Optimising remanufacturing decision-making using the bees algorithm in product digital twins

Remanufacturing is widely recognised as a key contributor to the circular economy (CE) as it extends the in-use life of products, but its synergy with Industry 4.0 (I4.0) has received little attention when compared to manufacturing. An agglomeration of I4.0 technologies and methodologies is reflected in the emerging digital twin (DT) concept, which has been identified as a life-extending enabler. This article captures the design and demonstration of a DT model that optimises remanufacturing planning using data from different instances in a product's life cycle. The model uses a neural network for remaining useful life predictions and the Bees Algorithm for decision making within a DT. The model is validated using a real case study. The findings support the idea that intelligent tools within a DT can enhance decision-making if they have visibility and access to the product's current status and reliable remanufacturing process information.

O39: THE HISTOPATHOLOGICAL AND MOLECULAR FEATURES OF BREAST CARCINOMA WITH HIGH-GRADE TUMOUR BUDDING

Background

Tumour budding (TB) is an adverse histological feature in many cancers. It is thought to represent epithelial-to-mesenchymal transition, a key step in the metastatic process. The role of TB in breast carcinoma (BC) remains unclear.

Aim

To investigate the relationship between TB and other histological and molecular features of BC.

Method

A systematic search was performed to identify studies that compared features of BC based on the presence or absence of high-grade TB. Dichotomous variables were pooled as odds ratios (OR) using the Cochran–Mantel–Haenszel method. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale (NOS).

Result

Seven studies with a total of 1040 patients (high grade TB n=519, 49.9%; low grade TB n=521, 50.1%) were included. A moderate- to high-risk of bias was noted. The median NOS was 7 (range 6-8). High-grade TB was significantly associated with lymph node involvement (OR 2.28, 95% c.i. 1.74 to 2.98, P<0.001) and lymphovascular invasion (OR 3.08, 95% c.i. 2.13 to 4.47, P<0.001). Regarding molecular subtypes, there was an increased likelihood of high-grade TB in oestrogen- (OR 1.66, 95% c.i. 1.21 to 2.29, P=0.002) and progesterone-receptor positive (OR 1.68, 95% c.i. 1.10 to 2.59, P=0.02) tumours. In contrast triple negative breast cancer had a reduced incidence of high-grade TB (OR 0.46, 95% c.i. 0.30 to 0.72, P=0.0006).

Conclusion

High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

Take-home message

High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The presentation, management and outcome of inflammatory breast cancer cases in the UK: Data from a multi-centre retrospective review

OBJECTIVES

Inflammatory Breast cancer (IBC) is a rare but aggressive form of breast cancer. Its incidence and behaviour in the UK is poorly characterised. We collected retrospective data from hospitals in the UK and Ireland to describe the presentation, pathology, treatment and clinical course of IBC in the UK.

MATERIALS AND METHODS

Patients with IBC diagnosed between 1997-2014 at fourteen UK and Irish hospitals were identified from local breast unit databases. Patient characteristics, tumour pathology and stage, and details of surgical, systemic and radiotherapy treatment and follow-up data were collected from electronic patient records and medical notes.

RESULT

This retrospective review identified 445 patients with IBC accounting for 0.4-1.8% of invasive breast cancer cases. Median follow-up was 4.2 years. 53.2% of tumours were grade 3, 56.2% were oestrogen receptor positive, 31.3% were HER2 positive and 25.1% were triple negative. 20.7% of patients had distant metastases at presentation. Despite trimodality treatment in 86.4%, 40.1% of stage III patients developed distant metastases. Five-year overall survival (OS) was 61.0% for stage III and 21.4% for stage IV patients.

CONCLUSIONS

This is the largest series of UK IBC patients reported to date. It indicates a lower incidence than in American series, but confirms that IBC has a high risk of recurrence with poor survival despite contemporary multi-modality therapy. A national strategy is required to facilitate translational research into this aggressive disease.

Improving diagnostic accuracy in clinically ambiguous paediatric appendicitis: a retrospective review of ultrasound and pathology findings with focus on the non-visualised appendix

OBJECTIVE

To compare pre-operative ultrasound to histopathological results and retrospectively assess the diagnostic accuracy of ultrasound in paediatric appendicitis.

METHODS

5 year review of all appendectomies performed in patients <16 years old in a tertiary referral university hospital. 983 patients had an appendicectomy over the time period while 189 patients had a preoperative ultrasound. We retrospectively reviewed all of the preoperative imaging in conjunction with the reports for the 189 patients; our aim was to determine the sensitivity of preoperative ultrasound for the diagnosis of acute appendicitis.

RESULTS

Of the 189 patients who had an ultrasound, 102 had histology positive for appendicitis and 87 had normal histology. Sensitivity overall was 72.55% [95% confidence interval (CI) 62.82 to 80.92] and specificity was 77.01% (95% CI 66.75 to 85.36). A suggested ultrasound diagnosis of appendicitis made positive pathology three times more likely and a normal ultrasound made positive pathology three times less likely [positive-predictive value 3.16 (95% CI 2.11 to 4.72) negative predictive value 0.36 (95% CI 0.25 to 0.50)]. 77% (67/87) of the patients whose pathology was ultimately normal had an ultrasound which was either normal or suggested an alternative diagnosis. However, in the 33 (17%) of patients with a non-visualised appendix, no secondary signs of inflammation or alternative diagnosis 16 (48%) had pathologically confirmed appendicitis.

CONCLUSION

Ultrasound has the potential to improve diagnostic accuracy in clinically ambiguous appendicitis.

ADVANCES IN KNOWLEDGE

This paper furthers the evidence on the efficacy of ultrasound as a diagnostic tool in acute appendicitis in children, especially when the diagnosis is clinically equivocal. It also sheds further light on the "non-visualized appendix" with almost half of these patients having pathologically confirmed appendicitis; meaning advanced imaging with CT or MR may be indicated in this cohort.

Trends in breast reconstruction practices in a specialized breast tertiary referral centre

BACKGROUND

Breast reconstruction is an important component of multidisciplinary breast cancer management. The practice of breast reconstruction after mastectomy has evolved significantly in the past decade as a result of both increasing mastectomy rates and advances in reconstructive strategy. These changes have significantly influenced the contemporary surgical management of breast cancer. The aim of this study was to examine trends in breast reconstruction after mastectomy in an Irish population.

METHODS

Data were reviewed from a database of all patients who had mastectomy with or without breast reconstruction at Galway University Hospital, a tertiary breast cancer referral centre, between 2004 and 2014. Trends in breast reconstruction after mastectomy were explored with respect to patient demographics, clinicopathological features, and neoadjuvant and adjuvant therapy.

RESULTS

Of 1303 patients who underwent mastectomy during interval studied, 706 (54.2 per cent) had breast reconstruction after mastectomy. In 629 patients (89·1 per cent), breast reconstruction was performed in the immediate setting. Reconstruction rates increased over time from 20·5 per cent in 2004 to 44·7 per cent in 2014. Reconstruction was more commonly performed in younger patients and those with benign, in situ and early-stage disease. A negative relationship between radiotherapy and reconstruction was observed. A pedicled flap with or without an implant was the most commonly used reconstructive approach in patients receiving radiotherapy.

CONCLUSION

Breast reconstruction after mastectomy has become the standard of care in the surgical treatment of breast cancer. Recent trends show a transition favouring implant-based approaches.

Utilisation of Clinical Networks to Facilitate Elective Surgical Workload; A Preliminary Analysis

Clinical networks have potential to increase elective surgical workload for benign conditions in non-cancer centres. The aims of this study were to determine outcomes for elective laparoscopic cholecystectomy in our unit and to evaluate early experience in managing benign surgical workload referred from the tertiary centre within our clinical network. An analysis of cholecystectomies performed at Mayo General Hospital was conducted (2003-2013). A review of elective procedures more recently referred from Galway University Hospital (GUH) waiting lists was also conducted. 1937 consecutive cholecystectomies were performed with an overall laparoscopic conversion rate of 1.7% (33/1875). The total major complication rate was 0.93% (18/1937). 151 selected procedures originating from GUH have been performed since December 2013 without adverse events. Laparoscopic cholecystectomy can be performed in significant volume in the general hospital environment. This and other appropriate benign surgical procedures may be performed outside of tertiary units according to network agreements.

Targeted resequencing of the microRNAome and 3'UTRome reveals functional germline DNA variants with altered prevalence in epithelial ovarian cancer

Ovarian cancer is a major cause of cancer deaths, yet there have been few known genetic risk factors identified, the best known of which are disruptions in protein coding sequences (BRCA1 and 2). Recent findings indicate that there are powerful genetic markers of cancer risk outside of these regions, in the noncoding mRNA control regions. To identify additional cancer-associated, functional non-protein-coding sequence germline variants associated with ovarian cancer risk, we captured DNA regions corresponding to all validated human microRNAs and the 3' untranslated regions (UTRs) of ~6000 cancer-associated genes from 31 ovarian cancer patients. Multiple single-nucleotide polymorphisms in the 3'UTR of the vascular endothelial growth factor receptor/FLT1, E2F2 and PCM1 oncogenes were highly enriched in ovarian cancer patients compared with the 1000 Genome Project. Sequenom validation in a case-control study (267 cases and 89 controls) confirmed a novel variant in the PCM1 3'UTR is significantly associated with ovarian cancer (P=0.0086). This work identifies a potential new ovarian cancer locus and further confirms that cancer resequencing efforts should not ignore the study of noncoding regions of cancer patients.

FGF receptor genes and breast cancer susceptibility: results from the Breast Cancer Association Consortium

BACKGROUND

Breast cancer is one of the most common malignancies in women. Genome-wide association studies have identified FGFR2 as a breast cancer susceptibility gene. Common variation in other fibroblast growth factor (FGF) receptors might also modify risk. We tested this hypothesis by studying genotyped single-nucleotide polymorphisms (SNPs) and imputed SNPs in FGFR1, FGFR3, FGFR4 and FGFRL1 in the Breast Cancer Association Consortium.

METHODS

Data were combined from 49 studies, including 53 835 cases and 50 156 controls, of which 89 050 (46 450 cases and 42 600 controls) were of European ancestry, 12 893 (6269 cases and 6624 controls) of Asian and 2048 (1116 cases and 932 controls) of African ancestry. Associations with risk of breast cancer, overall and by disease sub-type, were assessed using unconditional logistic regression.

RESULTS

Little evidence of association with breast cancer risk was observed for SNPs in the FGF receptor genes. The strongest evidence in European women was for rs743682 in FGFR3; the estimated per-allele odds ratio was 1.05 (95% confidence interval=1.02-1.09, P=0.0020), which is substantially lower than that observed for SNPs in FGFR2.

CONCLUSION

Our results suggest that common variants in the other FGF receptors are not associated with risk of breast cancer to the degree observed for FGFR2.

Abstract P3-08-04: Impact of CYP3A variation on estrone levels and breast cancer risk

Background: Epidemiological studies provide strong evidence for a role of endogenous sex steroids in the etiology of breast cancer. Our aim was to identify common variants in genes involved in sex steroid synthesis or metabolism that were associated with premenopausal hormone levels and breast cancer risk.

Methods: We measured urinary estrone glucuronide (E1G) and pregnanediol glucuronide (PG) using a protocol specifically developed to account for cyclic variation in hormone levels during the menstrual cycle, plasma sex hormone-binding globulin (SHBG) and androgenic precursors in up to 763 healthy premenopausal women. We genotyped 642 single nucleotide polymorphisms (SNPs) in these women; a single SNP was further tested for association with breast cancer risk in data from 10,551 breast cancer case patients and 17,535 control subjects. All statistical tests were two-sided.

Results: rs10273424 mapping approximately 50kb centromeric to the cytochrome P450 3A (CYP3A) cluster (7q22.1) was associated with a 21.8% reduction in E1G levels (P = 2.7 × 10−9) and a modest reduction in breast cancer risk in cases diagnosed at or before age 50 (OR = 0.91; P = 0.03) but not older cases (odds ratio (OR) = 1.01; P = 0.82). A rare non-synonymous SHBG SNP was associated with reduced plasma SHBG levels.

Conclusions: Genetic variation in non-coding sequences flanking the CYP3A locus contributes to variance in premenopausal E1G levels and breast cancer risk in younger cases. Since CYP3A4, the most predominantly expressed CYP3A gene, is responsible for metabolism of endogenous and exogenous hormones and hormonal agents such as tamoxifen, used in the treatment of breast cancer this association may have wider implications.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-08-04.

ONCOPOOL - a European database for 16,944 cases of breast cancer

ONCOPOOL is a retrospectively compiled database of primary operable invasive breast cancers treated in the 1990s in 10 European breast cancer Units. Sixteen thousand and nine hundred and forty four cases were entered, with tumours less than 5 cm diameter in women aged 70 or less (mean age 55).

DATA

Data were date of birth, mode of diagnosis, pathology (size, lymph node status, grade, type, lympho-vascular invasion and hormone receptor) and therapies and outcome measures: first local, regional or distant recurrences, contralateral primary, date and cause of death.

TUMOUR CHARACTERISTICS

Mean diameter 1.8 cm, 66% lymph node negative, 24% 1-3 lymph nodes involved and 10% had 4 or more involved. Grade 1, 29%; Grade 2, 41%; and Grade 3, 30%. Polynomial relationships were established between grade, stage and size. Seventy-five percent were oestrogen receptor (ER) positive. ER closely related to grade.

OUTCOMES

Overall Survival was 89% at 5 years from diagnosis, 80% 10 years and 73% 15 years; Breast Cancer-Specific survivals were 91%, 84% and 79%. Survival strongly related to the Nottingham Prognostic Index (NPI). Cases detected at screening had 84% 10-year survival, those presenting symptomatically 76%. ER positive cases treated with adjuvant hormone therapy had a reduction in risk of death of 13% over those not receiving adjuvant therapy (p=0.000). ER negative cases treated with chemotherapy showed a risk reduction of 23% over those not receiving chemotherapy (p=0.000).

Analysis of Primary Breast Tumour Stromal Cells and Their Potential Role in Disease Progression

It has emerged in recent years that interaction between breast cancer stromal and epithelial cells supports tumour progression through promotion of epithelial cell growth, migration and invasion. Although this is thought to be mediated through both secretion of paracrine factors and cell-cell contact, the precise mechanisms are poorly understood. The aim of this study was to further characterise stromal cells derived from primary breast tumours and potentially elucidate mechanisms through which they exert their action.Following written informed consent, specimens of human breast cancer were harvested from patients undergoing surgery. Cells were isolated from tumour (n=19) and tumour-associated normal (TAN, n=9) regions of breast tissue. Breast tissue obtained from reduction mammoplasty served as normal controls. Following tissue dissociation and digestion, stromal cells were isolated by differential centrifugation. Following culture of stromal cells, RNA was extracted, reverse transcribed and relative quantitative PCR performed using primers targeting Fibroblast Activation Protein (FAP), Transforming Growth Factor β (TGFβ), Transforming Growth Factor β Receptor II (TGFβRII), Matrix Metalloproteinase 3 (MMP3), and Vascular Endothelial Growth Factor A (VEGF A).There was a trend towards increased expression of VEGF A, TGFβRII and MMP3 in tumour compared to normal stromal cells, while the level of TGFβ expression was equivalent in all samples examined. There was a significant positive correlation between expression of the proangiogenic factor VEGF A and TGFβRII (Pearson correlation coefficient r=0.317, p&lt;0.05). There was also a significant positive correlation between expression of FAP and TGFβRII (r=0.404, p&lt;0.05).Tumour stromal cells have the potential to stimulate angiogenesis through secretion of paracrine factors such as VEGF. This proangiogenic factor is a known target of the TGFb signalling pathway. The elevated level of TGFβRII observed in this study may support TGFβ mediated upregulation of VEGF and thus promote tumour angiogenesis. Further characterisation of stromal cells and their impact on epithelial cell genotype and phenotype is critical to identify targets to inhibit initiation of the metastatic cascade.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4163.

The Relationship between Breast Cancer and Research; a Bibliometric Study

Background: Thousands of articles are published every year in the medical literature relating to the diagnosis and treatment of cancer patients. An area of contention of late has been the amount of research time and money being devoted to breast cancer, to what some believe is to the detriment of research into other forms of malignancy. The aims of this study were to further investigate the relationship between malignancy and research, in order to better quantify the degree to which breast cancer is being over- or under-represented in the research world.Methods: Bibliometrics is the science of studying written communication by systematic measurement and analysis of research publications. In this study, we examined research output over a one-year period for the 26 most commonly diagnosed cancers in the UK. Our strategy was based on that employed by a group in Edinburgh in 2001, and involved correlating research output with incidence and mortality statistics. In addition, we sought to elucidate changes in research output over time and then to correlate these changes with improvements in survival. The survival data used was that published by Coleman et al in 2004, and represents changes in survival over 5 year periods between 1986 and 1999 in England and Wales.Results: A total of 73,798 publications were included in this study. Breast cancer received more research attention than any other malignancy in the time period of this study. Proportional to its incidence and associated mortality, however, breast cancer was markedly underrepresented. This relationship was consistent across publication and study types, and in the higher impact journals. There was a strong positive correlation between improvement in 5-year survival and research output (p = 0.003). Those malignancies enjoying the greatest increases in output included those involving the prostate, non-hodgkins lymphoma, breast and vaginal cancer.Conclusions: This study was intended to provide a snapshot-in-time of research output in malignancy. It has shown that, on the basis of both incidence and mortality, breast cancer is not receiving disproportionate attention by the research community, contrary to popular opinion. Whilst the absolute figures clearly reflect the success of the breast cancer advocacy community in raising and maintaining the profile of the disease, the evidence suggests that, if anything, breast cancer is not receiving the interest it deserves, based on its burden to society.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1080.

Characterisation of 17q12-21 – Identification of Novel Therapeutic Targets

Introduction: Over-expression of the HER2/neu oncogene is associated with poorer clinical outcome in breast cancer. Notwithstanding the success achieved with Trastuzumab in treating HER2/neu positive patients, numerous questions remain. In particular, there are concerns regarding accurate identification of HER2/neu positivity and the correct management of these patients in terms of the dosage, timing and optimal combination of Trastzumab with chemotherapeutic regimens. One approach to answering these questions has been to focus on the area of chromosome 17 in which HER2/neu is located in order to identify other genes in the vicinity. As potential therapeutic targets, we examined the amplification and expression patterns of co-localised cancer-associated genes at the HER2/neu amplicon on chromosome 17.Aims: The primary objective of this study was to examine amplification and expression patterns of co-localised genes at 17q12-21. In doing so, we aimed to establish their relationship with HER2/neu positivity, and then to quantify their relative importance in developing a gene panel predictive of HER2/neu status.Methods: Breast tissue from a cohort of patients with HER2/neu positive (n=48) and negative (n=48) tumours was retrieved at time of surgery. Protein and gene expression levels were determined using immunohistochemistry and RQ-PCR, respectively. Results were analysed to detect patterns of amplification among the genes, namely HER2/neu, STARD3, GRB7, TOP2A, TUBG1, RPL19, LASP1, RARA, and ER Alpha, and to identify associations between expression levels and clinical data. A binary logistic approach and classification tree analysis was employed to determine whether the expression levels of our target genes were useful predictors of HER2/neu status.Results: Strong correlation was noted between expression levels of HER2/neu and multiple cancer-associated genes at 17q12-21, including the novel genes LASP1 (p=0.000) and RPL19 (p=0.000). A significant relationship was also noted between TOP2A and the previously unexplored TUBG1 (p=0.000). Analysis of gene expression patterns according to clinicopathological variables revealed significant associations across intrinsic breast cancer subtypes.Conclusion: This study reaffirms the correlation between HER2/neu and its co-localised genes at 17q12-21, including novel candidate genes LASP1 and RPL19. We have also identified a novel relationship between TOP2A and TUBG1. Furthermore, our work represents a tentative step in the development of more accurate means of characterising HER2/neu status. As such, this work has again indicated the central role which this amplicon may play in selection of patients for treatment, not alone for Herceptin and anthracyclines, but also for taxane-based therapies, and as such, has revealed novel pathways for us to follow as we move towards our goal of individually tailored therapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3137.

Bilateral Breast Cancer: Analysis of Incidence, Characteristics and Outcome of the Disease

Background: Despite the widespread adoption of breast conservation therapy in breast cancer, there is a dramatic increase in the rate of bilateral mastectomy in USA. The aim of this study was to address the incidence of bilateral breast cancer (BBC) and to investigate its characteristics, survival and outcome compared to unilateral breast cancer.Methods: Data was acquired from the prospectively maintained NUI Galway breast cancer database between 1988 and 2008. BBC were then categorized as synchronous (within 12 months) or metachronous cancer (after 12 months of first tumour). SPSS was used for data analysis.Results: The incidence of bilateral breast cancer in our population was 4.4% (112 of 2524). Of those 2.1% were synchronous while 2.3% were metachronous. Compared to unilateral cases, bilateral cancer patients were younger (0=0.021) and had smaller size (p=0.001) and earlier stage (p&lt;0.001) tumours at diagnosis. There were no differences in histological type (p=0.630) and grade (p=0.054)). While there was no significant difference in survival for patients with bilateral compared to unilateral tumour (p&gt;0.05), the synchronous bilateral tumour was associated with poor overall survival (p=0.010) and disease free survival (p=0.013) in comparison to metachronous bilateral tumour.Conclusion: We observed significant differences in bilateral tumour characteristics compared to unilateral disease. Although bilateral synchronous tumour was associated with poor outcome and overall survival, patients with metachronous disease do as well as patients with unilateral tumour. The increasing practice of bilateral mastectomy is not supported by this large single centre experience.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5033.

A rare case of arterial thrombosis in a 37-year-old male with Factor V Leiden mutation

BACKGROUND

The classic triad of symptoms seen in chronic mesenteric ischaemia is post-prandial pain, sitophobia (fear of food) and progressive weight loss. Patients with mesenteric ischaemia secondary to a prothrombotic state such as that rendered by the Factor V Leiden mutation, are substantially younger than the typical elderly patient in whom embolic disease triggered by atrial fibrillation is the main underlying cause.

METHOD

This is one such case report documenting arterial thrombosis in a 37-year-old male with a subsequently identified heterozygous Factor V Leiden mutation.

CONCLUSION

Factor V Leiden mutation is a contributing risk factor in cases of small bowel infarction.

Gain of imprinting of SLC22A18 sense and antisense transcripts in human breast cancer

The 11p15.5 region harbors three imprinted sense/antisense transcript pairs, SLC22A18/SLC22A18AS, IGF2/IGF2AS (PEG8), and KCNQ1/KCNQ1OT1 (LIT1). SLC22A18 (solute carrier family 22 (organic cation transporter) member 18) and its antisense transcript SLC22A18AS are paternally suppressed in fetal samples. In adult tissue, SLC22A18 displays polymorphic imprinting, but the imprinting status of SLC22A18AS remains elusive. SLC22AI8 DNA-PCR-RFLP analysis using NlaIII restriction digestion identified SLC22A18 heterozygotes within this breast tissue cohort (n = 89). Commercial sequencing identified informative SLC22A18AS samples. Random hexamer-primed cDNA synthesis, SLC22A18/SLC22A18AS-specific PCR, and imprinting evaluation by commercial sequencing demonstrated that SLC22A18AS displays a nonimprinted profile in reduction mastectomies (n = 6). However, SLC22A18 showed a gain of imprinting (GOI) in 1/4 of these normal cases. In the malignant cohort, GOI was also demonstrated in 18% for SLC22A18 and 14% for SLC22A18AS, occurring concomitantly in one case. This study reports the imprinting status of SLC22A18AS in adult tissue, and shows that GOI affects both the sense, and antisense transcripts at this locus in human breast tissue.

Pathology and clinical relevance of radial scars: a review

Radial scar (RS) is a benign, well recognised, radiological and pathological entity. Histologically, it is characterised by a fibroelastotic core with entrapped ducts and surrounding radiating ducts and lobules. Postmortem studies indicate that these lesions are present commonly in the population, especially in association with benign breast disease. In recent years, their clinical relevance has assumed more importance with the introduction of population based screening programmes. The exact pathogenesis of RS is unknown. Accumulating evidence indicates that they are associated with atypia and/or malignancy and, in addition, may be an independent risk factor for the development of carcinoma in either breast. In view of the association with atypia and malignancy, excision biopsy is justified in RS, although it has been argued that core biopsy evaluation and surveillance may be appropriate in selected patients.

Are elevated levels of the tumour marker CA19-9 of any clinical significance?--an evaluation

CA 19-9 is a tumour marker which has been used widely in patients with pancreatic adenocarcinoma. Elevated levels are associated with advanced disease at presentation and disease progression during follow-up. CA19-9 levels may also be elevated in a variety of other malignant and benign conditions. This study examined the significance and implications of elevated CA19-9 levels. An analysis of all CA19-9 measurements performed over a 4 yr period was undertaken and 204 patients with elevated CA19-9 levels were identified. One hundred and thirty patients (63.7 per cent) had malignant conditions and 74 (36.3 per cent) had benign conditions or no definite cause was found. There was a significant correlation between CA19-9 levels and CEA (r = 0.3137; P < 0.001) as well as alkaline phosphatase, ALT, AST, bilirubin, gamma glutamyl transpeptidase and lactate dehydrogenase. CA19-9 levels were significantly lower in patients with benign pathology than those with malignant pathology. Similar differences were observed for CEA. CA19-9 levels were in fact highest in patients with pancreatic carcinoma (P < 0.05) while no significant differences were observed for CEA. In conclusion CA19-9 may be elevated in both benign as well as malignant conditions and interpretation of CA19-9 results must be made in light of the clinical condition of the patient.

Randomized trial of drainage of colorectal anastomosis

A prospective randomized trial was carried out to determine whether use of a high-pressure closed-suction intraperitoneal drain was associated with a reduction in morbidity rate after colorectal resection and to examine the influence of drainage on postoperative fluid collections. A consecutive series of 148 patients who underwent colonic or colorectal resection were randomized to receive no drain (n = 51) or a high-pressure closed-suction drain for either 3 (n = 47) or 7 (n = 47) days. Three patients were excluded. All patients underwent abdominal ultrasonography on days 3 and 7 and those undergoing left-sided colorectal resection (n = 96) received a water-soluble contrast enema on day 7. The three groups of patients were similar in age, sex, diagnosis and the numbers of sutured and stapled anastomoses. The presence of a drain did not influence the postoperative morbidity or mortality rate. If the anastomosis leaked, neither faeces nor pus emerged from the drain. Ultrasonographic detection of a fluid collection was of no value: such collections bore no relationship to radiological or clinical leaks or the postoperative course. Routine use of a high-pressure suction drain after colorectal resection appears to be unnecessary.

An analysis of the diagnostic accuracy of endoscopic biopsy and cytology in the detection of oesophageal malignancy

The role of combined cytohistological examination in the differentiation of benign from malignant oesophageal mucosal lesions was studied in 331 patients. Malignancy was confirmed by specimen histopathology in 58 patients. Both endoscopic biopsy and cytology were positive in 41 (71%) patients. Endoscopic biopsy alone suggested malignancy in 10 cases (17%) while cytology was positive after negative biopsy in seven (12%). Cytology yielded four false positive and 10 false negative results giving a sensitivity level of 81%, a specificity of 98% and a positive predictive value for oesophageal malignancy of 92%. Histology on the other hand yielded one false positive and seven false negative results providing a sensitivity of 87%, a specificity of 99% and a positive predictive value of 96%. No patients were left undiagnosed using both diagnostic modalities; cytology increased the diagnostic yield from 87% to 100%. Exfoliative cytology was most valuable in the diagnosis of tumours of the lower one-third of the oesophagus where seven of 31 malignancies (23%) were identified by this method alone (P less than 0.05). Neither the histological type of the tumour nor the morphological appearance was found significantly to affect the diagnostic yield (P greater than 0.05). We conclude that cytological examination should be standard practice in the investigation of oesophageal lesions.

Primary gastric lymphoma: incidence and role of surgery

The histological subgroups of primary gastric tumours presenting to one surgical unit over two successive six year periods were analysed and the therapeutic value of gastric resection assessed. An increased incidence of gastric lymphoma (13% relative to 5%) occurred in the second six year period. This increase could not be attributed to improved morphological or histochemical techniques. The diagnosis of lymphoma was confirmed preoperatively in 13 (94%) of the 14 patients by a combination of multiple endoscopic biopsies and brush cytology. Five of the six patients who underwent a potentially curative resection are tumour free at a mean follow-up of four years. Histological grading, whether high or low, had no bearing on survival. Gastric lymphoma is increasing in incidence and should be considered in the evaluation of gastric tumours as surgical resection at present offers the best prospect of long term survival.