Bone formation and inflammation in cardiac valves

BACKGROUND

For nearly a century, the mechanical failure of calcified heart valves was attributed to a passive degenerative process. Recently, several case reports described bone formation in surgically excised heart valves and suggested an unexpected process of tissue repair.

METHODS AND RESULTS

We studied the prevalence and pathology of heterotopic ossification in 347 surgically excised heart valves (256 aortic, 91 mitral) in 324 consecutive patients (182 men, 142 women; mean age 68 years) who underwent cardiac valve replacement surgery between 1994 and 1998. The valves were examined microscopically to determine the prevalence and features of bone formation and remodeling. Two hundred eighty-eight valves (83%) had dystrophic calcification. Mature lamellar bone with hematopoietic elements and active bone remodeling were present in 36 valves (13%) with dystrophic calcification. Endochondral bone formation, similar to that seen in normal fracture repair, was identified in 4 valves. Microfractures were present in 92% of all valves with ossification. Neoangiogenesis was found in all valves with ossification. Bone morphogenetic proteins 2 and 4 (BMP 2/4), potent osteogenic morphogens, were expressed by myofibroblasts and preosteoblasts in areas adjacent to B- and T-lymphocyte infiltration in valves where ossification was identified. Mast cells were present in calcified and ossified valves and were especially prominent in atheromatous regions.

CONCLUSIONS

Heterotopic ossification consisting of mature lamellar bone formation and active bone remodeling is a relatively common and unexpected finding in end-stage valvular heart disease and may be associated with repair of pathological microfractures in calcified cardiac valves.

Early educational and health enrichment at age 3-5 years is associated with increased autonomic and central nervous system arousal and orienting at age 11 years: evidence from the Mauritius Child Health Project

Little is known about the effects of environmental enrichment on psychophysiological measures of arousal and orienting in humans. This study tests the hypothesis that early educational and health enrichment is associated with long-term increases in psychophysiological orienting and arousal. One hundred children were experimentally assigned to a two-year enriched nursery school intervention at ages 3-5 years and matched at age 3 years on psychophysiological measures, gender, and ethnicity to 100 comparisons who received the normal educational experience. Children were retested 6-8 years later at age 11 years on skin conductance (SC) and electroencephalogram (EEG) measures of arousal and attention during pre- and postexperimental rest periods and during the continuous performance task. Nursery enrichment was associated with increased SC amplitudes, faster SC rise times, faster SC recovery times, and less slow-wave EEG during both rest and CPT conditions. This is believed to be the first study to show that early environmental enrichment is associated with long-term increases in psychophysiological orienting and arousal in humans. Results draw attention to the important influence of the early environment in shaping later psychophysiological functioning.

MR imaging of the breast in patients with invasive lobular carcinoma

OBJECTIVE

Our objective was to assess the usefulness of MR imaging in patients diagnosed with invasive lobular carcinoma of the breast.

MATERIALS AND METHODS

Between July 1993 and September 1999, 32 women (33 cases) diagnosed with pure invasive lobular carcinoma of the breast underwent contrast-enhanced MR imaging examination. One woman was excluded because of lack of follow-up. Correlation was made between the mammographic and sonographic findings, the MR imaging findings, and the final pathology results for the remaining 32 cases.

RESULTS

In 18 women who did not undergo excisional biopsy before the MR imaging, MR imaging showed more extensive tumor burden or the detection of the primary lesion that was occult on conventional imaging in seven (38.9%) of 18 women. In nine (50%) of 18 women, MR imaging performed equally as well as mammography and sonography. In one case (5.6%), MR imaging and mammography underestimated disease extent. In another patient (5.6%), MR imaging overestimated tumor burden, although mammography failed to show the cancer. In 14 patients who had excisional biopsy before the MR imaging, residual tumor was shown in eight women (57.1%) with extensive tumor or additional separate foci in five of the eight patients. In two cases (14.3%) that were interpreted as equivocal, residual tumor was shown in both cases on reexcision. In three cases (21.4%), the MR imaging was interpreted as negative, but microscopic tumor was shown around seroma on reexcision. False-positive enhancement was seen in one case (7.1%).

CONCLUSION

MR imaging showed more extensive tumor than conventional imaging and affected the clinical management in 16 (50%) of 32 patients with invasive lobular carcinoma.

The effect of salinity on different developmental stages of an endemic annual plant, Aster laurentianus (Asteraceae)

Salinity reduces substrate water potential, thereby restricting water and nutrient uptake by plants; salinity may also cause ionic imbalance and toxicity. Because substrate salinity fluctuates through the growing season, a plant may be exposed to different salinity levels, at various stages of development, with potentially significant consequences on population dynamics. Here, we present the results of a study of the effect of substrate salinity on seed germination, seedling emergence, and growth of Aster laurentianus, an annual marsh plant, endemic to the Gulf of St. Lawrence and potentially threatened. Seed germination was reduced in low salt concentration (10 g sea salt/L) and completely inhibited by salinity levels >/=20 g sea salt/L. However, this inhibiting effect was reversible: seeds from the salt treatments germinated readily after being washed in distilled water. Though seedling emergence was diminished at low salinity levels, postemergence survival was little affected. Plant growth was reduced, but net carbon assimilation rate was not affected by high salinity levels. Increased root respiration and respiratory costs associated with salt tolerance might have contributed to lower C accumulation at higher salinity levels. All developmental processes considered are thus negatively affected by substrate salinity, with potentially significant consequences on population abundance and distribution in salt marshes. Yet, the tolerance of this species to high salinity levels after seedling emergence is remarkable. Seed germination represents a major bottleneck in the species life cycle, potentially controlling local distribution and abundance in the natural habitat.

Adaptation and survival of surface-deprived red blood cells in mice

The consequences of lost membrane area for long-term erythrocyte survival in the circulation were investigated. Mouse red blood cells were treated with lysophosphatidylcholine to reduce membrane area, labeled fluorescently, reinfused into recipient mice, and then sampled periodically for 35 days. The circulating fraction of the modified cells decreased on an approximately exponential time course, with time constants ranging from 2 to 14 days. The ratio of volume to surface area of the surviving cells, measured using micropipettes, decreased rapidly over the first 5 days after infusion to within 5% of normal. This occurred by both preferential removal of the most spherical cells and modification of others, possibly due to membrane stress developed during transient trapping of cells in the microvasculature. After 5 days, the cell area decreased with time in the circulation, but the ratio of volume to surface area remained essentially constant. These results demonstrate that the ratio of cell volume to surface area is a major determinant of the ability of erythrocytes to circulate properly.

The caM kinase, Pnck, is spatially and temporally regulated during murine mammary gland development and may identify an epithelial cell subtype involved in breast cancer

While screening for protein kinases expressed in the murine mammary gland, we identified previously a Ca2+/calmodulin-dependent kinase, Pnck, that is most closely related to CaMKI. In this report, we show that Pnck is temporally regulated during murine mammary development with highest levels of expression observed late in pregnancy, concomitant with the decreased cellular proliferation and terminal differentiation of the mammary epithelium. Consistent with this finding, Pnck is up-regulated in confluent mammary epithelial cells and is down-regulated as serum-starved cells are stimulated to reenter the cell cycle. In the mammary gland, Pnck is expressed in an epithelial-specific and markedly heterogeneous manner, suggesting that the expression of this kinase may be restricted to a particular mammary epithelial cell type. Potentially related to its heterogeneous in vivo expression pattern, Pnck expression is oncogene-associated in murine epithelial cell lines derived from mammary tumors arising in different transgenic mouse models of breast cancer; cell lines derived from mammary tumors initiated by c-myc or int-2/Fgf3 express Pnck, whereas cell lines initiated by neu or H-ras do not. In an analogous manner, expression of the human homologue of Pnck is restricted to a subset of human breast cancer cell lines. Moreover, PNCK was found to be highly overexpressed in a subset of human primary human breast cancers compared with benign mammary tissue. Together, our data suggest that Pnck may play a role in mammary development, and that expression of this kinase may be restricted to a mammary epithelial cell type that is transformed in a subset of human breast cancers.

Anti-CD20 chimeric monoclonal antibody treatment of refractory immune-mediated thrombocytopenia in a patient with chronic graft-versus-host disease

BACKGROUND

Autoimmune thrombocytopenia in chronic graft-versus-host disease may represent an instance of B-cell dysregulation leading to clinical disease.

OBJECTIVE

To attempt to treat refractory immune-mediated thrombocytopenia in a patient with chronic graft-versus-host disease by using anti-CD20 chimeric monoclonal antibody.

DESIGN

Case report.

SETTING

Academic medical center.

PATIENT

A patient with chronic graft-versus-host disease after allogeneic peripheral blood stem-cell transplantation who had severe refractory immune-mediated thrombocytopenia.

INTERVENTION

Weekly infusion of rituximab, 375 mg/m2, for 4 weeks.

MEASUREMENTS

Platelet count, CD3+ cell count, and CD19+ cell count.

RESULTS

Rituximab therapy resulted in marked depletion of B cells in the peripheral blood and decreased levels of platelet-associated antibody. The increase in platelet count persisted despite tapering and discontinuation of immunosuppressive therapy for chronic graft-versus-host disease.

CONCLUSION

The efficacy of rituximab for the treatment of immune-mediated thrombocytopenia suggests that this drug may have activity in other autoimmune diseases or chronic graft-versus-host disease.

Intercellular adhesion molecule expression in ductal carcinoma of the breast: correlation of immunohistochemical staining with cytologic smear pattern

Recent studies suggest that altered expression of intercellular adhesion molecules (ICAM) in ductal carcinoma of the breast is associated with a higher incidence of metastases and decreased patient survival. In addition, the presence of significant cellular dyscohesion in cytologic smear preparations has been found to correlate with the presence of regional and distant metastases in a subset of patients. In this study, we correlate the smear pattern in preparations taken directly from surgically excised breast tumors with their immunohistochemical staining pattern, using antibodies directed against a panel of ICAM. We found excellent correlation, as all three tumors with an extremely high degree of tumor cell cohesion showed strong staining with all ICAM antibodies in the vast majority (>/=90%) of tumor cells in corresponding tissue sections. In contrast, five tumors displaying a largely dyscohesive smear pattern demonstrated decreased staining (</=70% of tumor cells) with at least one of the ICAM antibodies used. Tumors with intermediate degrees of cellular cohesion in smear preparations showed varied patterns of ICAM staining. These findings support the theory that loss of ICAM expression represents the physiologic basis for patterns observed in cytologic smears of ductal carcinoma of the breast.

Quantitative vascularity of breast masses by Doppler imaging: regional variations and diagnostic implications

Seventy-four biopsy proven breast masses were imaged by color and power Doppler imaging to evaluate vascular pattern of malignant and benign breast masses. The images were analyzed for vascularity. The measurements were made over the entire mass as well as regionally at its core, at its periphery, and in the tissue surrounding it. The surgical specimens were analyzed for microvessel density. The diagnostic performance of Doppler sonographic vascularity indices was evaluated by receiver operating characteristic analysis. The malignant masses were 14 to 54% more vascular than the benign masses. Both types of masses were more vascular by ultrasonography than the tissue surrounding them. Whereas benign masses were 2.2 times more vascular than the surrounding tissue, the malignant masses were 5.0 times more vascular. In a subset of patients the regional vascularity at the core, periphery, and surrounding tissue by Doppler imaging exhibited a strong correlation (R2 > 0.9) with the corresponding histologic microvessel density measurements. Although the malignant masses exhibited a strong gradient in vascularity, core > periphery > surrounding tissue, the benign masses had relatively uniform distribution of vascularity. The area under the receiver operating characteristic curve (A(Z)) for the Doppler indices ranged from 0.56 +/- 0.07 to 0.65 +/- 0.07. A nonlinear analysis including age-specific values of Doppler indices improved the diagnostic performance to A(Z) = 0.85 +/- 0.06. In conclusion, quantitative Doppler imaging when used in combination with a nonlinear rule-based approach has the potential for differentiating between malignant and benign masses.

MR imaging in patients with nipple discharge: initial experience

PURPOSE

To investigate the potential of magnetic resonance (MR) imaging in patients with nipple discharge.

MATERIALS AND METHODS

Between February 1992 and December 1998, 23 patients with nipple discharge underwent contrast material-enhanced MR imaging at 1.5 T. Mammographic findings were negative in 22 of 23 patients and revealed asymmetry in one patient. Galactography was attempted in two patients, with negative findings in one patient and no success in the other. Fifteen of 23 patients underwent excisional biopsy-seven of 15 with MR imaging-guided localization, and one of 15 with mammographic localization. Eight of 23 patients were followed up clinically (range, 7-24 months; mean, 20 months).

RESULTS

In 11 of the 15 (73%) patients who underwent excisional biopsy, MR imaging findings correlated with histopathologic findings. MR imaging demonstrated four of six benign papillomas and one of two fibroadenomas as circumscribed, enhancing subareolar masses. Findings of one MR imaging examination were negative, and benign tissue was found at excisional biopsy. MR imaging findings were suspicious in six of the seven patients with excisional biopsy findings of malignancy (regional enhancement [n = 2], ductal enhancement [n = 2], peripherally enhancing mass [n = 1], and spiculated mass [n = 1]). In one of the seven patients, a benign-appearing intraductal mass was identified at MR imaging; excisional biopsy revealed a benign papilloma with an adjacent focus of DCIS.

CONCLUSION

MR imaging can help identify both benign and malignant causes of nipple discharge. It potentially offers a noninvasive alternative to galactography.

Accuracy of sentinel lymph node biopsy in patients with large primary breast tumors

BACKGROUND

Patients with large breast tumors are increasingly undergoing neoadjuvant treatment to downstage local disease; however, accurate staging of the axilla before the initiation of chemotherapy remains problematic. In the current study, the authors report on the accuracy of sentinel lymph node (SLN) biopsy in such patients to determine the feasibility of applying this technique before induction chemotherapy.

METHODS

One hundred three patients with 104 tumors classified as American Joint Committee on Cancer (AJCC) T2 (tumor >/= 2 cm but </= 5 cm) or larger were recruited at the University of Pennsylvania and the Mayo Clinic. In the majority of cases, combined blue dye and radiotracer was used for SLN identification. After SLN identification, a completion axillary lymph node dissection was performed in 87 cases. The SLN was evaluated with hematoxylin and eosin and immunohistochemistry.

RESULTS

The SLN was identified in 99% of cases. The overall rate of lymph node metastasis was 59% (95% exact confidence interval [95% CI], 49-68%) (61 of 104 cases). The SLN false-negative rate was 2% (95% exact CI, < 1-11.5%) (2 patients). In 56 tumors >/= 3 cm, 1 false-negative result (2% [95% exact CI, < 1-15%]) was identified, and the rate of lymph node metastasis was 62.5% (95% exact CI, 48. 5-75%) (35 of 56 tumors). Within 30 SLN positive patients with tumors >/= 3 cm and complete axillary lymph node dissection, 3 of 8 patients (37.5% [95% exact CI, 8.5-75.5%]) with micrometastasis (</= 2 mm) to the SLN had positive non-SLN compared with 21 of 22 patients (95.5% [95% exact CI, 77-100%]) with macrometastasis (> 2 mm) to the SLN (P = 0.002).

CONCLUSIONS

SLN biopsy for patients with large breast tumors is technically feasible and highly accurate. SLN biopsy should be considered for the staging of clinically negative axilla in patients scheduled to receive neoadjuvant chemotherapy.

Active macromolecule uptake by lymph node antigen-presenting cells: a novel mechanism in determining sentinel lymph node status

BACKGROUND

Although sentinel lymph node (SLN) biopsy is a powerful staging tool for patients with melanoma and breast cancer, controversy remains regarding specific aspects of technique. We examined particle uptake by antigen-presenting cells (APCs) to determine if this mechanism is responsible for the differential retention of radioactivity in SLNs relative to nonsentinel lymph nodes (NSLNs).

METHODS

Mapping was conducted in pigs injected with vital blue dye, fluoroscein isothiocyanate-labeled human serum albumin (FITC-HSA), and one of two 99mtechnetium-labeled tracers, i.e., human serum albumin, a small macromolecule, or unfiltered sulfur colloid, a mixture of small and large particles. Macromolecule uptake by APCs was studied in vitro by using FITC-HSA and measured by fluorescence-activated cell sorting (FACS). SLNs and NSLNs were analyzed by fluorescence microscopy or FACS, with counterstaining for leukocyte cell surface markers.

RESULTS

Both radiotracers were effective. Cultured APCs rapidly took up FITC-HSA. Microscopy showed FITC-HSA in the subcapsular sinus of SLNs shortly after injection and subsequent distribution to interfollicular areas. FACS revealed increasing amounts of FITC-HSA in SLNs over time. Cells responsible for uptake were APCs, expressing major histocompatibility (locus) class II.

CONCLUSIONS

This report establishes active macromolecule uptake as a mechanism that determines SLN status. This mechanism has important implications for performing SLN biopsy.

Losses of the tumor suppressor BIN1 in breast carcinoma are frequent and reflect deficits in programmed cell death capacity

Oncogenic activation of MYC occurs often in breast carcinoma and is associated with poor prognosis. Loss or inactivation of mechanisms that restrain MYC may therefore be involved in tumor progression. In this study, we show that the MYC-interacting adaptor protein BIN1 is frequently missing in malignant breast cells and that this loss is functionally significant. BIN1 was expressed in normal and benign cells and tissues but was undetectable in 6/6 estrogen receptor-positive or estrogen receptor-negative carcinoma cell lines examined. Similarly, complete or partial losses of BIN1 were documented in 30/50 (60%) cases of malignant breast tissue analyzed by immuno-histochemistry or RT-PCR. Abnormalities in the organization of the BIN1 gene were apparent in only a minority of these cases, suggesting that most losses were due to epigenetic causes. Nevertheless, they were functionally significant because ectopic BIN1 induced programmed cell death in malignant cells lacking endogenous BIN1 but had no effect on the viability of benign cells. We propose that loss of BIN1 may contribute to breast cancer progression by eliminating a mechanism that restrains the ability of activated MYC to drive cell division inappropriately.

The efficacy of zotepine in treating acute negative symptoms of schizophrenia: The results of a meta-analysis

INTRODUCTION

Zotepine is a unique antipsychotic drug, having effects which are both antiserotonergic and antidopaminergic that may make it more effective in the treatment of negative symptoms of schizophrenia than more conventional agents.

METHOD

A meta-analysis was performed on the effect of zotepine on the negative symptoms in seven double-blind studies, as measured by the SANS scale.

RESULTS

Of the trials selected for this meta-analysis, one showed significant improvement in acute negative symptoms in favour of zotepine. Negative symptoms measured in the other trials showed trends in favour of zotepine, except for one study where the trend was in favour of perazine. The meta-analysis showed zotepine to be significantly better then either placebo or conventional antipsychotic comparators using the standardized treatment difference methodology, and it confirmed the results from a previous study using patients with predominantly negative symptoms.

CONCLUSION

Zotepine may have a place in the treatment of this group of patients where conventional antipsychotic drugs have had little effect. ( Int J Psych Clin Pract 2000; 4: 209 - 214).

Breakpoints of the t(11;18)(q21;q21) in mucosa-associated lymphoid tissue (MALT) lymphoma lie within or near the previously undescribed gene MALT1 in chromosome 18

Lymphomas arising in mucosa-associated lymphoid tissue (MALT) are indolent B-cell tumors that have a predilection for epithelial sites and often develop in a setting of chronic inflammation or autoimmunity. As many as 50% of low-grade MALT lymphomas contain an (11;18)(q21; q21) chromosomal translocation. Using fluorescence in situ hybridization, we have analyzed the position of recombination within chromosome 18 DNA in three examples of MALT lymphoma bearing this translocation. In all three cases, the breakpoint maps to DNA in BAC b357H2, covering about 150 kb of sequence. A previously undescribed, ubiquitously expressed gene, which we refer to as MALT1, was identified within this sequence and was found to be broken in one case for which we have definitively located the position of recombination between chromosomes 18 and 11. The sequence of this gene indicates the presence of two immunoglobulin-like C2 domains and a region of partial homology to caspases, suggesting a possible role for MALT1 in the regulation of apoptosis.

Inhibition in the human motor cortex is reduced just before a voluntary contraction

OBJECTIVE

To examine inhibition in the human motor cortex before and during voluntary movements.

METHODS

The balance between the excitation and inhibition of corticospinal neurons in the human motor cortex was tested by conditioning the motor evoked potentials (MEP) evoked in forearm muscles by transcranial magnetic stimulation with a preceding subthreshold stimulus delivered through the same coil.

RESULTS

When normal individuals (n = 9) made a tonic wrist extension, inhibition of the forearm extensor MEP decreased, whereas that of the forearm flexors was unchanged. When these individuals made a tonic wrist flexion, inhibition of the forearm flexor MEP diminished, whereas that of the forearm extensors was unchanged. When normal individuals (n = 10) made a phasic wrist extension in response to an auditory signal, inhibition of the extensor MEP began to decline about 95 msec before the onset of the agonist EMG activity.

CONCLUSIONS

The changes in balance of excitation and inhibition of corticospinal neurons associated with a voluntary movement precede the movement and are directed at the corticospinal neurons projecting to the agonists. These changes may help to select the population of cortical neurons responsible for the movement.

The immunoassay of cytokines and growth factors in biological fluids

There are a number of problems associated with the development of standards suitable for use in the most commonly used assays to detect cytokines in biological fluids. These problems include: (i) the failure of some MoAbs used in immunoassays to detect all different <<species>> of recombinant or natural material; (ii) the use of many different MoAbs, with different specificities, in different immunoassay kits, and (iii) the detection of non-active cytokines (fragments, inhibitors, receptor antagonists, etc.) in these immunoassays. As a result, it is possible to have biologically active material which is not detected in these immunoassays. Alternatively, biologically inactive material can be detected in these assays and is indistinguishable from biologically active material. In addition, the use of different antibodies with different specificities, affinities and avidities in different kits designed to detect the same biological materials results in markedly different sensitivities and specificities. Many of these same concerns can be raised for the use of bioassays for detection of molecules in biological fluids. The solution will not be simple (if possible at all). In most cases, the immunoassay kits are designed to detect <<natural>> material in biological fluids, but are made with MoAbs against recombinant material. Because of the markedly different specificities, affinities, etc. of the MoAbs in these kits, their standardization is possible only with a highly purified preparation of natural material. For the assay of recombinant materials, immunoassays should be specifically designed with the recombinant material in mind (i.e. the MoAbs made specifically against the recombinant material to be detected or shown to bind effectively with the recombinant material). Importantly, it should be made clear to investigators using different immunoassays that: (i) the reporting of biological material detected using immunoassays can only be made in units of weight (i.e. ng/ml); (ii) because of the detection of biologically active and inactive material using immunoassay kits these assays cannot be directly compared to bioassays or their results represented as <<activity units>>; (iii) because of the difference in specificity and sensitivity of the different reagents used in different immunoassays, the results from different assays cannot be directly compared, and (iv) because of these same considerations, comparison of different <species>> of materials within a single immunoassay is also not possible. The use of specific immunoassays for recombinant material in combination with bioassays and the use of cytokine standards, made from highly purified natural material, would help to standardize the results in this field.

BI-RADS categorization as a predictor of malignancy

PURPOSE

To determine the positive predictive value (PPV) of the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) categories 0, 2, 3, 4, and 5 by using BI-RADS terminology and by auditing data on needle localizations.

MATERIALS AND METHODS

Between April 1991 and December 1996, 1,400 mammographically guided needle localizations were performed in 1,109 patients. Information entered into the mammographic database included where the initial mammography was performed (inside vs outside the institution), BI-RADS category, mammographic finding, and histopathologic findings. A recorded recommendation was available for 1,312 localizations in 1,097 patients, who composed the study population.

RESULTS

The 1,312 localizations yielded 449 (34%) cancers (139 [31%] were ductal carcinoma in situ [DCIS]; 310 [69%] were invasive cancers) and 863 (66%) benign lesions. There were 15 (1%) category 0 lesions; the PPV was 13% (two of 15 lesions). There were 50 (4%) category 2 lesions; the PPV was 0% (0 of 40 lesions). There were 141 (11%) category 3 lesions; the PPV was 2% (three of 141 lesions). The three cancers in this group were all non-comedotype DCIS. There were 936 (71%) category 4 lesions; the PPV was 30% (279 of 936 lesions). There were 170 (13%) category 5 lesions; the PPV was 97% (165 of 170 lesions).

CONCLUSION

Placing mammographic lesions into BI-RADS categories is useful for predicting the presence of malignancy. Perhaps, most important, a lesion placed into BI-RADS category 3 is highly predictive of benignity, and short-term interval follow-up as an alternative to biopsy would decrease the number of biopsies performed in benign lesions.

Sentinel lymph node biopsy with metastasis: can axillary dissection be avoided in some patients with breast cancer?

PURPOSE

Recent studies have suggested that the sentinel lymph node (SLN) biopsy is an accurate alternative staging procedure for women with breast cancer. The goal of this study was to identify a subset of breast cancer patients in whom metastatic disease was confined only to the SLN.

MATERIALS AND METHODS

From two institutions, we recruited 222 women with breast cancer for SLN biopsy. A SLN biopsy was performed in each patient, followed by an axillary dissection in 182 patients. Histologic and immunohistochemical cytokeratin stains were used on all SLNs.

RESULTS

The SLN was identified in 220 (97. 8%) of the 225 biopsies. Evidence of metastatic breast cancer in the SLN was found in 60 (27.0%) of the 222 patients. Of these patients, 32 (53.3%) had evidence of tumor in the SLN only. By multivariate analysis, two factors were found to be significantly associated with a higher likelihood of tumor involvement in the non-SLNs: primary tumor size larger than 2.0 cm (P =.0004) and macrometastasis (> 2.0 mm) in the SLN (P =.002). Additional analysis revealed that none (0%; 95% confidence interval, 0% to 18.5%) of the 18 patients with primary tumors < or = 2.0 cm and micrometastasis to the SLN had remaining axillary lymph node involvement.

CONCLUSION

The primary tumor size and metastasis size in the SLN are independent factors in predicting the incidence of tumor in the non-SLNs. Therefore, the SLN biopsy alone may be adequate for staging and/or therapy decision making in patients with primary breast tumors < or = 2.0 cm and micrometastasis in the SLN.

Immunohistochemistry with pancytokeratins improves the sensitivity of sentinel lymph node biopsy in patients with breast carcinoma

BACKGROUND

Sentinel lymph node (SLN) biopsy is being investigated as a staging procedure for breast carcinoma. The authors evaluated whether immunohistochemical (IHC) analysis improves the sensitivity of this procedure.

METHODS

Forty-four women with breast carcinoma were recruited for SLN biopsy. Preoperative lymphoscintigraphy was followed by intraoperative localization using a handheld gamma probe and blue dye. After SLN identification, an immediate complete axillary lymph node dissection was performed in all patients. All lymph nodes were subjected to routine histology (hematoxylin and eosin [H&E]) and IHC using antibody to cytokeratins.

RESULTS

The SLN was identified in 41 of 43 patients (95%). Successful SLN identification was independent of biopsy technique (open surgical [95%] vs. fine-needle aspiration/core needle biopsy [96%]). Twelve of 41 patients (29%) had evidence of lymph node metastasis in the SLN by routine histology. Of the twenty-nine patients with H&E negative SLN, 3 were found to have metastasis by IHC for a conversion rate of 10%. Fifteen of 41 patients (37%) had evidence of metastasis in SLN. All 26 patients with H&E and IHC negative SLN had negative nonsentinel lymph nodes by routine histology and IHC (100% negative predictive value). All patients with tumors < 2 cm and micrometastasis to the SLN had no additional lymph node disease, in contrast to patients with lesions > 2 cm or patients with macrometastasis to the SLN (P = 0.007).

CONCLUSIONS

These results confirm that SLN biopsy is extremely accurate for patients with breast carcinoma, even after open surgical biopsy. IHC analysis or serial sectioning of SLN improves the sensitivity of this staging technique.

Outcomes in breast cancer patients relative to margin status after treatment with breast-conserving surgery and radiation therapy: the University of Pennsylvania experience

PURPOSE

To evaluate the significance of final microscopic resection margin status on treatment outcomes in women with early breast cancer who are treated with breast-conserving surgery and definitive breast irradiation.

METHODS AND MATERIALS

An analysis was performed of 1021 consecutive women with clinical Stage I or II invasive carcinoma of the breast treated with breast-conserving surgery and definitive breast irradiation. Complete gross excision of tumor was performed in all cases, and an axillary staging procedure was performed to determine pathologic axillary lymph node status. The 1021 patients were divided into four groups based on the final microscopic margin from the tumor excision or from the re-excision if performed. These four groups were: (a) 518 patients with negative margins; (b) 124 patients with focally positive margins; (c) 96 patients with focally close margins (< or = 2 mm); and (d) 283 patients with unknown margins.

RESULTS

Local failure was not significantly different in patients with negative, focally positive, focally close or unknown final pathologic margins of resection at 8 years (8% vs. 10% vs. 17% vs. 16%, respectively, p = 0.21). The 8-year outcome also was not different among the four groups for overall survival (86% vs. 83% vs. 88% vs. 81%, respectively, p = 0.13), cause-specific survival (89% vs. 86% vs. 88% vs. 83%, respectively, p = 0.14), no evidence of disease survival (81% vs. 73% vs. 86% vs. 77%, respectively, p = 0.09), and freedom from distant metastases (85% vs. 75% vs. 86% vs. 79%, respectively, p = 0.08).

CONCLUSION

These results demonstrate that selected patients with focally positive or focally close microscopic resection margins can be treated with breast-conserving surgery and definitive breast irradiation with 8-year local control rates and survival rates that are similar to those seen in breast-conservation patients with negative or unknown final resection margins.

Sampling of grossly benign breast reexcisions: a multidisciplinary approach to assessing adequacy

The widespread use of breast-conserving therapy in the treatment of early-stage breast cancer has resulted in increasing numbers of reexcision specimens requiring histologic assessment for residual disease and margin status. Because many reexcisions are performed for only microscopically positive or close margins, reexcision specimens often appear grossly negative and directed tissue sampling cannot be performed. The issue of adequate sampling in these specimens has not been addressed in the literature. A multidisciplinary approach to identifying the clinically important lesions in breast reexcisions and a cost-effective approach to tissue sampling are needed. We reviewed 97 consecutive cases of grossly negative breast reexcisions in which all tissue had been embedded. Forty-seven specimens contained residual invasive or in situ carcinoma and 50 were histologically negative. Detailed histologic findings were presented to a medical oncologist, a radiation oncologist, and a surgeon, who assessed the clinical impact of each diagnosis. Of the 47 positive specimens, 30 resulted in a major change in patient management (recommendation for additional surgery), 10 resulted in minor changes (alteration in radiation dose or adjuvant chemotherapy regimen), and 7 did not alter management. A total of 1867 blocks were submitted. If one block per centimeter of maximal tissue dimension had been submitted and the remainder of the specimen examined only if initial sections revealed invasive or in situ carcinoma, then 901 blocks would have been processed (52% reduction), but we would have missed an average of 3.7 cases resulting in a major change in therapy, and 3.3 cases resulting in a minor change. In contrast, two blocks per centimeter would have missed an average of less than one case each of diagnoses resulting in major and minor therapy changes (0.9 and 0.8 cases, respectively), and 315 (17%) fewer tissue blocks would have been processed. We recommend submitting two blocks per centimeter in grossly benign reexcisions, and examining the remainder of the tissue only if carcinoma is detected on initial sections.

On the focal nature of inhibition and facilitation in the human motor cortex

OBJECTIVE

To find the area of the human cortex from which inhibition and facilitation of corticospinal neurons could be obtained.

METHODS

A patient with seizures had an array of 64 electrodes placed over the left fronto-temporal cortex. The motor evoked potential (MEP) elicited by stimulating through one pair of electrodes was conditioned by stimuli that were subthreshold for a MEP given through adjacent pairs of electrodes.

RESULTS

The MEP recorded over the right abductor pollicis brevis produced by stimulating over the hand area of the left cortex could be inhibited (at intervals less than 5 ms) and facilitated (at intervals greater than 5 ms) by subthreshold conditioning stimuli delivered through neighbouring pairs of electrodes. The inhibition and facilitation were only obtained when the conditioning stimuli were delivered within 1-2 cm of the test site. The sites producing inhibition and facilitation were not identical. Conditioning stimuli over the face area did not inhibit the MEP produced by stimulating the hand area or vice versa.

CONCLUSION

The inhibition and facilitation of corticospinal neurons projecting to a given muscle arise from small areas close to those corticospinal neurons.