Over surgery in breast cancer

Application of the OSNA Technique (One-Step Nucleic Acid Amplification Test) in Breast Cancer

Breast cancer is one of the most common cancers diagnosed in both countries with high and low levels of socio-academic development. Routine, regular screening tests being introduced in an increasing number of countries make it possible to detect breast cancer at an early stage of development, as a result of which the trend in the incidence of metastatic breast cancer has been decreasing in recent years. The latest guidelines for the treatment of this tumor do not recommend axillary dissection, which limits the need for rapid assessment of the nodes during surgery. Regardless of the progression of the disease, lymph node biopsy and their analysis is one of the most common diagnostic methods for detecting metastases. Systems using one-step amplification of nucleic acids have been present in the diagnosis of breast cancer for nearly 20 years. The one-step nucleic acid amplification (OSNA) test semi-quantitatively detects the number of cytokeratin 19 mRNA copies, a well-known tumor marker, which can be used to infer the presence of metastases in non-sentinel lymph nodes (SLN). Aim: OSNA is a widely used molecular method for SLN, intra-, or postoperative analysis. Its high accuracy has been proved over the years in clinical use. In this review, we checked current state of this technology and compared it to its competitors in the field of breast cancer diagnosis in the era of Axillary Lymph Nodes Dissection (ALND) importance decrease with intention to foresee its further potential use. Objectives: To evaluate OSNA current place in breast cancer diagnosis and treatment we compared OSNA to other lymph node assessing methods. We based our review on original articles and metanalyses published in the last decade. The research was conducted with PubMed, Science Direct, Google Scholar, and NCBI databases. The collected data allowed us to assess the accuracy of OSNA, its cost effectiveness, and its application in other cancers. Results: Regardless of the progression of the disease, a lymph node biopsy and its analysis constitutes one of the most common diagnostic methods for detecting metastases. The OSNA method is characterized by high sensitivity and specificity, and its predictive value has been confirmed by many studies over the years. While its cost effectiveness is still a matter of discussion, this method has been tested more thoroughly than other new lymph nodes assessing technologies. Conclusions: Despite the emergence of competing methods, this test is still widely used as a routine intraoperative examination of lymph nodes. Research carried out in recent years has proved its effectiveness in the diagnosis of other cancers, in the research field, and as a provider of additional data for prognosis improvement.

CircIQCH Contributes to the Progression of Breast Cancer by Elevating NFIB Through Decoying miR-139-5p

Circular RNAs (circRNAs) are implicated in the progression of breast cancer (BC). However, the explorations on circRNA IQ motif containing H (circIQCH) in BC progression remain limited. Functional experiments were conducted using in vitro and murine xenograft model assays, respectively. Dual-luciferase reporter assay and RIP assay detected the associations among circIQCH, miR-139-5p, and nuclear factor IB (NFIB). CircIQCH was upregulated in BC, and the silencing of circIQCH repressed BC cell growth, metastasis, and autophagy, arrested cell cycle, promoted cell apoptosis in vitro, and blocked tumor growth in vivo. CircIQCH positively modulated NFIB expression by sponging miR-139-5p. Moreover, the deletion of miR-139-5p abated the action of circIQCH deficiency on BC cell malignant behaviors. Overexpression of miR-139-5p repressed the malignant characteristics of BC cells, while these impacts were abolished by elevating NFIB. Collectively, CircIQCH functioned as an oncogene in BC through upregulating NFIB expression by sponging miR-139-5p.

Imaging of lumpectomy surface with large field-of-view confocal laser scanning microscope for intraoperative margin assessment - POLARHIS study

INTRODUCTION

Breast-conserving surgery (BCS) in case of breast cancer and/or in-situ-carcinoma lesions (DCIS) intends to completely remove breast cancer while saving healthy tissue as much as possible to achieve better aesthetic and psychological outcomes for the patient. Such modality should result in postoperative tumor-free margins of the surgical resection in order to carry on with the next therapeutical steps of the patient care. However, 10-40% of patients undergo more than one procedure to achieve acceptable cancer-negative margins. A 2nd operation or further operation (re-operation) has physical, psychological, and economic consequences. It also delays the administration of adjuvant therapy, and has been associated with an elevated risk of local and distant disease relapse. In addition, a high re-operation rate can have significant economic effects - both for the service provider and for the payer. A more efficient intraoperative assessment of the margin may address these issues. Recently, a large field-of-view confocal laser scanning microscope designed to allow real-time intraoperative margin assessment has arrived on the market - the Histolog Scanner. In this paper, we present the first evaluation of lumpectomy margins assessment with this new device.

MATERIALS AND METHODS

40 consecutive patients undergoing BCS with invasive and/or DCIS were included. The whole surface of the surgical specimens was imaged right after the operation using the Histolog Scanner (HLS). The assessment of all the specimen margins was performed intraoperatively according to the standard-of-care of the center which consists of combined ultrasound (IOUS) and/or conventional specimen radiography (CSR), and gross surgical inspection. Margin assessment on HLS images was blindly performed after the surgery by 5 surgeons and one pathologist. The capabilities to correctly determine margin status in HLS images was compared to the final histopathological assessment. Furthermore, the potential reduction of positive-margin and re-operation rates by utilization of the HLS were extrapolated.

RESULTS

The study population included 7/40 patients with DCIS (17.5%), 17/40 patients with DCIS and invasive ductal cancer (IDC NST) (42.5%), 10/40 patients with IDC NST (25%), 4/40 with invasive lobular cancer (ILC) (10%), and 1/40 patients with a mix of IDC NST, DCIS, and ILC. Clinical routine resulted in 13 patients with positive margins identified by final histopathological assessment, resulting in 12 re-operations (30% re-operation rate). Amongst these 12 patients, 10 had DCIS components involved in their margin, confirming the importance of improving the detection accuracy of this specific lesion. Surgeons, who were given a short familiarization on HLS images, and a pathologist were able to detect positive margins in 4/12 and 7/12 patients (33% and 58%), respectively, that were missed by the intraoperative standard of care. In addition, a retrospective analysis of the HLS images revealed that cancer lesions can be identified in 9/12 (75%) patients with positive margins.

CONCLUSION

The present study presents that breast cancer can be detected by surgeons and pathologists in HLS images of lumpectomy margins leading to a potential reduction of 30% and 75% of the re-operations. The Histolog Scanner is easily inserted into the clinical workflow and has the potential to improve the intraoperative standard-of-care for the assessment of breast conserving treatments. In addition, it has the potential to increase oncological safety and cosmetics by avoiding subsequent resections and can also have a significant positive economic effect for service providers and cost bearers. The data presented in this study will have to be further confirmed in a prospective phase-III-trial.

Receipt of breast conservation over mastectomy in Black women- does breast cancer subtype matter?

BACKGROUND

Breast conservation surgery (BCS) and mastectomy have equivalent survivability. However, perception of surgical benefit may be affected by breast cancer subtypes, impacting procedure choice. We evaluate surgical management among non-Hispanic Black (NHB) and White (NHW) breast cancer patients based on subtypes.

METHODS

Queried the National Cancer Database (NCDB) including BCS eligible women with T1 (<2cm) breast cancer between 2011 and 2016. We selected NHB and NHW women and evaluated differences in sociodemographic variables and treatment including surgery. To determine factors associated with receipt of BCS, a multivariable logistic regression analysis was performed adjusting for age, race, surgery type and breast cancer subtypes.

RESULTS

Analyzed 390,278 women with 89.7% NHW and 10.3% NHB, of mean age 63 years. 55.4% vs. 53.5% of NHW compared to NHB women had BCS (p<.001) as initial cancer therapy. Statistically significant differences between NHB and NHW in surgery were found on univariate analysis in all breast cancer subtypes except Luminal B. NHB women with TNBC and Luminal A subtypes were more likely to undergo BCS on multivariate analysis.

CONCLUSIONS

Significant differences are found in the surgical management of breast cancer with Black women more likely to receive BCS, less likely to undergo mastectomy compared to White counterparts even with TNBC or her-2+ subtypes. Understanding surgical decision making and how knowledge of subtype is applied deserves further study in women of diverse racial and ethnic groups.

Advances in Therapy for Hormone Receptor (HR)-Positive, Human Epidermal Growth Factor Receptor 2 (HER2)-Negative Advanced Breast Cancer Patients Who Have Experienced Progression After Treatment with CDK4/6 Inhibitors

Approximately 70% of breast cancer (BC) cases are hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) BC. Cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors have acted as star drugs for reversing endocrine therapy (ET) resistance and improving the prognosis of patients with HR+ advanced breast cancer (ABC) since they were initially approved. However, progression eventually occurs. In this review, we summarize the recent treatment strategies post CDK4/6 inhibitors: 1) CDK4/6 inhibitors plus exemestane and everolimus; 2) phosphoinositide-3-kinase (PI3K) inhibitor alpelisib plus fulvestrant for patients with PIK3CA mutation; 3) poly (ADP-ribose) polymerase (PARP) inhibitor for patients with germline PALB2 mutations, somatic BRCA1/2 mutations, or germline BRCA1/2 mutations; 4) exemestane and everolimus; and (5) chemotherapy. These strategies are all supported by evidence from clinical trials and retrospective studies. We also describe potential future treatment strategies post CDK4/6 inhibitors, such as the trophoblast cell surface antigen 2 (Trop-2) directed antibody–drug conjugate, cyclin-dependent kinase 7 (CDK7) inhibitors, and B-cell lymphoma-2 (BCL-2) inhibitors.

Effect of Margin Status on Survival After Resection of Hilar Cholangiocarcinoma in the Modern Era of Adjuvant Therapies

INTRODUCTION

Studies have shown that for patients with hilar cholangiocarcinoma (HC), survival is associated with negative resection margins (R0). This requires increasingly proximal resection, putting patients at higher risk for complications, which may delay chemotherapy. For patients with microscopically positive resection margins (R1), the use of modern adjuvant therapies may offset the effect of R1 resection.

METHODS

Patients at our institution with HC undergoing curative-intent resection between January 2008 and July 2019 were identified by retrospective record review. Demographic data, operative details, tumor characteristics, postoperative outcomes, recurrence, survival, and follow-up were recorded. Patients with R0 margin were compared to those with R1 margin. Patients with R2 resection were excluded.

RESULTS

Seventy-five patients underwent attempted resection with 34 (45.3%) cases aborted due to metastatic disease or locally advanced disease. Forty-one (54.7%) patients underwent curative-intent resection with R1 rate of 43.9%. Both groups had similar rates of adjuvant therapy (56.5% vs. 61.1%, P = .7672). Complication rates and 30 mortality were similar between groups (all P > .05). Both groups had similar median recurrence-free survival (R0 29.2 months vs. R1 27.8 months, P = .540) and median overall survival (R0 31.2 months vs. R1 38.8 months, P = .736) with similar median follow-up time (R0 29.9 months vs. R1 28.5 months, P = .8864).

CONCLUSIONS

At our institution, patients undergoing hepatic resection for HC with R1 margins have similar recurrence-free and overall survival to those with R0 margins. Complications and short-term mortality were similar. This may indicate that with use of modern adjuvant therapies obtaining an R0 resection is not an absolute mandate.

lncRNA TTN-AS1 facilitates proliferation, invasion, and epithelial-mesenchymal transition of breast cancer cells by regulating miR-139-5p/ZEB1 axis

Breast cancer is a common malignant tumor suffered predominantly by women worldwide, which results in serious levels of morbidity and mortality. To control the effects of the cancer, it is critically important to elucidate the pathophysiological processes by which it occurs and develops. Reports have demonstrated that long noncoding RNAs perform a critical role in the development and metastasis of cancers. The lncRNA TTN-AS1 is considered carcinogenic. Nevertheless, the importance and biological functions of TTN-AS1 in breast cancer require greater exploration. In the current paper, we observed that TTN-AS1 expression was significantly upregulated in breast cancer tissues/cells compared with those that are healthy. TTN-AS1 enhanced the proliferation, migration, invasion, and epithelial-mesenchymal transformation of breast cancer cells. Furthermore, a direct target of TTN-AS1, miR-139-5p was negatively regulated. In addition, zinc finger E-box binding homeobox 1 (ZEB1) is an important nuclear transcription factor, the expression of which is increased in multiple tumors. Here, we also found that ZEB1 is a target of miR-139-5p, of which TTN-AS1 could regulate the expression through competition with miR-139-5p. That is, TTN-AS1 promoted proliferation and invasion of breast cancer cells by interaction with the miR-139-5p/ZEB1 axis. In conclusion, the present study aimed to illustrate the significance of TTN-AS1 in breast cancer metastasis and contribute to potentially innovative strategies for its treatment.

Absence of residual fluorescence in the surgical bed at near-infrared fluorescence imaging predicts negative margins at final pathology in patients treated with breast-conserving surgery for breast cancer

INTRODUCTION

Positive margins after breast-conserving surgery (BCS) for breast cancer (BC) remain a major concern. In this study we investigate the feasibility and accuracy of indocyanine green (ICG) fluorescence imaging (FI) for the in vivo assessment of surgical margins during BCS.

MATERIALS AND METHODS

Patients with BC admitted for BCS from October 2015 to April 2016 were proposed to be included in the present study (NCT02027818). ICG (0.25 mg/kg) was intravenously injected at induction anesthesia and ICG-FI of the surgical beds was correlated with final pathology results.

RESULTS

Fifty patients consented to participate and thirty-five patients were retained for final analysis, 15 patients having been excluded for, respectively, incomplete video records data for signal to background ratio (SBR) calculation (11) and in situ tumors (4). The final pathological assessment of 35 breast specimens identified 5 (14.7%) positive margins. Intraoperative ICG-FI revealed hyperfluorescent signals in 15 (42.9%) patients and an absence of fluorescent signals in 20 (57.1%). Median SBR in patients with involved margins was 1.8 (SD 0.7) and was 1.25 (SD 0.6) in patients with clear margins (p = 0.05). The accuracy, specificity, positive and negative predictive value of ICG-FI for breast surgical margin assessment were 71%, 60%, 29% and 100%, respectively.

CONCLUSION

ICG-FI of BC surgical beds has a high negative predictive value for surgical margin assessment during BCS. The absence of residual fluorescence in the surgical bed of patients with fluorescent tumors predicts negative margins at final pathology and allows the surgeon to avoid further intraoperative analysis.

Attenuated measles vaccine strain have potent oncolytic activity against Iraqi patient derived breast cancer cell line

BACKGROUND

One of the world's leading causes of death among females is breast cancer. Oncolytic viruses are promising anticancer therapy that can overcome resistance to current conventional therapies. Measles virus replicates in and destroys malignant cells without affecting healthy cells. The study aimed to evaluate the lives attenuated Measles virus vaccine against Iraqi patient derived breast cancer cells that have functional BRCA1/BRCA2 genes and compare its activity against international breast cancer MCF-7 and CAL-51 cell lines.

METHODS

The virus was propagated in VERO-hSLAM slam cells. The MTT cytotoxicity assay used to test the virus's ability to kill three human breast cell lines (AMJ13), (MCF-7), and (CAL-51). The cytopathic effect of the measles virus was determined using an H&E stain. Immunocytochemistry assay using specific anti H protein monoclonal antibody for measles virus in the virally infected cells. Finally, apoptosis induction in the infected cells tested using double staining of acridine orange/propidium iodide.

RESULTS

The result shown that breast cancer cells are effectively infected and destroyed by live attenuated measles virus vaccine, and it caused a significant cytopathic effect in the infected cell lines after 48-72 h of infection with remarkable effect on AMJ13 cells (IC50 was 3.527 for AMJ13, when it was 5.079 and 9.171 for MCF-7 and CAL-51 respectively). Measles virus treatment induces apoptosis significantly in breast cancer cell lines compared with control cells.

CONCLUSION

MeV vaccine is useful and safe as anticancer therapy with a notable impact on the local Iraqi breast cancer AMJ13 cells.

Towards the use of diffuse reflectance spectroscopy for real-time in vivo detection of breast cancer during surgery

Background

Breast cancer surgeons struggle with differentiating healthy tissue from cancer at the resection margin during surgery. We report on the feasibility of using diffuse reflectance spectroscopy (DRS) for real-time in vivo tissue characterization.

Methods

Evaluating feasibility of the technology requires a setting in which measurements, imaging and pathology have the best possible correlation. For this purpose an optical biopsy needle was used that had integrated optical fibers at the tip of the needle. This approach enabled the best possible correlation between optical measurement volume and tissue histology. With this optical biopsy needle we acquired real-time DRS data of normal tissue and tumor tissue in 27 patients that underwent an ultrasound guided breast biopsy procedure. Five additional patients were measured in continuous mode in which we obtained DRS measurements along the entire biopsy needle trajectory. We developed and compared three different support vector machine based classification models to classify the DRS measurements.

Results

With DRS malignant tissue could be discriminated from healthy tissue. The classification model that was based on eight selected wavelengths had the highest accuracy and Matthews Correlation Coefficient (MCC) of 0.93 and 0.87, respectively. In three patients that were measured in continuous mode and had malignant tissue in their biopsy specimen, a clear transition was seen in the classified DRS measurements going from healthy tissue to tumor tissue. This transition was not seen in the other two continuously measured patients that had benign tissue in their biopsy specimen.

Conclusions

It was concluded that DRS is feasible for integration in a surgical tool that could assist the breast surgeon in detecting positive resection margins during breast surgery.

Trail registration NIH US National Library of Medicine–clinicaltrails.gov, NCT01730365. Registered: 10/04/2012 https://clinicaltrials.gov/ct2/show/study/NCT01730365

The sick lobe hypothesis, field cancerisation and the new era of precision breast surgery

Understanding the ductal anatomy of the breast provides insights into tumorigenesis, which in turn offers guidance on therapeutic decisions. In this regard, the sick lobe hypothesis, which states that cancer arises from genetically unstable cells through mutations acquired in utero, forms the basis of malignant transformation. These 'at risk' cells line the mammary ductal-lobular system of a single 'sick' lobe and when exposed to noxious events in the surrounding microenvironment, further genetic changes occur which completes conversion to malignancy, in certain defined patterns. This review explores how anatomy, pathology and genomics can merge, not only to guide optimum surgery, but also to provide a more comprehensive portal for precision medicine.

Update of the American Society of Breast Surgeons Toolbox to address the lumpectomy reoperation epidemic

In 2015, the American Society of Breast Surgeons (ASBrS) convened a multidisciplinary consensus conference, the Collaborative Attempt to Lower Lumpectomy Reoperation Rates (CALLER). The CALLER conference endorsed a "toolbox" of multiple processes of care for which there was evidence that they were associated with fewer reoperations. We present an update of the toolbox taking into consideration the latest advances in decreasing re excision rates. In this review, we performed a comprehensive review of the literature from 2015-2018 using search terms for each tool. The original ten tools were updated with the latest evidence from the literature and our strength of recommendation. We added an additional section looking at new tools and techniques that may provide more accurate intraoperative assessment of margins. The updates on the CALLER Toolbox for lumpectomy will help guide surgeons to various resources to aid in the removal of breast cancer, while being aware of cosmesis and decreasing re excision rates.

Reducing harms from treatment. Sixteen years of surgery of the axilla for screen-detected breast cancers in Italy

OBJECTIVES

Available evidence on axillary surgery has accumulated dramatically in the last two decades in favor of less invasive care. The aim of this paper is to study 16-years trends in the surgical management of the axilla in a large population-based data set of screen-detected breast cancers in Italy and to document at what extent recommendations have been adopted in actual clinical care.

MATERIAL AND METHODS

This is a retrospective cohort study documenting the surgical management of the axilla in primary breast cancer patients over time. We retrieved from the Italian database of screen-detected cancers 41213 cases diagnosed in women aged 50-69 between years 2000 and 2015 in twelve Italian Regions.

RESULTS

In pN0 cases, an increasing trend (p < 0.001) in the number of patients who received sentinel lymph node biopsy (SLNB) as the only axillary staging procedure was observed. In pN + cases SLNB was the only staging procedure in an increasing number of patients (p < 0.001) especially since the publication of the ACOSOG-Z0011 paper. In ductal carcinoma in situ (DCIS) SLNB was more frequent in mastectomies and in high grade and large lesions. However, 45% of low grade, small DCIS over the whole time period had some form of axillary surgery.

CONCLUSION

This large series of screen-detected cases documents a strong time trend in the direction of reducing axillary surgery and hence potential harms from treatment. The continuing practice of SLNB in low risk DCIS is of concern in an era of increasing awareness towards overdiagnosis and overtreatment.