Significance and problems of histopathological examination and utility of real-time reverse transcriptase-polymerase chain reaction method for the detection of sentinel lymph node metastasis in breast cancer

Analysis of molecular markers as predictive factors of lymph node involvement in breast carcinoma

Nodal status is the most significant independent prognostic factor in breast cancer. Identification of molecular markers would allow stratification of patients who require surgical assessment of lymph nodes from the large numbers of patients for whom this surgical procedure is unnecessary, thus leading to a more accurate prognosis. However, up to now, the reported studies are preliminary and controversial, and although hundreds of markers have been assessed, few of them have been used in clinical practice for treatment or prognosis in breast cancer. The purpose of the present study was to determine whether protein phosphatase Mg2+/Mn2+ dependent 1D, β-1,3-N-acetylglucosaminyltransferase, neural precursor cell expressed, developmentally down-regulated 9, prohibitin, phosphoinositide-3-kinase regulatory subunit 5 (PIK3R5), phosphatidylinositol-5-phosphate 4-kinase type IIα, TRF1-interacting ankyrin-related ADP-ribose polymerase 2, BCL2 associated agonist of cell death, G2 and S-phase expressed 1 and PAX interacting protein 1 genes, described as prognostic markers in breast cancer in a previous microarray study, are also predictors of lymph node involvement in breast carcinoma Reverse transcription-quantitative polymerase chain reaction analysis was performed on primary breast tumor tissues from women with negative lymph node involvement (n=27) compared with primary tumor tissues from women with positive lymph node involvement (n=23), and was also performed on primary tumors and paired lymph node metastases (n=11). For all genes analyzed, only the PIK3R5 gene exhibited differential expression in samples of primary tumors with positive lymph node involvement compared with primary tumors with negative lymph node involvement (P=0.0347). These results demonstrate that the PIK3R5 gene may be considered predictive of lymph node involvement in breast carcinoma. Although the other genes evaluated in the present study have been previously characterized to be involved with the development of distant metastases, they did not have predictive potential.

Powerful qPCR assays for the early detection of latent invaders: interdisciplinary approaches in clinical cancer research and plant pathology

Latent invaders represent the first step of disease before symptoms occur in the host. Based on recent findings, tumors are considered to be ecosystems in which cancer cells act as invasive species that interact with the native host cell species. Analogously, in plants latent fungal pathogens coevolve within symptomless host tissues. For these reasons, similar detection approaches can be used for an early diagnosis of the invasion process in both plants and humans to prevent or reduce the spread of the disease. Molecular tools based on the evaluation of nucleic acids have been developed for the specific, rapid, and early detection of human diseases. During the last decades, these techniques to assess and quantify the proliferation of latent invaders in host cells have been transferred from the medical field to different areas of scientific research, such as plant pathology. An improvement in molecular biology protocols (especially referring to qPCR assays) specifically designed and optimized for detection in host plants is therefore advisable. This work is a cross-disciplinary review discussing the use of a methodological approach that is employed within both medical and plant sciences. It provides an overview of the principal qPCR tools for the detection of latent invaders, focusing on comparisons between clinical cancer research and plant pathology, and recent advances in the early detection of latent invaders to improve prevention and control strategies.

Detection of micrometastasis in lymph nodes of oral squamous cell carcinoma: A comparative study

Background:

The annual mortality rate from head and neck squamous cell carcinoma (HNSCC) is over 11,000 worldwide. Squamous cell carcinoma of the head and neck (SCCHN) frequently metastasizes to the regional lymph nodes which are the first site of arrest of tumor cells that have invaded the peritumoral lymphatics, hence the strongest predictor of disease prognosis and outcome.

Aim:

The present study aims to compare the efficacy of frozen sections (cryosection), step-serial sectioning conventional H and E staining, immunohistochemistry (IHC) and RT-PCR analysis in detection of lymph node micrometastasis.

Materials and Methods:

A prospective series of 30 patients who were diagnosed with primary squamous cell carcinoma of the oral cavity and underwent surgical treatment including unilateral or bilateral selective neck dissection were considered for the study.

Result:

Metastatic carcinomatous cells were observed in H and E staining of frozen section in 18 lymph nodes (54%) and in 19 lymph nodes (57%) in step-serial sectioned H and E-stained sections of the 78 lymph nodes from 30 patients. Carcinomatous cells were immunolabeled with pancytokeratin in 18 lymphnodes (54%). CK19 mRNA was detected in 33 lymph nodes of 16 patients. RT-PCR gave positive signals for 24% and 23% of lymph nodes positive by histopathology and immunohistochemistry.

Conclusion:

Our study demonstrated that RT-PCR is far more sensitive in detection of micrometastasis than any other technique used in routine procedures and immunohistochemistry. Fifty-three percent patients with micrometastasis detected by RT-PCR had large T3/T4 tumors. Prognosis was poor for patients who were positive for micrometastasis detected only by RT-PCR, among which two patients died within a period of 6 months.

Computed tomographic lymphography for sentinel lymph node biopsy in male breast cancer: report of two cases

Male breast cancer is rare, accounting for less than 1% of breast cancers. Because of its rarity evidence of the usefulness sentinel lymph node biopsy (SLNB) for male breast cancer has not been established. Moreover, a navigation system which can easily determine the incision site of SLNB is needed because a second incision for SLNB is necessary in most cases. We report successful computed tomographic lymphography (CTLG)-guided SLNB in two male breast cancer cases: the first patient was a 79-year-old man and the second was a 64-year-old man. Both had presented with a lump behind the nipple. Clinical diagnoses were early breast carcinoma in both cases. The second patient took tamoxifen 20 mg daily as neoadjuvant endocrine therapy. SLNs were clearly visualized by CTLG, allowing mastectomies with SLNB to be performed. Both SLNB were negative, such that axillary lymph node dissection was not needed. Preoperative CTLG is useful for visualizing lymph flow and detecting SLN in male breast cancer.

Accurate and rapid novel genetic diagnosis for detection of sentinel lymph node metastasis in breast cancer patients

Background:

The transcription-reverse transcription concerted reaction (TRC) test is a novel molecular-based procedure, which can assess nodal metastasis accurately and quickly. We examined the usefulness of the TRC test with a double marker, cytokeratin 19 (CK19) and carcinoembryonic antigen (CEA) mRNA, to detect sentinel lymph nodes (SLN) metastasis in breast cancer patients.

Methods:

A total of 264 SLNs from 131 breast cancer patients were assigned to a training set (109 SLNs from 50 patients) and validation set (155 SLNs from 81 patients). Cytokeratin 19 and CEA mRNA were detected by TRC tests, and the sensitivity and specificity of the SLN metastasis between the TRC and histology cohorts were compared.

Results:

Mean copy numbers of CK19 and CEA by TRC tests were increased according to the metastatic size. In the training set, TRC test showed 100% sensitivity, specificity and concordance rates against the permanent histopathology test. In the validation set, sensitivity was 97.1%, specificity was 99.2% and the concordance rate was 99.4%.

Conclusion:

Our results showed that the detection of CK19 and CEA mRNA using the TRC test is, an accurate and rapid method for detection of SLN metastasis and can be applied as an intraoperative molecular diagnosis in breast cancer patients.

Sentinel lymph node micrometastasis in human breast cancer: an update

INTRODUCTION

The advent of sentinel lymph node biopsy (SLNB) and advances in histopathological and molecular analysis techniques have been associated with an increase in micrometastasis (MM) detection rate. However, the clinical significance of sentinel lymph node micrometastasis (SLN MM) continues to be a subject of much debate. In this article we review the literature concerning SLN MM, with particular emphasis on the prognostic significance of SLN MM. The controversies regarding histopathological assessment, clinical relevance and management implications are also discussed.

METHODS

Literature review facilitated by Medline and PubMed databases. Cross referencing of the obtained articles was used to identify other relevant studies.

RESULTS

Published studies have reported divergent and rather conflicting results regarding the clinical significance and implications of axillary lymph node (ALN) MM in general and SLN MM in particular. Some earlier studies demonstrated no associations, however most recent studies have found SLN MM to be an indicator of poorer prognosis and to be associated with non-SLN involvement. The use of adjuvant chemotherapy and/or hormonal manipulation therapy is associated with an improved survival in patients with SLN MM. Complete ALND may be safely omitted provided that adjuvant systemic therapy recommendations are equal to patients with node-positive disease. However, optimal management of SLN MM is yet to conclude. Furthermore, the identification of MM remains largely dependent on the analytical technique employed and the use of immunohistochemistry (IHC) increases the detection rate of SLN MM. Discrepancies in the histopathological interpretation of TNM classification of SLN tumour burden do exist. Published studies were non-randomized and have significant limitations including a small sample size, limited follow-up period, and lack of standardization and reproducibility of pathological examination of the SLN.

CONCLUSION

Patients with SLN MM have a poorer prognosis than those who are SLN negative. Therapeutic recommendations regarding patients with SLN MM should be taken in the context of multidisciplinary team setting and in selected cases of SLN MM, complete ALND may be safely omitted. A better reproducibility of pathological interpretation of the TNM classification is required so that future therapeutic guidelines can be applied without confusion.

[Prevalence of micrometastases and isolated tumor cells in the sentinel node at early stage breast cancer]

AIM

To analyze the prevalence of isolated tumor cells (ITC) and micrometastases in the sentinel node of early stage breast cancer.

MATERIAL AND METHODS

A total of 234 patients diagnosed of breast cancer, stages T1 or T2, with no axillary involvement detected by palpation or ultrasound-FNA, were studied. The sentinel node (SN) was identified by lymphoscintigraphy and removed in the operating room. Serial sections and immunohistochemical staining were then performed, classifying them as negative (SN-), negative with ITC (SN-ITC), positive with micrometastases (SN+mic) and positive with macrometastases (SN+mac). A complete axillary lymphadenectomy (CAL) was carried out in those cases with micro- or macrometastases, the former being classified as negative (CAL-), positive with micrometatases (CAL+mic), and positive with macrometastases (CAL+mac). The follow-up ranged from 6-71 months.

RESULTS

ITC were found in 12 patients (5.1%) and micrometastases in 24 (10.3%). Thus, a total of 36 patients were affected by some of these conditions (15.4%). In the group with micrometastases, the result of CAL was CAL- in 19/24 (79.1%), CAL+mic in 2 (8.3%) and CAL+mac in 3 (12.5%). No axillary recurrences have occurred up to date.

CONCLUSIONS

ITC and micrometastases were found in the sentinel node in a significant percentage of patients in the early stages of breast cancer. The low percentage of further axillary invasion in the group of micrometastases may open up the possibility of avoiding CAL in favor of other adjuvant treatments (chemotherapy, radiotherapy).

Clinical significance of sentinel lymph node isolated tumour cells in breast cancer

The advent of sentinel lymph node biopsy (SLNB) and improvements in histopathological and molecular analysis have increased the rate at which isolated tumour cells (ITC) are identified. However, their biological and clinical significance has been the subject of much debate. In this article we review the literature concerning SLNB with particular reference to ITC. The controversies regarding histopathological assessment, clinical relevance and management implications are explored. The literature review was facilitated by Medline, PubMed, Embase and Cochrane databases. Published studies have reported divergent results regarding the biological significance and clinical implications of ITC in general and SLN ITC in particular. Some studies demonstrate no associations, whilst others have found these to be indicators of poor prognosis, associated with non-SLN involvement, in addition to local recurrence and distant disease. Absolute consensus regarding the optimal analytical technique for SLN has yet to be reached, particularly concerning immunohistochemical (IHC) techniques targeting cytokeratins and contemporary molecular analysis. The clinical relevance of ITC within the SLN should be primarily determined by the magnitude of their impact on patient management and outcome measures. The modest up-staging within current classification systems is justified and reflects the marginally poorer prognosis for women with SLN ITC. Management need not be altered where further axillary treatment with surgical clearance or radiotherapy and systemic adjuvant treatment are already indicated. However, in the absence of level-1 guidance, each case requires discussion with regard to other tumour and patient related factors in the context of the multidisciplinary team. The identification of ITC remains highly dependent on the analytical technique employed and there exists potential for stage migration and impact on management decisions. Evidence supporting the routine analysis of deeper tissue sections by IHC is lacking and molecular technologies should be restricted to research purposes at present.

The role of micrometastatic disease in sentinel lymph node in breast cancer

Sentinel lymph node (SLN) biopsy is the standard procedure for axillary node staging in breast cancer. Improvements in histopathological analysis and immunohistochemistry have recently increased the rate of detection of lymph nodal micrometastases. The clinical implications and prognostic significance of micrometastases in SLN still remain a controversial issue. Literature review was analyzed by searches of Medline and PubMed data bases. Whereas most studies carried on small groups of patients did not show differences in survival, recently some studies with longer follow-up and with larger populations demonstrated that prognosis of patients with micrometastases is worse compared to that of patients with SLN free of disease. To date, completion axillary dissection remains the standard option when a macro or micrometastasis (0.2-2 mm) in the SLN is found. However, in absence of level-1 evidence guidelines, each case requires discussion in the context of a multi-disciplinary team.

Efficacy of intraoperative GeneSearch Breast Lymph Node (BLN) Assay for breast cancer metastasis detection in sentinel lymph node in Chinese patients

Although intraoperative assessment of the sentinel lymph node (SLN) is useful, it has not gained popularity in China as it involves a heavy workload for pathologists. We conducted a prospective clinical feasibility study of the GeneSearch Breast Lymph Node (BLN) Assay performed in 158 SLNs from 97 patients by comparison with postoperative permanent section histopathology, to validate its potential usefulness in China. Every SLN was cut into alternating 1.5 to 3.0 mm slabs. The BLN assay processed 50% of the fresh alternating slabs to detect the presence of cytokeratin 19 and mammaglobin mRNA. Assay results were compared with those for permanent section histopathology and intraoperative imprint cytology. Slides for imprint cytology were prepared from the BLN assay node tissue before it was processed. Full axillary lymph node (ALN) dissections were performed on some patients after a SLN biopsy. The BLN assay was successfully performed on 158 SLNs from 97 patients. Overall performance of the BLN assay compared with permanent section histopathology was sensitivity 83.9% (26/31), specificity 95.5% (63/66), positive predictive value 89.7% (26/29), negative predictive value 92.6% (63/68), and overall agreement 91.8% (89/97). The BLN assay detected about 25% more metastases than imprint cytology. Moreover, the BLN assay correctly identified most of the additional non-sentinel ALNs metastases (P = 0.005). Our results from a large series of Chinese patients with breast cancer indicate that the BLN assay may be a viable alternative for the standard intraoperative procedures used for metastases detection, especially in early stage breast cancer patients. Name of the trial register: GeneSearch Breast Lymph Node (BLN) Assay China Registration Study.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00869674.

Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions

Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

Molecular markers of breast axillary lymph node metastasis

In breast cancer, axillary lymph node status is one of the most important prognostic variables and a crucial component to the staging system. Several clinico-histopathological parameters are considered to be strong predictors of metastasis; however, they fail to accurately classify breast tumors according to their clinical behavior and to predict which patients will have disease recurrence. Methods based on genome-wide microarray analyses have been used to identify molecular markers with respect to the development of axillary lymph node metastasis. Most of these markers can be detected in the primary tumors, which can potentially lead to the ability to identify patients at the time of diagnosis who are at high risk for lymph node metastasis, allowing for early intervention and more suitable adjuvant treatments.

Positive sentinel lymph node biopsy predicts the number of metastatic axillary nodes of breast cancer

It remains to be clarified whether a positive sentinel lymph node biopsy (SLNB) can predict the number of metastatic axillary nodes. This study examined a consecutive series of women with unilateral invasive breast cancer who underwent axillary lymph node dissection after an intra-operative positive SLNB. The numbers of positive and negative sentinel lymph nodes (SLNs) were analyzed for a likelihood of pN1a, pN2a, and pN3a diseases as per the UICC TNM classification. Of the 368 study patients, 165 (45%) had one positive SLN and one or more negative SLNs. This result represented the most common combination of positive and negative SLNs. It was also the most predictive indicator (93%) of pN1a disease and the least predictive indicator (7% or 0%) of pN2a or pN3a disease, respectively. The numbers of positive and negative SLNs can predict the number of metastatic axillary nodes in breast cancer patients.

Identification and biologic significance of micrometastases in axillary lymph nodes in patients with invasive breast cancer

CONTEXT

The presence or absence of metastases in axillary lymph nodes is one of the most important prognostic factors for patients with breast cancer. During the past decade sentinel lymph node (SLN) biopsy has been increasingly adopted as a minimally invasive staging alternative to complete axillary node dissection.

OBJECTIVE

Sentinel lymph nodes are more likely to contain metastases than non-SLNs. In routine clinical practice SLNs are assessed by diverse methodologies including multiple sectioning, immunohistochemical staining, and molecular diagnostic tests. Despite the lack of standard histopathologic protocols during the years detailed evaluation of SLNs has resulted in an increased detection of small (micro) metastases.

DATA SOURCES

Breast cancer with micrometastases constitutes a heterogenous group of tumors with variable clinical outcome regarding the risk of additional metastases in the remaining axillary lymph nodes and to patients' survival.

CONCLUSION

The clinical significance of micrometastases has been subject to great controversy in patients with breast cancer. In this review we highlight controversies regarding micrometastases especially in relation to SLNs.

Clinical validation of a molecular assay for intra-operative detection of metastases in breast sentinel lymph nodes

BACKGROUND

In breast cancer patients, the status of the sentinel lymph nodes (SLNs) has been shown to accurately reflect the presence of metastases in the axillary lymph nodes (ALNs). Intra-operative SLN evaluation by frozen section histology may miss positive cases, leading to a second surgery for complete ALN dissection. Permanent section histology itself has tissue sampling limitations and is partially dependent on pathologist expertise.

METHODS

A prospective study (N=78) was conducted in our institution to validate a new intra-operative molecular assay, the GeneSearch breast lymph node (BLN) assay. This assay quantifies the expression of mammaglobin and cytokeratin-19 genes using quantitative RT-PCR technology to determine SLN status. Fresh SLN sections (2 mm thick) were analyzed alternatively by BLN assay or post-operative histology (haematoxylin-eosin and immunohistochemistry). The subject was considered positive when histology revealed a focus >0.2 mm.

RESULTS

BLN assay results corroborated with histologic results in 75 out of 78 patients for an overall agreement of 96%, a sensitivity of 92%, and a specificity of 97%. The positive and negative predictive values of the BLN assay were of 86% (12/14) and 98% (63/64), respectively. Interestingly, a statistically significant correlation was observed between the metastases' histologic size and both assay markers' expression levels as represented by cycle time to positivity (rho > or = 0.71, all p<0.0001).

CONCLUSIONS

The performance of the BLN assay in identifying nodal metastases >0.2 mm was similar to that of permanent section histology, with the added advantages of an objective and rapid output that could be used for intra-operative decision to remove additional ALN.

The clinical significance of sentinel lymph node micrometastasis in breast cancer

INTRODUCTION

The advent of sentinel lymph node biopsy (SLNB) and improvements in histopathological and molecular analysis have increased the rate at which micrometastases (MM) are identified. However, their significance has been the subject of much debate. In this article we review the literature concerning axillary lymph node (ALN) MM, with particular reference to SLNB. The controversies regarding histopathological assessment, clinical relevance and management implications are discussed.

METHODS

Literature review facilitated by Medline and PubMed databases.

RESULTS

Published studies have reported divergent results regarding the significance and implications of ALN MM in general and sentinel lymph node (SLN) MM in particular. Some studies demonstrate no associations, whilst others have found these to be indicators of poor prognosis, associated with non-SLN involvement, in addition to local and distant failure. Absolute consensus regarding the optimal analytical technique for SLNs has yet to be reached, particularly concerning immunohistochemical (IHC) techniques targeting cytokeratins and the utility of contemporary molecular analysis.

CONCLUSION

SLN MM are likely to represent an incremental detriment to prognosis and increased risk of non-SLN involvement, despite only modest up-staging within current classification systems. In the absence of level-1 guidance concerning the management of women with SLN MM, each case requires discussion with regard to other tumour and patient related factors in the context of the multidisciplinary team. Randomized studies are required to evaluate the prognostic significance and optimal management of each category of tumour burden within the SLN. The identification of MM remains highly dependent on the analytical technique employed and there exists potential for stage migration and impact on management decisions.