Oncoplastic Approach for Reconstruction of Large Partial Mastectomy Defects Using Reduction Mammoplasty in Large Breasted Women

Background: Women with large breast tumors are often treated with mastectomy as their definitive operation. However, women with large breasts can have a significant resection and still achieve an excellent aesthetic outcome if the partial mastectomy is combined with a reduction mammoplasty. It is not clear if the limitation for breast conservation should be made based on tumor size, or on the basis of the volume of tissue that needs to be resected relative to the total volume of breast tissue. Our study aims to assess the oncologic safety and cosmetic outcome of large partial mastectomies in large breasted women combined with reduction mammoplasty.Materials and Methods: All patients undergoing partial mastectomy and reduction mammoplasty performed at the University of California San Francisco were included. Medical records were reviewed for demographics, breast cancer data, oncologic and reconstructive operations, postoperative recurrences, complications, and need for additional operations.Results: Sixty-five patients undergoing partial mastectomy and reduction mammoplasty reconstruction were identified. Average tumor size was 2.8 cm (range 0.6 cm to 8.9 cm). The stage distribution for 63 patients was stage 0 (n=11), I (n=15), II (n=24), III (n=10), and IV (n=3), and 2 patients had Phylloides tumor. Twenty-five patients had neoadjuvant therapy, followed by breast reduction as their primary resection once chemotherapy was completed. Twenty patients (30.8%) required re-excision, four of whom required multiple re-excisions. Fifty nine patients (90.8%) were successfully treated with our approach, while 6 patients (9.2%) required completion mastectomy for their definitive resection, based on margin status after initial resection. There were a total of two recurrences, one in a patient who had a local DCIS recurrence after initial presentation with stage 0 disease and one in a patient who presented with metastatic disease. The patient with stage 0 disease and subsequent recurrence did not have radiation; the other patient presented initially with synchronous metastatic disease, had a poor response to chemotherapy, and her local recurrence occurred simultaneously with progression of distant disease. Of the patients with stage 0-III disease, the recurrence rate was 1.6% with a mean follow-up of 13 months. Eleven patients (15.9%) developed postoperative complications, including fat necrosis (n=1), hematoma (n=1), cellulitis (n=2), seroma (n=3), and wound healing complications (n=4). Despite complications and radiation therapy, all patients were exceptionally pleased with their reconstruction.Conclusion: Partial mastectomy with reduction mammoplasty breast reconstruction is a viable option that combines a safe oncologic procedure with immediate breast reconstruction. While further follow-up is needed, it is a viable alternative to mastectomy, enabling breast conservation and correction of significant breast redundancy and ptosis, which can impair the efficacy of radiation therapy. Prospective data collection should continue for these cases to establish the long term outcomes of large-breasted patients undergoing partial mastectomy and reduction mammoplasty.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4125.

Resistance to pyrethroid insecticides in Helicoverpa zea (Lepidoptera: Noctuidae) in Indiana and Illinois

The corn earworm, Helicoverpa zea (Boddie) (Lepidoptera: Noctuidae), can cause serious losses in many field and vegetable crops throughout the United States. Since their introduction, pyrethroid insecticides have become the primary insecticide class for managing H. zea. However, resistance has been reported in the southern United States and has recently became a concern in the Midwest after the observation of sporadic control failures and a decreased efficacy of pyrethroids in small-plot field trials. Larvae collected from Lafayette, IN, Vincennes, IN, and Collinsville, IL, were used to establish laboratory colonies in 2006 and 2007. Larvae from these colonies were tested for resistance to the pyrethroid insecticide bifenthrin by using topical assays. Adult males collected from pheromone traps in Lafayette were tested for resistance to cypermethrin by using the adult vial test (AVT) method. Resistance ratios of > or =8 were observed for the larvalbifenthrin assays in 2006 and 2007 in all colonies except for the 2007 Illinois colony. AVT assays conducted with cypermethrin showed approximately 15% survival in both 2006 and 2007 at the 5 microg per vial discriminating dose. These results suggest that low to moderate levels of pyrethroid resistance are present in these populations.

Malignant transformation of teratoma to primitive neuroectodermal tumor (PNET): Outcome analysis with retroperitoneal lymph node dissection and PNET specific chemotherapy

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Background: Malignant transformation of teratoma to PNET is a rare entity. Surgical resection has been the mainstay of therapy because these tumors are not curable with cisplatin based chemotherapy. We report long-term survival and potential cure with retroperitoneal lymph node dissection (RPLND) and PNET specific chemotherapy. Methods: Retrospective review of 75 patients (pts) with PNET in the testis or at distant metastasis treated from Jan 1988 to Dec 2007. 74 had RPLND as part of initial treatment or at relapse. PNET specific chemotherapy consisted of cyclophosphamide, doxorubicin, vincristine alternating with ifosfamide and etoposide. Available PNET specimens were tested for the Ewing's sarcoma (EWS) translocation using a FISH-based method. Results: The median follow-up was 40 months (range 2 to 235). 27 pts presented with clinical stage I disease. 18 underwent primary RPLND with PNET in the retroperitoneum in 5. 4 are dead of disease (DOD). 9 elected surveillance or adjuvant chemotherapy. 8 relapsed with PNET. 4 are DOD. 48 pts presented with metastatic disease. 20 are DOD, 24 have no evidence of disease (NED) and 4 are alive with disease. 50 of 75 pts had PNET documented metastasis with an estimated 5 years disease specific survival of 47%. 10 of these were treated with PNET specific chemotherapy for unresectable disease. 8 of the 10 achieved objective response with the duration of response ranging from 4 to 73 months. 2 pts are NED. 2 additional pts were treated with PNET specific chemotherapy as adjuvant to RPLND. Both are continuously NED. Specimens from 14 pts were tested for the EWS translocation, 2 were positive. Conclusions: Malignant transformation of teratoma to PNET carries an adverse prognosis. RPLND is an integral part of the therapeutic strategy. PNET specific chemotherapy, adjuvant to RPLND or for treatment of unresectable disease followed by surgery, may result in long-term survival and potential cure.

No significant financial relationships to disclose.

A literature review and case reports series on the use of phosphodiesterase inhibitors in the treatment of female sexual dysfunction

Summary

The term ‘female sexual dysfunction’ (FSD) encompasses a number of different disorders, and while their aetiologies are not fully understood, the sub-classifications of this broad umbrella term are increasingly becoming more established and accepted. However, there is less consensus regarding the optimal treatment of these conditions. While it is known that phosphodiesterase (PDE5) is involved in the female sexual response, the clinical and research evidence supporting the unlicensed use of PDE5 inhibitors (PDE5i) in women is inconclusive and at times contradictory. In this article we explore this further by means of a comprehensive literature review on the use of PDE5i in the treatment of FSD and we also present our clinical experience of using these drugs in this context.

Association of paediatric mastocytosis with a polymorphism resulting in an amino acid substitution (M541L) in the transmembrane domain of c-KIT

BACKGROUND

The receptor tyrosine kinase c-KIT plays a key role in normal mast cell development. Point mutations in c-KIT have been associated with sporadic or familial mastocytosis.

OBJECTIVES

Two unrelated pairs of apparently identical twins affected by cutaneous mastocytosis attending the Mastocytosis Clinic at the Royal Children's Hospital, Melbourne, provided an opportunity to assess the possible contribution of c-KIT germline mutations or polymorphisms in this disease.

METHODS

Tissue biopsy, blood and/or buccal swab specimens were collected from 10 children with mastocytosis. To detect germline mutations/polymorphisms in c-KIT, we studied all coding exons by denaturing high pressure liquid chromatography. Exons showing mismatches were examined by direct sequencing. The influence of the substitution identified was further examined by expressing the variant form of c-KIT in factor-dependent FDC-P1 cells.

RESULTS

In both pairs of twins, a heterozygous ATG to CTG transition in codon 541 was observed, resulting in the substitution of a methionine residue in the transmembrane domain by leucine (M541L). In each case, one parent was also heterozygous for this allele. Expression of M541L KIT in FDC-P1 cells enabled them to grow in human KIT ligand (stem cell factor, SCF) but did not confer factor independence. Compared with cells expressing wild-type KIT at a similar level, M541L KIT-expressing cells displayed enhanced growth at low levels of SCF, and heightened sensitivity to the KIT inhibitor, imatinib mesylate.

CONCLUSIONS

The data suggest that the single nucleotide polymorphism resulting in the substitution M541L may predispose to paediatric mastocytosis.

Molecular phylogeny and divergence dates for Australasian elapids and sea snakes (hydrophiinae): evidence from seven genes for rapid evolutionary radiations

One of the most prolific radiations of venomous snakes, the Australo-Melanesian Hydrophiinae includes approximately 100 species of Australasian terrestrial elapids plus all approximately 60 species of viviparous sea snakes. Here, we estimate hydrophiine relationships based on a large data set comprising 5800 bp drawn from seven genes (mitochondrial: ND4, cytb, 12S, 16S; nuclear: rag1, cmos, myh). These data were analysed using parsimony, likelihood and Bayesian methods to better resolve hydrophiine phylogeny and provide a timescale for the terrestrial and marine radiations. Among oviparous forms, Cacophis, Furina and Demansia are basal to other Australian elapids (core oxyuranines). The Melanesian Toxicocalamus and Aspidomorphus group with Demansia, indicating multiple dispersal events between New Guinea and Australia. Oxyuranus and Pseudonaja form a robust clade. The small burrowing taxa form two separate clades, one consisting of Vermicella and Neelaps calanotus, and the other including Simoselaps, Brachyurophis and Neelaps bimaculatus. The viviparous terrestrial elapids form three separate groups: Acanthophis, the Rhinoplocephalus group and the Notechis-Hemiaspis group. True sea snakes (Hydrophiini) are robustly united with the Notechis-Hemiaspis group. Many of the retrieved groupings are consistent with previous molecular and morphological analyses, but the polyphyly of the viviparous and burrowing groups, and of Neelaps, are novel results. Bayesian relaxed clock analyses indicate very recent divergences: the approximately 160 species of the core Australian radiation (including sea snakes) arose within the last 10 Myr, with most inter-generic splits dating to between 10 and 6 Ma. The Hydrophis sea snake lineage is an exceptionally rapid radiation, with > 40 species evolving within the last 5 Myr.

Evidence of local evolution of tomato-infecting begomovirus species in West Africa: characterization of tomato leaf curl Mali virus and tomato yellow leaf crumple virus from Mali

Tomato yellow leaf curl (TYLC) and tomato leaf curl (ToLC) diseases are serious constraints to tomato production in Mali and other countries in West Africa. In 2003 and 2004, samples of tomato showing virus-like symptoms were collected during a survey of tomato virus diseases in Mali. Three predominant symptom phenotypes were observed: (1) TYLC/ToLC (stunted upright growth and upcurled leaves with interveinal yellowing and vein purpling), (2) yellow leaf crumple and (3) broccoli or bonsai (severe stunting and distorted growth). Squash blot (SB) hybridization with a general begomovirus probe and/or SB/PCR analyses revealed begomovirus infection in plants with each of these symptom phenotypes and no evidence of phytoplasma infection. Sequence analysis of PCR-amplified begomovirus fragments revealed two putative new begomovirus species associated with the TYLC/ToLC and yellow leaf crumple symptom phenotypes, respectively. Full-length clones of these begomoviruses were obtained using PCR and overlapping primers. When introduced into N. benthamiana and tomato plants, these clones induced upward leaf curling and crumpling (the TYLC/ToLC-associated begomovirus) or downward leaf curl/yellow mottle (yellow leaf crumple-associated begomovirus) symptoms. Thus, these begomoviruses were named tomato leaf curl Mali virus (ToLCMLV) and tomato yellow leaf crumple virus (ToYLCrV). The genome organization of both viruses was similar to those of other monopartite begomoviruses. ToLCMLV and ToYLCrV were most closely related to each other and to tobacco leaf curl Zimbabwe virus (TbLCZV-[ZW]) and tomato curly stunt virus from South Africa (ToCSV-ZA). Thus, these likely represent tomato-infecting begomoviruses that evolved from indigenous begomoviruses on the African continent. Mixed infections of ToLCMLV and ToYLCrV in N. benthamiana and tomato plants resulted in more severe symptoms than in plants infected with either virus alone, suggesting a synergistic interaction. Agroinoculation experiments indicated that both viruses induced symptomatic infections in tomato and tobacco, whereas neither virus induced disease symptoms in pepper, common bean, small sugar pumpkin, African eggplant, or Arabidopsis. Virus-specific PCR primers were developed for detection of ToLCMLV and ToYLCrV and will be used to further investigate the distribution and host range of these viruses.

Heat-shock proteins and their role in chondrocyte protection, an application for autologous transplantation

Articular cartilage injury presents a unique therapeutic challenge. As cartilage possesses no blood or nerve supply of its own it has a particular susceptibility to early injury and a poor capacity for self-repair. Treatment options are limited and injury can eventually lead to osteoarthritis. Autologous chondrocyte transplantation is an exciting therapeutic development, but despite initial encouraging results, graft failure and formation of fibro- as opposed to hyaline cartilage remain problematic. Bleeding is an inevitable consequence of surgery, and blood-induced cartilage damage is well documented. It is hypothesised here that protecting chondrocytes against blood could significantly improve results. Heat-shock protein induction may confer chondroprotection. The expression of heat-shock proteins in human chondrocytes and rat femoral head cartilage following heat shock was analysed by Western blotting, and red-blood-cell-induced chondrocyte death was assessed by cell viability and apoptosis by flow cytometry. We demonstrate that heat-shock induced expression of heat-shock protein 70 (HSP70) (rat and human) and HSP32 (human). Blood and blood products reduced rat cartilage proteoglycan synthesis and human chondrocyte viability, and induced human chondrocyte apoptosis at concentrations considerably lower than those reported previously. The induction of HSP70 in rat cartilage was ineffective in reducing chondrocyte death in the absence or presence of red blood cells or red cell products. Heat shock to human chondrocytes reduced low levels of apoptosis (<20%) and cell death induced by low levels of blood products, but not higher levels. Induction of HSP32 with diacetylrhein appeared to be more effective and may hold greater promise. Blood has potent adverse effects on chondrocytes and the induction and chondroprotective effects of heat-shock proteins could be applied to increase the initial success of implanted chondrocytes improving the outcome of autologous chondrocyte transplantation.

A case of disseminated histoplasmosis successfully treated with the investigational drug posaconazole

A 79-year-old man with a 3-month history of weight loss and fever was diagnosed with disseminated histoplasmosis. When the infection became refractory to itraconazole therapy, posaconazole was prescribed. The patient became asymptomatic within 1 month of beginning treatment, and his general health improved. Posaconazole was discontinued after 6 months, and the patient has remained well since.

Defining the mechanisms by which leptin stimulates proliferation of ovarian cancer cells

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Background: Ovarian cancer (OvCa) ranks fourth as the cause of death related to cancer in women in the U.S. The vast majority (>90%) of OvCa originates from the ovarian surface epithelium. There is sufficient evidence to suggest that hormones, especially estrogen, may be involved in the etiopathogenesis of epithelial OvCa. Recent studies indicate that leptin participates either directly or indirectly to promote carcinogenesis in both breast and endometrial cancers. Furthermore it has been proposed that leptin may elicit its action via an estrogen related pathway. Leptin can stimulate proliferation of some OvCa cell lines and has been implicated as a potential biomarker for OvCa. However the mechanism(s) by which leptin contributes to the growth of OvCa has yet to be defined. We hypothesize that leptin’s effect will be mediated in part by estrogen receptor (ER) pathways. Methods: Three epithelial OvCa cell lines (IGROV1, OVCAR5 and TOV21G) and one benign human ovarian surface epithelial cell line (HOSE) were evaluated. Enzyme linked immunosorbent assay (ELISA) and Western blotting were used to assess leptin and leptin receptor (ObR), respectively. Leptin (0.06 nM–6.25 nM) induced effects on cell proliferation were assessed in the presence or absence of an aromatase enzyme inhibitor (Anastrozole) or the ER antagonist (ICI182780). Further, we explored leptin-induced effects on ERα promoter activity as evidenced by change in fluorescence via a dual luciferase promoter reporter. All experiments were conducted in triplicate. All data were subjected to ANOVA followed by Tukey’s post hoc test (p < 0.05). Results: All ovarian cell lines expressed ObR; whereas, no measurable amounts of leptin were detected in conditioned media. Leptin stimulated cell proliferation in both the benign and malignant lines. Leptin-induced cell proliferation was inhibited by Anastrozole and ICI182780. Furthermore, leptin stimulated luciferase activity of the ERα promoter/reporter. Conclusions: Leptin promotes proliferation of benign and malignant ovarian epithelial cells and appears to be mediated, at least in part, via aromatase and ER which may have therapeutic implications. This work was supported by the Vincent Memorial Hospital, SG Komen Foundation and the Advanced Medical Research Foundation.

No significant financial relationships to disclose.