Fungal-derived cues promote ocular autoimmunity through a Dectin-2/Card9-mediated mechanism

Uveitis (intraocular inflammation) is a leading cause of loss of vision. Although its aetiology is largely speculative, it is thought to arise from complex genetic-environmental interactions that break immune tolerance to generate eye-specific autoreactive T cells. Experimental autoimmune uveitis (EAU), induced by immunization with the ocular antigen, interphotoreceptor retinoid binding protein (IRBP), in combination with mycobacteria-containing complete Freund's adjuvant (CFA), has many clinical and histopathological features of human posterior uveitis. Studies in EAU have focused on defining pathogenic CD4⁺ T cell effector responses, such as those of T helper type 17 (Th17) cells, but the innate receptor pathways precipitating development of autoreactive, eye-specific T cells remain poorly defined. In this study, we found that fungal-derived antigens possess autoimmune uveitis-promoting function akin to CFA in conventional EAU. The capacity of commensal fungi such as Candida albicans or Saccharomyces cerevisae to promote IRBP-triggered EAU was mediated by Card9. Because Card9 is an essential signalling molecule of a subgroup of C-type lectin receptors (CLRs) important in host defence, we evaluated further the proximal Card9-activating CLRs. Using single receptor-deficient mice we identified Dectin-2, but not Mincle or Dectin-1, as a predominant mediator of fungal-promoted uveitis. Conversely, Dectin-2 activation by α-mannan reproduced the uveitic phenotype of EAU sufficiently, in a process mediated by the Card9-coupled signalling axis and interleukin (IL)-17 production. Taken together, this report relates the potential of the Dectin-2/Card9-coupled pathway in ocular autoimmunity. Not only does it contribute to understanding of how innate immune receptors orchestrate T cell-mediated autoimmunity, it also reveals a previously unappreciated ability of fungal-derived signals to promote autoimmunity.

Mesenchymal Stromal Cells are Readily Recoverable from Lung Tissue, but not the Alveolar Space, in Healthy Humans

Stromal support is critical for lung homeostasis and the maintenance of an effective epithelial barrier. Despite this, previous studies have found a positive association between the number of mesenchymal stromal cells (MSCs) isolated from the alveolar compartment and human lung diseases associated with epithelial dysfunction. We hypothesised that bronchoalveolar lavage derived MSCs (BAL-MSCs) are dysfunctional and distinct from resident lung tissue MSCs (LT-MSCs). In this study, we comprehensively interrogated the phenotype and transcriptome of human BAL-MSCs and LT-MSCs. We found that MSCs were rarely recoverable from the alveolar space in healthy humans, but could be readily isolated from lung transplant recipients by bronchoalveolar lavage. BAL-MSCs exhibited a CD90^Hi , CD73^Hi , CD45^Neg , CD105^Lo immunophenotype and were bipotent, lacking adipogenic potential. In contrast, MSCs were readily recoverable from healthy human lung tissue and were CD90^{Hi or Lo} , CD73^Hi , CD45^Neg , CD105^Int and had full tri-lineage potential. Transcriptional profiling of the two populations confirmed their status as bona fide MSCs and revealed a high degree of similarity between each other and the archetypal bone-marrow MSC. 105 genes were differentially expressed; 76 of which were increased in BAL-MSCs including genes involved in fibroblast activation, extracellular matrix deposition and tissue remodelling. Finally, we found the fibroblast markers collagen 1A1 and α-smooth muscle actin were increased in BAL-MSCs. Our data suggests that in healthy humans, lung MSCs reside within the tissue, but in disease can differentiate to acquire a profibrotic phenotype and migrate from their in-tissue niche into the alveolar space. Stem Cells 2016;34:2548-2558.

The requirements of a specialist Breast Centre

INTRODUCTION

In recognition of the advances and evidence based changes in clinical practice that have occurred in recent years and taking into account the knowledge and experience accumulated through the voluntary breast unit certification programme, Eusoma has produced this up-dated and revised guidelines on the requirements of a Specialist Breast Centre (BC).

METHODS

The content of these guidelines is based on evidence from the recent relevant peer reviewed literature and the consensus of a multidisciplinary team of European experts. The guidelines define the requirements for each breast service and for the specialists who work in specialist Breast Centres.

RESULTS

The guidelines identify the minimum requirements needed to set up a BC, these being an integrated Breast Centre, dealing with a sufficient number of cases to allow effective working and continuing expertise, dedicated specialists working with a multidisciplinary approach, providing all services throughout the patients pathway and data collection and audit. It is essential that the BC also guarantees the continuity of care for patients with advanced (metastatic) disease offering treatments according to multidisciplinary competencies and a high quality palliative care service. The BC must ensure that comprehensive support and expertise may be needed, not only through the core BC team, but also ensure that all other medical and paramedical expertise that may be necessary depending on the individual case are freely available, referring the patient to the specific care provider depending on the problem.

CONCLUSIONS

Applying minimum requirements and quality indicators is essential to improve organisation, performance and outcome in breast care. Efficacy and compliance have to be constantly monitored to evaluate the quality of patient care and to allow appropriate corrective actions leading to improvements in patient care.

Demonstration of CD44 gene expression in cells from fine needle aspirates of breast lesions by the polymerase chain reaction

Aim-To demonstrate the feasibility of studying specific gene expression in fine needle aspirates from clinical lesions. The reverse transcription/polymerase chain reaction (RT-PCR) technique was used to demonstrate CD44 gene expression in cells from diagnostic fine needle aspirates taken from patients attending the outpatient clinic for breast diseases.Methods-Polyadenylated RNA was extracted from the cells remaining in the syringe barrel after fine needle aspirate cytological diagnosis of 41 patients with breast lesions. Analysis of CD44 gene expression was performed by RT-PCR using primers flanking the site for insertion of the variant exons. The resulting products were separated on 1.2% agarose gels, transferred to nylon membranes using Southern blotting and hybridised with specific probes for standard (constitutive) and variant exons of this gene.Results-On hybridisation with the CD44 standard exon probe, the expected amplified product of approximately 482 base pairs was visualised in 22 of 41 samples examined. Further hybridisation with the "variant" exon probes (exons 7 (v2), 8 (v3), 9b (v4), 12 (v7), and 15 (v10)) on 12 of these samples showed the presence of large molecular variants in all of these samples. However, the expression pattern detected with the probes for exons 7 (v2), 8 (v3) and 9b (v4) differed among the patients.Conclusions-Expression of the standard and variant regions of the CD44 gene in cells remaining in the syringe after fine needle aspiration was demonstrated using RT-PCR. The 5' variant exon probes seemed to show different patterns of expression among the patients. Further studies are currently being conducted to determine whether there is any correlation between expression of the various components of this gene and cytological diagnosis. Using this method, it would be possible to study the expression of other candidate marker genes in breast cancer using fine needle aspirates.

The role of radiotherapy in treating small early invasive breast cancer

AIM

The aim of the study was to identify if radiotherapy can be safely avoided in a selected subgroup of largely screening detected small invasive breast cancer.

METHODS

One hundred and eighty-eight patients with node negative invasive early breast cancer < or =1cm (< or =T1b) treated in our centre between 1990 and 2004 were retrospectively followed for local, regional and distant recurrences. Treatment involved adequate local excision by breast conserving surgery (BCS). Axillary staging was performed by a four node axillary sampling until 2000, following which sentinel lymph node sampling was employed. All sections were assessed histologically by haematoxylin and eosin stained sections. The inked margins were reported as being involved, close and clear. Radiotherapy (RT) was employed only if the resected margins were inadequate, and in those with involved axillary nodes who refused further completion axillary clearance.

RESULTS

Ninety-four patients (Group A) had BCS alone and 79 patients (Group B) had both BCS and RT. There was no ipsilateral breast tumour recurrence (IBTR) in 88 patients in Group A, corresponding to an actuarial freedom from IBTR of 96%, 91% and 88.1% at 5 years, 8 years and 9 years. In Group B, there was no IBTR in 75 patients corresponding to an actuarial freedom from IBTR of 97%, 94.9% and 90.6% at 5 years, 8 years and 10 years.

CONCLUSION

Our experience over 14 years has shown that it is possible to safely avoid radiotherapy in a selected subgroup of small invasive breast cancer.

Predictive markers in breast cancer--the present

Breast cancer is a heterogeneous disease and there is a continual drive to identify markers that will aid in predicting prognosis and response to therapy. To date, relatively few markers have established prognostic power. Oestrogen receptor (ER) is probably the most powerful predictive marker in breast cancer management, both in determining prognosis and in predicting response to hormone therapies. Progesterone receptor (PR) is also a widely used marker, although its value is less well established. HER-2 status has also become a routine prognostic and predictive factor in breast cancer. Given the importance of these biological markers in patient management, it is essential that assays are robust and quality controlled, and that interpretation is standardized. Furthermore, it is important to be aware of the limitations in their predictive power, and how this may be refined through addition of further biological markers. The aim of this review is to provide an overview of the established role of ER, PR and HER-2 in patient management, the current standards for assessing these markers, as well as highlighting the controversies that still surround their use and methods of assessment.

Non-operative breast pathology: apocrine lesions

Apocrine metaplasia is a very common finding in the female breast after the age of 25. It is so common that many people regard it as a normal component of the breast. This, however, is only really the case in apocrine sweat glands of the axilla and in the peri-areolar apocrine glands. The apocrine cell does, however, contribute to a number of different breast lesions, some of which are very taxing diagnostically; apocrine variants of both in-situ and invasive cancer are encountered. This review considers the common apocrine metaplastic lesions seen in fibrocystic change as well as apocrine adenoma, apocrine change within sclerosing adenosis, atypical apocrine lesions and apocrine malignancies.

Methylene blue dye versus combined dye-radioactive tracer technique for sentinel lymph node localisation in early breast cancer

AIM

The study compared the accuracy and success rate of two techniques, methylene blue alone versus combined methylene blue and radioactive colloid in sentinel lymph node localisation in the management early breast cancer.

METHODS

Three hundred and twenty-nine patients with tumours less than 2 cm on ultrasound assessment were prospectively evaluated. One hundred and seventy-three patients (Group A) underwent sentinel lymph node localisation using 1 ml of 1% methylene blue. A combined technique of both methylene blue and radioactive colloid was used in 156 patients (Group B). Application of both was subdermal and subareolar. Sentinel lymph nodes were examined by standard microscopy. Patients underwent breast conservation surgery or mastectomy and sentinel node guided four node axillary sampling+/-clearance.

RESULTS

In Group A, the sentinel lymph node identification rate was 96.5%. The negative predictive value was 96.3%, with false negative of 3.7% and accuracy of 87.4%. In group B the identification rate for sentinel lymph node was 98.7%, with false negative of 4.1%, negative predictive value of 96%, and accuracy of 83.8%.

CONCLUSION

Sentinel lymph node localisation using methylene blue or combined dye and radioactive tracer technique predicts the axillary lymph node status in early breast cancer with comparable success rates, accuracy and false negative rates. The combined technique facilitates quicker identification of sentinel lymph node; however the dye technique alone can be used successfully in centres without nuclear medicine facilities.

Best Practice No 179. Guidelines for breast needle core biopsy handling and reporting in breast screening assessment

Non-operative diagnosis has become the norm in breast disease assessment and, until relatively recently, fine needle aspiration cytology has been the sampling method of choice. The introduction of automated core biopsy guns in the mid 1990s led to the additional introduction of core biopsy in assessment units. This paper presents a summary of the guidance on handling and routine reporting of breast needle core biopsy specimens in the context of breast disease multidisciplinary assessment. This guidance has been produced by the UK National Coordinating Committee for Breast Screening Pathology and is endorsed by the European Commission working group on breast screening pathology.

Integrin expression and survival in human breast cancer

BACKGROUND

Integrin cell adhesion molecules are fundamental to numerous cellular functions including anchorage, differentiation and proliferation. Reduced expression of certain alpha and beta integrin subunits in primary breast cancer cells has been correlated with increased invasion and metastasis. Conversely, over-expression of the alpha6 subunit has been linked to poorer survival. The objective of this study was to measure the survival of a cohort with breast carcinoma in relation to integrin expression and to evaluate their potential as prognostic indicators.

METHOD

Integrin expression on samples from 99 consecutive patients with breast cancer was assayed using monoclonal antibodies to the subunits alpha(1,2,3,6,V) and beta(1,3,4,5). This cohort has now been followed prospectively for almost five years allowing for early assessment of survival in relation to integrin expression.

RESULTS

Whilst analysis of the data confirmed the relation of survival to proven predictors of tumour grade, tumour size and vascular invasion, statistical significance was not demonstrated with regard to both lymph node status and all integrin subunits studied.

CONCLUSION

Previous research correlating certain integrin subunits with survival has not been confirmed in this study. Despite proven molecular importance in tumour cell adhesion, invasion and metastasis, integrin expression would appear not to translate clinically as independent indicators of prognosis, at least in the short-term.

Discrepancies in current practice of pathological evaluation of sentinel lymph nodes in breast cancer. Results of a questionnaire based survey by the European Working Group for Breast Screening Pathology

AIMS

To evaluate aspects of the current practice of sentinel lymph node (SLN) pathology in breast cancer via a questionnaire based survey, to recognise major issues that the European guidelines for mammography screening should address in the next revision.

METHODS

A questionnaire was circulated by mail or electronically by the authors in their respective countries. Replies from pathology units dealing with SLN specimens were evaluated further.

RESULTS

Of the 382 respondents, 240 European pathology units were dealing with SLN specimens. Sixty per cent of these units carried out intraoperative assessment, most commonly consisting of frozen sections. Most units slice larger SLNs into pieces and only 12% assess these slices on a single haematoxylin and eosin (HE) stained slide. Seventy one per cent of the units routinely use immunohistochemistry in all cases negative by HE. The terms micrometastasis, submicrometastasis, and isolated tumour cells (ITCs) are used in 93%, 22%, and 71% of units, respectively, but have a rather heterogeneous interpretation. Molecular SLN staging was reported by only 10 units (4%). Most institutions have their own guidelines for SLN processing, but some countries also have well recognised national guidelines.

CONCLUSIONS

Pathological examination of SLNs throughout Europe varies considerably and is not standardised. The European guidelines should focus on standardising examination. They should recommend techniques that identify metastases > 2 mm as a minimum standard. Uniform reporting of additional findings may also be important, because micrometastases and ITCs may in the future be shown to have clinical relevance.

Inadequate rates are lower when FNAC samples are taken by cytopathologists

Inadequate rates (IR) in FNAC from different sources were compared. The rates were lowest when FNAC was performed by a cytopathologist (12%) and highest when done by a non-cytopathologist (32%). These differences were mirrored in high IRs in breast cancer cases. IR was not significantly improved when non-cytopathologist FNAC was attended by a cytotechnician.

Consistency of staining and reporting of oestrogen receptor immunocytochemistry within the European Union—an inter-laboratory study

To assess the variability of oestrogen receptor (ER) testing using immunocytochemistry, centrally stained and unstained slides from breast cancers were circulated to the members of the European Working Group for Breast Screening Pathology, who were asked to report on both slides. The results showed that there was almost complete concordance among readers (kappa=0.95) in ER-negative tumours on the stained slide and excellent concordance among readers (kappa=0.82) on the slides stained in each individual laboratory. Tumours showing strong positivity were reasonably well assessed (kappa=0.57 and 0.4, respectively), but there was less concordance in tumours with moderate and low levels of ER, especially when these were heterogeneous in their staining. Because of the variation, the Working Group recommends that laboratories performing these stains should take part in a external quality assurance scheme for immunocytochemistry, should include a tumour with low ER levels as a weak positive control and should audit the percentage positive tumours in their laboratory against the accepted norms annually. The Quick score method of receptor assessment may also have too many categories for good concordance, and grouping of these into fewer categories may remove some of the variation among laboratories.

Phyllodes tumour of the breast: a retrospective analysis of 30 cases

Phyllodes tumour (PT) is a rare neoplasm of the female breast that resembles fibroadenoma but occurs in an older age group. We retrospectively reviewed the medical records of 30 women who were treated for phyllodes tumour in our centre. Histological examination was performed by an experienced breast pathologist in all cases and tumours were classified as benign, border line malignant or malignant according to standard histological criteria. The mean age at diagnosis was 49 years (range: 19-80 years). Twenty-one (70%) of 30 tumours were benign and 9 (30%) were malignant (n=7) or borderline malignant (n=2). The mean tumour size was 46 mm (range: 20-100 mm). The final microscopic margins contained tumour in 13 (43%) of 30 cases and were free of tumour in 17 (57%) of 30 patients. After a median follow-up period of 6 years (range: 6 months-20 years), the tumour recurred locally in 5 (17%) patients. One patient had six local recurrences over an 18-year period. Local recurrences were more frequently observed in patients with malignant tumours compared with those with benign lesions (33% versus 10%). However, this association failed to reach statistical significance. There was no association between local recurrence, patient age, tumour size or positive microscopic margins. There was one death (3%) associated with a completely excised malignant tumour. The present study suggests that histological type and margins do not accurately predict the clinical course of PT and that there is a need to identify novel biological markers that more accurately predict the behaviour of this rare neoplasm.

Pathological work-up of sentinel lymph nodes in breast cancer. Review of current data to be considered for the formulation of guidelines

Controversies and inconsistencies regarding the pathological work-up of sentinel lymph nodes (SNs) led the European Working Group for Breast Screening Pathology (EWGBSP) to review published data and current evidence that can promote the formulation of European guidelines for the pathological work-up of SNs. After an evaluation of the accuracy of SN biopsy as a staging procedure, the yields of different sectioning methods and the immunohistochemical detection of metastatic cells are reviewed. Currently published data do not allow the significance of micrometastases or isolated tumour cells to be established, but it is suggested that approximately 18% of the cases may be associated with further nodal (non-SN) metastases, i.e. approximately 2% of all patients initially staged by SN biopsy. The methods for the intraoperative and molecular assessment of SNs are also surveyed.

How significant is detection of ductal carcinoma in situ in a breast screening programme?

PURPOSE

To compare the histological grades of screen detected and non-screen detected ductal carcinoma in situ (DCIS) and to identify any differences that might support the contention that DCIS found by breast screening represents an over-diagnosis. The aim was also to establish whether any particular mammographic features of DCIS can be used to predict tumour grade reliably.

MATERIALS AND METHODS

Biopsy proven cases of DCIS (n=153) were reviewed with respect to grade and subdivided into high, intermediate and low grades using the Van Nuys classification. A more aggressive subset of DCIS (microinvasive and interval cancers) were similarly analysed. Mammograms were reviewed with regard to abnormal features and distribution, and the appearances correlated with grade.

RESULTS

Fifty-four percent (53/98) of screen detected and 62% (34/52) of non-screen detected DCIS were high grade. The rest were equally intermediate and low grade, with no statistical difference between the two groups. Eighty-four percent of the aggressive subset of tumours were high grade. Micro-calcification was present in 90% and in 10% there were soft tissue changes alone. Seventy-six percent of linear branching calcification was associated with high grade DCIS. Only 13% of high grade DCIS demonstrated punctate micro-calcification; however, 38% of cases of punctate micro-calfication were associated with high grade tumours and there was a great deal of overlap between the groups.

CONCLUSION

Most cases of DCIS in both screen and non-screen detected groups were high grade. Only one in five was low grade. Analysis of the aggressive subgroup underlines the significance of high grade DCIS. Mammographic patterns are not always reliable in the prediction of tumour grade. The detection of DCIS in screening programmes is important and should not be regarded as over-diagnosis.

Axillary node status in breast cancer patients prior to surgery by imaging with Tc-99m humanised anti-PEM monoclonal antibody, hHMFG1

In early breast cancer axillary nodes are usually impalpable and over 50% of such patients may have an axillary clearance when no nodes are involved. This work identifies axillary node status by imaging with a Tc-99m radiolabelled anti-Polymorphic Epithelial Mucin, humanised monoclonal antibody (human milk fat globule 1), prior to surgery in 30 patients. Change detection analysis of image data with probability mapping is undertaken. A specificity of 93% and positive predictive value of 92% (both 100% if a second cancer in the axilla with negative nodes is considered) were found. A strategy for combining negative imaging with the sentinel node procedure is presented.

Androgen receptor expression in ductal carcinoma in situ of the breast: relation to oestrogen and progesterone receptors

AIMS

Ductal carcinoma in situ (DCIS) of the breast has been diagnosed increasingly since the advent of mammographic screening. In contrast to the situation in invasive breast carcinoma, there are no reports on androgen receptor (AR) status in DCIS and few reports on oestrogen (ER) and progesterone (PR) receptors.

METHODS

AR expression was examined in 57 cases of DCIS of the breast and correlated to the degree of differentiation and ER/PR status using immunohistochemical methods.

RESULTS

AR positivity was noted in 19 of the cases, whereas the other 38 cases were negative. There was no significant association between AR expression and the degree of differentiation of DCIS; three of the 13 well differentiated DCIS cases, 10 of the 19 intermediately differentiated cases, and six of the 25 poorly differentiated cases were positive (p = 0.093). However, a strong association was shown between the expression of ER (p < 0.0001) and PR (p = 0.002) and the degree of differentiation of DCIS. In addition, no significant association was found between the expression of AR and the expression of ER (p = 0.26) or PR (p = 0.57) in DCIS of the breast.

CONCLUSIONS

A large number of cases of DCIS of the breast express AR and this may be associated with apocrine differentiation, which may impact on accurate typing of DCIS. Moreover, the expression of AR (but not ER or PR) in DCIS does not appear to be associated with the degree of differentiation.

Loss of heterozygosity and allelic imbalance in apocrine adenosis of the breast

Recently, there have been studies suggesting that apocrine adenosis of the breast is a putative precancerous lesion, despite the generally held view that apocrine adenosis is benign. Because apocrine adenosis is almost always present as a small area or areas, it cannot be easily studied by conventional methods. In this study, areas of apocrine adenosis were microdissected from archival paraffin-embedded tissue to examine loss of heterozygosity and allelic imbalance compared with normal breast tissue epithelium from the same patients. Seventeen cases of apocrine adenosis, four associated with carcinoma, were analyzed using polymorphic microsatellite markers and polymerase chain reaction for loss of heterozygosity/allelic imbalance at eight loci that were reported to show allele loss or imbalance in invasive and in situ breast cancer. Loss of heterozygosity/allelic imbalance was detected in six of 17 cases of apocrine adenosis; three of 12 (25%) informative cases at 1p (MYCL1), two of seven (28.6%) at 11q (INT2), one of three (33.3%) at 13q (D13S267), two of 12 (16.7%) at 16q (D16S539), and two of 10 (20%) at 17q (D17S250). Neither loss of heterozygosity nor allelic imbalance has been identified at 1p (D1S252), 17p (TP53), or 17p (D17S513). In two of the four cases associated with carcinoma, loss of heterozygosity/allelic imbalance was seen in the same allele as in the synchronous carcinoma. These results suggest that molecular alterations, such as loss of heterozygosity and allelic imbalance, identified in apocrine adenosis may constitute an early event in the pathogenesis of breast cancer; reinforcing the possibility of apocrine adenosis being a putative precancerous lesion.

Immunohistochemical localization of gross cystic disease fluid protein-15, -24 and -44 in ductal carcinoma in situ of the breast: relationship to the degree of differentiation

AIMS

Three major proteins present in breast gross cystic disease fluid and expressed by the cyst lining apocrine epithelium are gross cystic disease fluid protein-15 (GCDFP-15), apolipoprotein-D (APO-D; GCDFP-24) and zinc alpha2-glycoprotein (ZnGP; GCDFP-44). The aim of this study was to investigate the expression of these proteins in ductal carcinoma in situ (DCIS) of the breast and to relate their expression with the degree of differentiation of DCIS.

METHODS AND RESULTS

An immunohistochemical study of these proteins was performed in 57 cases of DCIS and nine cases of morphologically apocrine DCIS. Positivity was seen in 24/57 (42.1%) cases with anti-GCDFP-15, 20/57 (35.1%) cases with anti-GCDFP-24 and 22/57 (38.6%) cases with anti-GCDFP-44. GCDFP-15 positivity was noted in 5/13 (38.5%) of the well-differentiated, 11/19 (57.9%) intermediately differentiated and 8/25 (32.0%) of the poorly differentiated cases (P=0.217). GCDFP-24 positivity was seen in 3/13 (23.0%) well-differentiated, 9/19 (47.4%) intermediately differentiated and 8/25 (32.0%) poorly differentiated cases (P=0.336). GCDFP-44 was detected in 5/13 (38.5%) of well-differentiated cases, 11/19 (57.9%) intermediately differentiated and 6/25 (24.0%) poorly differentiated cases (P=0.074). In the nine cases of apocrine DCIS, GCDFP-15 positivity was detected in seven (77.8%), while five (55.6%) and six (66.7%) cases were positive for GCDFP-24 and GCDFP-44, respectively.

CONCLUSIONS

The results indicate that there is no significant association between the expression of the studied proteins and the degree of differentiation of DCIS of the breast. Moreover, some morphologically apocrine DCIS cases appear to lose expression of these proteins.

Audit of a one-stop breast clinic--revisited

BACKGROUND

A one-stop diagnostic service has been available for women with symptomatic breast disease at St Bartholomew's Hospital for 5 years and was originally audited in May 1993. In re-auditing the one-stop service our aim was to see if our practice had improved following the original audit and to look at the impact which these changes in practice had made to the service offered to the patient.

METHODS

A prospective audit of 4 consecutive clinics was undertaken in November 1997. A total of 300 patients (59 new and 241 follow up) were seen in clinic in this time. The primary outcome measure concerned the completeness of triple assessment in the 40 patients who required one stop investigations, including mammography, ultrasonography and fine-needle aspiration cytology. In addition, mean time to initial consultation and level of awareness of the one-stop facility and its attendant time delay were measured.

RESULTS

Of the 300 clinic attendees 40 (38 new, 2 follow-up) had one-stop investigations. As a result of the one-stop service being in practice, 36 patients (90%) had a definitive management decision made at their first outpatient visit. Of these 2 were symptomatic cancers, forming 5% of the workload. A total of 86% of the workload was benign. Four patients (10%) had equivocal results. The mean waiting time from designated appointment until surgical consultation was 36.7 minutes and was disappointingly unchanged from that of the previous audit. However this does not take into account the significant reduction in staffing levels which has occurred between the two periods of assessment.

CONCLUSIONS

The initial audit identified a significant problem with time constraints, necessitating that a large number of patients with carcinomas return at a later date for further investigations. Booking only new patients at the beginning of clinic has provided a solution. Disappointingly, our figures do not show a significant improvement in mean waiting time compared with the previous audit, despite allowing GPs greater access of referral. Encouragingly, we have been able to maintain a similar standard of provision of care despite lower staffing levels and to implement the changes suggested by the original audit (thereby closing the audit loop).

Platelet-derived growth factor expression in phyllodes tumors and fibroadenomas of the breast

The development of normal breast tissue and the pathogenesis of various tumors are influenced by growth factor-mediated epithelial-stromal interactions. Similar interactions may occur in fibroepithelial breast tumors. We have studied the expression of platelet-derived growth factor (PDGF) and PDGF beta receptor (PDGFRbeta) in 46 phyllodes tumors (18 benign, 15 borderline, 13 malignant), 11 fibroadenomas, and 6 samples of normal breast. There was neoplastic stromal cell positivity for PDGFRbeta in almost 50% of phyllodes tumors and for PDGF in 24%. Both were associated with prominent nuclear pleomorphism (P<.01), PDGF with high grade (P<.01), and a higher mean Ki-67 labeling index (P = .013), and PDGFRbeta with conspicuous stromal overgrowth (P<.01). Co-positivity for stromal PDGF and PDGFRbeta was found in 15% of phyllodes tumors, and for epithelial PDGF and stromal PDGFRbeta in 43%. Both types of co-positivity were associated with prominent nuclear pleomorphism and the latter type with conspicuous stromal overgrowth (all P<.01). Follow-up of 41 phyllodes tumors showed that disease-related death was associated with established histologic features of malignancy including mitotic count, stromal overgrowth, an infiltrative tumor margin, and nuclear pleomorphism. In addition, stromal PDGFRbeta positivity (P =.013) and epithelial PDGF/stromal PDGFRbeta co-positivity (P =.0075) were associated with disease-related death. Stromal PDGF and PDGFRbeta expression in fibroadenomas was less common and less extensive (P<.05) than in phyllodes tumors. The results suggest that PDGF influences the pathogenesis of fibroepithelial breast tumors and that PDGF-dependent paracrine and autocrine mechanisms may operate. Also, it is possible that assessment of PDGF and PDGFRbeta expression could contribute to the management of these tumors in the future.

Causes of inconsistency in diagnosing and classifying intraductal proliferations of the breast. European Commission Working Group on Breast Screening Pathology

It is now widely recognised that classifying ductal carcinoma in situ (DCIS) of the breast and diagnosing atypical ductal hyperplasia are associated with significant interobserver variation. Two possible reasons for this inconsistency are differences in the interpretation of specified histological features and field selection where morphology is heterogeneous. In order to investigate the relative contribution of these two factors to inconsistent interpretation of intraductal proliferations, histological sections of 32 lesions were sent to 23 European pathologists followed 3 years later by images of small parts of these sections. Kappa statistics for diagnosing hyperplasia of usual type, atypical ductal hyperplasia and ductal carcinoma in situ were 0.54, 0.35 and 0.78 for sections and 0.47, 0.29 and 0.78 for images, respectively, showing that most of the inconsistency is due to differences in morphological interpretation. Improvements can thus be expected only if diagnostic criteria or methodology are changed. In contrast, kappa for classifying DCIS by growth pattern was very low at 0.23 for sections and better at 0.47 for images, reflecting the widely recognised variation in the growth pattern of DCIS. Higher kappa statistics were obtained when any mention of an individual growth pattern was included in that category, thus allowing multiple categories per case; but kappa was still higher for images than sections. Classifying DCIS by nuclear grade gave kappa values of 0.36 for sections and 0.49 for images, indicating that intralesional heterogeneity has hitherto been underestimated as a cause of inconsistency in classifying DCIS by this method. More rigorous assessment of the proportions of the different nuclear grades present could lead to an improvement in consistency.

c-erbB2 oncoprotein expression, gene amplification, and chromosome 17 aneusomy in apocrine adenosis of the breast

Amplification of the c-erbB2 oncogene and numerical aberrations of chromosome 17 occur in human breast carcinomas. Apocrine adenosis (AA) of the breast has been shown occasionally to have c-erbB2 overexpression and a possible premalignant potential, but little is known about cellular level genetic alterations in AA of the breast. Fluorescence in situ hybridization (FISH) is a new approach to detect these. In this study, a series of AA was studied by immunohistochemistry for c-erbB2 protein expression and by FISH using dual colour DNA probes for the c-erbB2 gene and the centromeric region of chromosome 17. Cell membrane immunostaining was seen in 10/18 (55.6%) AA cases, but unequivocal c-erbB2 gene amplification or chromosome 17 aneusomy was not seen. The results of this study suggest that c-erbB2 overexpression without amplification may occur early in breast oncogenesis. Amplification and numerical chromosome aberrations may occur later in the pathogenesis of apocrine-derived breast carcinomas.

Telepathology: a diagnostic tool for the millennium?

Many developments in science have their origins in science fiction and telepathology is no exception. The concept was first illustrated in 1924 in the magazine 'Radio News'. It was not until 1980, however, that the first working telepathology system was demonstrated. Although the system was shown to work, it required special hardware, dedicated software and special microwave transmission links to be installed. Little interest was shown worldwide because of the very high cost and the inability of many people to replicate such a system. Ten years later, the personal computer (PC) was able to provide more than adequate performance at low cost for both image display quality and speed, and the development of video technology had resulted in high quality images being produced by television cameras that were now easily affordable. Microscopes were also relatively cheaper. Thus, by 1993 or 1994, all the hardware necessary to produce a telepathology system was available at reasonable cost. Telepathology can now be used for remote primary diagnosis, remote referral to a specialist pathologist, remote teaching, remote presentation of post-mortem or microscopic findings, quality assurance image circulation and feedback, and consensus diagnosis for pathological review in clinical trials. There are two residual problems. The first concerns the speed of data transmission, commonly referred to as the bandwidth. The second is that the software provided by most of the manufacturers and suppliers of these systems is not entirely suitable to the task and the systems are not interoperable. It is clear that the approach of the manufacturers is at present unlikely to produce telepathology systems which pathologists feel comfortable in using. A somewhat different approach is illustrated by the accompanying article in this issue from the Berlin group, where a relatively simple Java-based applet and the Internet are used to allow single or multiple users to view slides on a robotic microscope. This could form the basis for a truly useful system, but still needs modification for some applications.

Correlation between ultrasound characteristics, mammographic findings and histological grade in patients with invasive ductal carcinoma of the breast

AIM

To investigate the relationship between ultrasound characteristics, mammographic findings and histological grade in cases of invasive ductal carcinoma which produce a mass on ultrasound.

MATERIAL AND METHODS

A retrospective review was performed of the imaging findings in 120 patients diagnosed with invasive ductal carcinoma of the breast between January 1996 and December 1997. Imaging findings were correlated with the histological grade of tumour.

RESULTS

High-grade tumours were significantly larger both on ultrasound and mammography (P < 0.016). A spiculated margin on mammogram was documented in 72% of low-grade tumours compared with only 24% of high-grade tumours (P = 0.001). Twenty-two per cent of low-grade tumours had a poorly defined margin on mammography compared with 66% of high-grade tumours (P = 0.001). At ultrasound, 16% of high-grade tumours (95% confidence limits 7-29%) had a well-defined margin. Acoustic enhancement was seen in 36% of high-grade tumours compared with only 9% of low and intermediate-grade tumours (P = 0.003): 22% of all tumours showed acoustic enhancement. Acoustic shadowing was seen in 71% of low-grade tumours compared with only 28% of high-grade tumours (P = 0.003). Malignant-type microcalcification was seen on mammogram in 6% of low-grade tumours compared with 31% of high-grade tumours (P = 0.045).

CONCLUSION

The classical appearance of a malignant breast mass as a spiculated mass on mammogram associated with acoustic shadowing on ultrasound is more typical of a low-grade tumour. In comparison, high-grade tumours are more likely to demonstrate posterior acoustic enhancement, and a proportion has a well-defined margin on ultrasound. Therefore, high-grade invasive ductal carcinoma may paradoxically display similar imaging features to a benign breast mass.

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.

Immunohistochemical localisation of androgen receptor in apocrine metaplasia and apocrine adenosis of the breast: relation to oestrogen and progesterone receptors

AIM

To investigate the receptor status of the sex steroid hormones in apocrine metaplasia of the breast.

METHODS

82 cases of apocrine metaplasia, including 18 of the rare lesion apocrine adenosis, were studied immunohistochemically for the expression of androgen receptor, oestrogen receptor, and progesterone receptor proteins on formalin fixed, paraffin embedded tissue sections. The standard avidin biotin complex (ABC) technique was followed and appropriate positive and negative controls were used.

RESULTS

All the studied cases (82/82) were positive for androgen receptor, but were negative for oestrogen receptor and progesterone receptor.

CONCLUSIONS

Apocrine metaplastic epithelium, unlike the normal breast epithelium, is responsive to androgens, through androgen receptors, rather than to the female sex hormones. This may have clinical implications.

Fine needle aspiration cytology in the UK breast screening programme: a national audit of results

The National Breast Screening Service in the UK depends upon triple assessment, with or without core biopsy, to determine the need for diagnostic biopsy or treatment for screen-detected lesions. To determine the efficacy of cytology in this process a nationwide survey of sensitivity and specificity of the technique was instituted by the National Coordinating Committees for both Radiology and Pathology. Although some units were performing to the national recommended standards, a significant number of units were shown to have problems with a high false negative rate and high inadequate rates from lesions which were eventually diagnosed as cancer. This suggests problems in localizing lesions adequately at aspiration. Generally, indicators of pathology diagnostic performance (e.g. positive predictive values) were good. The figures suggest that some units are not benefiting from an optimal cytological service. Consequently training programmes targeted at aspiration technique may be beneficial.

p53 expression in phyllodes tumours is associated with histological features of malignancy but does not predict outcome

AIMS

To study p53 protein expression in phyllodes tumours of the breast, with particular attention to its prevalence and to its relationship with histological features and clinical outcome.

METHODS AND RESULTS

Stromal and epithelial p53 immunohistochemical expression was studied in 57 phyllodes tumours (27 benign, 17 borderline, 13 malignant) using an avidin-biotin peroxidase method. High levels of expression (> 30% of stromal nuclei) were found in eight phyllodes tumours (14%). p53 expression was associated with tumour grade (P = 0.001), prominent stromal overgrowth (P = 0.0003), prominent stromal nuclear pleomorphism (P = 0.006), high stromal mitotic count (P = 0.05), and an infiltrative tumour margin (P = 0. 05). Six patients were lost to follow-up after surgery. Mean follow-up time of the remaining 51 patients was 7.3 years (median 4. 3, range 0.5-25) or until death. Sixteen patients (31%) experienced tumour recurrence. Recurrence was more likely if there was an infiltrative tumour margin (P = 0.006) or prominent stromal overgrowth (P = 0.04) but not p53 expression (P = 0.55). A minority of recurrences expressed p53 more extensively than their primary counterparts. There were five tumour-related deaths (10% of patients). Death was associated with high grade (P = 0.0002), prominent stromal overgrowth (P = 0.0001), an infiltrative margin (P = 0.0002), prominent nuclear pleomorphism (P = 0.005), a high mitotic count (P = 0.01) and tumour size (P = 0.03). Again, p53 expression was not associated with tumour-related survival (P = 0. 13).

CONCLUSIONS

p53 abnormalities occur in a minority of borderline and malignant phyllodes tumours. p53 expression is associated with known negative prognostic factors, but does not appear to be a useful determinant of tumour recurrence or long-term survival.

The significance of new densities and microcalcification in the second round of breast screening

AIM

To assess the nature of new densities and microcalcifications in the second round of breast screening.

MATERIALS AND METHODS

A total of 34 634 women were screened at our unit in the second round of the United Kingdom National Health Service Breast Screening Programme. Of those attending for the second time, 302 were recalled for further work-up of 311 new lesions. The lesions were divided into masses, microcalcifications, asymmetric densities and architectural distortions. Masses were classified according to margin and density, and microcalcifications according to morphology and distribution.

RESULTS

Among women attending for the second time, the cancer detection rate was 0.45% (89 cancers). One hundred and eighty-eight new masses were identified: 53 well-defined (two malignant), 67 partially defined (six malignant), 54 ill-defined (18 malignant), and 14 spiculate (14 malignant). Well-defined masses were usually cysts, especially in women on hormone replacement therapy. Of 97 new microcalcifications, 71 were pleomorphic (28 malignant), 12 linear (one malignant), and 14 punctate (none malignant). Twenty-five new asymmetric densities were identified (five malignant). One of two architectural distortions was malignant. Malignancy was found in 21% of new masses, 30% of new microcalcification and 20% of asymmetric densities.

CONCLUSION

Carcinoma was found in 24% of all new mammographic abnormalities appearing in a 3-year screening period. Spiculate and ill-defined masses, clustered pleomorphic microcalcification, and new asymmetric densities should be regarded with particular suspicion. The use of fine needle aspiration cytology in combination with imaging assessment may help to reduce the number of benign excisional biopsies for new mammographic lesions.

A cluster of oppositely imprinted transcripts at the Gnas locus in the distal imprinting region of mouse chromosome 2

Imprinted genes tend to occur in clusters. We have identified a cluster in distal mouse chromosome (Chr) 2, known from early genetic studies to contain both maternally and paternally imprinted, but unspecified, genes. Subsequently, one was identified as Gnas, which encodes a G protein alpha subunit, and there is clinical and biochemical evidence that the human homologue GNAS1, mutated in patients with Albright hereditary osteodystrophy, is also imprinted. We have used representational difference analysis, based on parent-of-origin methylation differences, to isolate candidate imprinted genes in distal Chr 2 and found two oppositely imprinted genes, Gnasxl and Nesp. Gnasxl determines a variant G protein alpha subunit associated with the trans-Golgi network and Nesp encodes a secreted protein of neuroendocrine tissues. Gnasxl is maternally methylated in genomic DNA and encodes a paternal-specific transcript, whereas Nesp is paternally methylated with maternal-specific expression. Their reciprocal imprinting may offer insight into the distal Chr 2 imprinting phenotypes. Remarkably, Gnasxl, Nesp, and Gnas are all part of the same transcription unit; transcripts for Gnasxl and Nesp are alternatively spliced onto exon 2 of Gnas. This demonstrates an imprinting mechanism in which two oppositely imprinted genes share the same downstream exons.

An audit of patient acceptance of one-stop diagnosis for symptomatic breast disease

AIMS

The impetus for optimizing outpatient provision of breast-care services has come both from the patient and management in order to reduce anxiety and make full use of scarce resources. The one-stop diagnostic clinic for the investigation of symptomatic breast lesions is a relatively recent concept with well-known service benefits. However, acceptance to the patient has not been previously investigated.

RESULTS

The results of this prospective audit demonstrate a high level of patient satisfaction with the multi-disciplinary, one-stop breast clinic.

Imprinting of distal mouse chromosome 2 is associated with phenotypic anomalies in utero

Previous studies have shown that the distal region on mouse chromosome (Chr) 2 is subject to imprinting as mice with maternal duplication/paternal deficiency (MatDp.dist2) and the reciprocal (PatDp.dist2) for this region exhibit phenotypic anomalies at birth and die neonatally. We show here that imprinting effects are detectable in utero. Notably PatDp.dist2 embryos show an increase in wet weight compared with normal, which peaks at 16.5 d post coitum (dpc), and diminishes by birth, whereas the wet weight of placenta is slightly reduced in the latter half of gestation. Newborns have increased length of the long bones. By contrast, the wet weight of MatDp.dist2 embryos decreases during the second half of gestation. Measurements of dry weights of embryos at 16.5 dpc have indicated that there is no difference in either PatDp.dist2 or MatDp.dist2 compared with normal so that the wet weight differences are due to fluid retention in PatDp.dist2 but fluid loss in MatDp.dist2. In PatDp.dist2 embryos excess fluid is particularly prominent in the subcuticular skin layer, whereas by birth fluid is evident around the neck and tongue. At 16.5 dpc the PatDp.dist2 embryos are severely oedematous, as the average fluid content per unit dry weight per embryo was increased by 40%, whereas the MatDp.dist2 embryos are dehydrated as the average water content per unit dry weight per embryo was reduced by 6%. A preliminary conclusion is that there is neither growth enhancement in PatDp.dist2 nor growth retardation in MatDp.dist2 offspring.

99mTc-labelled SM3 in the preoperative evaluation of axillary lymph nodes and primary breast cancer with change detection statistical processing as an aid to tumour detection

The extent of primary surgery for breast cancer could be tailored to the patient if previous information on the presence or absence of lymph node involvement could be reliably determined. Prospective radioimmunoscintigraphy in 29 patients with primary breast cancer that was found on screening has been undertaken with 555 MBq (15 mCi) 99mTc SM3, an Imperial Cancer Research Fund (ICRF) murine monoclonal antibody, 0.5 mg with images at 10 min and 22 h, and analysis using a change detection algorithm. Sites of significant change between the early and later images were displayed as a map of probabilities. Image-positive and -negative axillary lymph nodes were compared by histology in the 28 evaluable patients. The correct identification of the presence or absence of node involvement, even if impalpable, has been shown in 24 out of 28 patients (29 lymph node groups). Sensitivity was 90% (nine out of ten), specificity 84% (16 out of 19) and accuracy 86%. These results encourage further assessment of this technique.

Altered cell-matrix contact: a prerequisite for breast cancer metastasis?

The integrins are receptors that regulate interaction between epithelial cells and the extracellular matrix. Previous studies have shown that a reduction in the expression of the alpha2beta1, alpha3beta1, alpha6beta1, alpha(v)beta1 and alpha(v)beta5 integrins in primary breast cancer is associated with positive nodal status. In order to assess the functional significance of altered integrin expression, primary breast cancer cells were derived from individual patients with known tumour characteristics using immunomagnetic separation. Purified human fibronectin, vitronectin, laminin and type IV collagen were used to represent the principal extracellular matrix proteins in an in vitro adhesion assay. Primary breast cancer cells from lymph node-positive patients were significantly less adhesive to each of the matrix proteins studied (P<0.001, Mann-Whitney U-test). Matrix adhesion of primary breast cancer cells from node-negative patients was inhibited by appropriate integrin monoclonal antibodies (P<0.001, paired Wilcoxon test). Adhesion to fibronectin, vitronectin and laminin, but not type IV collagen, was influenced by the inhibitor arginine-glycine-aspartate, suggesting that breast cancer cell recognition of collagen IV is mediated through alternative epitopes. Weak matrix adhesion correlated with loss of integrin expression in tissue sections from corresponding patients assessed using immunohistochemistry. This study demonstrates a link between altered integrin expression and function in primary breast cancers predisposed to metastasize.

Managed care strategies for rural providers

The increasing prevalence of managed care outside of urban centers is forcing many healthcare providers in rural areas to carefully evaluate the demand for their services and their ability to exert leverage in pricing services. Rural providers often face different challenges and employ different strategies than their urban counterparts, but quality, cost, and access remain critical components common to both urban and rural providers.

Integrin expression in breast cancer cytology: a novel predictor of axillary metastasis

The integrins are heterodimeric transmembrane receptors of varying alpha and beta subunits that modulate cell adhesion to each other and to the extracellular matrix. Loss of integrin expression on primary breast cancer frozen sections measured by immunohistochemistry may be related to the presence of axillary metastasis. The clinical application of this finding would be increased if integrin expression could also be shown to be reliably measured on breast cancer cells obtained by fine needle aspiration cytology. Axillary operations may be planned as a single stage procedure from outpatients, and neoadjuvant therapy protocols may be developed without surgery to the axilla. Expression of the alpha 1, alpha 2, alpha 3, alpha 6, alpha v, beta 1, beta 3 and beta 5 integrin subunits were measured by immunohistochemistry and immunocytochemistry in 58 patients. Integrin measurement by both these methods were found to be closely associated using the kappa-test. Loss of expression of the alpha 1, alpha 2, alpha 3, alpha 6, alpha v, beta 1 and beta 5 integrin subunits measured by cytology and histology were each related to positive nodal status (chi(2) test). Measuring integrin expression on cytology is of clinical value and may prove to have prognostic significance.

In vitro regulation of human breast cancer cell adhesion and invasion via integrin receptors to the extracellular matrix

The extracellular matrix consists of the interstitium and the basement membrane. Cellular interaction with fibronectin, laminin and collagen provides a possible mechanism by which cancer cells adhere, invade and metastasize. The integrins are a major family of adhesion molecules that recognize epitopes on the extracellular matrix as ligands. These include the alpha 2 beta 1, alpha 3 beta 1, alpha v beta 1 and alpha v beta 5 integrins, most of which were found to be expressed on MCF-7, T47D, MDA-MB-231, ZR75-1 and Hs578T breast cancer cell lines. Each cell line adhered to the matrix proteins in a dose-dependent manner and was inhibited by monoclonal antibodies against relevant integrins. Only Hs578T was significantly invasive through fibronectin but both Hs578T and MDA-MB-231 invaded through laminin and type IV collagen in an in vitro assay. The invasive potential of these cell lines could be inhibited by integrin antibodies added to cells before incubation, but the addition of antibodies after cells were allowed to adhere to the matrix failed to inhibit invasion. Inhibition of cellular adhesion to the matrix reduced the invasive potential of breast cancer cell lines. As integrin antibodies inhibit cell invasion in vitro, the integrins may be of potential value as antitumour therapeutic agents.

Modulation of very late activation-2 laminin receptor function in breast cancer metastasis

BACKGROUND

Very late activation-2 (VLA-2) is an integrin receptor for laminin that consists of an alpha 2- and a beta 1-subunit. In human breast cancer, down-regulation of VLA-2 expression is related to positive nodal status. The functional significance of altered integrin expression in individual patients has never been investigated. To test the hypothesis that less adhesive primary breast cancer cells were predisposed to metastasize, variation in VLA-2 modulation of cell attachment to laminin with nodal status was studied.

METHODS

Integrin expression was measured by means of immunohistochemistry on cryostat sections. Primary breast cancer cells were isolated by enzymatic disaggregation and immunomagnetic separation. Cell adhesion to laminin was evaluated in an in vitro assay, and the effect of monoclonal antibodies against the component subunits of VLA-2 was assessed.

RESULTS

Adhesion of primary breast cancer cells from women with positive nodes to laminin was significantly reduced compared with women with negative nodes (p < 0.001, Wilcoxon signed rank test). VLA-2 antibodies inhibited primary breast cancer cell attachment of women with negative nodes but not women with positive nodes. Strong adhesion to laminin was related to node-negative status (chi-squared, 16.33; p < 0.001) and to positive integrin expression (chi-squared, 31.54; p < 0.001).

CONCLUSIONS

VLA-2-mediated adhesion of primary breast cancer cells to laminin differs with nodal status. Measurement of VLA-2 expression may thus be of clinical value as a prognostic indicator in the assessment of breast cancer.

Apocrine adenosis: a precursor of aggressive breast cancer?

AIM

To investigate overexpression of c-erbB2, expression of the p53 protein product and proliferation rates in benign breast lesions with specific reference to apocrine adenosis.

METHODS

Twenty one cases of apocrine adenosis were stained with monoclonal antibodies to p185, the protein product of the c-erbB2 oncogene, the protein product of the p53 tumour suppressor gene and to the cell cycle related protein Ki67. Three cases were associated with concomitant ductal carcinoma in situ of large cell type and two were associated with invasive tubular or cribriform carcinoma.

RESULTS

Twelve (57.1%) cases showed membrane staining for c-erbB2 oncoprotein of apocrine cells within sclerosing adenosis and six (28.6%) had occasional p53 protein positive cells. One case not associated with carcinoma showed extensive staining of apocrine metaplasia outside the area of apocrine adenosis. The proliferation rate, as measured by Ki67 staining, was increased in some of the lesions and all lesions showed at least some of the cells to be in the cell cycle.

CONCLUSIONS

The expression of abnormal oncogene products and increased proliferation in some of these apocrine lesions questions the supposed degenerative nature of the atypia seen in such cases and suggests that there may be an association between these lesions and large cell ductal carcinoma in situ and hence invasive carcinoma.

Clinical audit of a specialist symptomatic breast clinic

The efficient delivery of health care requires vigilant quality assurance. We describe the audit of our symptomatic breast clinic, which includes the option of a one-stop diagnostic service. A total of 134 new and 386 follow-up patients attended over four consecutive clinics. The majority of new referrals (68%) were seen by a consultant surgeon. Urgent referrals were seen significantly sooner than routine referrals (P < 0.001, chi 2-test), and the mean wait from designated appointment to seeing the surgeon was 37.6 (range-68 to 171) min. One-stop investigations were offered to 50 patients; of these, 36 women (72%) had a total wait of less than 2 h. For those not investigated at the same clinic, the mean time until investigations was 6.1 (range 0-36) days and mean recall was 2.7 (range 1-8) weeks. Patients undergoing definitive surgery for cancer (n = 5) were operated on average 14.2 (range 7-27) days after the decision was made in outpatients, while the mean waiting time for non-cancer operations was 49.7 (range 15-98) days. Objective audit on outpatient services is possible and can lead to improvement of services.

Benign biopsies in the prevalent round of breast screening: a review of 137 cases

In the first round of the National Health Service Breast Screening Programme, 35,533 women attended for screening at the two breast screening units served by St Bartholomew's Hospital. Further assessment was necessary in 2212 women (6.2%), of whom 412 (1%) subsequently underwent surgical biopsy. Of these 137 had benign lesions. The predominant mammographic abnormality leading to biopsy was microcalcification in 55, a mass in 48, parenchymal asymmetry in 18 and architectural distortion in 16. Histology revealed fibrocystic change in 66, fibroadenoma in 27, radial scar/complex sclerosing lesion in 23, atypical ductal hyperplasia only in eight, and a variety of unusual benign lesions in 13. In an attempt to determine criteria which would minimize unnecessary biopsy of benign lesions in future, the mammographic and cytological features of these benign lesions were reviewed and compared with the final histology. The most common diagnostic problems were clustered and variable microcalcification, the radial scar/complex sclerosing lesion, and mammographic features shown to be atypical hyperplasia on histology.