Interplay of management and environmental drivers shifts size structure of reef fish communities

Countries are expanding marine protected area (MPA) networks to mitigate fisheries declines and support marine biodiversity. However, MPA impact evaluations typically assess total fish biomass. Here, we examine how fish biomass disaggregated by adult and juvenile life stages responds to environmental drivers, including sea surface temperature (SST) anomalies and human footprint, and multiple management types at 139 reef sites in the Mesoamerican Reef (MAR) region. We found that total fish biomass generally appears stable across the region from 2006 to 2018, with limited rebuilding of fish stocks in MPAs. However, the metric of total fish biomass masked changes in fish community structure, with lower adult than juvenile fish biomass at northern sites, and adult:juvenile ratios closer to 1:1 at southern sites. These shifts were associated with different responses of juvenile and adult fish to environmental drivers and management. Juvenile fish biomass increased at sites with high larval connectivity and coral cover, whereas adult fish biomass decreased at sites with greater human footprint and SST anomalies. Adult fish biomass decreased primarily in Honduran general use zones, which suggests insufficient protection for adult fish in the southern MAR. There was a north-south gradient in management and environmental drivers, with lower coverage of fully protected areas and higher SST anomalies and coastal development in the south that together may undermine the maintenance of adult fish biomass in the southern MAR. Accounting for the interplay between environmental drivers and management in the design of MPAs is critical for increasing fish biomass across life history stages.

Impact on Radiation Therapy Recommendation and Treatment Modality for Patients with Ductal Carcinoma In Situ Using the 7Gene Biosignature: Analysis of the PREDICT Study

PURPOSE/OBJECTIVE(S)

Breast conserving surgery (BCS) followed by adjuvant radiotherapy (RT) has been a mainstay in the treatment of DCIS based on multiple randomized trials demonstrating a local recurrence benefit with RT. However, these studies have failed to identify subsets of patients who did or did not benefit from adjuvant RT after BCS, raising concerns regarding both over and undertreatment. Thus, better prognostic and predictive tools are needed to appropriately risk stratify patients and understand their benefit of RT. The 7-gene predictive DCIS biosignature provides a validated score (DS) for women undergoing BCS that assesses their 10-year risk of in-breast and invasive recurrence with and without adjuvant RT. This trail was designed to evaluate the decision impact of the 7-gene predictive biosignature score on DCIS treatment recommendations.

MATERIALS/METHODS

The PREDICT study is a prospective, multi-institutional trial for patients who received DCISionRT testing as part of their routine care. The registry includes females 26 and older who are diagnosed with DCIS, are candidates for BCS, and eligible for RT. Treating physicians completed treatment recommendation forms before and after receiving test reports to capture surgical, radiation and hormonal treatment (HT) recommendations and patient preferences. Analysis was performed in 2,012 patients treated at 63 clinical sites.

RESULTS

Median age was 62 years old with 32% grade 3 and 10% size 2.5 cm or greater. Post-test, RT recommendation changed for 38% of patients (p<0.001), with a net reduction of 20% in patients recommended to receive RT(p<0.001). The DCISionRT test results had the greatest impact (OR 26.2, 95% CI 19.1-36.4, when analyzed categorically using DS>3 cut-off; 2.3 per DS, 95% CI 2.1-2.6, when evaluated continuously) on post-test RT recommendation in multivariable analysis when compared to all other factors including patient preference, patient clinical and tumor pathological factors, patient race/ethnicity, treatment facility, physician specialty. The post-test RT recommendation rate increased with increasing DS (0-2, 2-4, 4-10) on a categorical basis, with odds ratios of 6.8 DS (2-4 vs 0-2), and 35.0 for DS (4-10 vs 0-2). After DCISionRT test result, patient preference was the second most important factor in post-testing RT recommendation. There was also a significant change in the modality of RT recommended to 34% of those patients recommended RT pre-test and post-test by radiation oncologists (n = 937), with intensified RT modality for higher DS (p<0.001) and de-escalation for lower DS (p<0.001).

CONCLUSION

This analysis of over 2,000 patients demonstrates significant changes in recommendations to add or omit RT based on the 7-gene predictive. The integration of DCISionRT into clinical decision processes has substantial impact on recommendations aimed at optimal management to prevent over- or under-treatment.

Invasive lionfish had no measurable effect on prey fish community structure across the Belizean Barrier Reef

Invasive lionfish are assumed to significantly affect Caribbean reef fish communities. However, evidence of lionfish effects on native reef fishes is based on uncontrolled observational studies or small-scale, unrepresentative experiments, with findings ranging from no effect to large effects on prey density and richness. Moreover, whether lionfish affect populations and communities of native reef fishes at larger, management-relevant scales is unknown. The purpose of this study was to assess the effects of lionfish on coral reef prey fish communities in a natural complex reef system. We quantified lionfish and the density, richness, and composition of native prey fishes (0-10 cm total length) at sixteen reefs along ∼250 km of the Belize Barrier Reef from 2009 to 2013. Lionfish invaded our study sites during this four-year longitudinal study, thus our sampling included fish community structure before and after our sites were invaded, i.e., we employed a modified BACI design. We found no evidence that lionfish measurably affected the density, richness, or composition of prey fishes. It is possible that higher lionfish densities are necessary to detect an effect of lionfish on prey populations at this relatively large spatial scale. Alternatively, negative effects of lionfish on prey could be small, essentially undetectable, and ecologically insignificant at our study sites. Other factors that influence the dynamics of reef fish populations including reef complexity, resource availability, recruitment, predation, and fishing could swamp any effects of lionfish on prey populations.

Abstract P6-09-45: Long-term follow-up of early stage breast cancer patients with results of MammaPrint®, Oncotype DX® and MammoStrat® risk classification assays

Introduction: The use of genomic tests for the prediction of breast cancer recurrence is becoming more common. MammaPrint® (MP, Agendia Inc.) is a 70-gene microarray assay designed to assess the 10-year risk of recurrence in an untreated population that was not selected for ER/HER2 results. The Oncotype DX® Recurrence Score® (RS, Genomic Health, Inc.) is a 21-gene RT-PCR assay that is clinically validated to predict the 10-year risk of distant recurrence in ER+ patients treated with Tamoxifen. MammoStrat® (MS, Clarient, Inc.) is an IHC assay that uses 5 antibodies and has been validated in a similar population as RS. Several recent reports show that these assays classify patients differently with significant discordances for all risk groups (Shivers, et al., SABCS 2013; Denduluri, et al., ASCO Breast 2011; Poulet, et al., SABCS 2012; Schneider, et al., ASCO 2013). The present study is an analysis of long-term follow-up in a cohort of patients who have results for all three of these risk-stratifying assays side by side in the same samples.

Methods: Patients with ER+ N0-N1 early-stage breast cancer with an MP result obtained as part of their routine clinical care were identified at the University of South Florida (USF, N=65) and Morton Plant Hospital (N=83). After local IRB approval, slides and/or blocks were cut and de-identified at USF and sent to Genomic Health and Clarient for blinded testing. Clinicopathological features were also reviewed by 3 breast pathologists.

Results: 148 patients with an MP result had tissue available to send for RS and MS assays. These patients had a median age of 62 years; median tumor size 1.8 cm; 9% low grade, 59% intermediate grade and 32% high grade. In our previous analysis of this study, of 148 patients with MP results, 53% were low risk and 47% were high risk. Of 135 samples that yielded enough RNA to produce an RS result, 53% were low risk, 26% were intermediate risk and 21% were high risk. Of 129 samples that yielded an MS result, 44% were low risk, 28% were moderate risk and 28% were high risk. Of 121 patients with results for all 3 assays, only 22% were concordant for low risk and 9% were concordant for high risk across all 3 assays. Overall, 30% of cases showed a major discordance such as low risk for one assay and high risk for another. After median follow-up of 54 months, 9 patients have had a distant metastasis and/or 8 patients have died (11 patients total). One patient who had bone metastasis and died had been classified as low risk by all 3 assays. Three patients with distant metastases had a major discordance between assays, with two high risk and one low risk result. Seven patients were classified as high or intermediate/moderate risk by all 3 assays.

Conclusions: This direct comparison demonstrates that although the assays classify a large proportion of patients differently, the patients who ended up with a distant metastasis and/or died of breast cancer had been classified as high risk by at least two of the three assays. This study has important clinical implications since these assays are used to help make treatment decisions regarding which patients might benefit from chemotherapy.

Citation Format: Shivers SC, Russell S, Blumencrancz L, Mehindru A, Acs G, Ellis D, Vrcelj V, Zanchi A, Blumencrancz PW, Carter E, King J, Cox CE. Long-term follow-up of early stage breast cancer patients with results of MammaPrint®, Oncotype DX® and MammoStrat® risk classification assays [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-45.

Abstract P5-16-05: MINT trial yields MammaPrint High1/High2 risk classes associated with significant differences in pCR and receptor subtype

Background: Previous clinical trials have validated that the 70-gene signature MammaPrintTM provides prognostic and predictive information for early stage breast cancer patients and can identify low risk patients who may safely avoid adjuvant chemotherapy. Additionally, the neo-adjuvant I-SPY 1&2 TRIALs demonstrated that further stratification of patients into MammaPrint High 1 (MP1) and MammaPrint High 2 (MP2) risk groups may help predict chemo-sensitivity. There were significant differences in pathological complete response (pCR) rates for early stage, locally advanced breast cancer patients who were not HR+HER2- MammaPrint Low Risk. Specifically, the PARP inhibitor veliparib in combination with carboplatin recently graduated the I-SPY 2 phase 2 screening trial, having met the 85% predictive probability criterion with a triple-negative breast cancer signature, which was the subset recommended for this regimen's subsequent development. Given these data, we wanted to determine whether the Multi Institutional Neo Adjuvant Therapy MammaPrint Project (MINT) patient population confirmed the MP1/MP2 risk stratification, clarify if there is an associated receptor subtype for MP1/MP2 risk classes, and conclude if the stratification correlates to a significant difference in pCR. Methods: Array data from pre-treatment samples were obtained from 180 patients classified as MammaPrint High Risk, subtyped by IHC and treated with neo-adjuvant chemotherapy according to protocol. Response was measured by centrally assessed residual cancer burden pursuant to guidelines. Patients were then further stratified based on the MammaPrint Index per their classification threshold between MP1/MP2. Fisher's exact test was used to assess significance of association with pCR overall and within hormone receptor (HR) and HER2 subtypes. Results: MP1 vs MP2 risk classes yielded subsets with significant (p=0.007) differences in pCR. 44% (40/92) of MP2 patients achieved a pCR, compared to 24% (21/88) of MP1 patients. Next, we investigated whether the MP1 and MP2 risk classes were associated with receptor subtype. MP1 demonstrated a significant association and MP2 near significance. 32% (21/66) of triple-negative patients were classified as MP2 vs only 3% (2/66) MP1. Similarly, in the overall population, 28% (51/180) HR+HER2- are classified as MP1 vs 4% (8/180) MP2. Results in the pCR population were reflective of these subtype trends. 63% (58/92) of MP2 patients were classified triple-negative, of which nearly one quarter (21/92) had a measured pCR, whereas 58% (51/88) of MP1 patients were HR+HER2- with 3% (3/88) achieving pCR (Table1). Conclusion: This analysis in the MINT patient population supports previously published data and suggests that the MammaPrint High 1/2 risk classification may help predict chemo-sensitivity. Given the statistical significance of these data, we are currently investigating the biological mechanisms distinguishing the MP1/MP2 subgroups that may account for its use as a specific biomarker of response to chemotherapy treatment in future trials.

Table 1.MP1MP2HER2+HER2-HER2+HER2-HR+HR-HR+HR-HR+HR-HR+HR-793241322185486456371514518818858Row#1= pCR, #2= RD, #3= Total

Citation Format: Blumencranz LE, Shivers SC, Untch S, Treece TD, Yoder E, Blumencranz PW, Cox CE. MINT trial yields MammaPrint High1/High2 risk classes associated with significant differences in pCR and receptor subtype [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-16-05.

Abstract P1-11-06: Learning curve for the SAVI SCOUT breast localization and surgical guidance system

Background: The gold standard for localizing non-palpable breast lesions for surgical excision is wire localization (WL). Multiple disadvantages for WL include complicated scheduling and migration of the wire after placement. Radioactive seed localization (RSL) mitigates these disadvantages, but regulatory requirements regarding radiation limit more universal adoption. The SAVI SCOUT surgical guidance system (an FDA cleared medical device) eliminates the drawbacks of WL without the regulatory requirements of RSL. SCOUT utilizes electromagnetic wave technology and infrared light to provide intra-operative guidance during surgical excision. The purpose of this study is to describe the learning curve associated with adoption of this new technology.

Method: An IRB-approved prospective, single-arm, multi-site trial enrolled women with non-palpable breast lesions requiring localized surgical excision. After informed consent, a radiologist or surgeon used imaging guidance to implant the SCOUT reflector into the target lesion. Intraoperatively, the surgeon used SCOUT for localization of the reflector and removal of the target lesion. We evaluated the association of several independent variables with respect to successful localization and surgical excision including: tumor side, tumor quadrant, distance of reflector from the skin, and the number of SCOUT localized breast excisions performed by operating surgeon up to the 1st five cases. We studied the relationship between these independent variables and the following dependent variables: reflector detection post-placement, reflector detection pre-incision, and reflector localization post-incision.Statistical analysis utilized the z-test to perform a two-sided test of equality at an alpha level of 0.05 with adjustment for multiple comparisons by the Bonferroni method. T-tests were used to perform two-sided tests of equality for numeric variables.

Results: Across 11 institutions, 16 surgeons performed a total of 153 surgical excisions. Overall success rates of reflector detection pre-incision and post-incision were 98% (150/153) and 99% (151/153), respectively. The reflectors were successfully removed in 100% (153/153) of cases. Difficulty with reflector detection immediately post placement was significantly associated with reflectors more than 4 cm (P=0.034) or 5 cm (P=0.007) from the skin, or the procedure being the 1st SCOUT case by the operating surgeon (P=0.036). Operating surgeons performing their 1st SAVI localization procedure were significantly associated with difficult reflector detection post-incision (p=0.044). Subsequent procedures, up to the first five SCOUT localizations, noted no significant difficulty with reflector detection.

Conclusions: The SAVI SCOUT surgical guidance system is a viable surgical localization procedure for non-palpable breast lesions. Surgeons were 100% successful at removing the reflectors during surgical excision. Difficulty with reflector detection was not noted after the surgeon's 1st SCOUT procedure. Overall, it appears the learning curve for reflector placement and localization for non-palpable breast lesions is relatively short. However, depth of the reflector in relation to skin likely affects reflector detection during this early learning period.

Citation Format: Shukla SC, Shivers SC, Mattingly A, Russell S, Mehindru A, Carter E, Cox CE. Learning curve for the SAVI SCOUT breast localization and surgical guidance system [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-11-06.

Abstract P3-13-08: A prospective, single-arm, multi-site, clinical evaluation of the SAVI SCOUT® surgical guidance system for the location of non-palpable breast lesions during excision

Background and Objectives: The standard preoperative technique for localizing non-palpable breast lesions is wire localization (WL). Radioactive seed localization (RSL) is an alternative approach that addresses a number of clear disadvantages associated with WL but, the adoption of RSL has been impacted by considerable regulatory requirements for the handling of radioactive materials. To advance the progress made with RSL and eliminate issues associated with radioactive components, the SAVI SCOUT® surgical guidance system was developed. SAVI SCOUT is an FDA-cleared medical device that utilizes non-radioactive electromagnetic wave technology to provide real-time guidance during excisional breast procedures. The purpose of this study is to evaluate the performance of SAVI SCOUT in guiding the removal of non-palpable breast lesions.

Methods: Following a 50 patient pilot study that showed SAVI SCOUT to be safe and effective, IRB approval was granted for this prospective, single-arm, multi-site study for women with a non-palpable breast lesion. Pts underwent localization and excision with the SAVI SCOUT system, which consists of an electromagnetic wave reflective device (reflector), handpiece and console. Using mammographic or ultrasound guidance, the reflector was implanted into the target tissue. Before making an incision, the surgeon used the handpiece, which emits electromagnetic waves and infrared light, to detect the location of the reflector and subsequently plan the surgical incision. During the procedure, the surgeon used the handpiece to guide the localization and removal of the reflector along with the surrounding breast tissue. The console provides audible feedback of reflector proximity to the handpiece. Successful reflector placement, localization and retrieval were the primary endpoints.

Results: A total of 61 pts have participated in the study to date, along with 7 surgeons and 9 radiologists across 6 institutions. The reflectors were successfully placed in all pts, including 27 under mammographic guidance and 34 under ultrasound guidance. In 28 cases, the reflectors were placed on the same day as surgery. Otherwise, the reflectors were placed up to 7 days (average 2.9 days) before surgery. Thirteen pts underwent excisional biopsy and 48 pts had a lumpectomy. The intended lesion and reflector were successfully removed in all pts. Reflector migration did not occur and no adverse events occurred. Final pathology is currently available for 52 pts: 8/10 excisional biopsy pts had no invasive or in situ carcinoma identified. For pts with cancer and complete data, 39/39 had clear margins, but one patient was recommended for re-excision due to a close margin (1 mm) for DCIS.

Conclusions: The preliminary data from this prospective, multi-site study show that real-time surgical guidance with SAVI SCOUT is an accurate technique for directing the removal of non-palpable breast lesions and is reproducible at multiple clinical sites. At present, the study has yielded 100% surgical success with a re-excision rate of 3.0%. Ongoing accrual to this clinical evaluation study will validate these findings with planned enrollment of 150 pts at up to 15 total sites.

Citation Format: Cox CE, Prati R, Blumencranz P, Allen K, Banull C, Cline M, Howard T, Portillo M, Whitworth P, Funk K, Police A, Lin E, Combs F, Anglin B, King J, Shivers SC. A prospective, single-arm, multi-site, clinical evaluation of the SAVI SCOUT® surgical guidance system for the location of non-palpable breast lesions during excision. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-08.

Re-examining the relationship between invasive lionfish and native grouper in the Caribbean

Biotic resistance is the idea that native species negatively affect the invasion success of introduced species, but whether this can occur at large spatial scales is poorly understood. Here we re-evaluated the hypothesis that native large-bodied grouper and other predators are controlling the abundance of exotic lionfish (Pterois volitans/miles) on Caribbean coral reefs. We assessed the relationship between the biomass of lionfish and native predators at 71 reefs in three biogeographic regions while taking into consideration several cofactors that may affect fish abundance, including among others, proxies for fishing pressure and habitat structural complexity. Our results indicate that the abundance of lionfish, large-bodied grouper and other predators were not negatively related. Lionfish abundance was instead controlled by several physical site characteristics, and possibly by culling. Taken together, our results suggest that managers cannot rely on current native grouper populations to control the lionfish invasion.

Abstract OT1-2-01: MINT I: Multi-institutional neo-adjuvant therapy, MammaPrint project I

Background: Women with locally advanced breast cancer (LABC) are often treated with neo-adjuvant chemotherapy to reduce the size of the tumor prior to surgery, to enable breast conserving surgery and to observe the clinical effect of therapy in real time. Studies have shown that the 25–27% of individuals who have a pathologic complete response (pCR) to neoadjuvant therapy have a survival advantage of 80% in 5 years, which is double the expected survival of the remaining patients without pCR. If patients who are likely to show a pCR could be identified prior to initiation of therapy, it would enable more informed treatment decisions – patients likely to respond would be served well by current neoadjuvant chemotherapy protocols, while those unlikely to respond may be better suited to innovative new strategies for drug discovery [von Minckwitz et al. JCO 2006]. Genomic assays, which are widely used to provide prognostic and predictive information in early breast cancer, have the potential to provide information on the likelihood of a patient with LABC responding to neo-adjuvant therapy [Glück et al. ASCO 2012].

Trial design: MINT I is a prospective study designed to test the ability of molecular profiling, as well as traditional pathologic and clinical prognostic factors, to predict response to neo-adjuvant chemotherapy in patients with LABC. MammaPrint risk profile, BluePrint molecular subtyping profile, TargetPrint estrogen receptor (ER), progesterone receptor (PR) and HER2 single gene readout, and TheraPrint Research Gene Panel will be analyzed on a fresh tumor specimen using the whole genome array. Patients will receive neo-adjuvant chemotherapy pre-specified in the protocol. Response will be measured centrally. pCR is defined as the absence of invasive carcinoma in both the breast and axilla at microscopic examination of the resection specimen, regardless of the presence of carcinoma in situ.

Eligibility: The study will include women ≥18 years with histologically-proven invasive breast cancer T2 (≥3.5cm)-T4, N0M0 or T2-T4N1M0, adequate bone marrow reserves and normal renal and hepatic function who signed an IRB approved informed consent.

Objectives: The objectives of the study are to:

1. Determine the predictive power of MammaPrint and BluePrint for sensitivity to neo-adjuvant chemotherapy as measured by pCR.

2. Compare TargetPrint ER, PR and HER2 with local and centralized IHC and/or CISH/FISH assessment.

3. Identify correlations between TheraPrint and response to neo-adjuvant chemotherapy.

4. Identify and/or validate predictive gene expression profiles of clinical response or resistance to neo-adjuvant chemotherapy.

5. Compare BluePrint with IHC-based subtype classification.

Statistical methods: Standard statistical tests such as the Pearson Chi-square test will be used to characterize and evaluate the relationship between chemoresponsiveness and gene expression patterns.

Accrual: A total of 226 eligible patients will be enrolled from multiple institutions. To date (June 06, 2013), 57 patients have been enrolled.

Clinical trial registry number: NCT01501487.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-2-01.

Carmine red (E-120)-induced occupational respiratory allergy in a screen-printing worker: a case report

Here we present a case report of a patient suffering from occupational rhinoconjunctivitis and asthma due to IgE-mediated carmine red allergy. This is the first description of carmine red allergy in a screen-printing worker in which the diagnosis was documented by quantification of specific IgE antibodies, by skin tests, by a flow-assisted basophil activation test, and by a carmine red challenge test.

Analgesic nephropathy selectively affecting a unilateral non-functioning hypoplastic kidney

Analgesic nephropathy results from chronic abuse of non-narcotic analgesics, most frequently with the use of phenacetin and mixed analgesic preparations. Renal papillary necrosis and chronic interstitial nephritis with progressive scarring are characteristic of the histopathology of analgesic nephropathy. Typically, papillary necrosis in these patients is bilateral and affects almost all renal papillae. This report describes a case of severe analgesic nephropathy that discriminantly affected a unilateral non-functioning kidney and spared the contralateral normally developed kidney. The patient herein consumed therapeutic doses of acetaminophen and naproxen daily and for several years. We estimated the cumulative doses of acetaminophen and naproxen used by the patient during that period to be approximately 1.0 and 0.4 kg, respectively. The cumulative dose of acetaminophen is at the threshold of doses that were traditionally associated with an increased risk for end-stage kidney failure. Simultaneous intake of both analgesics could have had a synergetic adverse effect on renal function. This case also demonstrates that preexisting renal insufficiency is prerequisite to the development of analgesic nephropathy. Conversely, kidneys with normal function are resistant to the chronic nephrotoxicity associated with habitual analgesic use.

Controversial topics in breast lymphatic mapping

As a result of increased accuracy of staging and decreased patient morbidity, lymphatic mapping and sentinel lymph node (SLN) biopsy for breast cancer has enjoyed a rapid acceptance into clinical practice. Despite the use of lymphatic mapping techniques to obtain nodal staging information, many controversies remain. We have attempted to highlight the major controversies in this report.

Importance of delayed imaging for blunt renal trauma

The advent of noninvasive computed tomography of the abdomen and pelvis for evaluation of blunt renal trauma has led to the practice of expectant management for hemodynamically stable patients. Although expectant management of higher grade injuries (American Association for the Surgery of Trauma Renal Injury Scale) would intuitively result in an increased frequency of urologic complications, this has not been previously examined in a large series of patients utilizing contemporary radiologic imaging techniques. A retrospective review of patients from a single institution within a recent 4-year period revealed 4 grade I, 13 grade II, 21 grade III, 7 grade IV, and 4 grade V injuries. None of grade 1, 15% of grade II, 38% of grade III, 43% of grade IV, and 100% of grade V injuries had one or more (15 major and 11 minor) urologic complications. The incidence of urinary complications correlated significantly with increasing grade (0%, 15%, 38%, 43%, and 100% for grades I to V, respectively; r = 0.94, p = 0.0158). Of the delayed urologic complications, 50% were diagnosed on follow-up imaging studies and 33% of them required intervention. Therefore we advocate repeat imaging 2 to 4 days after trauma resulting in grade III to V blunt renal lacerations to identify delayed complications that may require intervention.

Learning curves for breast cancer sentinel lymph node mapping based on surgical volume analysis

BACKGROUND

Implementation of new procedures, including lymphatic mapping for breast cancer, must be done and overseen by the medical community in a responsible way to ensure that the procedures are performed correctly. This study addresses the issues of adequacy of training and certification of surgeons performing lymphatic mapping. Ensuring quality in surgical care requires outcomes measures that are described in this study.

STUDY DESIGN

Sixteen surgeons performed lymphatic mapping in 2,255 patients with breast cancer using a combination blue dye and Tc99m-labeled sulfur colloid to identify the sentinel lymph nodes (SLNs). All participants were trained in a 2-day CME-accredited course. The Cox learning curve model (total number of mapping failures/total number of mapping cases) for a consecutive series of lymphatic mapping cases is described. The relationship of the Surgical Volume Index, the cases performed in a 30-day period, to the failure rate for each surgeon was modeled as a logistic regression curve (y = e(a+bx)/[1 + e(a+bx)]).

RESULTS

Surgeons performing less than three SLN biopsies per month had an average success rate of 86.23% +/- 8.30%. Surgeons performing three to six SLN biopsies per month had a success rate of 88.73% +/- 6.36%. Surgeons performing more than six SLN biopsies per month had a success rate of 97.81% +/- 0.44%.

CONCLUSIONS

This experience defines a learning curve for lymphatic mapping in breast cancer patients. Data suggest that increased volumes lead to decreased failure rates. These data provide surgeons performing SLN biopsy with a new paradigm for assessing their skill and adequacy of training and describes the relationship between volume of cases performed and success rate of SLN detection.

Utility of internal mammary lymph node removal when noted by intraoperative gamma probe detection

BACKGROUND

Lymphatic mapping (LM) for breast cancer has made internal mammary node (IMN) detection practical and dependable. This study demonstrates the necessity of IMN removal when suggested by intraoperative radioguided surgery detection.

METHODS

From April 1998 to July 2000, 1273 patients underwent LM for breast cancer. LM was performed using the combined dye and radiocolloid technique. Patients were scanned operatively with a gamma probe over the IMN area, and most underwent preoperative lymphoscintigraphy. Nodes were removed from patients in whom radioactivity was detected in the internal mammary area.

RESULTS

Thirty of the 1273 (2.4%) patients mapped had at least one IMN removed. Twenty-two of 30 (73.3%) had inner quadrant lesions. Five of 30 (16.7%) patients had IMNs that were positive for metastatic disease. Three of these five had no metastatic spread to the axillary sentinel lymph node (SLN). One of thirty (3.3%) patients with IMN localization had neither hot nor blue nodes detected in an SLN procedure.

CONCLUSIONS

Radioguided SLN detection should be attempted in the IMN basin with all tumors. If an IMN is identified, it should be removed. IMN biopsy is a feasible, low-risk procedure when directed by radioguided LM and provides a guide for radiotherapy for patients with positive IMNs.

Father involvement and children's functioning at age 6 years: a multisite study

Research suggests that fathers' involvement in their children's lives is associated with enhanced child functioning. The current study examined (a) whether presence of a father was associated with better child functioning, (b) whether children's perceptions of fathers' support was associated with better functioning, and (c) whether the above association was moderated by the father's relationship to the child, the child's race, and the child's gender. Participants included 855 six-year-old children and their caregivers. Father presence was associated with better cognitive development and greater perceived competence by the children. For children with a father figure, those who described greater father support had a stronger sense of social competence and fewer depressive symptoms. The associations did not differ by child's gender, race, or relationship to the father figure. These findings support the value of fathers' presence and support to their children's functioning. Priorities for future research include clarifying what motivates fathers to be positively involved in their children's lives and finding strategies to achieve this.

Clinical relevance of internal mammary node mapping as a guide to radiation therapy

BACKGROUND

The surgical management of breast cancer has changed markedly with the development of lymphatic mapping and sentinel lymph node (SLN) biopsy. Lymphatic mapping technique varies with respect to injection method, mapping agent, and surgical technique. The decision to pursue the internal mammary nodes (IMN) is another source of controversy.

METHODS

From April 1998 to November 2000, 1,470 patients underwent lymphatic mapping for breast cancer and were prospectively entered into the breast database. The combined technique method was used, consisting of both isosulfan blue dye and technetium-99 labeled sulfur colloid. Patients with inner quadrant lesions and suspicion for internal mammary metastasis had preoperative lymphoscintigraphy. Those with internal mammary radioactivity noted by either lymphoscintigraphy or gamma probe underwent removal of the internal mammary sentinel nodes.

RESULTS

Thirty-six of the 1,470 (2.4%) patients mapped had at least 1 internal mammary lymph node removed. Inner quadrant lesions were present in 24 of the 36 (67%) IMN mapped patients. Of the 36 patients mapping to the IM area, 5 (14%) had at least 1 IM node positive. Two of the 5 (40%) had only IM metastasis, with 1 of these patients having 5 of 5 IMN positive and no disease detected in her axilla. A total of 2 of the 5 (40%) IM positive patients had more than 1 IMN positive. Twenty-eight of the 36 (78%) IM node harvested patients had preoperative lymphoscintigraphy, with 18 (64%) IMN appearing on imaging. Complications occurred in 3 of the 36 (8%) IMN mapped patients, without clinical significance.

CONCLUSIONS

Mapping to the IMN basin with the finding of metastasis results in N3 disease by the current staging system. The consequence for these patients is radiation therapy to the IMN basin. It is significant to note that 14% (5 of 36) were upstaged as result of IMN detection and 40% (2 of 5) had multiple positive IMNs. Substantial disease was detected in these 5 patients necessitating additional radiation therapy while avoiding IM radiation and its attendant complications in 86% of patients mapping to the IM basin.

Lymphatic mapping in breast cancer: combination technique

The current standard of care for patients with invasive breast cancer is complete removal of the tumor by mastectomy or lumpectomy, with documentation of negative margins, followed by complete axillary dissection. Our group has examined the efficacy of lymphatic mapping of the sentinel node via the combination technique in 594 patients with breast cancer. A radiocolloid was injected at six intraparenchymal locations surrounding the tumor 2 hours prior to the operation. A 1% solution of isosulfan blue dye was injected into the breast just before prepping the patient. The breast was compressed and massaged for 5 minutes. The surgical and pathological data were prospectively collected. Lymphatic mapping of the sentinel node with a combination of blue dye and radiocolloid enhanced preop localization, operation efficiency, internal mammary node detection, and quantitative measure of detection. The combined technique also significantly reduced the learning curve for achieving proficiency.

Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of nonpalpable breast lesions: radioactive seed versus wire localization

BACKGROUND

Standard wire localization (WL) and excision of nonpalpable breast lesions has several shortcomings.

METHODS

Ninety-seven women with nonpalpable breast lesions were prospectively randomized to radioactive seed localization (RSL) or WL. For RSL, a titanium seed containing 125I was placed at the site of the lesion by using radiographical guidance. The surgeon used a handheld gamma detector to locate and excise the seed and lesion.

RESULTS

Both techniques resulted in 100% retrieval of the lesions. Fewer RSL patients required resection of additional margins than WL patients (26% vs. 57%, respectively, P = .02). There were no significant differences in mean times for operative excision (5.4 vs. 6.1 minutes) or radiographical localization (13.9 vs. 13.2 minutes). There were also no significant differences in the subjective ease of the procedures as rated by surgeons, radiologists, and patients. All WLs were carried out on the same day as the excision, whereas RSL was performed up to 5 days before the operative procedure.

CONCLUSIONS

RSL is as effective as WL for the excision of nonpalpable breast lesions and reduces the incidence of pathologically involved margins of excision. RSL also reduces scheduling conflicts and may allow elimination of intraoperative specimen mammography. RSL is an attractive alternative to WL.

Radioguidance for nonpalpable primary lesions and sentinel lymph node(s)

BACKGROUND

Radioguided surgery can also be used for the simultaneous guidance to a nonpalpable primary tumor and sentinel lymph nodes.

METHODS

Retrospective review of a prospective database. The surgeon used a gamma probe for guidance to an iodine-125 labeled titanium seed at the primary lesion and technetium-99 labeled sulfur colloid at the sentinel lymph node.

RESULTS

Forty-three patients with nonpalpable breast carcinoma underwent dual isotope radioguided surgery. The radioactive seed and primary lesion were retrieved in the first excision in all 44 patients (100%). Eleven patients (25%) had pathologically involved margins. Sentinel lymph node mapping was successful in 42 patients (98%). A mean of 2.4 sentinel nodes were excised and metastatic carcinoma was present in four patients (10%).

CONCLUSIONS

Dual isotopes can be effectively used in breast cancer patients for simultaneous radioguidance to both a nonpalpable primary lesion and sentinel lymph node and allows for improved logistics.

The effect of sentinel node selective axillary lymphadenectomy on the incidence of postmastectomy pain syndrome

BACKGROUND

Postmastectomy pain syndrome (PMPS) has been reported following procedures involving complete lymph node dissection (CLND). Since the triggering event is probably related to nerve injury, sentinel lymph node dissection (SLND) should decrease the incidence of PMPS. The purpose of this report is to determine the impact of SLND on the number of patients referred to the pain clinic for PMPS treatment.

METHODS

The records of all breast surgical patients with a diagnosis of PMPS referred to the Moffitt Cancer Center pain clinic were reviewed. The criterion for diagnosis of PMPS was a history of postoperative pain in the upper anterior chest wall, upper extremity, axilla, and/or shoulder in the absence of recurrent disease.

RESULTS

A total of 55 patients with a diagnosis of PMPS were seen in the pain clinic since 1991. Treatments included local anesthetics/corticosteroid injection, stellate ganglion block, and tricyclic antidepressants. A decrease from 15 patients in 1991 to 3 in 1998 was observed. All but one of the 55 patients with PMPS had CLND, and none referred to the pain clinic had undergone SLND.

CONCLUSIONS

PMPS is a complication of CLND. The increased use of SLND in our center has reduced the number of referrals to the pain clinic for treatment of PMPS. This benefit of SLND reduces suffering in the postoperative breast patient.

Importance of missed axillary micrometastases in breast cancer patients

Axillary lymph node metastases dramatically worsen the prognosis of patients with breast cancer. Despite this prognostic significance, routine histologic examination of axillary lymph nodes examines less than 1% of the submitted material. It is therefore obvious that micrometastatic disease is missed with this rather cursory examination, and the question arises as to the significance of this missed disease. Most lines of evidence suggest that missed axillary micrometastases exist and contribute to patient mortality. Most large studies of breast cancer micrometastases have suggested that undetected axillary micrometastases can be identified with more detailed examinations of the regional lymph nodes and that this group of patients has a poorer prognosis than those with no metastases identified. In addition, small-volume nodal disease, too small to be detected by traditional hematoxylin and eosin staining, has been shown to be capable of producing tumors in animal models. Finally, micrometastases have been shown to be of significance in other diseases. This article reviews the lines of evidence and the ongoing studies that are attempting to clarify the significance of micrometastatic disease in patients with breast cancer.

The process of clinical trials: a model for successful clinical trial participation

PURPOSE/OBJECTIVES

To present barriers and strategies related to successful clinical trial participation and integrate them into a model for successful trial participation.

DATA SOURCES

The proposed model was developed based on a literature review related to clinical trial participation, review of empirical studies related to clinical trials, and experiences with subject participation.

DATA SYNTHESIS

Successful clinical trial participation depends on study design, participant factors, issues related to ethnic diversity, the informed consent process, and physician factors.

CONCLUSIONS

Clinical trial participation is critical for all disciplines. However, nurses either are researchers or co-investigators with physicians on clinical trials, and it is critical for them to understand specific barriers and success strategies for patient participation. Future studies need to be conducted related to participation in nursing clinical trial research. These study results will facilitate successful nursing clinical trials.

IMPLICATIONS FOR NURSING PRACTICE

This model can be used in implementation of clinical trials across disciplines prior to and during enrollment of patients into studies.

Characteristics of the sentinel lymph node in breast cancer predict further involvement of higher-echelon nodes in the axilla: a study to evaluate the need for complete axillary lymph node dissection

BACKGROUND

Sentinel lymph node (SLN) biopsy techniques provide accurate nodal staging for breast cancer. In the past, complete lymph node dissection (CLND) (levels 1 and 2) was performed for breast cancer staging, although the therapeutic benefit of this more extensive procedure has remained controversial.

HYPOTHESIS

It has been demonstrated that if the axillary SLN has no evidence of micrometastases, the nonsentinel lymph nodes (NSLNs) are unlikely to have metastases.

OBJECTIVE

To determine which variables predict the probability of NSLN involvement in patients with primary breast carcinoma and SLN metastases.

METHODS

An analysis of 101 women with SLN metastases and subsequent CLND was performed. Variables included size of the primary tumor, tumor volume in the SLN, staining techniques used to initially identify the micrometastases (cytokeratin immunohistochemical vs hematoxylin-eosin), number of SLNs harvested, and number of NSLNs involved with the metastases. Tumor size was determined by the invasive component of the primary tumor. Patients with ductal carcinoma in situ who were upstaged with cytokeratin staining were considered to have stage T1a tumors.

RESULTS

Sentinel lymph node micrometastases (<2 mm) detected initially by cytokeratin staining were associated with a 7.6% (2/26) incidence of positive CLND compared with a 25% (5/20) incidence when micrometastases were detected initially by routine hematoxylin-eosin staining. Sentinel lymph node micrometastases, regardless of identification technique, inferred a risk of 15.2% (7/46) for NSLN involvement. As the volume of tumor in the SLN increased (ie, <2 mm, >2 mm, grossly visible tumor), so did the risk of NSLN metastases (P<.001).

CONCLUSIONS

Our study demonstrated that patients with micrometastases detected initially by cytokeratin staining had low-volume disease in the SLN with a small chance of having metastases in higher-echelon nodes in the regional basin other than the SLN. Characteristics of the SLN can provide information to determine the need for a complete axillary CLND. Complete lymph node dissection may not be necessary in patients with micrometastases detected initially by cytokeratin staining since the disease is confined to the SLN 92.4% of the time. However, the therapeutic value of CLND in breast cancer remains to be determined by further investigation.

Importance of lymphatic mapping in ductal carcinoma in situ (DCIS): why map DCIS?

The appropriateness of sentinel lymph node biopsy in the management of patients with biopsy diagnoses of ductal carcinoma in situ (DCIS) or DCIS with microinvasion (DCISM) has not been established. Three hundred forty-one patients presented with a biopsy diagnosis of DCIS or DCISM. Two hundred forty (70%) underwent sentinel node biopsy at their definitive procedure. All clinical and pathologic data were collected prospectively. Of 224 patients with a biopsy diagnosis of DCIS 23 (10%) were upstaged to infiltrating ductal carcinoma (IDC) at their definitive therapy and of 16 patients with a biopsy diagnosis of DCISM seven (44%) were upstaged to IDC. Excisional biopsies were no more sensitive for detecting IDC than was core biopsy. Lymph node metastases were detected in 26 of 195 (13%) patients with a definitive diagnosis of DCIS, in three of 15 (20%) with a definitive diagnosis of DCISM, and in eight of 30 (27%) with a definitive diagnosis of IDC. Sentinel lymph node biopsy is a valuable tool in the treatment of patients with DCIS and DCISM and is particularly needed in those undergoing mastectomy. No "high-risk" group of patients can be identified for selective sentinel lymph node biopsy.

Constitutive activation of Stat3 by the Src and JAK tyrosine kinases participates in growth regulation of human breast carcinoma cells

Constitutive activation of signal transducer and activator of transcription (STAT) proteins has been detected in a wide variety of human primary tumor specimens and tumor cell lines including blood malignancies, head and neck cancer, and breast cancer. We have previously demonstrated a high frequency of Stat3 DNA-binding activity that is constitutively-induced by an unknown mechanism in human breast cancer cell lines possessing elevated EGF receptor (EGF-R) and c-Src kinase activities. Using tyrosine kinase selective inhibitors, we show here that Src and JAK family tyrosine kinases cooperate to mediate constitutive Stat3 activation in the absence of EGF stimulation in model human breast cancer cell lines. Inhibition of Src or JAKs results in dose-dependent suppression of Stat3 DNA-binding activity, which is accompanied by growth inhibition and induction of programmed cell death. In addition, transfection of a dominant-negative form of Stat3 leads to growth inhibition involving apoptosis of breast cancer cells. These results indicate that the biological effects of the Src and JAK tyrosine kinase inhibitors are at least partially mediated by blocking Stat3 signaling. While EGF-R kinase activity is not required for constitutive Stat3 activation in breast cancer cells, EGF stimulation further increases STAT DNA-binding activity, consistent with an important role for EGF-R in STAT signaling and malignant progression. Analysis of primary breast tumor specimens from patients with advanced disease revealed that the majority exhibit elevated STAT DNA-binding activity compared to adjacent non-tumor tissues. Our findings, taken together, suggest that tyrosine kinases transduce signals through Stat3 protein that contribute to the growth and survival of human breast cancer cells in culture and potentially in vivo.

Pharmaceutical Care Research and Education Project: Patient Outcomes

OBJECTIVE

To compare patients' adherence to therapy, expectations, satisfaction with pharmacy services, and health-related quality of life (HRQOL) after the provision of pharmaceutical care with those of patients who received traditional pharmacy care.

DESIGN

Randomized controlled cluster design.

SETTING

Sixteen community pharmacies in Alberta, Canada.

PATIENTS AND OTHER PARTICIPANTS

Ambulatory elderly (> or = 65 years of age) patients covered under Alberta Health & Wellness's senior drug benefit plan and who were concurrently using three or more medications according to pharmacy profiles.

INTERVENTION

Pharmacies were randomly assigned to either treatment (intervention) or control (traditional pharmacy care) groups. Patients at treatment pharmacies were recruited into the study, and pharmacists provided comprehensive pharmaceutical care services. Pharmacists at control pharmacies continued to provide traditional pharmacy care.

MAIN OUTCOME MEASURES

Study participants' opinions, adherence to therapy, and scores on the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36).

RESULTS

Compared with those of patients receiving traditional care, treatment patients' expectations that their pharmacist would perform activities congruent with pharmaceutical care changed over the study period. Treatment patients' satisfaction with the constructs "trust," "evaluation and goal setting," and "communicates with doctor" were also positively affected. HRQOL and patient adherence were not significantly affected by pharmaceutical care interventions.

CONCLUSION

Successful implementation of a pharmaceutical care practice model has the potential to increase patients' satisfaction with their pharmacists' activities and may increase patients' expectations that pharmacists will work on their behalf to assist them with their health care needs. If pharmaceutical care affects patients' HRQOL, instruments more specific than the SF-36 may be needed to detect the differences.

Pharmaceutical Care Research and Education Project: Pharmacists' Interventions

OBJECTIVES

To describe the processes of care used by community pharmacists participating in the Pharmaceutical Care Research and Education Project (PREP) in terms of drug-related problems (DRPs), pharmacists' recommendations, and status of DRPs at follow-up, and to determine characteristics associated with DRPs.

DESIGN

Descriptive analysis of the treatment group from a larger randomized, controlled cluster design.

SETTING

Five independent community pharmacies in Alberta.

PARTICIPANTS

One hundred fifty-nine patients who were covered under Alberta Health and Wellness's senior drug benefit plan (i.e., 65 years or older), were taking three or more medications concurrently according to pharmacy records, were able to complete telephone interviews as determined by pharmacists, maintained residence in Alberta for 12 of the 15 study months, agreed to receive their prescription medications only from the study pharmacy during the study period, and provided informed consent.

MAIN OUTCOME MEASURES

Frequency of DRPs, recommendations, status of DRPs, and analysis of clinical results as determined during pharmacists' follow-up care.

RESULTS

In telephone surveys, patients reported taking 4.7 prescription medications per day, but pharmacists documented 8.7 prescription medications per day in their records. Pharmacists documented 559 DRPs, a mean (+/- SD) of 3.9+/-3.2 problems per patient. Approximately 39% of problems were actual DRPs, while 60% were potential DRPs. Medical conditions associated most frequently with a DRP involved the respiratory, cardiovascular, and musculoskeletal systems. The most common DRP categories were "patient requires drug therapy" or "patient requires influenza or pneumococcal vaccination." Pharmacists wrote 551 initial clinical notes using the subjective, objective, assessment, plan (SOAP) format, and they recorded 346 follow-up interventions, also using SOAP notes. Counseling, preventive consultations, and clinical monitoring represented 40% of their recommendations. In 80% of situations, the pharmacist made the recommendation directly to the patient. On follow-up, 40% of the 559 DRPs identified were resolved, controlled, or improved. Patients accepted 76% of pharmacists' recommendations, and physicians accepted 72% of pharmacists' suggested resolutions of DRPs. Pharmacists were more likely to follow up about actual DRPs, as compared with potential ones; overall, they followed up on 62% of identified DRPs.

CONCLUSION

Pharmacists identified more DRPs for study patients than previous community-based, observational studies have reported. Undertreatment appears to be a prevalent DRP. Community pharmacists' recommendations to prevent and resolve DRPs were made primarily to patients and were well accepted. More follow-up was needed for all DRPs. When follow-up occurred, the DRP results generally showed improvement.

Breast cancer: advances in surgical management

The surgical management of breast cancer has changed dramatically from a deforming ablative procedure to an approach that for the majority of breast cancer patients can preserve the breast and axillary anatomy. The current approach to the diagnosis of breast cancer and the evolution of the more limited approach to surgical resection are discussed. The technique of sentinel lymph node biopsy, originally developed for melanoma patients, has now been adopted for use in the treatment of breast cancer. The methodology and advantages of this approach to the axillary lymph nodes in both tumor recognition and reduced risk to the patient are detailed.

The effects of postinjection massage on the sensitivity of lymphatic mapping in breast cancer

BACKGROUND

The technique of lymphatic mapping and sentinel lymph node (SLN) biopsy is rapidly becoming the preferred method of staging the axilla of the breast cancer patient. This report describes the impact of postinjection massage on the sensitivity of this surgical technique.

STUDY DESIGN

Lymphatic mapping at the H Lee Moffitt Cancer Center is performed using a combination of isosulfan blue dye and Tc99m labeled sulfur colloid. Data describing the rate of SLN identification and the node characteristics from 594 consecutive patients were calculated. Patients who received a 5-minute massage after injection of blue dye and radiocolloid were compared with a control group in which the patients did not receive a postinjection massage.

RESULTS

When compared with controls, the proportion of patients who had their SLN identified using blue dye after massage increased from 73.0% to 88.3%, and the proportion of patients who had their SLN identified using radiocolloid after massage increased from 81.7% to 91.3%. The overall rate of SLN identification increased from 93.5% to 97.8%. The proportion of nodes that were stained blue among those removed increased from 73.4% to 79.7% after massage.

CONCLUSIONS

As experience increases with this new procedure, the surgical technique of lymphatic mapping continues to evolve. The addition of a postinjection massage significantly improves the uptake of blue dye by SLNs and may also aid in the accumulation of radioactivity in the SLNs, further increasing the sensitivity of this procedure.

The role of selective sentinel lymph node dissection in breast cancer

Axillary nodal status continues to be the most statistically significant predictor of survival for patients with breast cancer. Although still providing regional control of axillary disease, axillary dissection is more important as a staging and prognostic tool. Trials are currently underway to investigate the possibility of replacing the current standard treatment of breast cancer, axillary lymph node dissection, with the less invasive lymphatic mapping and sentinel lymph node biopsy. This issue and the technical aspects of sentinel lymph node mapping for breast cancer are discussed in detail in this article.

NCCN Practice Guidelines for Breast Cancer

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. In many situations, the patient and physician have the responsibility to jointly explore and ultimately select the most appropriate option from among the available alternatives. With rare exception, the evaluation, treatment, and follow-up recommendations contained within these guidelines were based largely on the results of past and present clinical trials. However, there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement. Therefore, patient and physician participation in prospective clinical trials allows patients not only to receive state-of-the-art cancer treatment but also to contribute to the improvement of treatment of future patients.

The role of sentinel lymph node biopsy in women undergoing prophylactic mastectomy

BACKGROUND

Indications for prophylactic mastectomy (PM) range from LCIS to BRCA 1-2 positive, cosmesis, and cancer phobia. Occult cancers have been found in up to 5% of PM cases. Consequently, consideration must be given to the role of sentinel lymph node (SLN) biopsy as a diagnostic procedure in these patients as PM excludes the subsequent option of SLN biopsy.

METHODS

From April 1994 to November 1999, all patients undergoing PM had SLN biopsy after four quadrant periareolar injections of radiocolloid (450 mci) and blue dye (5 cc). All patients were prospectively accrued to the computerized database of breast patients. The SLN were all evaluated with hematoxylin and eosin (H&E) as well as CAM5.2 cytokeratin immunohistochemical (CK-IHC) stains.

RESULTS

Over a 67-month period, 1,356 patients were mapped; 57 patients underwent PM in which 148 nodes (2.6 nodes per patient) were evaluated. Nodes were examined by routine H&E and CK-IHC staining. Two patients, neither of whom was found to have a cancer in the prophylactic mastectomy breast, were found to have a positive SLN by CK-IHC staining. Infiltrating carcinoma was discovered within the PM breasts of 2 additional patients. Sentinel lymph node biopsy was negative for malignancy by H&E as well as CK-IHC stains. No lymphedema has been detected in PM patients.

CONCLUSIONS

Sentinel node biopsy has been shown to be an accurate and minimally invasive method of evaluating the lymphatic basin. This study shows that the absence of known disease within the breast does not preclude the presence of occult cancer or metastatic nodal disease. Four patients (7%) had a significant change in their surgical management as a direct result of sentinel lymph node biopsy. Two patients were spared the complications of a complete axillary node dissection. This minimally invasive procedure accurately evaluated the known disease status and provided new diagnostic information. Most important, once a mastectomy is performed, the opportunity for SLN biopsy is lost should a cancer be found within the breast specimen.

Android obesity at diagnosis and breast carcinoma survival: Evaluation of the effects of anthropometric variables at diagnosis, including body composition and body fat distribution and weight gain during life span,and survival from breast carcinoma

BACKGROUND

Although a large body of research exists concerning pathologic prognostic indicators of the rate of incidence and survival from breast carcinoma, to the authors' knowledge very few studies have examined the effects of anthropometric variables such as height, obesity, weight gain in adulthood, timing of weight gain, and body composition to survival, although these variables are related to the incidence rate.

METHODS

The survival status of 166 patients diagnosed with primary breast carcinoma and followed for at least 10 years was obtained from the Cancer Center's registry, and significant anthropometric and other known prognostic indicators regarding survival after diagnosis were determined by Cox proportional hazards analysis.

RESULTS

Eighty-three of 166 breast carcinoma patients (50%) with up to 10 years of follow-up died of disease. Android body fat distribution, as indicated by a higher suprailiac:thigh ratio, was a statistically significant (P < 0.0001) prognostic indicator for survival after controlling for stage of disease, with a hazards ratio of 2.6 (95% confidence interval [95% CI], 1.63-4.17). Adult weight gain, as indicated specifically by weight at age 30 years, was a statistically significant (P < 0.05) prognostic indicator for survival with a hazards ratio of 1.15 (95% CI, 1.0-1.28). In addition, the authors observed the Quatelet Index, a negatively significant (P < 0.01) prognostic indicator for survival with a hazards ratio of 0.92 (95% CI, 0.87-0.98). Other markers of general obesity such as weight at diagnosis, percent body fat, and body surface area were not significant markers influencing survival. Similarly, height; triceps, biceps; subscapular, suprailiac, abdominal, and thigh skinfolds; waist and hip circumferences; family history; and reproductive and hormonal variables at the time of diagnosis showed no apparent significant relation to survival.

CONCLUSIONS

The results of the current study provide some evidence that android body fat distribution at diagnosis and increased weight at age 30 years increases a woman's risk of dying of breast carcinoma.

Lymphatic mapping and sentinel lymph node biopsy in patients with breast cancer

The standard of care for the evaluation of axillary nodal involvement remains complete lymph node dissection. Lymphatic mapping and sentinel lymph node (SLN) biopsy are changing this long-held paradigm; indeed, several leading institutions already reserve complete axillary dissection for patients with metastasis to the SLN. In addition to reviewing the literature, this chapter describes our lymphatic mapping experience at the H Lee Moffitt Cancer Center and Research Institute with 1147 breast cancer patients. Our results, in addition to a meta-analysis of data from 12 institutions comprising an additional 1842 patients undergoing complete axillary dissection, demonstrate that SLN biopsy is an accurate method of axillary staging. Although the results from small series may exaggerate the probability of false negative results, the risk of nodal disease based on tumor size and other risk factors should be evaluated when considering the results of SLN sampling.

Do cytokeratin-positive-only sentinel lymph nodes warrant complete axillary lymph node dissection in patients with invasive breast cancer?

The small number of nodes harvested with lymphatic mapping and sentinel lymph node (SLN) biopsy has allowed a more detailed pathologic examination of those nodes. Immunohistochemical stains for cytokeratin (CK-IHC) have been used in an attempt to minimize the false negative rate for SLN mapping. This study examines the value of CK-IHC positivity in predicting further lymph node involvement in the axillary basin. From April 1998 through May 1999, 519 lymphatic mappings and SLN biopsies were performed for invasive breast cancer. SLNs were examined by imprint cytology, hematoxylin and eosin (H&E), and CK-IHC. Patients with evidence of metastatic disease by any of the above techniques were eligible for complete axillary node dissection (CAND). The frequency with which these modalities predicted further lymph node involvement in the axillary basin was compared. Of the 519 lymphatic mappings, 39 patients (7.5%) had a CK-IHC-positive-only SLN. Five (12.8%) of these 39 patients had at least 2 SLNs positive by CK-IHC. Twenty-six of the CK-IHC-positive-only patients underwent CAND. Three of these 26 patients (11.5%) had additional metastases identified after CAND. The sensitivity levels with which each modality detected further axillary lymph node involvement were as follows: CK-IHC, 98 per cent; H&E, 94 per cent; and imprint cytology, 87 per cent. A logistic regression to compare the prognostic value of the three modalities was performed. All were significant, with odds ratios of 19.1 for CK-IHC (P = 0.015), 5.3 for H&E (P = 0.033), and 3.86 for imprint cytology (P = 0.0059). These data validate the enhanced detection of CK-IHC for the evaluation of SLNs. Detection of CK-IHC-positive SLNs appears to warrant CAND in patients with invasive breast cancer. However, the therapeutic value of CAND or adjuvant therapies based on CK-IHC-positive SLNs would be best answered by prospective randomized trials.

Sentinel node biopsy in ductal carcinoma in situ patients

BACKGROUND

Sentinel lymph node (SLN) mapping is an effective and accurate method of evaluating the regional lymph nodes in breast cancer patients. The SLN is the first node that receives lymphatic drainage from the primary tumor. Patients with micrometastatic disease, previously undetected by routine hematoxylin and eosin (H&E) stains, are now being detected with the new technology of SLN biopsy, followed by a more detailed examination of the SLN that includes serial sectioning and cytokeratin immunohistochemical (CK IHC) staining of the nodes.

METHODS

At Moffitt Cancer Center, 87 patients with newly diagnosed pure ductal carcinoma in situ (DCIS) lesions were evaluated by using CK IHC staining of the SLN. Patients with any focus of microinvasive disease, detected on diagnostic breast biopsy by routine H&E, were excluded from this study. DCIS patients, with biopsy-proven in situ tumor by routine H&E stains, underwent intraoperative lymphatic mapping, using a combination of vital blue dye and technetium-labeled sulfur colloid. The excised SLNs were examined grossly, by imprint cytology, by standard H&E histology, and by IHC stains for CK. All SLNs that had only CK-positive cells were subsequently confirmed malignant by a more detailed histological examination of the nodes.

RESULTS

CK IHC staining was performed on 177 SLNs in 87 DCIS breast cancer patients. Five of the 87 DCIS patients (6%) had positive SLNs. Three of these patients were only CK positive and two were both H&E and CK positive. Therefore, routine H&E staining missed microinvasive disease in three of five DCIS patients with positive SLNs. In addition, DCIS patients with occult micrometastatic disease to the SLN underwent a complete axillary lymph node dissection, and the SLNs were the only nodes found to have metastatic disease. Of interest, four of the five node-positive patients had comedo carcinoma associated with the DCIS lesion, and one patient had a large 9.5-cm low grade cribriform and micropapillary type of DCIS.

CONCLUSIONS

This study confirms that lymphatic mapping in breast cancer patients with DCIS lesions is a technically feasible and a highly accurate method of staging patients with undetected micrometastatic disease to the regional lymphatic basin. This procedure can be performed with minimal morbidity, because only one or two SLNs, which are at highest risk for containing metastatic disease, are removed. This allows the pathologist to examine the one or two lymph nodes with greater detail by using serial sectioning and CK IHC staining of the SLNs. Because most patients with DCIS lesions detected by routine H&E stains do not have regional lymph node metastases, these patients can safely avoid the complications associated with a complete axillary lymph node dissection and systemic chemotherapy. However, DCIS patients with occult micrometastases of the regional lymphatic basin can be staged with higher accuracy and treated in a more selective fashion.

Tools used to help community pharmacists implement comprehensive pharmaceutical care

OBJECTIVE

To describe the tools and processes used in the practice enhancement program (PEP) of the Pharmaceutical Care Research and Education Project to enable community pharmacists to acquire the necessary skills, knowledge, and attitudes to deliver comprehensive pharmaceutical care to elderly ambulatory patients.

SETTING

Independent community pharmacies in Alberta.

PRACTICE DESCRIPTION

The PEP was designed to allow self-directed learning in a problem-based environment. The intent was for pharmacists to apply the knowledge they gained to improve drug therapy outcomes.

PRACTICE INNOVATION

As a systematic approach to providing care, several tools were adapted to help pharmacists execute tasks required by the nine steps of the pharmaceutical care process proposed by Helper and Strand. These tools and processes facilitated (1) self-directed learning about diseases and drugs, (2) acquisition of relevant patient data, (3) a consistent and stepwise approach to the identification and resolution of drug-related problems, (4) documentation of care provided, and (5) continuity of care.

RESULTS

To help pharmacists in the PEP acquire the necessary competency to provide pharmaceutical care, they were required to use the tools and processes described herein to work up and resolve patient problems. Initially, patient problems were presented as paper cases covering a range of acute and chronic problems, including topics applicable to geriatric patients. This was followed by a practicum phase wherein patient problems represented individuals from among their clientele.

CONCLUSION

The tools and processes used in the project increased community pharmacists' competency for providing pharmaceutical care, by helping them develop the needed skills, knowledge, and attitudes.

Implementation of new surgical technology: outcome measures for lymphatic mapping of breast carcinoma

BACKGROUND

Recent advances in technology and the subsequent development of minimally invasive surgical techniques have heralded a new era in the surgical treatment of breast cancer. The dilemma of how to train surgeons in new technologies requires teaching, certification, and outcomes reporting in a non-threatening and non-economically damaging manner. This study examines 700 cases of lymphatic mapping and sentinel lymph node (SLN) biopsy for breast cancer and documents surgeon-specific and institution-specific learning curves.

METHODS

Seven hundred cases of lymphatic mapping and SLN biopsy were examined. All procedures were performed using a combination of vital blue dye and radiolabeled sulfur colloid. Learning curves were generated for each surgeon as a plot of failure rate versus number of cases.

RESULTS

Examination of the learning curves in this study demonstrates similar characteristics. Following a high initial failure rate, there is a rapid decrease after the first twenty cases. The learning curve, representing the mean of the five surgeons' experience, indicates that 23 cases and 53 cases are required to achieve success rates of 90% and 95%, respectively.

CONCLUSIONS

The initial reports regarding lymphatic mapping combined with this experience of 700 cases confirm the presence of a significant learning curve. Although this procedure may have an inherent failure rate, it is important to identify those factors that are under the control of the surgeon and, therefore, subject to improvement. We believe that these data provide surgeons performing lymphatic mapping and SLN biopsy with a new paradigm for assessing their skill and adequacy of training.

Lymphatic mapping with sentinel lymph node biopsy in patients with breast cancers <1 centimeter (T1A-T1B)

Because of its high cost and attendant morbidity, the necessity of axillary dissection in patients with small invasive primary tumors has been questioned. Lymphatic mapping with sentinel lymph node (SLN) biopsy is an alternative to complete axillary dissection; however, researchers have excluded patients with T1A-T1B lesions. Seven hundred patients with newly diagnosed breast cancers underwent an Institutional Review Board-approved prospective trial of intraoperative lymphatic mapping using a combination of Lymphazurin and filtered technetium-labeled sulfur colloid. An SLN was defined as a blue node and/or hot node with a 10:1 ex vivo radioactivity ratio in the SLN versus non-SLNs. All SLNs were evaluated by both hematoxylin and eosin and cytokeratin immunohistochemical stains. Of the 700 patients, 665 (95.0%) were mapped successfully. One hundred ninety-six (28.0%) had T1A-T1B tumors. Forty patients (20.4%) with T1A-T1B tumors had metastases to the SLNs. We conclude that breast cancer SLN mapping is highly accurate and sensitive when combined dye techniques (radiocolloid and vital blue dye) are utilized. This technique is particularly useful in patients with small invasive primary tumors, which, despite their size, still demonstrate a significant rate of axillary metastasis. These patients should not be excluded from lymphatic mapping protocols.

The role of sentinel lymph node biopsy in breast cancer

BACKGROUND

Lymphatic mapping and sentinel lymph node (SLN) biopsy are new techniques that accurately provide crucial staging information while inflicting far less morbidity than complete axillary dissection. As these techniques continue to gain acceptance, issues such as adequacy of training, certification, and outcomes measures become increasingly important. The purpose of this paper is to report the initial lymphatic mapping experience at the H Lee Moffitt Cancer Center and Research Institute and to provide a detailed description of the technical aspects of lymphatic mapping.

STUDY DESIGN

From April 1994 to April 1998, 700 patients with newly diagnosed breast cancers underwent an IRB-approved prospective trial of lymphatic mapping using a combination of Lymphazurin (USSC, Norwalk, CT) blue dye and filtered technetium 99m-labeled sulfur-colloid. Failure of the procedure was defined as the inability to detect an SLN by either radiocolloid uptake within a lymph node by the gamma probe or the inability to visualize blue staining of a lymph node. Learning curves were then generated as the failure rate versus serial number of patients for each of the 5 surgeons involved in this study.

RESULTS

The SLN was identified in 665 of 700 patients (95.0%). A total of 1,348 SLNs were successfully removed, of which 238 (17.7%) were positive for metastatic disease in 176 of 665 patients (26.5%). In patients who underwent a complete axillary dissection after SLN biopsy, SLNs were identified in 173 of 186 patients (93.0%). Of the 173 patients, 53 patients (30.6%) had positive SLNs and 120 patients (69.4%) had negative SLNs. In the 120 patients with negative SLNs, one patient was found to have disease on complete dissection, for a false-negative rate of 0.83% (95% CI: 0.02%, 4.6%). A learning curve representing the mean of the 5 surgeons' experience indicates that on average 23 patients are required by an individual surgeon to achieve a 90% +/- 4.5% success rate and 53 patients are required to achieve a 95% +/- 2.3% success rate (p = 0.05).

CONCLUSIONS

These data validate lymphatic mapping and SLN biopsy as indispensable tools in the surgical treatment of breast cancer. With adequate multidisciplinary training, these techniques can be readily implemented at institutions treating breast cancer.

Learning curves and certification for breast cancer lymphatic mapping

To determine the usefulness of lymphatic mapping and SLN biopsy, two distinct aspects of the technique must be evaluated, mapping success rates and mapping accuracy. The mapping success rate simply reflects the ability to successfully map a SLN. Mapping accuracy is reflected by the false-negative rate defined as the proportion of patients with axillary metastases among those in whom the SLN is negative for disease. It is critical within each institution that these two measurements be obtained to validate the multidisciplinary collaborative effort. It seems that surgeons with appropriate training should be able to map with 85% efficiency with zero or one false-negative cases in their first 10 patients with metastatic disease. It is our recommendation that individual surgeons join together and follow an institutional (IRB approved) protocol for lymphatic mapping in which each surgeon is required to perform at least 30 procedures of SLN biopsy followed by completion axillary lymph node dissections (phase I). There are several advantages for surgeons and patients to participate in national trials as a new technique is established: 1. Patients are fully informed. 2. For those patients who have SLN biopsy followed by a CLND (phase I), there is still an added advantage in that the SLN can be scrutinized more closely resulting in more accurate staging. 3. The surgeon and the institution can be reimbursed even while the surgeon is on the learning curve. 4. It provides for good publicity for the institution. The data should be reviewed for each surgeon after completing the first 30 cases. If the aforementioned goals of 85% success with one or fewer false-negative cases is achieved, then the individual surgeon may move on to a second (phase II) mapping protocol. In phase II, a SLN biopsy is performed and a CLND is performed only if a SLN cannot be located or the SLN contains metastases. Should the aforementioned criteria not be met, then additional procedures or onsite intraoperative mentoring may be required to further evaluate the deficiencies of the mapping procedure by the surgeon or institution. Remember that failure to map may be a function of surgical skill, nuclear medicine injection methodology, or the pathologic evaluation of the SLN. Should institutional problems arise, onsite mentoring may be helpful by someone with adequate mentoring skills to troubleshoot a potential problem. The previously outlined recommendations are similar to the recently published requirements of the American Society of Breast Surgeons that recommend documentation of 30 cases or more with an 85% or higher success rate in identifying a SLN and 5% or greater false-negative rate (single false-negative SLN in the series). A national network of training centers is being established for radioguided surgery. This new technology has the potential of being applicable to 350,000 new cases of cancer diagnosed annually in the United States. Applications include breast cancer, melanoma, and other skin tumors like Merkel cell carcinoma and poorly differentiated squamous cell carcinoma, parathyroid localization, vulvar and vaginal lesions, and bone localization. This network of training centers will provide an opportunity for surgeons, nuclear medicine physicians, and pathologists to come together and learn about this new technology. Training will include didactic sessions, live surgery, and hands-on experience with animal models. The faculty will consist of leading experts from across the country. Participating centers include the H. Lee Moffitt Cancer Center and Research Institute, John Wayne Cancer Institute, and the M.D. Anderson Cancer Center. Training sites will also be available in Durham, NC; Pittsburgh, PA; Seattle, WA; Little Rock, AR; and St. Louis, MO. The network provides access to a national lymphatic mapping database (http:/(/)mapping.rad.usf.edu), participation in national trials, and web site listings (melanoma.net, or breastdoctor.com, and endocrine

Techniques for lymphatic mapping in breast carcinoma

Lymphatic mapping and sentinel lymph node biopsy are new surgical techniques enabling surgeons to accurately determine the status of the axillary nodal basin in breast cancer patients. This article provides a detailed description of the lymphatic mapping technique including a discussion of the most commonly used equipment.