Abstract GS5-02: Axillary dissection vs. no axillary dissection in patients with cT1-T2cN0M0 breast cancer and only micrometastases in the sentinel node(s): Ten-year results of the IBCSG 23-01 trial

BACKGROUND: The phase III IBCSG 23-01 multicenter, randomized, non-inferiority trial compared disease-free survival (DFS) in breast cancer patients with one or more micrometastatic (≤2 mm) sentinel nodes (SNs) randomized to either axillary dissection (AD) or no axillary dissection (no-AD). Results after 5 years showed no difference in DFS between the arms. Here we report results after a median follow-up of 9.8 years.

METHODS: Eligible patients had cancers of pathological diameter ≤5 cm and one or more micrometastatic (≤2 mm) foci, including isolated tumor cells, in the SNs. Patients with axillary macrometastases were excluded. Breast surgery was conservative or mastectomy. Eligible patients were randomized to AD vs. no-AD. The primary endpoint was disease-free survival (DFS); secondary endpoints were overall survival (OS), site of recurrence (particularly axillary recurrence), and surgical complications of AD. DFS and OS were estimated using the product-limit method, and the log-rank test was used to compare the treatment groups. Patients without a DFS or OS event were censored at the date of last follow-up. Non-inferiority margin for no-AD vs. AD was defined as a DFS hazard ratio (HR, no-AD relative to AD) of <1.25, and was assessed using a z-test applied to the log HR. Active follow-up of patients was terminated in February 2017.

RESULTS: From 2001 to 2010, 934 patients were randomized at 27 centers; 931 were evaluable (467 in the no-AD group and 464 in the AD group). Median follow-up was 9.8 (IQR: 7.8–12.7) years. The number and types of first DFS events according to treatment group are shown in the Table.

Disease-free Survival EventsNo-ADADTotal101117Breast cancer related events7475Local1413Contralateral breast1012Regional [ipsilateral axillary events]9 [8]3 [2]Distant4147Non-breast cancer related events2742Second malignancies1723Death without prior cancer event62Death with unknown cancer status417

10-year DFS was 75% (95% confidence interval [CI]: 72%–81%) in the no-AD group and 75% (95% CI: 71%–79%) in the AD group (HR [no-AD vs. AD]=0.85; 95% CI: 0.65–1.11; log-rank p=0.23; non-inferiority p=0.002). There were 45 deaths in the no-AD group and 58 in the AD group. 10-year OS was 91% (95% CI: 88%–94%) in the no-AD group and 88% (95% CI: 85%–92%) in the AD group (HR [no-AD vs. AD]=0.77; 95% CI: 0.56–1.07; log-rank p=0.19).

CONCLUSION: Findings after a median follow-up of 9.8 years fully support the findings at 5 years in that no-AD is not inferior to AD with respect to DFS, and there is no significant difference between the arms for DFS and OS, thus confirming that AD is not indicated in patients with micrometastatic SNs.

Citation Format: Galimberti V, Cole BF, Viale G, Veronesi P, Vicini E, Intra M, Mazzarol G, Massarut S, Zgajnar J, Taffurelli M, Littlejohn D, Egli T, Tondini C, Di Leo A, Colleoni M, Regan MM, Coates AS, Gelber RD, Goldhirsch A. Axillary dissection vs. no axillary dissection in patients with cT1-T2cN0M0 breast cancer and only micrometastases in the sentinel node(s): Ten-year results of the IBCSG 23-01 trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr GS5-02.

Extensive Frozen Section Examination of Axillary Sentinel Nodes to Determine Selective Axillary Dissection

As experience accumulates on the use of sentinel node biopsy in breast cancer, it is becoming clear that the method can reliably predict the state of the axilla and thus be used to decide whether to perform complete axillary dissection. Ongoing controlled trials will soon provide definitive evidence on the latter point. The key issue regarding sentinel node biopsy is pathologic evaluation of the biopsied node, which should be done intraoperatively whenever possible. In our initial experience with a conventional intraoperative frozen section method, the false-negative rate was 19% compared to examination of permanent sections of the biopsied node. We therefore devised a new intraoperative method in which pairs of sections are obtained every 50 mm for the first 15 sections and every 100 mm for any remaining node, which essentially samples the entire node; the method takes about 40 minutes. Sentinel node metastases were found in 119 of 295 (40%) of T1N0 breast cancer patients examined by this new method. This high rate of positivity indicates that the new method is reliable. In all cases, metastases were identified on hematoxylin-eosin (HE)-stained sections, although in 4% of positive cases the HE sections were doubtful, and cytokeratin immunostaining on the adjacent section was useful for confirming malignancy. Of 295 patients, 8 (2.7%) had a negative sentinel node but another axillary node metastasis. In conclusion, we found that extensive intraoperative frozen section examination of sentinel nodes correctly predicts a metastasis-free sentinel node in 95.4% of cases (negative predictive value), it is therefore suitable for identifying patients in whom axillary dissection might be avoided. Immunocytochemical staining for cytokeratins or other epithelial markers may be helpful for reducing the risk of missing micrometastatic foci.

Dual regulation of Myc by Abl

The tyrosine kinase c-Abl (or Abl) and the prolyl-isomerase Pin1 cooperatively activate the transcription factor p73 by enhancing recruitment of the acetyltransferase p300. As the transcription factor c-Myc (or Myc) is a known target of Pin1 and p300, we hypothesized that it might be regulated in a similar manner. Consistent with this hypothesis, overexpression of Pin1 augmented the interaction of Myc with p300 and transcriptional activity. The action of Abl, however, was more complex than predicted. On one hand, Abl indirectly enhanced phosphorylation of Myc on Ser 62 and Thr 58, its association with Pin1 and p300 and its acetylation by p300. These effects of Abl were exerted through phosphorylation of substrate(s) other than Myc itself. On the other hand, Abl interacted with the C-terminal domain of Myc and phosphorylated up to five tyrosine residues in its N-terminus, the principal of which was Y74. Indirect immunofluorescence or immunohistochemical staining suggested that the Y74-phosphorylated form of Myc (Myc-pY74) localized to the cytoplasm and coexisted either with active Abl in a subset of mammary carcinomas or with Bcr-Abl in chronic myeloid leukemia. In all instances, Myc-pY74 constituted a minor fraction of the cellular Myc protein. Thus, our data unravel two potential effects of Abl on Myc: first, Abl signaling can indirectly augment acetylation of Myc by p300, and most likely also its transcriptional activity in the nucleus; second, Abl can directly phosphorylate Myc on tyrosine: the resulting form of Myc appears to be cytoplasmic, and its presence correlates with Abl activation in cancer.

Minimal axillary lymph node involvement in breast cancer has different prognostic implications according to the staging procedure

It is still controversial whether the identification of micrometastases and isolated tumor cells in the axillary lymph nodes of patients with breast cancer has any prognostic value. We evaluated the prognostic role of isolated tumor cells and micrometastases in the axillary lymph nodes in 3,158 consecutive patients pT1-2 pN0-N1mi (with a single involved lymph node) and M0, referred to the Division of Medical Oncology after surgery performed at the European Institute of Oncology from April 1997 to December 2002. Median follow-up was 6.3 years (range 0.1-11 years). Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) were performed in 2,087 and 1,071 patients, respectively. A worse metastasis-free survival was observed for patients with micrometastatic disease compared to node-negative patients, if staged with ALND (log-rank P < .0001; HR: 3.17; 95% CI 1.72-5.83 at multivariate analysis), but not for patients who underwent SLNB (log-rank P = 0.36). The presence of a single micrometastatic lymph node is associated with a higher risk of distant recurrence as compared to node-negative disease only for patients undergoing ALND for staging purposes. Treatment recommendations for systemic therapy should not take into account the presence of a single micrometastatic lymph node identified during complete serial sectioning of sentinel node(s).

[Conservative approach for breast cancer. The experience of the European Institute of Oncology]

Conservative surgery represents the standard care for patients with early breast cancer. The aim of this review was to discuss the extension of conservative surgery in controversial fields such as after primary chemotherapy for large tumours or the possibility to repeat conservative surgery for a local reappearance. The project of a conservative approach to breast cancers continues with sentinel node biopsy which is worldwide performed more and more frequently. In our institute sentinel node biopsy is the standard procedure in the axillary staging of breast cancer even in those clinical scenarios which were previously considered either controversial or a contraindication such as in multicentric breast cancer, during pregnancy, in intra-ductal neoplasias, after primary chemotherapy, and male breast cancer. This conservative approach is completed by the possibility to deliver a partial breast irradiation and to provide patients with more personalized adjuvant treatments tailored on the biological features of the tumour.

Long-term oncological results of breast conservative treatment with oncoplastic surgery

Oncoplastic surgery combining breast conservative treatment (BCT) and plastic surgery techniques may allow more extensive breast resections and improve aesthetic outcomes, but no long-term oncological results have been published. Long-term oncologic results of 148 consecutive BCT with concomitant bilateral plastic surgery have been analysed and were compared to historical data of BCT trials. Median follow-up was 74 months. Complete excision was obtained in 135 patients (91%); focally involved margins in 8 (5%); and close (<2 mm) margins in 5 (3%). Five patients developed ipsilateral recurrence (3%), 19 (13%) developed distant metastasis and 11 patients died (7.53%). Patients with tumours larger than 2 cm were at greater risk of local recurrences and distant metastasis. Long-term oncologic results of BCT with oncoplastic surgery are comparable with the results of BCT randomized trials.

Breast cancer diagnosed during pregnancy and lactation: biological features and treatment options

AIM OF THE STUDY

Assessment of biological features and treatment of patients with breast cancer presenting during pregnancy or lactation.

PATIENTS AND METHODS

Immunohistochemical analysis of estrogen receptor (ER) and progesterone receptor (PgR), Ki-67, HER2/neu, prognostic markers, treatment and follow-up of 21 patients with breast cancer during pregnancy (BCdP) and 17 with breast cancer during lactation (BCdL) are presented.

RESULTS

Median age was 36 and 33 years, median tumour size was 2.4 and 2.5 cm, axillary lymph nodes were positive in 10 of 21 pregnant patients and 11 of 17 lactating patients, respectively. Both ER and PgR were not expressed in six of 21 pregnant women and nine of 17 lactating patients. All the six women who had concurrent diagnosis of breast cancer and pregnancy (first trimester) preferred termination of pregnancy although an alternative option was discussed. Five patients received anthracycline containing chemotherapy during the second and third trimester with no complications for patient and child. Conservative surgery was performed in 15 of 21 patients during pregnancy with no local reappearance after a median follow-up of 24 months. Three pregnant women underwent lymphoscintigraphy and sentinel lymph node biopsy.

CONCLUSIONS

Patients who had concurrent diagnosis of breast cancer and pregnancy (early first trimester) preferred termination of pregnancy to allow easier completion of treatment. Conservative surgery was safe also in women with BCdP. Sentinel node biopsy might be considered for pregnant patients with a clinically negative axilla.

Preoperative and perioperative chemotherapy with 5-fluorouracil as continuous infusion in operable breast cancer expressing a high proliferation fraction: cytotoxic treatment during the surgical phase

BACKGROUND

Experimental data on perioperative chemotherapy (PeCT) indicate that its initiation might be most useful if administered as close as possible to the time of first 'disturbance of the tumour'. Regimens including 5-fluorouracil (5-FU) as continuous infusion are commonly used in the preoperative setting, especially for large tumours and locally advanced disease. We therefore evaluated the role of PeCT with 5-FU as continuous infusion after preoperative chemotherapy (PreCT), covering the surgical phase and acute wound healing period, in patients with breast cancer too large to attempt breast-conserving surgery upon diagnosis.

PATIENTS AND METHODS

Breast cancer patients, clinical stages T2-T3, N0-N2, M0, and Ki-67 labelling index >/= 20%, were treated every 3 weeks with a maximum of six courses of vinorelbine 20 mg total dose intravenously (i.v.) on days 1 and 3, cisplatin 60 mg/ m(2) i.v. on day 1 and 5-FU 200 mg/m(2)/day as a continuous infusion (ViFuP regimen). Patients who achieved a clinical and radiological objective remission with PreCT were also treated with perioperative 5-FU that was continued until 30 min before, and restarted immediately after surgery, prolonging infusion until 15 days after surgery.

RESULTS

Following preoperative treatment, 39 of 49 evaluable patients [80%; 95% confidence interval (CI) 70% to 90%] had an objective response. Pathological complete remission (pCR) was achieved in 14 (29%) patients. No relevant clinical or haematological toxicity due to PeCT was observed. In 36 patients submitted to PeCT the rate of pCR was 33% (95% CI 18% to 48%). The highest response of the primary tumour to PreCT and PeCT was observed in women with tumours not expressing estrogen and progesterone receptors (pCR 46%; 95% CI 19% to 73%).

CONCLUSIONS

Preoperative therapy can be protracted into the surgical (and wound healing) period without significant additional short-term toxicity. Proper selection of patients according to biological features might improve the therapeutic yield of preoperative therapies.

Recognizing features that are dissimilar in male and female breast cancer: expression of p21Waf1 and p27Kip1 using an immunohistochemical assay

BACKGROUND

Male breast cancer (MBC) is an uncommon disease, and most of our current knowledge of its biology, natural history and treatment has been extrapolated from data on the disease in women. Information is still needed on the molecular biological properties of male breast tumors and their predictive relevance. Kinase inhibitor proteins (KIPs) p27Kip1 and p21Waf1 negatively regulate cell cycle progression by preventing the passage of cycling cells from G1 to S phase through G1 cyclin-dependent kinase activation. No studies exist on the role of these factors in male breast carcinoma.

PATIENTS AND METHODS

We have retrospectively analyzed the immunohistochemical expression of p21Waf1 and p27Kip1 protein in 27 primary MBC and in 101 female breast cancers (FBC) treated at the European Institute of Oncology between 1997 and 2000. We also assessed sex hormone receptors status, p53, bcl-2 and c-erb-B2 protein expression, and Ki-67 labeling index.

RESULTS

We observed a statistically significant difference in the immunostaining of KIPs p27Kip1 and p21Waf1 in male patients compared with females. Expression of p21Waf1 was observed in 19 of the 27 (70.3%) primary MBCs versus 29 of 101 FBC (29%). Fourteen of 22 negative c-erbB-2 MBCs cases expressed immunostaining for p21Waf1 (P = 0.05). p27Kip1 immunoreactivity was been detected in 26 of 27 (96.2%) male breast patients versus 39 of 101 FBC (39.3%) (P = 0.000). Highly positive staining for P27Kip1 was found in 21 of 25 androgen receptor-expressing samples. Higher levels of p27Kip1 were expressed in bcl-2-positive samples (17 of 20). Eighteen of 22 c-erbB-2-negative cases were strongly immunoreactive for p27Kip1.

CONCLUSIONS

p27Kip1 and p21Waf1 immunoreactivity is higher in MBCs compared with FBCs. The findings of higher p27Kip1 and p21Waf1 immunostaining may be an additional predictive factor in MBC. These biological features could be possible indicators for different biological pathways in the tumorigenesis of MBCs.

Internal mammary node lymphoscintigraphy and biopsy in breast cancer

BACKGROUND

In patients with breast cancer, sentinel nodes (SNs) are detected outside the axilla in 1-2% of cases after superficial injection of radiocolloid in the breast. We investigated whether deep injection of tracer visualized internal mammary chain lymph (IMC) nodes more often, and assessed the impact of IMC status on disease staging.

METHODS

A total of 400 patients were enrolled in this trial. The study group included 200 patients with T1-T2 N0 breast cancer in an inner quadrant. Radio tracer was injected superficially in 100 (group A), and deeply under the tumor in the others (group B). If an IMC took up tracer in group B patients it was biopsied. An additional 200 patients with outer quadrant lesions were also studied lymphoscintigraphically following superficial (100 patients) or deep (100 patients) injection, but IMC nodes were not biopsied as this would have required an additional surgical excision.

RESULTS

An SN was visualized in the IMC in 65.6% of inner quadrant patients after deep injection and in 2.1% after superficial injection. In outer quadrant patients, deep injection visualized an SN in the IMC in 10% of cases. The IMC SN was located mainly in the 2nd and 3rd intercostal spaces. Radioguided IMC biopsy was performed in 62 patients. Node removal proved simple and risks insignificant. Stage migration occurred in 8% of cases.

CONCLUSIONS

Deep injection allows SN localization in the IMC in 65% of inner quadrant breast lesions. Biopsy of the axillary plus IMC resulted in stage migration in 8% of patients. It is unclear whether this additional information can lead to better survival.

Monoclonal proliferation of germinal center cells (incipient follicular lymphoma) in an axillary lymph node of a melanoma patient

A monoclonal proliferation of germinal center cells within a lymph node follicle was incidentally discovered during the staging surgical procedures in a patient with Clark III-level cutaneous melanoma. In one of the 19 axillary lymph nodes examined, we identified a single morphologically atypical lymphoid follicle, predominantly composed of medium-sized cells and immunoreactive for B-cell antigens and for the markers of germinal center origin CD10 and bcl-6. A monoclonal rearrangement of the immunoglobulins heavy chains (IgH) was documented by polymerase chain reaction after laser capture microdissection. The cells of the aberrant follicle expressed the bcl-2 protein at higher levels than the surrounding T lymphocytes in the absence of bcl-2 gene rearrangement. We propose for this lesion the designation of incipient follicular lymphoma. The present findings also confirm the previously reported association between melanoma and lymphoproliferative disorders.

The problem of the accuracy of intraoperative examination of axillary sentinel nodes in breast cancer

BACKGROUND

Sentinel node (SN) biopsy has become accepted as a reliable method of predicting the state of the axilla in breast cancer. The key issue, however, is the accuracy of the pathological evaluation of the biopsied node, which should be done intraoperatively whenever possible.

METHODS

In our initial experience on 192 patients using a conventional intraoperative frozen section method, the false-negative rate was 6.3%, and the negative predictive value was 93.7%. We devised a new and exhaustive intraoperative method, requiring about 40 minutes, in which pairs of sections are taken every 50 microm for the first 15 sections and every 100 microm thereafter, sampling the entire node. Sentinel node metastases were found in 143 of the 376 T1N0 cases examined (38%).

RESULTS

Metastases were always identified on hematoxylin and eosin sections, although in 4% of cases, cytokeratin immunostaining on adjacent sections was useful for confirming malignancy. In 233 patients the SNs were disease-free; of these patients, 222 had metastasis-free axillary nodes, and 11 (4.7%) had another metastatic node.

CONCLUSION

Extensive intraoperative examination of frozen sentinel nodes correctly predicts an uninvolved axilla in 95.3% of cases (negative predictive value). This method is, therefore, suitable for identifying patients in whom axillary dissection can be avoided.

Mandible reconstruction and autogenous frozen bone graft: experimental study on rats

The aim of this study was to evaluate the biological behaviour of a frozen bone graft in orthotopic and heterotopic sites in the rat. The previous experimental study on this subject was published 25 years ago without sufficient detail about the histology and comparison between the orthotopic and ectopic sites. Therefore, being very important for future clinical application, we decided to evaluate the frozen bone graft using rats. The procedure was performed on two groups of five rats each (Charles River). After wide dissection of the inferior border of the mandible from the surrounding muscle, an inferior segmental resection 4 mm in length was performed, taking care not to fracture the superior part and to maintain mucosal integrity. This segment was placed in liquid nitrogen for two periods of 10 minutes each with a third period to allow it to reach room temperature. In the first group (A), the frozen segment was placed ectopically in a gluteal muscle pocket, and in the second group (B), the frozen bone was fixed in the same position in the same mandible. After 1 month of follow-up, the animals were killed, the bone graft was removed, and histology was performed. Results were consistent in both groups. In group A, the segment was surrounded by strong inflammatory reaction, with no vital cells or bone cells, but some vascular penetration. We concluded that there was no bone deposition and no bone rehabitation. In group B, the initial segment was strongly fixed to the remaining mandible, there was an increase of the macroscopic dimension that paralleled the increase in the dimension of the remaining mandible and the growth of the animal. The cortical part had thinned down, the medullary part presented signs of bone deposition as well as bone resorption and vascular penetration. The periosteum from the adjacent normal mandible was growing and covering the frozen bone graft, offering additional stimulus to the bone deposition. In conclusion, the frozen bone graft acts as a normal bone graft. It needs to be placed in contact with vascularised bone and surrounded by well vascularised soft tissue to allow deposition of new bone. If the frozen graft is placed ectopically, it will be surrounded by chronic inflammatory reaction with no bone deposition.

Sentinel node biopsy in head and neck cancer

The purpose of this study was to assess the value of sentinel node (SN) biopsy in oral cancer by means of a lymphoscintigraphic technique and intraoperative detection by blue-dye combined with gamma-ray probe to facilitate identification of the SN. Forty-one T1-T2N0 patients underwent lymphoscintigraphy, SN biopsy, and modified radical neck dissection. An SN was identified in 39 of 41 patients by the combined use of intraoperative blue dye and the probe and was removed. Complete neck dissections were performed and the histological evaluation compared. Thirty-eight SNs in 35 patients were negative at final pathology and correctly predicted the pathological status of the specimens from the full-neck dissections. Five SNs in four patients had micrometastases and were the only metastatic nodes identified. The results of this study on a homogenous series of patients show that SN biopsy is a valuable staging technique in T1 and T2 oral cancer with uninvolved neck, provided that no previous surgery or radiotherapy has altered lymphatic drainage in the oral cavity or in the neck. In a large number of patients, SN biopsy can avoid unnecessary neck dissection and its relevant morphofunctional sequelae.

Reverse transcription-polymerase chain reaction assay for multiple mRNA markers in the detection of breast cancer metastases in sentinel lymph nodes

The identification of specific tumor mRNA markers by reverse transcription-polymerase chain reaction might be a valuable diagnostic adjunct for the detection of breast cancer metastases in axillary sentinel lymph nodes (SLNs). In this study we have compared the diagnostic accuracy of an extensive histopathologic examination of 146 SLNs from 123 breast carcinoma patients with that of the evaluation of 5 mRNA markers. When analyzed individually, none of the different markers attained a sensitivity higher than 77.8%, and the general concordance with the histopathologic findings ranged from 78.8 to 83.6%. In a multiple-marker assay, taking into account the expression of at least 1 of the 5 tumor markers, the sensitivity of the test rose to 95.6%, with a specificity of 66.3% and a general concordance with the histopathologic status of 75.3%. Finally, when at least 2 of 3 markers (maspin, cytokeratin 19 and mammaglobin 1) were expressed, the concordance with either SLN or axillary lymph node status was highest (88.4% and 84.6%, respectively). The high prevalence of positive reverse transcription-polymerase chain reaction assays in histologically uninvolved SLNs, however, may hamper extensive application of these techniques in the clinical setting.

Reverse transcription-polymerase chain reaction assay for multiple mRNA markers in the detection of breast cancer metastases in sentinel lymph nodes

The identification of specific tumor mRNA markers by reverse transcription-polymerase chain reaction might be a valuable diagnostic adjunct for the detection of breast cancer metastases in axillary sentinel lymph nodes (SLNs). In this study we have compared the diagnostic accuracy of an extensive histopathologic examination of 146 SLNs from 123 breast carcinoma patients with that of the evaluation of 5 mRNA markers. When analyzed individually, none of the different markers attained a sensitivity higher than 77.8%, and the general concordance with the histopathologic findings ranged from 78.8 to 83.6%. In a multiple-marker assay, taking into account the expression of at least 1 of the 5 tumor markers, the sensitivity of the test rose to 95.6%, with a specificity of 66.3% and a general concordance with the histopathologic status of 75.3%. Finally, when at least 2 of 3 markers (maspin, cytokeratin 19 and mammaglobin 1) were expressed, the concordance with either SLN or axillary lymph node status was highest (88.4% and 84.6%, respectively). The high prevalence of positive reverse transcription-polymerase chain reaction assays in histologically uninvolved SLNs, however, may hamper extensive application of these techniques in the clinical setting.

Histologic detection and clinical implications of micrometastases in axillary sentinel lymph nodes for patients with breast carcinoma

BACKGROUND

Sentinel lymph node (SLN) biopsy is used increasingly in patients with clinically lymph node negative, early-stage breast carcinoma, because it can spare axillary dissection when the sentinel lymph nodes are negative. The question arises, however, whether complete axillary lymph node dissection (ALND) also is necessary in patients with only micrometastases (< or = 2 mm in greatest dimension) in axillary SLNs. The authors carried out the current study to ascertain the risk of non-SLN axillary metastases in such patients and to assess the detection rate of SLN micrometastases in relation to the sectioning interval and the number of sections examined.

METHODS

The authors examined 109 patients with micrometastatic SLNs from a series of 634 patients with carcinoma of the breast who underwent SLN biopsy and complete ALND as part of the surgical treatment for their disease. The SLNs were sectioned completely at 50-microm intervals, and the sections were examined intraoperatively.

RESULTS

The overall frequency of metastases in axillary non-SLNs was 21.8%. The frequency was correlated significantly with the size of the SLN micrometastatic focus (P = 0.02): 36.4% of patients with foci > 1 mm had metastases in axillary lymph nodes--a percentage approaching 44.7% of patients with macrometastatic SLNs--whereas only 15.6% of patients with micrometastases < or = 1 mm had other involved axillary lymph nodes.

CONCLUSIONS

Outside of clinical trials, patients with T1 and small T2 breast carcinoma and micrometastatic SLNs should undergo complete ALND for adequate staging. However, patients with SLN micrometastases up to 1 mm in greatest dimension have a significantly lower risk of additional axillary metastases, raising the question of whether ALND may be avoided in this subgroup of patients.

Life-threatening giant mediastinal goiter: a surgical challenge

Mediastinal goiter is a well known benign disease, usually resectable through a cervical approach with minimal morbidity and mortality. Only occasionally a median sternotomy or a lateral thoracotomy may be required. The present case is worthy of presentation because of the exceptional dimension of the disease and the surgical challenge that it presented. In a 72-year-old woman a large intrathoracic goiter of the right thorax caused a severe dyspnoea due to an important contralateral mediastinal shift with compression of the lung, superior vena cava system and trachea. At surgical exploration, through a cervico-sternotomic approach, the mediastinal structures dislocation and the strong adherences between the anomalous neovascularized capsula of the mass and the surrounding structures, complicated the surgical dissection. An accidental lesion of the innominate artery required its reimplantation on the ascending aorta. An immense mass, was finally removed and pathological examination revealed a rare case of neovascularized, pseudosarcomatoid capsula among a benign hyperplastic proliferation. In spite of its benign nature, a giant goiter caused a life-threatening compression of the respiratory tract and lung parenchyma in this patient. The dimension of the lesions, the mediastinal anatomy alterations and the severe intraoperative haemorrhage represented major technical difficulties during surgical resection.

Inhibition of matrix metalloproteinases by over-expression of tissue inhibitor of metalloproteinase-2 inhibits the growth of experimental hemangiomas

Inhibitors of proteases prevent tumor-associated matrix degradation, affecting tumor growth, angiogenesis and metastasis. Our study was designed to investigate the effect of inhibition of matrix metalloproteinases (MMPs) on the growth of experimental hemangiomas, using the model of murine endothelioma eEnd.1 cells. In nude mice, these cells generate hemangiomas, consisting mostly of host-recruited endothelial cells, whose growth requires the activity of MMPs. In vitro, eEnd.1 cells produce factors that recruit endothelial cells and stimulate them to release MMPs. Over-expression of TIMP-2, following retrovirus-mediated gene transfer, decreased tumor growth in vivo. The infected clone CR1, which produces high levels of TIMP-2 (as assessed by Northern blot, ELISA and reverse zymography), formed slow-growing tumors that did not grow beyond 0.4 g, while clone 1H, which produces little TIMP-2, grew not dissimilarly to mock-infected cells and parental e.End.1 cells. Histologically, control tumors presented the features of cavernous hemangiomas, while CR1 tumors had a more solid pattern, showing foci of apoptotic cells. In vitro, TIMP-2 over-expression had no autocrine anti-proliferative effect on endothelioma cells but reduced their ability to recruit endothelial cells. CR1 cells lacked the capacity of mock-infected or parental eEnd.1 cells to stimulate endothelial cell motility and invasiveness. Antibodies against TIMP-2 restored the ability of CR1 to induce endothelial cell invasion. We conclude that, in this model, genetic increase of TIMP-2 inhibits tumor growth, apparently by affecting the recruitment and organization of host endothelial cells by the transformed cells.

Huge malignant localized fibrous tumor of the pleura

Localized fibrous tumor is an unfrequent mesenchymal neoplasm. The malignant variant of the pleura is exceptional and differential diagnosis with the more frequent benign type or with other neoplasms such as soft tissue sarcoma and mesothelioma is rarely possible in a preoperative setting. The best treatment of this disease is radical surgical resection. No definitive data exist about the role of chemotherapy. We report a case of a giant right intrathoracic mass whose preoperative diagnosis, from an open biopsy, was consistent with sarcoma and, in a second review, with fibrous tumor of the pleura without any indication about malignancy. A right pleuropneumonectomy and pericardial resection was performed through a right hemiclam-shell approach. Histology demonstrated an aggressive behaviour: high mitosis rate, Ki 67 of 34% and diffuse necrosis were present. In consideration of the apparent local radicality we did not perform any adjuvant treatment. Six months after the operation a wide local recurrence was evident and a systemic treatment with Ifosfamide and Adriamicina is still in progress. So far a good response has been documented. Preoperative diagnosis of malignancy has an important role as a therapeutic strategy in management of fibrous tumours of the pleura. When there is suspicion of a malignant form neoadjuvant chemotherapy can represent a further tool to control poorly differentiated and large tumors, and a wide surgical resection of the lesion must be performed.

Response to primary chemotherapy in breast cancer patients with tumors not expressing estrogen and progesterone receptors

BACKGROUND

We recently demonstrated that in premenopausal patients with estrogen receptors (ER)-absent tumors, early initiation of systemic chemotherapy after primary surgery might improve outcome. These data indicate a different responsiveness to chemotherapy for tumors not expressing hormone receptors. To test this hypothesis we evaluated the responsiveness to preoperative chemotherapy in patients with ER and progesterone receptors (PgR)-absent tumors.

PATIENTS AND METHODS

Patients with biopsy-proven T2-T3, N0-2 breast cancer treated at a single institution from January 1995 to August 1999 with preoperative chemotherapy were retrospectively evaluated. ER and PgR were determined immunohistochemically and classified for this purpose as absent (0% of the cells positive) or positive (> or = 1% of the cells).

RESULTS

On 117 evaluable patients 72 had an objective response (61%). A significant difference in response was observed for patients with ER and PgR absent compared with those with ER and/or PgR-positive tumors (82% vs. 57%, P = 0.03 Fishers's exact test). Pathological complete remission rates were also significantly different in the two groups (23% vs. 7%, respectively; P = 0.04).

CONCLUSIONS

The different degree of response according to hormone receptors expression supports the hypothesis that tumors not expressing both ER and PgR might represent a different clinical entity in terms of chemotherapy responsiveness.

Is there a role for sentinel node biopsy in early N0 tongue tumors?

BACKGROUND

Detecting metastases to the cervical lymph nodes is the main problem in the management of squamous cell carcinoma of the tongue. We investigated the ability of sentinel node (SN) biopsy to predict neck status in 11 patients with lateral T1-T2, N0, and M0 squamous cell carcinoma of the tongue who underwent ipsilateral neck dissection 30 to 40 days after primary surgery.

METHODS

In 5 patients, technetium 99m-labeled particles were injected close to the operation scar on the day before neck dissection, and the labeled neck nodes were revealed by lymphoscintigraphy. The next 6 patients underwent lymphoscintigraphy both before surgery and before neck dissection. During neck dissection, the ipsilateral SNs were identified by using a hand-held probe and removed separately.

RESULTS

Three patients (27%) had metastatic neck nodes. In all cases, labeled nodes were revealed by scintigraphy. Ipsilateral SNs were removed from 8 patients and correctly predicted the state of the neck (6 negatives and 2 positives). Lymphoscintigraphy before and after surgery revealed that drainage was modified after surgery in 5 of 6 patients; the pre-surgery drainage pattern varied markedly among the 5 pN0 patients.

CONCLUSIONS

The technique allows easy and safe identification of SNs and shows promise in guiding selective neck dissection. Surgery on the primary tumor often modifies lymphatic drainage, so that SN biopsy may only be useful if the primary operation and neck dissection are performed at the same time.

Sentinel node localization in primary melanoma: learning curve and results

Ninety primary melanoma patients were studied to investigate the importance of adopting the simultaneous use of patent blue dye (PBD) and lymphoscintigraphy plus gamma detection probe to locate the sentinel node (SN). In total 135 SNs in 105 basins were visualized preoperatively under a gamma camera after lymphoscintigraphy. When a SN was identified intraoperatively, its radioactivity level and colour were verified and documented. Two of the SNs seen on lymphoscintigraphy were not found. Using PBD 78.52% of the SNs were identified; 95.5% were identified using the gamma detection probe. Using both methods together 98.5% of the SNs were detected. Twenty-two patients (24.4%) had pathologically positive SNs. The surgical learning curve was assessed for the two techniques. The learning curve associated with the methodology was important in finding the SN when using PBD associated with lymphoscintigraphy, but not when the gamma detection probe was used; we found a statistically significant reduction in the percentage of stained SNs found using PBD in the initial 14 SNs biopsied compared with the subsequent 121 nodes. This is important as not all institutions have access to a gamma probe. The time required to identify each SN was documented and analysed. The duration of the procedure was significantly shorter for stained SNs than for non-stained SNs, which support the use of both PBD and the gamma probe. In conclusion, SN biopsy should be performed by surgeons and nuclear medicine doctors in co-operation, both methods being adopted simultaneously to reduce the percentage of procedure failures.

Rare presentation of small bowel leiomyosarcoma with liver metastases

Intraabdominal sarcomas are rare tumours usually diagnosed at an advanced stage. These lesions at presentation are bulky and symptoms are often related to pressure effects on adjacent organs. This case report describes a rare presentation of a small bowel leiomyosarcoma whose initial presentation was free haemorrhage into the abdominal cavity and concomitant liver metastases. This case report also demonstrates that, even with such a rare presentation, an aggressive surgical approach is indicated in this type of tumour and helps a patient with advanced disease to live a few disease-free months with a good quality of life.

p21WAF1/CIP1 expression in colorectal carcinoma correlates with advanced disease stage and p53 mutations

Defects in the mechanisms controlling the cell cycle are crucial in cell transformation and/or tumour progression. p21WAF1/CIP1 is an inhibitor of cyclin-dependent kinases, induced by p53-dependent and p53-independent pathways, which can block progression through the cell cycle. p21WAF1/CIP1 expression has been investigated immunohistochemically in a series of 191 patients with colorectal cancer of known p53 status. The purpose of the study was two-fold: to assess the relationship between p21WAF1/CIP1 immunoreactivity and p53 alterations, and to evaluate the prognostic significance of p21WAF1/CIP1 expression. In 96 carcinomas (51 per cent), p21WAF1/CIP1 was expressed in over 10 per cent of tumour cells, whereas in 26, p21WAF1/CIP1 was detected in under 10 per cent of neoplastic cells; 69 tumours lacked p21WAF1/CIP1 expression. Immunoreactivity was more frequent in tumours of the right colon (p < 0.003) and was inversely correlated with tumour stage (p < 0.03), p53 gene mutations (p < 0.0007), p53 protein accumulation (p < 0.019), and Bcl-2 expression (p < 0.0005). In univariate analysis, down-regulation of p21WAF1/CIP1 expression was associated with poor overall (p = 0.0022) and disease-free survival (p = 0.0009). Multivariate analysis, however, did not confirm any independent prognostic significance of p21WAF1/CIP1 expression. The results indicate that p21WAF1/CIP1 is associated with abnormal accumulation of p53 protein and the occurrence of p53 gene mutations in colorectal cancer and that lack of p21WAF1/CIP1 expression is correlated with reduced patient survival in univariate analysis. These data underline the crucial pathogenetic role of the p53-p21WAF1/CIP1 pathway in carcinomas of the large bowel.

Sentinel node localisation: A new prospective in the treatment of nodal melanoma metastases

Sentinel node (SN) mapping and biopsy is a procedure that accurately stages the regional lymph node (LN) basin. Defined patterns of lymphatic drainage allow intraoperative determination of the first (sentinel) lymph node in the regional basin, and the absence of metastatic disease in the SN accurately reflects the absence of melanoma in the remaining regional nodes. The use of radiocolloid and a hand-held gamma detecting probe (GDP) together with a vital blue dye provides optimal results, and allows for the successful identification of the SN in over 99% of the procedures. Close collaboration between surgeons, nuclear radiologists and pathologists is required to ensure optimal results. Examination of serially sectioned SNs by hematoxylin-eosin staining (H&E), immunohistochemical staining and perhaps in the near future RT-PCR should reduce the number of patients with missed microscopic melanoma in the regional lymph nodes. Furthermore, the survival benefit recently reported in patients with melanoma metastatic to regional nodes using high dose of interferon alpha-2b signals that the surgeons should aggressively examine patients for the presence of occult regional melanoma metastases. Intraoperative SN mapping and SN biopsy are cost-effective procedures that allows accurate identification of regional lymph nodes that contain metastatic melanoma.

Medical decision making for melanoma of the glans penis

This case report describes a rare presentation of penile melanoma in which 3 successive primaries arose and were operated from an area of melanosis on the glans penis and prepuce. One of the major factors accounting for the poor prognosis of this patient was the long delay in presentation. This was largely due to the patient's reluctance because of the site of the disease. When diffuse melanotic areas are present in the genital region, in particular given the reluctance of patients with skin lesions in this region to present, the index of suspicion should be high with respect to the risk of transformation and an aggressive follow-up policy should be advocated. Treatment guidelines should not significantly differ from the usual approach of cutaneous melanoma.

Intraoperative examination of axillary sentinel lymph nodes in breast carcinoma patients

BACKGROUND

Routine histologic examination of axillary sentinel lymph nodes predicts axillary lymph node status and may spare patients with breast carcinoma axillary lymph node dissection. To avoid the need for two separate surgical sessions, the results of sentinel lymph node examination should be available intraoperatively. However, routine frozen-section examination of sentinel lymph nodes is liable to yield false-negative results. This study was conducted to ascertain whether extensive intraoperative examination of sentinel lymph nodes by frozen section examination would attain a sensitivity comparable to that obtained by routine histologic examination without intraoperative frozen section examination.

METHODS

In a consecutive series of 155 clinically lymph node negative breast carcinoma patients, the axillary sentinel lymph nodes were examined intraoperatively, before complete axillary lymph node dissection. The frozen sentinel lymph nodes were sectioned subserially at 50-microm intervals. For each level, one section was stained with hematoxylin and eosin and the other section immunostained for cytokeratins using a rapid immunocytochemical assay.

RESULTS

Sentinel lymph node metastases were detected in 70 of the 155 patients (45%). In 37 cases the sentinel lymph nodes were the only axillary lymph nodes with metastases. Immunocytochemistry did not increase the sensitivity of the examination. Five patients had metastases in the nonsentinel axillary lymph nodes despite having negative sentinel lymph nodes. The general concordance between sentinel and axillary lymph node status was 96.7%; the negative predictive value of intraoperative sentinel lymph node examination was 94.1%.

CONCLUSIONS

The intraoperative examination of axillary sentinel lymph nodes is effective in predicting the axillary lymph node status of breast carcinoma patients and may be instrumental in deciding whether to spare patients axillary lymph node dissection.

p21WAF1/CIP1 expression in colorectal carcinoma correlates with advanced disease stage and p53 mutations

Defects in the mechanisms controlling the cell cycle are crucial in cell transformation and/or tumour progression. p21WAF1/CIP1 is an inhibitor of cyclin-dependent kinases, induced by p53-dependent and p53-independent pathways, which can block progression through the cell cycle. p21WAF1/CIP1 expression has been investigated immunohistochemically in a series of 191 patients with colorectal cancer of known p53 status. The purpose of the study was two-fold: to assess the relationship between p21WAF1/CIP1 immunoreactivity and p53 alterations, and to evaluate the prognostic significance of p21WAF1/CIP1 expression. In 96 carcinomas (51 per cent), p21WAF1/CIP1 was expressed in over 10 per cent of tumour cells, whereas in 26, p21WAF1/CIP1 was detected in under 10 per cent of neoplastic cells; 69 tumours lacked p21WAF1/CIP1 expression. Immunoreactivity was more frequent in tumours of the right colon (p < 0.003) and was inversely correlated with tumour stage (p < 0.03), p53 gene mutations (p < 0.0007), p53 protein accumulation (p < 0.019), and Bcl-2 expression (p < 0.0005). In univariate analysis, down-regulation of p21WAF1/CIP1 expression was associated with poor overall (p = 0.0022) and disease-free survival (p = 0.0009). Multivariate analysis, however, did not confirm any independent prognostic significance of p21WAF1/CIP1 expression. The results indicate that p21WAF1/CIP1 is associated with abnormal accumulation of p53 protein and the occurrence of p53 gene mutations in colorectal cancer and that lack of p21WAF1/CIP1 expression is correlated with reduced patient survival in univariate analysis. These data underline the crucial pathogenetic role of the p53-p21WAF1/CIP1 pathway in carcinomas of the large bowel.