Infiltrating fibromatosis of the breast: a potential pitfall

Mammary fibromatosis is a rare condition. It presents a big dilemma for the clinician, because it mimics breast cancer clinically, radiologically and sometimes cytologically. We report a case of fibromatosis of the breast and highlight the diagnostic difficulties and management.

Telomerase activity and Bcl-2 expression in human breast cancer

AIMS

Telomerase is a ribonucleoprotein that synthesizes telomeres and plays an important role in cellular immortalization. Bcl-2 gene encodes for a mitochondrial protein thought to prevent apoptosis of normal cells. We previously reported telomerase activity in 74% of human invasive breast cancers and detected a significant association between telomerase activity and prognostic parameters such as nodal status, tumour size and cellular proliferation. We hypothesized that telomerase reactivation in human breast cancer was associated with increased immunohistochemical expression of Bcl-2.

METHODS

Bcl-2 immunohistochemical expression was determined in 25 infiltrating breast carcinomas with known telomerase activity (17 telomerase-positive and 8 telomerase-negative). The percentage of strongly and moderately stained tumour cells for Bcl-2 was determined by a breast pathologist who was blinded to telomerase data. Fisher's exact test was used to examine the association between telomerase activity and Bcl-2 expression.

RESULTS

The median percentage of strongly stained tumour cells was 50% for telomerase-positive tumours (range, 0--100%) and 45% for telomerase-negative tumours (range, 0--100%). Twelve (70%) of 17 telomerase-positive tumours expressed strong or moderate Bcl-2 staining in >50% of tumour cells compared with six (75%) of eight telomerase-negative tumours (P=1.0).

CONCLUSION

Telomerase reactivation seems to be independent of Bcl-2 protein expression in human breast cancer.

The association between telomerase activity and hormone receptor status and p53 expression in breast cancer

BACKGROUND

Telomerase is a ribonucleoprotein enzyme that seems to play an important role in cellular immortality and carcinogenesis. p53 mutations account for approximately 50% of human cancers and represent the most frequent genetic lesion in breast cancer.

AIMS

This study aims to examine the association between telomerase reactivation and hormonal receptor status and p53 expression in invasive breast cancer.

METHODS

Using a polymerase chain reaction-based assay, telomerase activity was determined in 47 invasive breast carcinomas and 21 adjacent non-cancerous breast tissue specimens (stored at -80 degrees C) prospectively collected from 47 women undergoing elective surgical treatment in our centre. The histopathological features of the tumour were determined by experienced breast pathologists using light microscopy and haematoxylin and eosin staining. Oestrogen receptor (ER), progesterone receptor (PR) and p53 expressions were determined using immunohistochemistry techniques.

RESULTS

Telomerase activity was detected in 34 (72%) of 47 breast carcinomas and in none of the adjacent non-cancerous breast specimens. There was a significant association between telomerase reactivation, tumour size and nodal status. Telomerase positive tumours were more likely to be poorly differentiated (65% versus 46%), but this association failed to reach statistical significance. There was no significant difference in ER expression (68% versus 85%). PR expression (62% versus 62%) and p53 expression (19% versus 27%) between telomerase positive and telomerase negative cancers.

CONCLUSION

Telomerase reactivation is associated with important prognostic factors such as tumour size and nodal status in invasive breast cancer and seems to be independent of hormonal receptor status and p53 expression.

Advances in breast oncology: the 2002 ASCO meeting

At this year's American Society of Clinical Oncology (ASCO) meeting, a number of important advances in breast cancer diagnosis, treatment and prevention were reported. In this article, we review these current developments, focusing particularly on the ASCO technology assessment report--which discussed the adjuvant use of aromatase inhibitors in breast cancer--and other significant studies which were presented or updated: the role of taxanes in neoadjuvant and adjuvant therapy; current concepts regarding the timing of hormonal therapy during adjuvant chemotherapy; and cyclooxygenase-2 (COX-2) as a target for disruption in breast cancer treatment and prevention. With regards to advances in surgery, we review studies which were presented concerning the evolving role of sentinel lymph node biopsy in the management of the axilla in breast cancer, and review the latest meta-analysis on this subject presented at the meeting.

The mRNA expression of cyclo-oxygenase-2 (COX-2) and vascular endothelial growth factor (VEGF) in human breast cancer

AIMS

There is a growing body of evidence that cyclo-oxygenase 2 (COX-2) plays an important role in carcinogenesis and angiogenesis of human tumours. The present study aims to compare COX-2 expression in human breast cancer and adjacent non-cancerous tissue (ANCT), and to identify any correlation between COX-2 and VEGF expression.

METHODS

Total cellular RNA was extracted from frozen breast tissue samples according to standard methodology. The mRNA copy numbers for COX-2 and vascular endothelial growth factor 189 (VEGF-189) were determined 40 infiltrating carcinomas and 40 matched ANCT specimens using quantitative RT-PCR and TaqMan methodology.

RESULTS

The COX-2 mRNA copy number per microg of RNA was two-fold higher in ANCT compared with the cancerous tissue (p = 0.01). Median mRNA copy number was 5.44 x 10(6) for ANCT and 2.30 x 10(6) for tumour, (ANCT range: 1 x 10(6) to 4.12x 10(7)) (tumour range: 1.29 x 10(5) to 1.07 x 10(7)). There was a significant correlation between COX-2 and VEGF-189 mRNA copy numbers in the cancer specimens (correlation coefficient = 0.5528, p = 0.0076).

CONCLUSIONS

COX-2 mRNA is overexpressed in both human breast cancer and ANCT. We found higher levels in the matched ANCT which suggests that paracrine effects may be important in the role of COX-2 in mammary carcinogenesis. Furthermore, our results indicate that in human breast cancers COX-2 overexpression is linked to VEGF-189 overexpression and therefore tumour angiogenesis.

Recent advances in breast cancer (the Twenty-fourth San Antonio Breast Cancer Symposium, December, 2001)

This paper reviews the Twenty-fourth Annual San Antonio Breast Cancer Symposium. The preliminary results of the ATAC study have shown that Arimidex is superior to tamoxifen in postmenopausal women with ER-positive early breast cancer in terms of DFS, adverse effects and prevention of contralateral breast cancer. However, longer follow up is required to assess the drug safety regarding bone mineral density and cognitive function. Letrozole seems to be superior to tamoxifen as a first-line therapy in ER-positive advanced breast cancer in postmenopausal women. Although the incidence of acute myeloid leukaemia is significantly increased (cumulative incidence at 5 years = 1.1%) in breast cancer patients receiving cyclophosphamide and anthracyclines, the risk of this complication is easily outweighed by the benefits of chemotherapy. Adjuvant clodronate was found to be associated with a significant reduction in the incidence of bone metastases during the treatment period. A randomised trial comparing axillary dissection and axillary radiotherapy (RT) for early breast cancer reported no significant difference in survival at 15 years. However, axillary recurrence was significantly increased in the RT group. hTERT protein expression by IHC was found to correlate significantly with breast cancer-specific survival. There is no evidence to support the use of IHC of the sentinel node in routine clinical practice. LCIS is currently considered as a non-obligate precursor to breast cancer rather than just a risk factor.

Breast cancer chemoprevention--an update

This article reviews the recent findings of the IBIS-1 and ATAC trials regarding the role of tamoxifen and anastrozole in the chemoprevention of breast cancer. It also emphasises the need to individualise chemoprevention strategies, and to identify high-risk women who are most likely to develop oestrogen receptor (ER)-positive breast cancer. The prevention of ER-negative disease requires further research, and is likely to be challenging.

The evolving role of mammary ductoscopy

Mammary ductoscopy (MD) is an emerging technique that allows direct visualisation of the mammary duct system, and that produces sharp and clear video images and ductal washings for cytological analysis. There is a growing body of evidence that MD may have a role in the management of women with pathological nipple discharge, the guiding of breast conserving surgery for cancer, and the screening of high risk women. Further research is required to confirm these potential applications and the feasibility of its use in the rapid intervention and outpatient setting under local anaesthesia. Furthermore, the addition of molecular and genetic analysis of cells obtained by MD and the emergence of newer generations of microendoscopes are likely to enhance the use of this technique.

The significance of human telomerase reverse transcriptase (hTERT) in cancer

Since the discovery of the enzyme telomerase in humans, it has become apparent that it is the most general of tumour markers known, and enormously significant in its potential for diagnostic, prognostic and therapeutic applications. Extensive work has identified three core components of the enzyme, of which the catalytic subunit hTERT (human telomerase reverse transcriptase) appears to be the most important. The aim of this article is to review the current evidence for the function and activity of hTERT in malignant conditions, and to discuss the future possibilities in terms of cancer diagnosis and treatment.

Is MRI more accurate than CT in estimating the real size of adrenal tumours?

BACKGROUND

The size of adrenal tumour plays an important role in the indications for surgical excision of non-functioning adrenal tumours and in selecting the best surgical approach. Computed tomography (CT) has been reported to underestimate the real size of adrenal lesions. The accuracy of magnetic resonance imaging (MRI) in predicting the true tumour size has not been previously investigated. The present retrospective study investigates the accuracy of MRI and CT in the pre-operative determination of true adrenal tumour size.

METHODS

The medical records of 65 patients who underwent adrenalectomy for an adrenal mass were reviewed. The size of adrenal tumours as determined by pre-operative MRI and/or CT was compared with the "true" histopathological size. The impact of histological diagnosis on size estimation was also investigated.

RESULTS

The median age at diagnosis was 42 years (range 1-82 years) and more patients were female (60%). Five patients had bilateral adrenalectomy, thus giving rise to 70 adrenal specimens. The histopathological size of adrenal tumours ranged from 0.9 to 26 cm with a mean of 5.96 cm and a median of 4.70 cm. For tumours larger than 3 cm, MRI significantly underestimated the real tumour size by 20% (P<0.001). CT also underestimated the size of such tumours by 18.1% (P<0.003). Adrenal phaeochromocytomas were consistently underestimated by both modalities.

CONCLUSIONS

MRI and CT significantly underestimated the true size of adrenal tumours larger than 3 cm by 20% and 18%, respectively. Surgeons and endocrinologists should interpret the pre-operative size of adrenal lesions with caution.

Predictors of positive margins after local excision of ductal carcinoma in situ

BACKGROUND

This study aimed to examine the association between clinicopathologic parameters and positive margins in women with ductal carcinoma in situ (DCIS) treated by breast-conserving surgery (BCS).

METHODS

We retrospectively reviewed the clinical, radiologic, and pathologic data of 100 women who had undergone BCS for DCIS in our center.

RESULTS

Sixty-seven percent of patients presented via breast screening and 55% of all cases were diagnosed preoperatively on fine needle aspiration cytology ([FNAC] ie, C5). Overall, 45% of patients had clear margins after initial local excision. Positive margins showed a nonsignificant trend of association with distribution of microcalcifications (MCC), nonconsultant operating surgeon, inconclusive preoperative FNAC, presence of necrosis, and low specimen weight. There was a highly significant association between low grade DCIS (P = 0.003) and incomplete excision. There was no significant association with age, associated invasive focus, morphology of MCC, or with mode of presentation.

CONCLUSION

Positive margins after local excision of DCIS are significantly associated with low nuclear grade, and preoperative determination of nuclear grade by core biopsy may have surgical implications.

The Twenty-third Annual San Antonio Breast Cancer Symposium

This paper reviews the recent Twenty-third Annual San Antonio Breast Cancer Symposium. A total of 580 studies were presented either orally or as posters. Two phase III multi-centre clinical trials found that fulvestrant (Falsodex), given as a once-monthly intramuscular injection (250 mg), was well-tolerated and at least as good as anastrozole (1 mg) in postmenopausal women with advanced breast cancer that had progressed or recurred on prior endocrine therapy. Another phase III randomised trial found that letrozole (2.5 mg daily) was superior to tamoxifen as a neoadjuvant therapy in postmenopausal women with ER- and/or PgR-positive breast cancer unsuitable for breast-conserving surgery. In a phase III study, capecitabine (Xeloda) was found to be well-tolerated and able to improve survival by three months when added to Taxotere. Cutting edge data on microarray gene profiling in breast cancer were presented. The potential role of this new technology in predicting outcome and selecting therapy was discussed. Furthermore, its limitations and the need for validation were highlighted. The role of new diagnostic tools, such as fibre-optic ductoscopy (FDS) and microcatheters to obtain ductal cells, was discussed. Finally, the worldwide overview was presented.

Pure antiestrogens and breast cancer

Tamoxifen, which is the most commonly used drug for treatment of breast cancer, has both estrogen agonist and antagonist actions. Pure antiestrogens are devoid of any estrogen agonist effects. ICI 182,780 (fulvestrant) (Faslodex) and ICI 164,384 are competitive inhibitors of estrogen by binding to the estrogen receptor (ER). Preclinical and clinical studies show that fulvestrant and ICI 164,384 are more potent than tamoxifen in inhibiting the growth of breast cancer cells. They are devoid of any estrogen-agonist action on the uterus and vagina but lack the beneficial effects of tamoxifen on the bone and serum lipid profile. Fulvestrant is the first pure antiestrogen to complete phase III clinical trials. Such studies have shown that fulvestrant is at least as good as anastrozole in the treatment of post-menopausal women with advanced breast cancer who had relapsed or progressed on prior endocrine therapy. The drug was well tolerated and only minor side-effects were reported. Its potential role in the adjuvant setting will be determined by its adverse effects on bone mass and serum lipids. EM-800 and EM-652 are the most potent pure antiestrogens and EM-652 has the highest affinity of all antiestrogens to ER. They have no stimulatory effects on the uterus or vagina. It seems reasonable to expect that pure antiestrogens will be good alternatives to tamoxifen and aromatase inhibitors in the treatment of breast cancer.

Recent advances in breast cancer (the 37th ASCO meeting, May 2001)

Data from phase III clinical trials suggest that high dose chemotherapy (HDC) is currently not indicated for any stage of breast cancer. Therefore HDC should only be considered within the context of clinical trials. Furthermore, there is no significant evidence to support the routine use of taxanes in women with metastatic breast cancer (MBC) and further research is required to address this issue. A well-designed randomised controlled trial has shown that expressive support psychosocial therapy does not improve survival of women with MBC. Her2 overexpression seems to be a significant predictor of response to taxanes and anthracyclines, and FISH testing for Her2 seems to be superior to IHC in predicting response to Herceptin. Recent evidence confirms the independent prognostic value of VEGF, UPA and PAI-1 in women with early breast cancer and suggests that such parameters may have a role in selecting systemic therapy. Biological therapy using inhibitors/antagonists of angiogenesis and EGFR seems to be safe and well tolerated. Although the response rates are currently unimpressive, further research using survival as an endpoint is required.

Aromatase inhibitors

The new non-steroidal and steroidal aromatase inhibitors are at least as effective as megestrol acetate (MA) as second-line hormonal agents in postmenopausal women with breast cancer. However, they are superior to MA in terms of tolerability and adverse effects. Letrozole and exemestane have been shown to be superior to MA in terms of efficacy. Furthermore, exemestane and anastrozole demonstrated a survival advantage over MA. These drugs are therefore considered established second-line hormonal agents. There is a growing body of evidence supporting the role of third-generation aromatase inhibitors as first-line therapy for ER-and/or PgR-positive advanced breast cancer in postmenopausal women, and as a neoadjuvant therapy in postmenopausal women with hormone receptor positive tumours unsuitable for breast conserving surgery. Studies comparing these drugs head-to-head and with adjuvant tamoxifen are currently in progress. The potential role of these drugs in breast cancer prevention is worth investigating.

The prevention of breast cancer: an overview

The role of lifestyle modifications, antioestrogens, cyclo-oxygenase-2 inhibitors and prophylactic mastectomy in reducing breast cancer is reviewed. It is concluded that avoiding postmenopausal obesity and regular physical activity are simple measures that seem to reduce breast cancer risk. There is no conclusive evidence that dietary modification and vitamin supplementation significantly reduce the risk of breast cancer. The evidence suggests that tamoxifen significantly reduces the risk of breast cancer in women at increased risk, but whether it reduces breast cancer mortality remains unknown. Ongoing clinical trials may prove that raloxifene is superior to tamoxifen in breast cancer prevention due to its anti-oestrogenic effects on the endometrium. Bilateral prophylactic mastectomy reduces the risk of breast cancer by 90% in high risk women.

From HER2 to herceptin

HER2 overexpression occurs in 25% of breast cancers and seems to correlate with poor prognosis. HER2 overexpression may predict tamoxifen failure and different response rates to chemotherapeutic agents such as the taxanes and anthracyclines. The detection of HER2 and its overexpression is performed using fluorescent in situ hybridisation (FISH) and/or immunohistochemistry (IHC). Trastuzumab [Herceptin (H)] is a humanised IgG monoclonal antibody specific for the growth factor receptor HER2. Pre-clinical trials using monoclonal antibodies have shown inhibition of breast tumour growth in athymic nude mice. Phase II and III clinical trials have evaluated the efficacy and safety of Herceptin in women with metastatic breast cancer in combination with other agents and as a single agent. Currently, Trastuzumab and paclitaxel is the only combination indicated for the treatment of patients with metastatic breast cancer whose tumours overexpress HER2. It is also indicated as a single agent in women with HER2-overexpressing metastatic breast cancer that has progressed after previous chemotherapy. Herceptin is a well-tolerated drug and the side-effects that are commonly seen with chemotherapy, such as neutropenia, alopecia and mucositis, are rarely observed. The main risk factors for cardiotoxicity are concurrent or previous anthracycline exposure. The potential role of Herceptin in the adjuvant setting is currently being evaluated.

Is dissection of the internerve tissue during axillary lymphadenectomy for breast cancer necessary?

AIMS

The study evaluates the necessity of dissecting the tissue between the long thoracic and thoracodorsal nerves (internerve tissue) during axillary dissection in breast cancer surgery. By reviewing the lymph node yield and the metastatic rate in the internerve tissue, we examine whether the internerve tissue could be left in situ to minimize the risk of nerve injury.

METHODS

A prospective study was conducted on 30 consecutive women undergoing axillary lymphadenectomy for breast cancer. The internerve tissue remaining was excised separately after a routine axillary dissection and was examined by the same pathologist.

RESULTS

Twenty (67%) of 30 internerve specimens contained lymph nodes; the internerve nodes were positive for carcinoma in three cases (10%). In one case the lymph node in the internerve tissue was the only metastatic node in the axilla.

CONCLUSIONS

There is a significant incidence of lymph nodes (67%) and axillary node metastases (10%) in the tissue lying between the long thoracic and thoracodorsal nerves. Therefore excision of this internerve tissue is strongly recommended in order to optimize decision making regarding adjuvant treatment and oucome in women with operable breast cancer.

Radial scar and carcinoma of the breast: microscopic findings in 32 cases

We retrospectively reviewed the microscopic findings in 32 histologically confirmed radial scars in 31 women diagnosed in our unit during 1994-1998. The median age at diagnosis was 53 years (range 47-63 years). Thirty-one (97%) of 32 lesions presented as screen detected mammographic abnormalities (28 stellate lesions, 2 microcalcifications and only 1 architectural distortion). One lesion presented as a palpable breast mass. Stereotactic or ultrasound-guided fine needle aspiration cytology (FNAC) was performed in 28 cases. Cytological analysis of FNAs revealed malignant cells (C5) in 8 (29%) cases, highly suspicious cells (C4) in 3 (11%) cases, atypical benign cells (C3) in 7 (25%) cases and benign epithelial cells (C2) in 10 (35%) cases. All non-palpable lesions were surgically excised following wire localization. Histological examination of the breast specimens (mean weight=16 g) demonstrated, in addition to a radial scar, 6 invasive carcinomas (2 infiltrating ductal, 2 tubular, 1 mixed ductal/lobular and 1 secretory carcinoma) and 4 ductal carcinoma in situ lesions (2 high grade, 1 high grade with micro-invasion and 1 low grade) arising in the radial scar. Of the remaining cases the radial scar was associated with atypical epithelial hyperplasia in 2 cases and regular epithelial hyperplasia in 17 cases (4 florid and 13 mild to moderate). In the 10 cases associated with malignancy, 9 had FNAC and was reported as malignant (C5) in 6 (67%) cases, highly suspicious (C4) in 2 (22%) cases and atypical (C3) in 1 (11%). False positive FNAC (C5) occurred in two patients, one of whom presented with pleomorphic microcalcifications suggestive of ductal carcinoma in situ. This patient was treated with a wire guided segmental mastectomy. All invasive tumours were less than 20 mm in size (T1) and of these 4 were grade I and 2 were grade II. Axillary dissection was performed in 4 patients none of whom had axillary node metastases. Our study demonstrates a significant incidence of malignancy associated with radial scars (31%) suggesting that radial scars may be premalignant lesions. This is supported by detecting various stages of mammary carcinogenesis (atypical epithelial hyperplasia, ductal carcinoma in situ, and early invasive malignancy) in these lesions. Fine needle aspiration cytology seems to be unreliable in the diagnosis of radial scar associated malignancy (67% sensitivity and 91% specificity). Stellate lesions, therefore, should be excised to obtain an histological diagnosis regardless of cytological findings. Further studies examining the biology of radial scars are required.

Clinical significance of telomerase activity in the non-cancerous epithelial region of oesophageal squamous cell carcinoma

Treatment of gallbladder cancer by radical resection

A. A. Riaz, A. M. Isla, Department of General Surgery, Imperial College of Medicine, Hammersmith Hospital Campus, London W12 0TS, UK

Authors' reply : T. Todoroki, Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Tennodai, Tsukuba-shi 305-8575, Japan

Clinical significance of telomerase activity in the non-cancerous epithelial region of oesophageal squamous cell carcinoma

K. Mokbel, C. Choy, A. Engledow. Department of Surgical Oncology, St Bartholomew's Hospital, London EC1A 7BE, UK

Authors' reply : K. Koyanagi, S. Ozawa, N. Ando, H. Takeuchi, M. Ueda, M. Kitajima, Department of Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, USA

Colonic motility is abnormal before surgery for rectal prolapse

A. Macdonald, Department of Surgery, Monklands Hospital, Airdrie ML6 0JS, UK

Authors' reply : A. J. Brown, A. F. Horgan, J.H. Anderson, R. F. McKee, I.G. Finlay, Department of Coloproctology, Royal Infirmary, 16 Alexandra Parade, Glasgow G31 2ER, UK

Telomerase activity in phyllodes tumours

AIMS

To investigate telomerase, a ribonucleoprotein that synthesizes telomeres. Recent evidence suggests that telomerase reactivation is associated with the acquisition of immortalization and malignancy.

METHODS

Using a sensitive PCR-based assay (the TRAP assay), we examined telomerase activity in two recurrent phyllodes tumours in two patients.

RESULTS

Both tumours expressed telomerase activity. Histological examination of the lesions, according to the criteria proposed by Azzopardi and Salvadori, revealed a malignant phyllodes tumour in one patient and a benign phyllodes tumour in the other patient.

CONCLUSIONS

Our findings suggest that telomerase activity may have a potential role as a prognostic marker in predicting the clinical behaviour of these rare tumours.