysin in MDA-MB-231 was successfully eliminated by the retroviral hammerhead ribozyme transgene for matrilysin as revealed by reverse transcription-PCR. Matrilysin transgene-transduced cancer cells (MDA-MB-231DeltaMatrilysin) exhibited a significantly lower degree of invasion (number of invading cells 16.0 +/- 2.5) compared with wild type (MDA-MB-231(WT); 26.2 +/- 6.2, P < 0.05) or control transgene-transduced cancer cells (MDA-MB-231pRevTRE; 25.3 +/- 4.2, P < 0.01). However, the rate of growth of the cells in vitro was not significantly affected. In the in vivo tumor model, MDA-MB-231DeltaMatrilysin tumors, which had very low levels of immunoreactive matrilysin, grew at a significantly lower rate (0.24 +/- 0.03 cm3, 4 weeks after inoculation) compared with the wild-type MDA-MB-231(WT) (1.46 +/- 0.04 cm3) and MDA-MB-231pRevTRE (1.12 +/- 1.0 cm3) tumors. In human breast tumors, breast cancer cells stained matrilysin at a significantly higher density, compared with normal mammary epithelium. The highest level of matrilysin was seen in high-grade tumors and that from patients with moderate and poor prognosis. Finally, high levels of matrilysin were significantly linked with a poor long-term survival (P = 0.0143).

CONCLUSION

Matrilysin, which is aberrantly expressed in human breast tumors, can be effectively eliminated from breast cancer cells by way of hammerhead ribozyme transgene. Elimination of matrilysin is associated with low invasiveness and slow tumor growth. Taken together, the study suggests that targeting matrilysin may have important therapeutic implications.

Skin and fat necrosis of the breast following methylene blue dye injection for sentinel node biopsy in a patient with breast cancer

Sentinel lymph node biopsy (SLNB) is a simple technique that uses subdermal or peri-tumoral injection of vital blue dye and/or radioactive isotope to identify the first lymph node(s) draining the primary tumor. It has been shown to accurately predict axillary node status in patients with clinically node negative breast cancer. The SLNB is emerging as a new standard of care in patients with early breast cancer. However, the use of methylene blue (MB) dye can be associated with a number of local complications due to its tissue reactive properties. We report a rare case of skin and fat necrosis followed by a dry gangrene of the skin in a female patient with breast cancer who underwent SLNB localization using peri-tumoral injection of MB dye in another institution. This case and literature review suggest that the use of MB dye for SLNB identification should be avoided and replaced with alternative types of blue dye such as Patent Blue V preferably in conjunction with a radioactive isotope tracer.

Is there a link between breast cancer and abortion: a review of the literature

The hormonal changes that take place in pregnancy cause breast tissue to proliferate and differentiate. Abortion interrupts this process and may leave the proliferated, undifferentiated breast tissue at higher risk of carcinogenesis. This review explains the supposed difference in effects of induced and spontaneous abortion upon the breast tissue and examines the literature for a link with breast cancer. Additional subcategories examined include parity, number of abortions, gestation, and maternal age at abortion. A comparison of retrospective and prospective studies is made and possible sources of bias are identified. There is no evidence to support a link between spontaneous abortion and breast cancer. Absence of a link with induced abortion is less clear, and further research should concentrate on investigating any relationship. We suggest that prospective research is used, with point of entry at first termination.

In vitro fertilization and breast cancer risk: a review

INTRODUCTION

Breast cancer is a classic model of a hormone-dependent malignancy. Since the drugs used for ovulation induction as part of in vitro fertilization (IVF) treatment increase the levels of endogenous gonadal hormones, concerns have arisen regarding a possible association between IVF and the risk of developing breast cancer. The aim of this paper was to review the literature and examine the potential effects of IVF treatment on breast cancer risk.

METHODS

Medline search was conducted using the key words below in English-language articles. Further papers were obtained using the bibliographies of relevant articles. Furthermore, a combined analysis of retrieved data was performed.

RESULTS

Fifteen studies were identified; of these, 11 were cohort studies and 4 were case-control studies. None of the individual studies showed an overall significant association between IVF and breast cancer and, in fact, one study showed that treatment with hCG significantly reduced the risk of breast cancer in women whose maximum nonpregnant body mass index was less than 27.5. A combined analysis of the cohort studies including a total of 60,050 women treated with ovulation induction/IVF showed no significant association between these treatments and increased risk of breast cancer (observed vs. expected: 601 vs. 568, pooled relative risk [RR] = 1.06, P = 0.337). The case-control studies included a total of 11,303 women in the breast cancer groups and 10,930 controls. Women in the breast cancer groups were slightly less likely to have received IVF (2.2% vs. 2.5%, pooled RR = 0.88, P = 0.231). However, one study showed that infertility treatment was associated with an increased risk of breast cancer of borderline significance among women with a family history of the disease. Another study showed that the incidence of breast cancer within the first year of exposure to fertility drugs was higher than expected, possibly due to the promotion of preexisting cancer lesions caused by superovulation or due to the early diagnosis made in the course of IVF treatment. Conflicting results were reported regarding the type of fertility treatment and breast cancer risk.

CONCLUSION

Overall, there is no clear evidence that ovulation induction or IVF increases the risk of breast cancer. However, there may be a transient increase in the incidence of breast cancer in the first year due to earlier diagnosis. Furthermore, the risk may be increased in women with a positive family history. Future research should focus on the type of fertility treatment used and breast cancer risk. Aromatase inhibitors should be evaluated further as an alternative to standard ovulation-inducing drugs.

Dairy products and breast cancer risk: a review of the literature

BACKGROUND

Dietary elements and, in particular, dairy products have been implicated in the etiology of breast cancer. High saturated fat contents, contaminants such as pesticides, and insulin-like growth factor I (IGF-1) have been hypothesized as possible carcinogenic factors. In contrast, calcium, vitamin D, and conjugated linoleic acid (CLA) all are considered to reduce breast cancer risk. We aim to review the current epidemiological literature on the relationship between the intake of dairy products and breast cancer risk.

METHODS

A Medline search was conducted using the key words breast neoplasms and dairy products. Further articles were obtained by cross-matching references of relevant articles. Thirty-nine case-control and 11 cohort studies were identified since 1981. Two meta-analyses and several review articles were also noted.

RESULTS

Results from previous studies were analyzed and comparisons were made between each type of study. Controversy exists regarding this subject and we found conflicting evidence in recent literature regarding this hypothesis.

CONCLUSION

There is no substantial epidemiological evidence to support a significant link between the intake of dairy products and breast cancer risk.

Phytoestrogens and the risk of breast cancer: a review of the literature

BACKGROUND

Over the last decade, interest in the physiological role of bioactive compounds in plants has increased dramatically. Of particular interest in relation to human health are the class of compounds known as the phytoestrogens, which embody several groups of nonsteroidal estrogens that are widely distributed within the plant kingdom, including isoflavones and lignans. Epidemiological studies suggest that diets rich in phytoestrogens, particularly soy and unrefined grain products, may be associated with low risk of breast cancer. This review presents the studies published so far exploring a link between dietary phytoestrogens and breast cancer risk.

METHODS

A Medline search was conducted using the key words below. Further articles were obtained by cross-matching references of relevant articles. Twenty-one case-control and 15 prospective studies were identified since 1978. One meta-analysis and several review articles also were noted.

RESULTS

Results from previous studies were analyzed and comparisons were made between each type of study. Controversy exists regarding this subject, and we found conflicting evidence in recent literature regarding this hypothesis.

CONCLUSION

There is no clear evidence that phytoestrogen intake influences the risk of developing breast cancer.

hTERT protein expression is independent of clinicopathological parameters and c-Myc protein expression in human breast cancer

Background

Telomerase is a ribonucleoprotein enzyme that synthesises telomeres after cell division and maintains chromosomal length and stability thus leading to cellular immortalisation. The hTERT (human telomerase reverse transcriptase) subunit seems to be the rate-limiting determinant of telomerase and knowledge of factors controlling hTERT transcription may be useful in therapeutic strategies. The hTERT promoter contains binding sites for c-Myc and there is some experimental and in vitro evidence that c-Myc may increase hTERT expression. We previously reported no correlation between c-Myc mRNA expression and hTERT mRNA or telomerase activity in human breast cancer. This study aims to examine the correlation between hTERT expression as determined by immunohistochemistry and c-Myc expression, lymph node status, and tumour size and grade in human breast cancer.

Materials and methods

The immunohistochemical expression of hTERT and c-Myc was investigated in 38 malignant breast tumours. The expression of hTERT was then correlated with the lymph node status, c-Myc expression and other clinicopathological parameters of the tumours.

Results

hTERT expression was positive in 27 (71%) of the 38 tumours. 15 (79%) of 19 node positive tumours were hTERT positive compared with 11 (63%) of 19 node negative tumours. The expression was higher in node positive tumours but this failed to reach statistical significance (p = 0.388). There was no significant association with tumour size, tumour grade or c-Myc expression. However, hTERT expression correlated positively with patients' age (correlation coefficient = 0.415, p = 0.0097).

Conclusion

hTERT protein expression is independent of lymph node status, tumour size and grade and c-Myc protein expression in human breast cancer

Tuberin and hamartin are aberrantly expressed and linked to clinical outcome in human breast cancer: the role of promoter methylation of TSC genes

PURPOSE

The tuberous sclerosis (TSC) genes TSC1 and TSC2 encode the protein products hamartin and tuberin, respectively, and are putative tumour suppressor genes. Germ-line mutation of either TSC gene leads to the development of the heritable disorder TSC. This disorder is characterized by the development of hamartomas in many organs and is associated with the proliferative lung disease, lymphangioleiomyomatosis, the brain tumour giant cell astrocytoma and occasionally with renal cell carcinoma. However, the TSC genes have not been studied in breast cancer. The current study investigated the expression of the TSC gene products and the potential mechanisms of their aberrancy in human breast cancer cells and tissues.

EXPERIMENTAL DESIGN AND RESULTS

Using immunohistochemical analysis, both hamartin and tuberin were found to be strongly stained in normal mammary epithelial cells and weakly in stromal cells. In invasive tumour tissues, however, the staining of both proteins were to be markedly reduced (P < 0.01). At message level, although normal and tumour tissues expressed both TSC products, the transcript levels of tuberin was significantly lower in tumour tissues compared with normal tissues (P < 0.05). There was no statistical difference between node negative and node positive tumours with both hamartin and tuberin. Tumours from patients who developed recurrence and died from breast cancer had significantly low levels of tuberin compared with those who remained disease free (P = 0.03 and 0.05, respectively). Likewise, hamartin levels were significantly lower in patients with metastasis, recurrence and mortality, when compared with those remained disease free (P = 0.001, 0.041 and 0.003, respectively). Using methylation specific PCR, the TSC1 promoter was found to be heavily methylated in ZR751, MDA MB 435, and BT549, but not in MCF-7 which expressed highly level of hamartin. TSC1 promoter methylation was also seen in most breast tumours, but only in a limited number of normal tissues. The methylation of TSC2 promoter appears to be less frequent. MDA MB 468, MDA MB 483, MDA MB 435S and weakly MDA MB 435 were found to have methylated TSC2 promoter. In breast tissues, however, a very small number of samples were found to have methylation of the TSC2 promoter.

CONCLUSION

TSC1 genes are aberrantly expressed in human breast cancer cell lines and breast tumour tissues and their promoters are seen to be methylated in breast tumour tissues. The expression of TSC1 is associated with an unfavourable clinical outcome in patients with breast cancer.

Evidence for a Tumour Suppressive Function of APRG1 in Breast Cancer

INTRODUCTION

Deletion mapping studies have shown that genes in the region 3p21.3 are often deleted in epithelial malignancies. Although the regions deleted differ between individual cancers there appears to be a specificity for the type of malignancy produced. As a result this area of chromosome 3 is thought to contain multiple tumour suppressor genes. The present study concentrates on one gene in that region, APRG1. This gene codes for a protein, which has been implicated in cell membrane interactions. The aim was to determine using quantitative PCR whether the levels of this gene were negatively correlated with clinical outcome in breast cancer.

METHODS

One hundred and twenty tumour tissues and 33 normal tissues were analyzed. Levels of transcription of APRG1 were determined using real-time quantitative PCR. APRG1 expression was normalized against CK19. Levels of expression were analyzed against staging, nodal involvement, grade, distant metastasis and survival over a 6 year follow up period.

RESULTS

Levels of APRG1 mRNA were lower in malignant tissues. They fell further with increasing stage using the TNM classification This became statistically significant when TNM stages 3 and 4 were compared to TNM 1 (p = 0.0046, p = 0.04, t-test). They were lower in those with positive nodes although this did not reach statistical significance. There was a statistically significant reduction in APRG1 in grade 3 tumours cf. grade 1 (p = 0.0081). APRG1 expression was highly negatively correlated with progressive disease: alive with metastasis (p = 0.0069), local recurrence (p = 0.0055), died of breast cancer (p = 0.11), all progressive disease (p = 0.035).

CONCLUSION

This study shows a compelling trend for APRG1 transcription levels to be lower in malignant tissues and lower still in those patients who develop progressive disease. There was also a statistically significant difference in APRG1 levels between grade 3 and grade 1 tumours. These results are highly suggestive of APRG1 acting as a tumour suppressor gene.

Exercise for breast cancer survival: the effect on cancer risk and cancer-related fatigue (CRF)

To date, all epidemiological research in this area has focused on the relationship between physical activity level and the risk of breast cancer in healthy women, or more recently, those who have recovered from the disease. Most of this research highlights the fact that those women who are physically active are at a reduced risk of the disease. Although physical activity is similar to exercise, it lacks the specificity of a prescribed exercise training program. Consequently, such research can only be viewed as a promising indicator of the beneficial effect that regular exercise may have for breast cancer survivors. Furthermore, due to the nature of such research, there has been a failure to provide specific evidence concerning the most suitable modality, duration, intensity, and frequency of training for risk reduction in breast cancer survivors. Thus, evidence aiding the correct prescription of exercise for this population has been lacking. More promising evidence is provided by randomized controlled trials, which examine the effect of exercise on specific risk factors and provide convincing scientific rationale for the use of exercise among breast cancer survivors. These studies not only provide understanding of the physiological mechanisms by which exercise can be effective at aiding a reduction in breast cancer risk, but also allow conclusions on the correct prescription to be drawn. Additionally, exercise has proven to be effective in combating cancer-related fatigue (CRF), significantly improving both quality of life outcomes (QOL) and physiological capacity in women who have survived breast cancer. In order to promote a wider understanding of the beneficial effect that exercise holds for this population regarding reduction of breast cancer risk and CRF, this review discusses this research, making conclusions regarding the necessary training prescription to elicit such benefits.

Commentary: optimal adjuvant endocrine therapy of postmenopausal breast cancer

There is a growing body of evidence that the optimal adjuvant endocrine therapy for hormone-sensitive breast cancer in postmenopausal women should include an aromatase inhibitor. However, further research is required to establish the optimal aromatase inhibitor and whether such a drug should be used as monotherapy or in sequence after 2 to 3 years of tamoxifen.

The potential role of breast ductoscopy in breast cancer screening

Breast cancer remains the most common malignancy among women in the Western world. Mammography, which is currently the main screening modality for early detection, has a low positive predictive value of only 25%, especially in young women with very dense breasts. Therefore, new screening approaches are needed for the early detection of breast cancer in all age groups. Mammary ductoscopy (MD) is a newly developed endoscopic technique that allows direct visualization and biopsy of the mammary ductal epithelium where most cancers originate. The procedure can be performed under local anesthesia in the office setting. At present, MD is used as a diagnostic adjunct in patients with pathological nipple discharge and to guide duct excision surgery. This article focuses on the potential of this technique in breast cancer screening and highlights its limitations in this context.

Is preoperative core biopsy accurate in determining the hormone receptor status in women with invasive breast cancer?

Background

The objective of this study was to determine the concordance rate between core needle biopsy (CNB) and surgical excision of invasive breast cancer regarding the oestrogen receptor (ER) and Progesterone receptor (PgR) status as determined by Immunohistochemistry (IHC).

Methods

Hormone receptor status was established using IHC (using quickscore system 0–8) on preoperative CNB and subsequent surgical excision in 93 patients with invasive breast cancer. Results were compared taking into account tumour's size, grade, and patient's age.

Results

The ER concordance rate between CNB and surgical excisions was 95%. The PgR concordance rate was 89%. This shows that CNB has a sensitivity of 97% for ER and 95% for PgR.

There is a positive correlation of ER and PgR between CNB and surgical excision (p < 0.000001). There was no significant difference in the number of core biopsies between concordant and discordant cases.

Conclusion

Preoperative core biopsy is highly sensitive for the IHC detection of ER and PgR in invasive breast cancer. The concordance rate is higher for ER than PgR, which could be due to the fact that ER is more homogeneously distributed.

Pneumothorax after a clinical breast fine-needle aspiration of a lump in a patient with Poland's syndrome

We report the first case in the medical literature of a pneumothorax complicating fine needle aspiration cytology (FNAC) of a breast lump in a woman with a mild form of Poland's syndrome. The pneumothorax was treated conservatively. This is the first case of breast FNA-related pneumothorax seen in our clinical practice. We believe that the absence of pectoral muscles has increased the risk of this complication. We have also diagnosed an incidental screen-detected breast cancer affecting the ipsilateral breast in the same patient. We conclude that caution should be exercised when performing FNAC of breast lesions in patients with Poland's syndrome. The procedure should be preferably performed under image guidance in such patients in order to minimise the risk of this complication.

Mammary ductoscopy: past, present, and future

Mammary ductoscopy (MD) allows direct visual access to the mammary ducts, using fiberoptic microendoscopes inserted through the ductal opening onto the nipple surface. Therefore it has a potential role in the diagnosis and treatment of intraductal breast disease. This article describes the anatomy of the mammary ductal system, the early beginnings of MD, its ongoing evolution, and the need for further development for its future usage in increasing clinical indications. MD is a useful diagnostic adjunct in patients with pathological nipple discharge (PND) and can guide duct excision surgery. However, its potential use in the early detection of breast cancer, in guiding breast-conserving surgery (BCS) for cancer, and in the therapeutic ablation of intraductal disease, as well as in guiding risk-reducing strategies among high-risk women, requires further research and evaluation. The development of a biopsy kit that obtains adequate microbiopsy samples for histological diagnosis under direct visualization will enhance the use of this technique by breast surgeons and radiologists. Future developments also include combining MD with molecular diagnostic markers and optical biopsy systems for the diagnosis of premalignant and early malignant disease, and combining MD with radiofrequency for curative ablation of intraductal lesions.

SYK expression in human breast cancer

Background

Syk (Splenic Tyrosine Kinase) is an intracellular receptor protein kinase involved in cell proliferation, differentiation and phagocytosis. It has been studied in T and B lymphocytes, NK cells and platelets. The strong expression of Syk in mammary gland prompted research into its potential role in mammary carcinogenesis. There have been very few studies about its role in breast cancer with conflicting results. This study aims to investigate the hypothesis that Syk expression is down-regulated in breast cancer compared with ANCT and the association between its expression and clinicopathological parameters.

Materials and methods

mRNA was extracted from 48 breast cancer specimens. Relative Syk to ribosomal RNA expression was determined by RT-PCR and Taqman methodology. Mann-Whitney U test was used to examine the association between Syk expression in cancer and ANCT. Spearman's rank correlation test was used to examine the association between Syk expression in tumours and patients' age, tumour size, tumour grade, estrogen and progesterone receptor status, lymph node metastasis, vascular invasion and clinical outcome.

Results

The median for the relative value of Syk expression was 0.17 and 0.18 (range: 0.12 – 0.56 and 0.0 – 1.77) for tumours and ANCT respectively. There was no significant association between Syk expression in cancers and ANCT (p= 0.598) nor between Syk expression in tumours and patients' age, tumour size, tumour grade, estrogen and progesterone receptor status, lymph node metastasis, vascular invasion or prognosis.

Conclusion

This study shows that Syk mRNA expression does not seem to vary between breast tumours and ANCT. Furthermore, we observed no significant association between Syk expression and clinicopathological parameters.