Development of axillary surgery in breast cancer

Large Tumor Size is an Indicator for the Timely Administration of Adjuvant Radiotherapy in Luminal Breast Cancer with Positive Lymph Node

Purpose

The optimum timing of adjuvant radiotherapy for breast cancer patients who had undergone surgery remains unclear. The present study aimed to identify the clinical factors which could assist the selecting of time interval (TI) between surgery and adjuvant radiotherapy in luminal breast cancer with lymph node metastasis.

Patients and Methods

This retrospective study included 1054 luminal breast cancer patients with lymph node metastasis, diagnosed between May 2004 and December 2014, and treated with surgery followed by adjuvant therapy. Overall survival (OS) and disease-free survival (DFS) were compared between patients in the short and long TI groups. Multivariate analysis was performed to examine clinical factors associated with DFS. Subgroups analysis was further performed based on the significant predictors of DFS to explore the association of TI and tumor prognosis.

Results

For the whole group of patients, there was no difference in OS and DFS between patients with long and short TI. Multivariate analysis showed that age, N stage and tumor size were significant predictors of DFS. Subgroup analysis demonstrated that neither age nor N stage were informative in TI selection; in contrast, in patients with large tumors, a short TI was associated with better DFS than a long TI. In patients with small tumors, there was no significant association between TI and tumor prognosis. In the multivariable analysis, TI was independent predictor of DFS and local recurrence-free survival in patients with large tumors.

Conclusion

Large tumor size is an indicator for the timely administration of adjuvant radiotherapy in luminal breast cancer with positive lymph node.

Contrast of Mastoscopic and Conventional Axillary Lymph Node Dissection of Patients With Breast Cancer: Meta-Analysis

Mastoscopic axillary lymph node dissection (MALND) is a currently used and safe surgical treatment option for breast cancer. However, the extensive application of MALND is still debatable because of the use of conventional axillary lymph node dissection (CALND). Therefore, in the current study, we aimed to compare the efficacy and safety of MALND and CALND for obtaining evidence-based conclusions about the short-term and long-term outcomes of MALND for patients with breast cancer. PubMed, Web of Science, Cochrane Library, and CNKI were comprehensively searched for articles published between January 1998 and January 2019. Then Newcastle-Ottawa scale was used for quality assessment. The Review Manager software version 5.0 was utilized for generating forest maps and funnel plots. Twelve studies including 2157 patients were selected for the meta-analysis. There were no significant differences in the number of lymph node dissections, tumor recurrence rate, axillary drainage, postoperative hospitalization time, and tumor size between the MALND and CALND groups (P > .05). In the MALND group, the surgery time was longer, while the incidence of intraoperative bleeding was lesser and the duration of drainage was shorter than those in the CALND group (P < .01). The complications in the MALND group were also fewer than those in the CALND group (P < .05). The results of the current study showed that MALND is reliable and feasible for breast cancer owing to the lesser incidence of intraoperative bleeding, shorter drainage duration, and lower incidence of complications compared to CALND.

Radiomics Nomogram of DCE-MRI for the Prediction of Axillary Lymph Node Metastasis in Breast Cancer

Purpose

This study aimed to establish and validate a radiomics nomogram based on dynamic contrast-enhanced (DCE)-MRI for predicting axillary lymph node (ALN) metastasis in breast cancer.

Method

This retrospective study included 296 patients with breast cancer who underwent DCE-MRI examinations between July 2017 and June 2018. A total of 396 radiomics features were extracted from primary tumor. In addition, the least absolute shrinkage and selection operator (LASSO) algorithm was used to select the features. Radiomics signature and independent risk factors were incorporated to build a radiomics nomogram model. Calibration and receiver operator characteristic (ROC) curves were used to confirm the performance of the nomogram in the training and validation sets. The clinical usefulness of the nomogram was evaluated by decision curve analysis (DCA).

Results

The radiomics signature consisted of three ALN-status-related features, and the nomogram model included the radiomics signature and the MR-reported lymph node (LN) status. The model showed good calibration and discrimination with areas under the ROC curve (AUC) of 0.92 [95% confidence interval (CI), 0.87-0.97] in the training set and 0.90 (95% CI, 0.85-0.95) in the validation set. In the MR-reported LN-negative (cN0) subgroup, the nomogram model also exhibited favorable discriminatory ability (AUC, 0.79; 95% CI, 0.70-0.87). DCA findings indicated that the nomogram model was clinically useful.

Conclusions

The MRI-based radiomics nomogram model could be used to preoperatively predict the ALN metastasis of breast cancer.

Axillary lymph node dissection in node-positive breast cancer: are ten nodes adequate and when is enough, enough?

PURPOSE

National guidelines define adequate axillary lymph node dissections as those yielding ≥ 10 lymph nodes (LNs). We aimed to identify the optimal LN yield among node-positive patients.

METHODS

Using the National Cancer Data Base (2010-2015), we categorized node-positive patients as follows: (1) neoadjuvant chemotherapy (NAC, cN1-3 or ypN1mi-3) or (2) upfront surgery (pN1-3). A restricted cubic splines model was used to estimate LN retrieval thresholds associated with change in overall survival (OS).

RESULTS

129,685 patients were identified: 21.2% NAC, 78.8% upfront surgery. Low, moderate, and high retrieval thresholds were estimated to be 1-6, 7-21, and > 21 LNs (upfront surgery), and 1-7, 8-22, and > 22 LNs (NAC). In an adjusted model, high versus low LN yield was associated with greater receipt of adjuvant chemotherapy (upfront surgery OR 1.96, p < 0.001) and greater use of adjuvant radiation (upfront surgery OR 1.08, p = 0.02; NAC OR 1.23, p = 0.002). After adjustment, high versus low LN retrieval was associated with improved OS (upfront surgery HR 0.86, p < 0.001; NAC HR 0.77, p < 0.001). Worse OS was associated with retrieving fewer LNs, likely as a result of an under-staged axilla and missed opportunity for adjuvant therapy, while better OS was independently associated with retrieval of up to approximately 20 LNs, after which survival did not improve.

CONCLUSION

In node-positive breast cancer, the number of nodes retrieved is significantly associated with an increased positive nodal count and greater use of adjuvant therapy. Removal of approximately 20 LNs may improve survival by both more accurate nodal staging and increased adjuvant therapy use.

Determinants for non-sentinel node metastases in primary invasive breast cancer: a population-based cohort study of 602 consecutive patients with sentinel node metastases

Background

Sentinel node biopsy (SNB) is the standard procedure for axillary staging in patients with clinically lymph node negative invasive breast cancer. Completion axillary lymph node dissection (c-ALND) may not be necessary for all patients as a significant number of patients have no further metastases in non-sentinel nodes (non-SN) and c-ALND may not improve survival. The first aim of our study is to identify clinicopathological determinants associated with non-SN metastases. The second aim is to determine the impact of the number of sentinel node (SN) with macro-metastases and the type of SN metastases on metastatic involvement in non-SN.

Methods

This is a retrospective study of 602 patients with primary invasive breast cancer operated on with SNB and c-ALND in Lund and Malmö during 2008–2013. All these patients had micro- and/or macro-metastases in SNs. Information was retrieved from the national Information Network for Cancer Care (INCA). The risk of metastases to non-SNs were analyzed in relation to clinicopathological determinants such as age, screening mammography, tumour size, tumour type, histological grade, estrogen status, progesterone status, HER2 status, multifocality and lymphovascular invasion. Additionally, we compared the association between the number of the SN and the type of metastases in SN with the risk of metastases to non-SNs. Binary logistic regression was used, yielding odds ratios (OR) with 95% confidence intervals (CI).

Results

We found that 211 patients (35%) had metastases in non-SNs and 391 patients (65%) had no metastases in non-SNs. Lobular type (18%) of breast cancer (1.73; 1.0 1-2.97) and multifocal (31.3%) tumours (2.20; 1.41–3.44) had a high risk of non-SNs metastases. As compared to only micro-metastases, the presence of macro-metastases in SNs was associated with a high risk of metastases to non-SNs (4.91; 3.01–8.05). The number of SN with macro-metastases, regardless of the number of SNs removed by surgery, increases the risk of finding non-SNs with metastases. The total number of SN removed by surgery had no impact on diagnosis of metastases in non-SNs. No statistically significant associations were observed regarding other studied determinants.

Conclusion

We conclude in the present study that lobular cancer and multifocal tumours were associated with a high risk of non-SN involvement. The presence of the macro-metastases in SNs and the number of SN with macro-metastases has a positive association with presence of metastases in non-SNs. The total number of SNs removed by surgery had no impact on finding metastases in non-SNs. These factors may be valuable considering whether or not to omit c-ALND.

Preoperative Prediction of Axillary Lymph Node Metastasis in Breast Cancer using Radiomics Features of DCE-MRI

The accurate and noninvasive preoperative prediction of the state of the axillary lymph nodes is significant for breast cancer staging, therapy and the prognosis of patients. In this study, we analyzed the possibility of axillary lymph node metastasis directly based on Magnetic Resonance Imaging (MRI) of the breast in cancer patients. After mass segmentation and feature analysis, the SVM, KNN, and LDA three classifiers were used to distinguish the axillary lymph node state in 5-fold cross-validation. The results showed that the effect of the SVM classifier in predicting breast axillary lymph node metastasis was significantly higher than that of the KNN classifier and LDA classifier. The SVM classifier performed best, with the highest accuracy of 89.54%, and obtained an AUC of 0.8615 for identifying the lymph node status. Each feature was analyzed separately and the results showed that the effect of feature combination was obviously better than that of any individual feature on its own.

Intraoperative imprint cytology versus histological diagnosis for the detection of sentinel lymph nodes in breast cancer treated with neoadjuvant chemotherapy

OBJECTIVES

To compare imprint cytology and paraffin section histology for sentinel lymph node detection in women with breast cancer treated with neoadjuvant chemotherapy.

METHOD

A cross-sectional study and report of the sentinel lymph node statuses of 64 patients with breast cancer who underwent intraoperative imprint cytology and neoadjuvant chemotherapy in a referral cancer institute in Rio de Janeiro, Brazil, between 2014 and 2016.

RESULTS

The mean age was 51 years. The most common histological type was invasive ductal carcinoma (93.75%), and the most common differentiation grade was 2 (62.5%). Overall, 153 lymph nodes were identified, with a mean of 2.39/case. Thirty-four lymph nodes tested positive for malignancy by imprint cytology, and 55 tested positive by histology. Of the 55 positive lymph nodes, 41 (74.5%) involved macrometastases, and 14 (25.5%) involved micrometastases. There were 21 false negatives with imprint cytology, namely, 7 for macrometastases and 14 for micrometastases, resulting in a rate of 17.6%. The sensitivity of imprint cytology was 61.8%, with a specificity and positive predictive value of 100%, a negative predictive value of 82.4% and an accuracy of 86.3%. The method presented null sensitivity for the identification of micrometastases.

CONCLUSIONS

The false-negative rate with imprint cytology was associated with the number of sentinel lymph nodes obtained. The rate found for complete response to neoadjuvant chemotherapy was comparable to the rates reported in the literature. The accuracy of imprint cytology was good, and its specificity was excellent for sentinel lymph node detection; however, the method was unable to detect lymph node micrometastases.

Frequency and Predictors of Axillary Lymph Node Metastases in Iranian Women with Early Breast Cancer

Background:

Axillary lymph node metastasis is the most important predictive factor for recurrence risk and survival in patients with invasive breast carcinoma. The aim of this study was to determine factors associated with metastatic involvement of axillary lymph nodes in Iranian women with early breast cancer.

Methods:

This article reports a retrospective study of 774 patients with T1-T2 breast cancer who underwent resection of the primary tumor and axillary staging by SLNB and/or ALND between 2005 and 2015 at our institution.

Results:

Of the 774 patients included in this study, 35.5% (275 cases) had axillary lymph node involvement at the time of diagnosis. Factors associated with nodal involvement in univariate analyses were tumor size, lymphovascular invasion (LVI), tumor grade, ER/PR status and HER2 expression. All factors identified with univariate analyses were entered into a multivariate logistic regression model and tumor size (OR= 3.01, CI 2.01–4.49, P <0.001), ER/PR positivity (OR = 1.74, CI 1.1.16–2.62, P = 0.007) and presence of LVI (OR = 3.3.8, CI 2.31–4.95, P <0.001) remained as independent predictors of axillary lymph node involvement.

Conclusions:

In conclusion, the results of this study suggests that positive hormonal receptor status, LVI and tumor size are predictive factors for ALNM in Iranian women with early breast cancer.

Predictive factors for sentinel node metastases in primary invasive breast cancer: a population-based cohort study of 2552 consecutive patients

BACKGROUND

Axillary lymph node status is one of the most important prognostic factors for breast cancer. The aim of this study was to determine predictive factors for metastasis to sentinel node (SN) in primary invasive breast cancer.

METHOD

This is a study of 3979 patients with primary breast cancer during 2008-2013 in Malmö and Lund scheduled for surgery and included in the information retrieved from Information Network for Cancer Care (INCA). The final study population included 2552 patients with primary invasive breast cancer. The risk of metastases to SN were examined in relation to potential clinicopathological factors such as age, screening mammography, tumor size, tumor type, histological grade, estrogen status, progesterone status, Her-2 status, multifocality, and lymphovascular invasion. Binary logistic regression was used; adjusted analyses yielded odds ratio (OR) with 95% confidence interval.

RESULTS

Tumors detected by mammography screening were less likely to be associated with metastases to SN compared to those not found by mammography screening (0.63; 0.51-0.80). Negative hormonal status for estrogen associated with lower risk for SN metastases compared to tumor with positive estrogen status (0.64; 0.42-0.99). Tumors with a size more than 20 mm had higher risk to metastasize to SN (1.84; 1.47-2.33) compared to tumors less than 20 mm. Multifocality (1.90; 1.45-2.47) and lymphovascular invasion (3.74; 2.66-5.27) were also strong predictive factors for SN metastases.

CONCLUSION

SN metastasis is less likely to occur in women with invasive breast cancer diagnosed by screening mammogram. Tumors with negative estrogen status are associated with low risk for SN metastases. Tumors larger than 20 mm, multifocality, or lymphovascular invasion are also factors associated with high risk for SN metastases.

Nomograms for preoperative prediction of axillary nodal status in breast cancer

Background

Axillary staging in patients with breast cancer and clinically node‐negative disease is performed by sentinel node biopsy (SLNB). The aim of this study was to integrate feasible preoperative variables into nomograms to guide clinicians in stratifying treatment options into no axillary staging for patients with non‐metastatic disease (N0), SLNB for those with one or two metastases, and axillary lymph node dissection (ALND) for patients with three or more metastases.

Methods

Patients presenting to Skåne University Hospital, Lund, with breast cancer were included in a prospectively maintained registry between January 2009 and December 2012. Those with a preoperative diagnosis of nodal metastases were excluded. Patients with data on hormone receptor status, human epidermal growth factor receptor 2 and Ki‐67 expression were included to allow grouping into surrogate molecular subtypes. Based on logistic regression analyses, nomograms summarizing the strength of the associations between the predictors and each nodal status endpoint were developed. Predictive performance was assessed using the area under the receiver operating characteristic (ROC) curve. Bootstrap resampling was performed for internal validation.

Results

Of the 692 patients eligible for analysis, 248 were diagnosed with node‐positive disease. Molecular subtype, age, mode of detection, tumour size, multifocality and vascular invasion were identified as predictors of any nodal disease. Nomograms that included these predictors demonstrated good predictive abilities, and comparable performances in the internal validation; the area under the ROC curve was 0·74 for N0versus any lymph node metastasis, 0·70 for one or two involved nodes versusN0, and 0·81 for at least three nodes versus two or fewer metastatic nodes.

Conclusion

The nomograms presented facilitate preoperative decision‐making regarding the extent of axillary surgery.

Defines need for staging?

Rapid diagnosis of lymph node metastasis in breast cancer using a new fluorescent method with γ-glutamyl hydroxymethyl rhodamine green

Sentinel lymph node biopsy is performed as a standard procedure in breast cancer surgery, and the development of quick and simple methods to detect metastatic lesions is in high demand. Here, we validated a new fluorescent method using γ-glutamyl hydroxymethyl rhodamine green to diagnose metastatic lymph nodes in breast cancer. One hundred and forty-nine lymph nodes from 38 breast cancer patients were evaluated in this study. Comparison of fluorescent and pathological images showed that this fluorescent method was successful for visualizing breast cancer cells in lymph nodes. This method had a sufficiently high sensitivity (97%), specificity (79%) and negative predictive value (99%) to render it useful for an intraoperative diagnosis of cancer. These preliminary findings suggest that this novel method is useful for distinguishing non-cancerous specimens from those in need of careful examination and could help save time and cost for surgeons and pathologists.

Comparison of mastoscopic and conventional axillary lymph node dissection in breast cancer: long-term results from a randomized, multicenter trial

OBJECTIVE

To compare the long-term results of mastoscopic axillary lymph node dissection (MALND) and conventional axillary lymph node dissection (CALND).

PATIENTS AND METHODS

From January 1, 2003, through December 31, 2005, a group of 1027 consecutive patients with operable breast cancer were randomly assigned to 1 of 2 study groups: MALND and CALND. The median follow-up was 63 months. The primary end points of the study were operative outcomes, complication reduction, function conservation, and cosmetics. The secondary end points were disease-free and overall survival.

RESULTS

The mean operative blood loss in the MALND group was less than in the CALND group (P<.001). The patients who underwent MALND had less axillary pain, numbness or paresthesias, and arm swelling (P<.001). The aesthetic appearance of the axilla in the MALND group was much better than that in the CALND group (P=.001 at 6 months and P=.002 at 24 months). A significant difference was found between the 2 groups in distant metastasis (P=.04). The disease-free survival rate was 64.5% in the MALND group and 60.8% in the CALND group (P=.88). The overall survival rate was 81.7% in the MALND group and 78.6% in the CALND group (P=.95).

CONCLUSION

Compared with CALND, MALND has advantages in operative outcomes, complication reduction, function conservation, and cosmetics.

Should axillary ultrasound be used in patients with a preoperative diagnosis of ductal carcinoma in situ?

BACKGROUND

We evaluated the usefulness of axillary ultrasound (US) in patients with core biopsy-proven ductal carcinoma in situ (DCIS).

METHODS

Preoperative axillary US, fine-needle aspiration (FNA), and sentinel lymph node (SLN) data from women with DCIS were reviewed.

RESULTS

Eighty-two women with DCIS underwent axillary US. In 16 women (19.5%) US was abnormal; however, FNA was negative in all cases. Sixty-one women (74%) underwent SLN surgery; 2 were positive for macrometastasis (3%) and 1 had isolated tumor cells. None of them had an abnormal US. Axillary US did not change the management in any of the cases.

CONCLUSIONS

Axillary US and FNA did not change the management in any of the 82 cases. In women with a core biopsy diagnosis of DCIS, positive nodes are uncommon and unlikely to be detected by axillary US. Routine preoperative axillary US is not recommended for pure DCIS on core biopsy.

A 10-year follow-up of treatment outcomes in patients with early stage breast cancer and clinically negative axillary nodes treated with tangential breast irradiation following sentinel lymph node dissection or axillary clearance

We compare long-term outcomes in patients with node negative early stage breast cancer treated with breast radiotherapy (RT) without the axillary RT field after sentinel lymph node dissection (SLND) or axillary lymph node dissection (ALND). We hypothesize that though tangential RT was delivered to the breast tissue, it at least partially sterilized occult axillary nodal metastases thus providing low nodal failure rates. Between 1995 and 2001, 265 patients with AJCC stages I-II breast cancer were treated with lumpectomy and either SLND (cohort SLND) or SLND and ALND (cohort ALND). Median follow-up was 9.9 years (range 8.3-15.3 years). RT was administered to the whole breast to the median dose of 48.2 Gy (range 46.0-50.4 Gy) plus boost without axillary RT. Chi-square tests were employed in comparing outcomes of two groups for axillary and supraclavicular failure rates, ipsilateral in-breast tumor recurrence (IBTR), distant metastases (DM), and chronic complications. Progression-free survival (PFS) was compared using log-rank test. There were 136/265 (51%) and 129/265 (49%) patients in the SLND and ALND cohorts, respectively. The median number of axillary lymph nodes assessed was 2 (range 1-5) in cohort SLND and 18 (range 7-36) in cohort ALND (P < 0.0001). Incidence of AFR and SFR in both cohorts was 0%. The rates of IBTR and DM in both cohorts were not significantly different. Median PFS in the SLND cohort is 14.6 years and 10-year PFS is 88.2%. Median PFS in the ALND group is 15.0 years and 10-year PFS is 85.7%. At a 10-year follow-up chronic lymphedema occurred in 5/108 (4.6%) and 40/115 (34.8%) in cohorts SLND and ALND, respectively (P = 0.0001). This study provides mature evidence that patients with negative nodes, treated with tangential breast RT and SLND alone, experience low AFR or SFR. Our findings, while awaiting mature long-term data from NSABP B-32, support that in patients with negative axillary nodal status such treatment provides excellent long-term cure rates while avoiding morbidities associated with ALND or addition of axillary RT field.

Sentinel Lymph Node Biopsy in Breast Cancer

The axillary lymph node status is the most reliable prognostic indicator of recurrence and overall survival in patients with breast cancer. The current standard surgical procedure for the management of invasive breast cancer is the complete removal of the cancer with total axillary clearance. However, recently, selective sentinel lymph node mapping and biopsy is gaining acceptance as a useful and accurate staging procedure, as it is minimally invasive. The sentinel lymph node is the first node into which a primary cancer drains, and is thus the first node to be involved by metastases. Patients whose sentinel nodes are negative for breast cancer metastases, can be spared a more extensive axillary lymph node dissection, with reduction in the postoperative morbidity. Sentinel node mapping is usually performed by intradermal or peritumoral injection of a combination of blue dye and radiotracer. Sentinel node examination is sometimes done intraoperatively, by imprint cytology and frozen sections, for an immediate assessment, to plan the extent of surgery at a single sitting. Permanent sections of the sentinel node are studied by serial sectioning, and immunohistochemistry for cytokeratin is done to detect micrometastases which are frequently missed on hematoxylin and eosin (H&E)-stained sections. The various aspects of sentinel node examination, and its role to decide further management in patients with ductal carcinoma-in-situ, and in other clinical settings, are discussed in this review.

Debating the mathematical model to validate the sentinel lymph biopsy techniques in breast cancer patients. The danger of bias and its practical implications

BACKGROUND

Sentinel node biopsy (SNB) is an effective alternative to axillary lymph node dissection (ALD) for axillary staging. SNB (test) needs a validation period in which ALD (the gold standard) is always performed. Sensitivity, specificity and predictive values (PV) are used to define the accuracy of the procedure. We hypothesise that, during the period of validation, a bias is produced if the result of SNB is included as a part of the ALD.

PATIENTS AND METHODS

A hypothetical population of 350 patients was analysed. First analyses were performed by including the sentinel lymph node as a part of 'the rest of the axilla'. Second analyses were re-done according to our theory, and sentinel lymph node was considered outside 'the rest of the axilla'. Sensitivity, specificity and PV were compared for both models.

RESULTS

First group (classic) - sensitivity: 94%; specificity: 100%; positive PV: 100%; negative PV: 97%. Second group (new proposed model) - sensitivity: 87%; specificity: 81%; positive PV: 44%; negative PV: 97%.

CONCLUSION

The classic concept of sentinel lymph node to calculate sensitivity, specificity and positive PV can result in a bias. The magnitude of this bias will vary in terms of the obtained values, but its direction is always optimistic.

Sentinel lymph node biopsy in two Burgundy districts: prospective multicentric study on 528 breast cancers during the year 2005

OBJECTIVES

Our purpose was to assess development of sentinel lymph node biopsy (SLNB) in two Burgundy districts during the year 2005.

METHODS

All women undergoing breast surgery as primary care between 1 January 2005 and 1 January 2006 were eligible for inclusion. Eleven surgeons from five different breast-treatment centres took part in this prospective multicentric study. As our objective was to evaluate practices, patients were not randomized and surgeons were free to choose treatment patterns.

RESULTS

The 528 enrolled cases account for 90% of all new breast cancers in 2005 in Cote d'Or and Saône et Loire. Half of these patients (286) fulfilled requirements for SLNB. The others (242) had primary full axillary clearance (AC). Four of our five centres offer double-detection of sentinel lymph nodes as well as intraoperative pathology examination. Most tumours were invasive ductal carcinomas, with an average size of 12 mm in the SLNB group (T1C) and 22 mm in the AC group (T2). Two or three lymph nodes were removed during each SLNB procedure. Whereas most SLNB studies report around 25% positive nodes, we barely recorded 18.5% (53 of our 256 patients). Moreover, 2/3 of these node-positive patients had optimal care since additional axillary clearance was done right away.

CONCLUSION

Sentinel lymph node biopsy has become routine practice in our Burgundy area. It is mainly dedicated to early stage breast cancer with limited metastatic risk. Our surgeons follow the most recent guidelines and indications are the same regardless of treatment centre.

Tissue array for Tp53, C-myc, CCND1 gene over-expression in different tumors

AIM: To rapidly detect molecular alterations in different malignancies and investigate the possible role of Tp53, C-myc, and CCND1 genes in development of tumors in human organs and their adjacent normal tissues, as well as the possible relation between well- and poorly-differentiated tumors.

METHODS: A tissue array consisting of seven different tumors was generated. The tissue array included 120 points of esophagus, 120 points of stomach, 80 points of rectum, 60 points of thyroid gland, 100 points of mammary gland, 80 points of liver, and 80 points of colon. Expressions of Tp53, C-myc, and CCND1 were determined by RNA in situ hybridization. 3’ terminal digoxin-labeled anti-sense single stranded oligonucleotide and locked nucleic acid modifying probe were used.

RESULTS: The expression level of Tp53 gene was higher in six different carcinoma tissue samples than in paracancerous tissue samples with the exception in colon carcinoma tissue samples (P < 0.05). The expression level of CCND1 gene was significantly different in different carcinoma tissue samples with the exception in esophagus and colon carcinoma tissue samples. The expression level of C-myc gene was different in esophagus carcinoma tissue samples (χ² = 18.495, P = 0.000), stomach carcinoma tissue samples (χ² = 23.750, P = 0.000), and thyroid gland tissue samples (χ² = 10.999, P = 0.004). The intensity of signals was also different in different carcinoma tissue samples and paracancerous tissue samples.

CONCLUSION: Over-expression of the Tp53, CCND1, and C-myc genes appears to play a role in development of human cancer by regulating the expression of mRNA. Tp53, CCND1 and C-myc genes are significantly correlated with the development of different carcinomas.

Accuracy of computed tomography perfusion in assessing metastatic involvement of enlarged axillary lymph nodes in patients with breast cancer

INTRODUCTION

The purpose of this study was to evaluate the diagnostic accuracy of computed tomography (CT) perfusion in differentiating metastatic from inflammatory enlarged axillary lymph nodes in patients with breast cancer.

METHODS

Twenty-five patients with 26 locally advanced breast tumors and clinically palpable axillary lymph nodes underwent dynamic multi-detector CT (LightSpeed 16; General Electric Company) at one scan per second for 150 seconds at the same table position after 40 ml intravenous contrast injection at 4.0 ml/second. Semi-automatic calculation of values of perfusion parameters - blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability surface (PS) - was performed. Results were compared with pathology and with Her-2/neu and Ki-67 levels in a surgical specimen of the primary tumor.

RESULTS

Examined lymph nodes were inflammatory in 8 cases and metastatic in 18. Mean values of perfusion parameters in inflammatory and metastatic nodes, respectively, were BF of 76.18 (confidence interval [CI], 31.53) and 161.60 (CI, 40.94) ml/100 mg per minute (p < 0.05), BV of 5.81 (CI, 2.50) and 9.15 (CI, 3.02) ml/100 mg (not significant [n.s.]), MTT of 6.80 (CI, 1.55) and 5.50 (CI, 1.84) seconds (p = 0.07), and PS of 25.82 (CI, 4.62) and 25.96 (CI, 7.47) ml/100 mg per minute (n.s.). Size of nodes, stage of breast cancer, Ki-67 and Her-2/neu levels in breast cancer, and expression of primary tumor activity were not correlated to any perfusion parameter in metastatic nodes.

CONCLUSION

CT perfusion might be an effective tool for studying enlarged axillary lymph nodes in patients with breast cancer. It gives information on vascularization of lymph nodes, helping to understand the changes occurring when neoplastic cells implant in lymph nodes.

Is there any Prognostically Different Subgroup among Patients with Stage IIIC (Any TN3M0) Breast Carcinoma?

BACKGROUND

We investigated whether there are prognostically different subgroups among patients with stage IIIC (any TN3M0) breast carcinoma.

METHODS

The file records of 348 female patients operated for stage IIIC breast carcinoma were reviewed. The endpoint was disease recurrence.

RESULTS

Patients with a T1, T2 or T3 tumor had significantly better disease-free survival (DFS) compared to those with a T4 tumor. In the patient group with T1,2,3N3M0 disease, the DFS was significantly better in patients with between 10 and 15 metastatic axillary lymph nodes, compared to patients with 16 or more metastatic lymph nodes (p = 0.0360) and in patients with a nodal ratio ( number of metastatic lymph nodes divided by number of removed nodes) less than or equal to 0.80, compared to patients with a nodal ratio greater than 0.80 (p = 0.0003). In the patient subgroup with between 10 and 15 metastatic lymph nodes, those with a nodal ratio greater than 0.80 had significantly worse DFS, whereas in the patient subgroup with 16 or more metastatic lymph nodes the nodal ratio had no prognostic significance. The DFS of patients with 10 to 15 positive lymph nodes and a nodal ratio of up to 0.80 was significantly better than that of both the patients with 10 to 15 positive lymph nodes and a nodal ratio greater than 0.80 (p = 0.0002), and the patients with 16 or more positive lymph nodes (p = 0.0002); survival of the latter two patient groups was similar.

CONCLUSIONS

Patients with T1,2,3N3M0 disease can be divided into prognostically different subgroups according to the number of metastatic lymph nodes in the axilla and the nodal ratio; in this way, different patient subgroups may be offered different treatment strategies.

One-step nucleic acid amplification for intraoperative detection of lymph node metastasis in breast cancer patients

PURPOSE

Detection of sentinel lymph node (SLN) metastasis in breast cancer patients has conventionally been determined by intraoperative histopathologic examination of frozen sections followed by definitive postoperative examination of permanent sections. The purpose of this study is to develop a more efficient method for intraoperative detection of lymph node metastasis.

EXPERIMENTAL DESIGN

Cutoff values to distinguish macrometastasis, micrometastasis, and nonmetastasis were determined by measuring cytokeratin 19 (CK19) mRNA in histopathologically positive and negative lymph nodes using one-step nucleic acid amplification (OSNA). In an intraoperative clinical study involving six facilities, 325 lymph nodes (101 patients), including 81 SLNs, were divided into four blocks. Alternate blocks were used for the OSNA assay with CK19 mRNA, and the remaining blocks were used for H&E and CK19 immunohistochemistry-based three-level histopathologic examination. The results from the two methods were then compared.

RESULTS

We established CK19 mRNA cutoff values of 2.5 x 10(2) and 5 x 10(3) copies/muL. In the clinical study, an overall concordance rate between the OSNA assay and the three-level histopathology was 98.2%. Similar results were obtained with 81 SLNs. The OSNA assay discriminated macrometastasis from micrometastasis. No false positive was observed in the OSNA assay of 144 histopathologically negative lymph nodes from pN0 patients, indicating an extremely low false positive for the OSNA assay.

CONCLUSION

The OSNA assay of half of a lymph node provided results similar to those of three-level histopathology. Clinical results indicate that the OSNA assay provides a useful intraoperative detection method of lymph node metastasis in breast cancer patients.

Alteration of cyclin D1 in Chinese patients with breast carcinoma and its correlation with Ki-67, pRb, and p53

BACKGROUND

For the female population in Asia, systematic investigation on alterations of cyclin D1 in breast carcinoma is rare, and correlation between cyclin D1 expression with clinicopathological parameters, survival rate, and other prognostic marker associated with cell cycle is unclear.

METHODS

Expression of cyclin D1 protein, Ki-67, pRb, and p53 was determined by immunohistochemistry in 18 cases of early breast carcinomas and 80 cases of invasive ductal carcinomas. Genetic alteration of cyclin D1 gene and overexpression of cyclin D1 mRNA were detected by Southern blot and RT-PCR, respectively.

RESULTS

Expression of cyclin D1 is negative in usual ductal hyperplasia (UDH) and atypical ductal hyperplasia (ADH). However, in 52.0% (51/98) of all breast carcinomas, positive expression of cyclin D1 was observed. Five-year survival rate of the patients with positive expression of cyclin D1 (52.7%) is significantly lower than the cases with negative expression of cyclin D1 (72.1%). Positive rate of cyclin D1 protein in invasive ductal carcinoma (52.5%) is slightly higher than overexpression rate (40.8%) of cyclin D1 mRNA but significantly higher than amplification rate of cyclin D1 gene (18.4%). Expression of cyclin D1 is correlated with Ki-67 expression, but not correlated with pRb and p53 expression.

CONCLUSIONS

Positive expression of cyclin D1 could serve as a poor prognostic marker for Chinese patients with breast carcinoma independent of nodal metastasis and clinical stage. Expression of cyclin D1 protein is affected more directly by overexpression of cyclin D1 mRNA rather than cyclin D1 gene amplification. The cooperation between pRb and p53 with cyclin D1 protein in the carcinogenesis of breast carcinoma is not supported by the results.

The tissue distribution of Evans blue dye in a sheep model of sentinel node biopsy

BACKGROUND

Tc-Evans blue is a 'single dose' agent for lymphatic mapping combining radioactivity and blue dye for sentinel node identification. The mechanism and distribution of blue dye retention in the lymph node is not clearly understood.

OBJECTIVE

To demonstrate the cellular distribution of Tc-Evans blue in sheep sentinel lymph nodes by measuring the radioactivity of different tissue components and correlating this with pathological examination.

METHODS

Tc-Evans blue was used to identify sheep lymph nodes. Part of each node was sent for pathological examination including imprint cytology, and frozen and permanent section examination. Sections were examined without stains, with only red stains and conventional haematoxylin & eosin staining. The remaining nodal tissue was homogenized and components separated by enzymatic digestion and density gradient centrifugation. Fractions representing each tissue component were counted in a gamma counter and the distribution of Tc-Evans blue calculated.

RESULTS

A dispersed population of blue staining cells was found. Their distribution, number and size indicated that they were histiocytes such as macrophages or antigen presenting cells. Radioactivity was distributed throughout the lymph node. Over 70% remained in the plasma, 19% in the leukocyte layer, and 10% was associated with erythrocytes and undigested tissue.

CONCLUSION

The accumulation of radioactivity and blue colour in the lymph nodes indicates the mechanism of retention is a result of the binding interaction between Tc-Evans blue-protein and lymph node histiocytes including macrophages and antigen presenting cells.