Abstract CT230: A prospective, multi-center, randomized, double-arm trial to determine the impact of the Perimeter B-Series OCT System on positive margin rates in breast conservation surgery

Background: Optical coherence tomography (OCT) is a high-resolution tissue-imaging modality that enables real-time imaging up to 2mm deep. The Perimeter B-Series OCT System combines wide field-OCT (WF-OCT) with an artificial intelligence system, ImgAssist, to assist clinicians in the detection of lesions suspicious for breast cancer. The objective of this investigational device trial is to assess adjunctive Perimeter B-Series OCT System use compared to standard care in identifying and addressing positive margins intraoperatively.

Design: Prospective, multicenter, randomized, double-arm trial in females with biopsy-confirmed cancer undergoing breast conservation surgery (BCS) (NCT05113927). Following lumpectomy and standard-of-care intraoperative margin assessment participants will be randomized to a device or control arm (2:1 schema). Controls may undergo intraoperative pathology or frozen section analysis, per routine. WF-OCT will be done on all device arm specimens, with an opportunity to excise tissue from the lumpectomy cavity post-analysis. The new margin will be imaged with WF-OCT and the surgeon may take up to a maximum of 6 total shaves, including up to 2 shaves in each orientation.

Eligibility: Adult females undergoing breast conservation surgery for biopsy-confirmed Stage 0-III invasive ductal and/or DCIS are eligible, including post-neoadjuvant therapy. Pregnant or lactating, those with Stage IV cancer, lobular carcinoma as primary diagnosis, previous ipsilateral breast surgery, multi-centric or bilateral disease, use of cryolocalization, or any treatment affecting margin integrity will be excluded.

Specific Aim: The study hypothesis is that use of the Perimeter B-Series OCT System in BCS will reduce the proportion of subjects with at least 1 unaddressed positive margin. The primary endpoint is occurrence of aat least 1 unaddressed positive margin for a subject. The secondary endpoint is the number of unaddressed positive margins per subject. Safety includes Adverse Events; false-positive shaves per subject (device arm); and BREAST-Q Satisfaction with Breasts subscale. Other outcomes are total excised tissue volume, initial and all procedures including repeat surgeries; margin-level effectiveness (sensitivity, specificity, NPV and PPV); and operative time.

Statistical Methods: The study was powered via the primary endpoint, assuming a 15% unaddressed margin rate, 90% power, 2:1 device-to-control ratio, and 10% loss of subjects due to screen or device failure. Both the primary and secondary effectiveness endpoints are based on within-subject comparison of the 2 treatments in the device arm (SOC+WF-OCT).

Planned Accrual: 309 subjects (206 device, 103 control) will be enrolled at 8 centers over approximately 12 months.

Citation Format: David Rempel, Andrew Berkeley, David Moos, Allison A. DiPasquale, Maryam Elmi, Richard E. Fine, Marie Lee, Bridget O’Brien, John F. Turner, Lee G. Wilke, Alastair Thompson. A prospective, multi-center, randomized, double-arm trial to determine the impact of the Perimeter B-Series OCT System on positive margin rates in breast conservation surgery [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT230.

Abstract P3-19-25: ICE3 trial - Radiation following cryoablation for low-risk breast tumors: Assessment of safety and variables that effect referral

Objectives. The ICE3 Trial is a study aimed to evaluate safety and efficacy of cryoablation in low-risk early-stage breast cancer in women ≥60 years. ICE3 Trial enrolled patients from 2014 through February 2019. In total, 206 females underwent cryoablation: however, 3 received treatment that was off protocol and 9 were excluded due to inclusion criteria. Of the 194 patients remaining, 27 had adjuvant radiotherapy. We aimed to examine treatment decisions regarding radiation referral and evaluate safety of the combined modalities in this population. Methods. The ICE3 study is a multi-center, single arm, non-randomized controlled clinical trial with 19 US sites. Data regarding factors that may affect recommendation for adjuvant radiotherapy was evaluated, including the patients' age, ethnicity, tumor characteristics and the treatment center location. We evaluated patient factors that might affect adverse events (AEs) including BMI, nicotine use, diabetes mellitus, as well as adjuvant therapy received. Results. All patients had early-stage breast cancer, 188 were Luminal A (96.9%), 194 were Her-2 negative (100%), 194 were ER positive (100%), 181 were PR positive (93.3%), 98 were Nottingham score 1 (50.5%) and the reminder (96) were Nottingham score 2 (49.5%). Overall mean age was 75.32 years (SD= 7.01), 70.81 years for the radiated group (n=27, SD=6.48) and 76.05 years (n=167, SD=6.83) for the non-radiated group respectively. We evaluated the number and percentage of patient’s receiving radiation at each center as a substitute for referral pattern at the centers. In the entire cohort, 27 of 194 patients (13.32%) underwent radiotherapy. We observed a wide range of variability between the centers (0%-60%) of patients underwent radiotherapy). The age of patient (P-value=0.0006) and the center (P-value=0.0009) were the only factors that appeared to influence if the patient received adjuvant radiation. In all but one center, the mean age of patients who received radiotherapy was lower than those who did not. Other factors including ethnicity, Nottingham score, tumor borders, tumor size, depth and shape did not impact the decision to offer radiation. Regarding safety evaluation, we compared factors leading to device-related AEs between radiated and non-radiated groups. In the total cohort, 21 of 194 patients had mild AEs (10.8%). In the radiated group, 5 AEs occurred in 3 of 27 patients (11.1%). AEs were classified as mild and included injection site pain, bruising, localized edema and breast infection. In the non-radiated group, 36 AEs occurred in 18 of 167 patients (10.8%). AEs were classified as non-serious; 31 were mild and 5 were moderate and included pain, bruising, hemorrhage, rash, induration and thermal injury. We also considered other factors such as age, adjuvant therapy, BMI, nicotine use and whether the patient had diabetes mellitus. No statistically significant factor was observed to effect AE. Conclusions. Cryoablation in the ICE3 trial was used as a replacement for surgical resection in patients with low-risk breast tumors. Many of these patients were elderly and could avoid radiation based on data from CALGB 93431. Still, 13.32% of patients received radiation and contributing factors seem to be patient’s age and referral practice of the treatment center. AEs in the cohort were infrequent and typically minor, and there was no difference between the radiated and nonradiated groups. Radiation in the setting of cryoablation is safe with minimal short-term side effects. 1Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343.Hughes KS, Schnaper LA, Bellon JR, Cirrincione CT, Berry DA, McCormick B, Muss HB, Smith BL, Hudis CA, Winer EP, Wood WCJ Clin Oncol. 2013 Jul 1; 31(19):2382-7.

Citation Format: Jill R Dietz, Richard E Fine, Susan K Boolbol, Roni Haziza. ICE3 trial - Radiation following cryoablation for low-risk breast tumors: Assessment of safety and variables that effect referral [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-25.

Cryoablation Without Excision for Low-Risk Early-Stage Breast Cancer: 3-Year Interim Analysis of Ipsilateral Breast Tumor Recurrence in the ICE3 Trial

BACKGROUND

The ICE3 trial is designed to evaluate the safety and efficacy of breast cryoablation, enabling women older than 60 years with low-risk early-stage breast cancers to benefit from a nonsurgical treatment and to avoid the associated surgical risks.

METHODS

The ICE3 trial is a prospective, multi-center, single-arm, non-randomized trial including women age 60 years or older with unifocal, ultrasound-visible invasive ductal carcinoma size 1.5 cm or smaller and classified as low to intermediate grade, hormone receptor (HR)-positive, and human epidermal growth factor receptor 2 (HER2)-negative. Ipsilateral breast tumor recurrence (IBTR) at 5 years was the primary outcome. A 3-year interim analysis of IBTR was performed, and the IBTR probability was estimated using the Kaplan-Meier method.

RESULTS

Full eligibility for the study was met by 194 patients, who received successful cryoablation per protocol. The mean age was 75 years (range, 55-94 years). The mean tumor length was 8.1 mm (range, 8-14.9 mm), and the mean tumor width was 7.4 mm (range, 2.8-14 mm). During a mean follow-up period of 34.83 months, the IBTR rate was 2.06% (4/194 patients). Device-related adverse events were reported as mild in 18.4% and moderate in 2.4% of the patients. No severe device-related adverse events were reported. More than 95% of the patients and 98% of the physicians reported satisfaction with the cosmetic results at the clinical follow-up evaluation.

CONCLUSIONS

Breast cryoablation presents a promising alternative to surgery while offering the benefits of a minimally invasive procedure with minimal risks. Further study within a clinical trial or registry is needed to confirm cryoablation as a viable alternative to surgical excision for appropriately selected low-risk patients.

Androgen Receptor Is a Non-canonical Inhibitor of Wild-Type and Mutant Estrogen Receptors in Hormone Receptor-Positive Breast Cancers

Sustained treatment of estrogen receptor (ER)-positive breast cancer with ER-targeting drugs results in ER mutations and refractory unresponsive cancers. Androgen receptor (AR), which is expressed in 80%–95% of ER-positive breast cancers, could serve as an alternate therapeutic target. Although AR agonists were used in the past to treat breast cancer, their use is currently infrequent due to virilizing side effects. Discovery of tissue-selective AR modulators (SARMs) has renewed interest in using AR agonists to treat breast cancer. Using translational models, we show that AR agonist and SARM, but not antagonist, inhibit the proliferation and growth of ER-positive breast cancer cells, patient-derived tissues, and patient-derived xenografts (PDX). Ligand-activated AR inhibits wild-type and mutant ER activity by reprogramming the ER and FOXA1 cistrome and rendering tumor growth inhibition. These findings suggest that ligand-activated AR may function as a non-canonical inhibitor of ER and that AR agonists may offer a safe and effective treatment for ER-positive breast cancer.

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Androgen receptor (AR) agonists inhibit estrogen receptor (ER)-positive breast cancer

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Activating AR reprograms ER and FOXA1 cistrome, resulting in ER inhibition

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AR agonist alters the phosphoproteome signature consistent with growth inhibition

Abstract P6-12-06: Nonsteroidal, tissue selective androgen receptor modulator (SARM), enobosarm, reduces growth of androgen receptor-positive breast cancer in patient-derived preclinical models

Introduction: In breast cancer the androgen receptor (AR) is the most abundantly expressed steroid receptor with 75-95% of estrogen receptor (ER)-positive and 40-70% of ER-negative breast cancers expressing the AR. Historically, advanced breast cancer has been treated with androgens, resulting in significant clinical response. However, the use of steroidal androgens fell from favor as a result of their virilizing side effects. Nonsteroidal, tissue selective androgen receptor modulators (SARMs) will provide a novel targeted approach to exploit the therapeutic benefits of androgens in breast cancer.

Aims: To test the effects of enobosarm (a first-in-class SARM) and enzalutamide (AR antagonist) on the growth of patient-derived breast cancer xenografts (PDX) and to discern the mechanism of action of AR-targeted therapies in AR-positive breast cancer.

Materials and Methods: AR-positive PDXs with varying receptor expression (ER, progesterone receptor (PR), and HER2) were implanted in immunecompromised mice. Mice carrying PDXs were treated with vehicle, 10 mg/kg/day (mpk) enobosarm (GTx, Inc., Memphis, TN), or 20 mpk enzalutamide (Medivation Inc.), orally. Tumor volume was measured twice or thrice weekly. Tumors that received enobosarm were further analyzed to determine the mechanism of action.

Results: Enobosarm significantly (p<0.01) inhibited the growth of ER-, PR-, and HER2- positive HCI-7 and ER- and PR- negative and HER2-positive HCI-12 PDX. While enobosarm inhibited the growth of HCI-12 by ~80% and HCI-7 by ~60%, enzalutamide failed to inhibit the growth of the HCI-7 PDX. In contrast, neither enobosarm nor enzalutamide inhibited the growth of ER- and PR-negative and HER2-positive HCI-9 PDX, consistent with the heterogeneity of AR-positive breast cancers. Growth of two triple-negative breast cancer (TNBC) PDXs were inhibited by 30-40% by enobosarm, but not by enzalutamide. These results were reproduced in xenografts developed with breast cancer cell lines, MCF-7 and MDA-MB-231 expressing the AR. Gene expression studies conducted with the HCI-12 tumors indicated that enobosarm inhibited the expression of various proliferative genes (MUC2, IL10RA, IGSF1, SLC6A4, and others) and increased the expression of growth inhibitory genes (CYP4F8, MYBPC1, and others). Ingenuity pathway analysis demonstrated that enobosarm inhibited genes that are downstream of HER2 signaling. Interestingly, miR-21-3p, which has been implicated in chemo-resistance, was consistently expressed at approximately 10-50-fold higher than miR-21-5p in PDXs. This imbalance was partially reversed by enobosarm.

Conclusion: These results indicate that AR-positive breast cancers are highly heterogeneous and that enobosarm has promise as novel targeted therapy to treat AR-positive breast cancer. Enobosarm is currently in phase II clinical trial in both ER-positive breast cancer and in TNBC patients.

Citation Format: Narayanan R, Ponnusamy S, Fan M, Yang CH, Grimes BL, Fleming MD, Pritchard EF, Berry MP, Oswaks RM, Fine RE, Loiseau J-C, Schwartzberg LS, Pfeffer LM. Nonsteroidal, tissue selective androgen receptor modulator (SARM), enobosarm, reduces growth of androgen receptor-positive breast cancer in patient-derived preclinical models [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 P6-12-06.

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

Purpose A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT). Methods A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data. Recommendations The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

Purpose

A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT).

Methods

A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data.

Recommendations

The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-016-5558-8) contains supplementary material, which is available to authorized users.

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

A joint American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology panel convened to develop a focused update of the American Society of Clinical Oncology guideline concerning use of postmastectomy radiotherapy (PMRT).

METHODS

A recent systematic literature review by Cancer Care Ontario provided the primary evidentiary basis. The joint panel also reviewed targeted literature searches to identify new, potentially practice-changing data.

RECOMMENDATIONS

The panel unanimously agreed that available evidence shows that PMRT reduces the risks of locoregional failure (LRF), any recurrence, and breast cancer mortality for patients with T1-2 breast cancer with one to three positive axillary nodes. However, some subsets of these patients are likely to have such a low risk of LRF that the absolute benefit of PMRT is outweighed by its potential toxicities. In addition, the acceptable ratio of benefit to toxicity varies among patients and physicians. Thus, the decision to recommend PMRT requires a great deal of clinical judgment. The panel agreed clinicians making such recommendations for individual patients should consider factors that may decrease the risk of LRF, attenuate the benefit of reduced breast cancer-specific mortality, and/or increase risk of complications resulting from PMRT. When clinicians and patients elect to omit axillary dissection after a positive sentinel node biopsy, the panel recommends that these patients receive PMRT only if there is already sufficient information to justify its use without needing to know additional axillary nodes are involved. Patients with axillary nodal involvement after neoadjuvant systemic therapy should receive PMRT. The panel recommends treatment generally be administered to both the internal mammary nodes and the supraclavicular-axillary apical nodes in addition to the chest wall or reconstructed breast.

Abstract P5-02-08: Incidence of misattributed specimen provenance among surgical breast biopsies

Background:

The medical literature reports on the diagnostic challenges posed by tissue contamination and transposition among surgical biopsy specimens. These specimen provenance complications (SPCs) can lead to a misdiagnosis of cancer, resulting in unnecessary surgery and a potential delayed diagnosis. The histopathology process involves many manual steps during which specimens must be estranged from their identification, and provenance errors are often invisible absent DNA analysis. Prostate biopsy is the setting in which specimen provenance has been studied, with complication rates reported in over 0.9% of positive diagnoses despite best efforts to minimize errors. Because the processing workflow is virtually identical for histopathology specimens of all types, it is expected that error rates among breast biopsy specimens are similar to prostate.

Methods:

We analyzed over 4200 patients diagnosed with breast cancer between February 2011 and April 2014. All biopsies were collected using a uniform best-practice protocol including forensic chain of custody principles, bar-coding of specimen containers, and collection of the patient’s reference DNA sample via buccal swab. After a pathologic diagnosis of breast cancer a portion of the diagnostic specimen was forwarded to an independent DNA laboratory (Strand Diagnostics, Indianapolis, IN) where genetic STR profiles were compared to the patient’s reference DNA to rule out the presence of undetected SPCs prior to therapy.

Results:

3545 breast cancer cases from 7 practices contributing 100 or more cases each were examined (Fig1). DNA testing revealed occult provenance complications in 15 cases (.42%), of which 6 (.17%) were a complete transposition with another patient and 9 (.25%) reflected contamination of the specimen by tissue from one or more unidentified individuals. Three (43%) of the practices experienced at least one provenance error during the study period, with the highest error rate being 1.41% at one practice. Pathology was performed by 14 different laboratories, 6 (43%) of which were implicated in occult SPCs (Fig2). Finally, patients seen by 7(11%) of the 62 physicians performing surgical biopsies in the cohort were subjects of occult specimen provenance errors.

Conclusions:

These data suggest that the incidence of SPCs among breast biopsies is comparable to that reported for prostate biopsies. The errors are distributed broadly across laboratories, practices, and physicians. Due to the potential clinical consequences for patients with undetected SPCs, and the medical malpractice implications, further study of the nature and economics of provenance complications in the breast biopsy setting is warranted.

Fig 1  Type IType II PracticeCasesErrorsErrorsSPC Rate (%)A220548.54B617  0C173  0D162 1.62E1422 0F128  0G118  0Total354569.42Figure 1 SPCs by Practice    Type I=Transpositions    Type II=Contanimations    

Fig 2  Type IType II LabCaseErrorsErrorsSPC Rate (%)A143523.35B967 3.31C430  0D2602 .77E182  0F84 11.19G78  0H712 2.82I20  0J9 222.22K5  0L2  0M1  0N1  0Total354569.42Figure 2 SPC's by Path Lab    Type I=Transpositions    Type II=Contaminations    

Citation Format: Arthur G Lerner, Arla L Bush, Andrew S Kenler, David D Dorfman, Travis A Morgan, Beth Boyd, William E Burak, Richard E Fine. Incidence of misattributed specimen provenance among surgical breast biopsies [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-02-08.

Traditional electrosurgery and a low thermal injury dissection device yield different outcomes following bilateral skin-sparing mastectomy: a case report

Introduction

Although a skin- and nipple-sparing mastectomy technique offers distinct cosmetic and reconstructive advantages over traditional methods, partial skin flap and nipple necrosis remain a significant source of post-operative morbidity. Prior work has suggested that collateral thermal damage resulting from electrocautery use during skin flap development is a potential source of this complication. This report describes the case of a smoker with recurrent ductal carcinoma in situ (DCIS) who experienced significant unilateral skin necrosis following bilateral skin-sparing mastectomy while participating in a clinical trial examining mastectomy outcomes with two different surgical devices. This unexpected complication has implications for the choice of dissection devices in procedures requiring skin flap preservation.

Case presentation

The patient was a 61-year-old Caucasian woman who was a smoker with recurrent DCIS of her right breast. As part of the clinical trial, each breast was randomized to either the standard of care treatment group (a scalpel and a traditional electrosurgical device) or treatment with a novel, low thermal injury dissection device, allowing for a direct, internally controlled comparison of surgical outcomes. Post-operative follow-up at six days was unremarkable for both operative sites. At 16 days post-surgery, the patient presented with a significant wound necrosis in the mastectomy site randomized to the control study group. Following debridement and closure, this site progressively healed over 10 weeks. The contralateral mastectomy, randomized to the alternative device, healed normally.

Conclusion

We hypothesize that thermal damage to the subcutaneous microvasculature during flap dissection may have contributed to this complication and that the use of a low thermal injury dissection device may be advantageous in select patients undergoing skin- and nipple-sparing mastectomy.

Four-year clinical update from the American Society of Breast Surgeons MammoSite brachytherapy trial

BACKGROUND

We present a 4-year update on the efficacy, cosmetic results, and complications of MammoSite breast brachytherapy in patients enrolled in the American Society of Breast Surgeons registry trial.

METHODS

A total of 1,449 breasts in 1,440 patients with early stage breast cancer undergoing breast-conserving therapy were treated with adjuvant, accelerated partial breast irradiation (APBI) (34 Gy in 3.4-Gy fractions) delivered with the MammoSite device. The median follow-up period for the entire group was 36.1 months.

RESULTS

The 3-year actuarial rate of ipsilateral breast tumor recurrence was 2.15%. The 3-year actuarial rate of axillary recurrence was .36%. Complication rates were as follows: infection, 9.5%; seroma, 26.8% (symptomatic seroma, 12.7%); and fat necrosis, 2.0%. The percentages of breasts with good or excellent cosmetic results were as follows: 12 months, 95%; 24 months, 94%; 36 months, 94%; and 48 months, 91%.

CONCLUSIONS

Locoregional control, complications, and cosmetic outcomes from MammoSite APBI at the 4-year update are acceptable and similar to results seen with other forms of APBI.

A cyclic peptide that binds p75(NTR) protects neurones from beta amyloid (1-40)-induced cell death

The current study determined the ability of a p75(NTR) antagonistic cyclic peptide to rescue cells from beta amyloid (Abeta) (1-40)-induced death. p75(NTR)-, p140(trkA)-NIH-3T3 cells or E17 foetal rat cortical neurones were incubated with 125I-NGF or 125I-Abeta (1-40) and increasing concentrations of the cyclic peptide (CATDIKGAEC). Peptide ability to displace 125I-NGF or 125I-Abeta (1-40) binding was determined. Duplicate cultures were preincubated with CATDIKGAEC (250 nM) or diluent and then stimulated with Abeta (1-40). Peptide ability to displace Abeta (1-40) binding, interfere with Abeta (1-40)-induced signalling and rescue cells from Abeta-mediated toxicity was determined by immunoprecipitation and autoradiography, Northern blotting, JNK activation, MTT and trypan blue assays. The peptide inhibited NGF and Abeta (1-40) binding to p75(NTR), but not to p140(trkA). Abeta (1-40) induced c-jun transcription (57.3% +/- 0.07%) in diluent-treated p75(NTR)-cells, but not in cells preincubated with the cyclic peptide. Also, at 250 nM, the peptide reduced Abeta (1-40)-induced phosphorylation of JNK by 71.8% +/- 0.03% and protected neurones against Abeta-induced toxicity as determined by: trypan blue exclusion assay (53% +/- 11% trypan blue-positive cells in diluent pretreated cultures vs. 28% +/- 5% in cyclic peptide-pretreated cultures); MTT assay (0.09 +/-0.03 units in diluent-pretreated cells vs. 0.12 +/- 0.004 units in cyclic peptide-pretreated cells); and visualization of representative microscopic fields. Our data suggest that a cyclic peptide homologous to amino acids 28-36 of NGF known to mediate binding to p75(NTR) can interfere with Abeta (1-40) signalling and rescue neurones from Abeta (1-40)-induced toxicity.

Percutaneous radiofrequency-assisted excision of fibroadenomas

INTRODUCTION

Fibroadenomas are a frequently encountered benign tumor that will occur in approximately 10% of women during their lifetime. Although the natural history would suggest fibroadenomas diagnosed with minimally invasive needle core biopsy can be safely observed, the majority are still surgically removed in the operating room. In an effort to limit the more than 500,000 surgical fibroadenoma removals performed each year, percutaneous excision has become a viable alternative. Percutaneous excision of intact fibroadenomas versus removal with a multiple core sampling technique has the dual potential advantage of causing minimal intervention combined with provision of adequate sample for thorough histopathology and margin analysis for confirmation of complete removal. An 18-month retrospective analysis was undertaken to evaluate the utilization of a new radiofrequency-assisted biopsy device in the successful removal and continued absence of histologically confirmed fibroadenomas on 4- to 6-month follow-up imaging.

METHODS

Between April 2004 and November 2005, 100 patients underwent ultrasound- or stereotactic-guided, radiofrequency-assisted intact percutaneous excision of 106 diagnosed fibroadenomas of the breast. Patients were comprised of 100 women whose ages ranged from 18-70 years (median age, 45 years).

RESULTS

Indications for the procedure included palpable mass, 77; abnormal mammogram, 13; and abnormal ultrasound, 10, as the patient's initial presentation. Ultrasound was used to guide the procedure in 82 patients, and stereotactic was used in 18 patients. One early study procedure was performed under general anesthesia; the remaining studies were performed under local anesthesia (1% lidocaine) using from 10 to 45 mL. On pathologic examination, the tumors ranged in size from 6 to 27 mm (mean diameter, 14 mm) and weighed from 0.6 to 2.0 g (mean weight, 1.0 g). Patients reported minimum discomfort related to the procedure; pain scores ranged from 0 to 10 (mean pain score, <1). Complications were minimal, with only 2 patients having bleeding, which was controlled by conservative measures. At the 4- to 6-month follow-up, 79 of 85 (93%) evaluable patients showed no physical or imaging evidence of residual fibroadenoma, an additional 5 patients have reported no physical findings or further complaints and have required no further need for medical evaluation, 8 have been lost to follow-up, and 2 have yet to be reevaluated.

CONCLUSIONS

Percutaneous ultrasound- or stereotactic-guided, radiofrequency-assisted excision of fibroadenomas of the breast may be performed in an ambulatory setting under local anesthesia. The procedure provides intact specimens that in most cases appear to be completely removed after follow-up of 4 to 6 months. The procedure is well tolerated by patients and is associated with minimal complications.

Insulin degrading enzyme is localized predominantly at the cell surface of polarized and unpolarized human cerebrovascular endothelial cell cultures

Insulin degrading enzyme (IDE) is expressed in the brain and may play an important role there in the degradation of the amyloid beta peptide (Abeta). Our results show that cultured human cerebrovascular endothelial cells (HCECs), a primary component of the blood-brain barrier, express IDE and may respond to exposure to low levels of Abeta by upregulating its expression. When radiolabeled Abeta is introduced to the medium of cultured HCECs, it is rapidly degraded to smaller fragments. We believe that this degradation is largely the result of the action of IDE, as it can be substantially blocked by the presence of insulin in the medium, a competitive substrate of IDE. No inhibition is seen when an inhibitor of neprilysin, another protease that may degrade Abeta, is present in the medium. Our evidence suggests that the action of IDE occurs outside the cell, as inhibitors of internalization fail to affect the rate of the observed degradation. Further, our evidence suggests that degradation by IDE occurs on the plasma membrane, as much of the IDE present in HCECs was biotin-labeled by a plasma membrane impermeable reagent. This activity seems to be polarity dependent, as measurement of Abeta degradation by each surface of differentiated HCECs shows greater degradation on the basolateral (brain-facing) surface. Thus, IDE could be an important therapeutic target to decrease the amount of Abeta in the cerebrovasculature.

Initial Outcomes for Patients Treated on the American Society of Breast Surgeons MammoSite Clinical Trial for Ductal Carcinoma-In-Situ of the Breast

BACKGROUND

The MammoSite device was designed as a breast brachytherapy applicator and is currently used to deliver accelerated partial breast irradiation (APBI). We hypothesized that APBI delivered with the MammoSite device would be well tolerated and be associated with a good cosmetic outcome in patients with ductal carcinoma-in-situ (DCIS).

METHODS

From 2002 to 2004, 191 patients with DCIS were enrolled in a registry trial to assess the MammoSite applicator. Fifteen patients were excluded from analysis because of device- or patient-related factors; 7 patients were excluded after receiving a radiotherapy boost, thus leaving 169 patients available for study. Follow-up information was available for 158 patients. The average length of follow-up was 7.35 months. Forty-three patients had at least 1 year of follow-up.

RESULTS

Skin spacing for the MammoSite applicator was as follows: < 5 mm, 3 patients (1.78%); 5 to 7 mm, 18 patients (10.65%); and > or = 7 mm, 148 patients (87.57%). Patients with a device-to-skin distance of > or = 7 mm had the best cosmetic result. Patients with a device-to-skin distance of > or = 7 mm also had a lower incidence of radiation dermatitis. Data on 43 patients who were followed up for at least 1 year confirmed these findings. Additional adverse events were primarily related to skin changes, with breast infections occurring in five patients (3.16%). No patient in the study has experienced a recurrence.

CONCLUSIONS

APBI delivered via MammoSite is well tolerated in patients with DCIS, and the lowest toxicity was obtained in patients with the greatest device-to-skin distance. Long-term follow-up data regarding patient satisfaction, cosmesis, and efficacy are needed and will be determined from a recently opened large randomized study.

Identification of the protein disulfide isomerase family member PDIp in experimental Parkinson's disease and Lewy body pathology

Parkinson's disease (PD) is a slowly progressing neurodegenerative disorder with no clear etiology. Pathological hallmarks of the disease include the loss of dopaminergic neurons from the substantia nigra (SN) and the presence of Lewy bodies (LBs) (alpha-synuclein and ubiquitin-positive, eosinophilic, cytoplasmic inclusions) in many of the surviving neurons. Experimental modeling of PD neurodegeneration using the neurotoxins 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and 1-methyl-4-phenyl-pyridinium (MPP(+)) has identified changes in gene expression of different endoplasmic reticulum (ER) stress proteins associated with MPTP- and PD-related neurodegeneration. We show that the protein disulfide isomerase (PDI) family member pancreatic protein disulfide isomerase (PDIp), previously considered exclusively expressed in pancreatic tissue, is uniquely upregulated among PDI family members within 24 h following exposure of retinoic acid (RA)-differentiated SH-SY5Y human neuroblastoma cells to either 1 mM MPP(+) or 10 microM of the highly specific proteasome inhibitor lactacystin. RT-PCR confirms PDIp expression in brain of post-mortem human PD subjects and immunohistochemical studies demonstrate PDIp immunoreactivity in LBs. Collectively, these findings suggest that increased PDIp expression in dopaminergic (DA) neurons might contribute to LB formation and neurodegeneration, and that this increased PDIp expression may be the result of proteasome impairment.

First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity

BACKGROUND

Eighty-seven institutions participated in a Registry Trial that was designed to collect data on the clinical use of the MammoSite breast brachytherapy catheter for delivering breast irradiation. Patient demographics, technical reproducibility, cosmesis, and early toxicity were evaluated.

METHODS

From May 4, 2002 through July 30, 2004, 1419 patients with Stage 0, I, or II breast carcinoma who were undergoing breast-conserving therapy were enrolled on the trial. The device was placed in 1403 of these patients. The 1237 patients (87% of enrolled patients) who received accelerated partial breast irradiation (APBI) (34 grays prescribed to 1.0 cm in 10 fractions; 95% of patients who received APBI) constituted the study population; 86% of those patients (1068) had Stages I-II breast carcinoma (median tumor size, 10 mm), and 14% of those patients (169) had Stage 0 breast carcinoma. Ninety-one percent of the patients with invasive carcinoma (977 of 1068 patients) had negative lymph node status, and 99% of all patients had negative margins. The median patient age was 65 years. Systemic chemotherapy alone was administered to 79 patients with invasive carcinoma (7%), hormone therapy was administered to 501 patients (45%), and both were administered to 39 patients (4%). The median follow-up was 5 months.

RESULTS

Five hundred fifty-four catheters (45%) were placed with an open cavity at the time of lumpectomy, and 683 catheters (55%) were placed with a closed cavity after lumpectomy. Skin spacing ranged from 2 mm to 75 mm (median, 10 mm). In 89% of patients, there was a minimum balloon-to-skin distance of 7 mm (2% of patients had distances < 5 mm). In terms of cosmetic assessment, 95% of patients (1030 of 1084 patients) who had a cosmetic assessment had a good/excellent result (last follow-up visit). Cosmetic results at 12 months were good/excellent in 92% of 248 evaluable patients. The median skin spacing (> or = 7 mm vs. < 7 mm) was associated significantly with a good/excellent cosmetic result (96.1% vs. 86.8%; P = 0.0001) overall and at 6 months (P = 0.006). Increasing skin spacing was associated with a good/excellent cosmetic result as a continuous variable (P < 0.0001). In total, 92 of 1140 evaluable patients (8.1%) developed an infection in the breast, which was device-related in 5.3% of patients (60 of 1140 patients). Good/excellent cosmetic results were noted in 86% of these patients (last follow-up visit). Fifteen of 442 evaluable patients (3.4%) developed a radiation recall reaction. Good/excellent cosmetic results were noted in 93% of these patients at their last follow-up visit. One local recurrence (0.1%) was reported (new primary carcinoma).

CONCLUSIONS

Clinical evaluation of the ability of the MammoSite breast brachytherapy catheter to deliver APBI demonstrated acceptable technical reproducibility between multiple institutions and use in appropriate groups of patients. Cosmetic results at 12 months (92% good/excellent) were comparable to those reported with whole-breast RT. Early toxicity rates (infections, radiation recall) appeared to be acceptable.

Upregulation of clusterin/apolipoprotein J in lactacystin-treated SH-SY5Y cells

Clusterin (apolipoprotein J) is a highly conserved, multifunctional, vertebrate glycoprotein. Several isoforms of clusterin have been described including the predominant secreted isoform (sCLU) and several nuclear isoforms (nCLU) associated with cell death. sCLU has been shown to bind a variety of partly unfolded, stressed proteins including those associated with Lewy bodies (LBs) in patients with Parkinson's disease (PD). The development of familial and sporadic PD has been associated with the ubiquitin-proteasome system (UPS) dysfunction and aberrant protein degradation. This suggests that failure of the UPS to degrade abnormal proteins may underlie nigral degeneration and LB formation in PD. The effects of toxin-mediated proteasomal impairment on changes in gene expression and cell viability were studied in differentiated SH-SY5Y cells. Clusterin expression was increased in cells exposed for 24 hr to the proteasomal inhibitor lactacystin (10 microM) as determined by gene microarray analysis. RT-PCR showed that sCLU, not nCLU, was the major clusterin isoform expressed in both control and lactacystin-treated cells. Western blot analysis identified statistically significant increases in sCLU in total cell lysates after 24 hr of lactacystin exposure and showed that sCLU fractionates with the endoplasmic reticulum. Time-course studies demonstrated that maximal decreases in proteasome activity (4 hr) preceded maximal increases in clusterin expression (24 hr). Together these data suggest that proteasome impairment results in the upregulation of sCLU in SH-SY5Y cells, supporting the hypothesis that the association of clusterin with LBs in PD may be related to UPS failure.

Insulin degrading enzyme is expressed in the human cerebrovascular endothelium and in cultured human cerebrovascular endothelial cells

Insulin degrading enzyme (IDE) is found in the cytosol, peroxisomes and plasma membrane of many cells. Although it preferentially cleaves insulin it can also cleave many other small proteins with diverse sequences including the monomeric form of the amyloid beta peptide (A beta). In the brain, IDE has been reported to be expressed predominantly in neurons. In this study, IDE expression was detected in cultured human cerebrovascular endothelial cells. Using laser capture microdissection followed by PCR analysis, it was found that IDE mRNA is expressed in human brain blood vessels. Using immunofluorescence and multiphoton microscopy IDE was localized to the endothelium of the cerebrovascular blood vessels in human.

The evolution of breast surgery: where technology and compassion meet

The origins and development of The American Society of Breast Surgeons are closely tied to technology. Innovative technical progress means less-invasive procedures, more precise diagnoses, more outpatient services, and--with all of this--less pain and stress for our patients. It means more compassionate breast care for women. The Society's mission revolves around improving all aspects of patient care, and this is where technology and compassion meet.

Updates in breast ultrasound

Ultrasound is becoming an indispensable tool for the surgeon in the diagnosis and treatment of a variety of breast problems. Hands-on ultrasound education for surgeons and the ongoing improvements in imaging technology have made surgeon-performed breast ultrasound an effective method of identifying and diagnosing breast lesions and have increased the surgeon's ability to perform ultrasound-guided interventional procedures. This article reviews the current state of surgeon-performed breast ultrasound.

Escherichia coli Shiga toxin 1 and TNF-α induce cytokine release by human cerebral microvascular endothelial cells

Infection with Shiga toxin (Stx)-producing Escherichia coli can lead to development of hemolytic uremic syndrome (HUS). Patients with severe HUS often exhibit central nervous system (CNS) pathology, which is thought to involve damage to brain endothelium, a component of the blood-brain barrier. We hypothesized that this neuropathology occurs when cerebral endothelial cells of the blood-brain barrier, sensitized by exogenous TNF-alpha and stimulated by Stx1, produce and release proinflammatory cytokines. This was tested by measuring changes in cytokine mRNA and protein expression in human brain endothelial cells (hBEC) in vitro when challenged by TNF-alpha and/or Stx. High doses of Stx1 alone were somewhat cytotoxic to hBEC; Stx1-treated cells produced increased amounts of IL-6 mRNA and secreted this cytokine. IL-1beta and TNF-alpha mRNA, but not protein, were increased, and IL-8 secretion increased without an observed increase in mRNA. Cells pretreated with TNF-alpha were more sensitive to Stx1, displaying greater Stx1-induction of mRNA for TNF-alpha, IL-1beta, and IL-6, and secretion of IL-6 and IL-8. These observations suggest that in the pathogenesis of HUS, Stx can induce cytokine release from hBEC, which may contribute toward the characteristic CNS neuropathology.

cDNA microarray analysis of changes in gene expression associated with MPP+ toxicity in SH-SY5Y cells

cDNA microarray analysis of 1-methyl-4-phenyl-pyridinium (MPP+) toxicity (1 mM, 72 h) in undifferentiated SH-SY5Y cells identified 48 genes that displayed a signal intensity greater than the mean of all differentially expressed genes and a two-fold or greater difference in normalized expression. RT-PCR analysis of a subset of genes showed that c-Myc and RNA-binding protein 3 (RMB3) expression decreased by approximately 50% after 72 h of exposure to MPP+ (1 mM) but did not change after 72 h of exposure to 6-hydroxydopamine (25 microM), rotenone (50 nM), and hydrogen peroxide (600 microM). Exposure of retinoic acid (RA)-differentiated SH-SY5Y cells to MPP+ (1 mM, 72 h) also resulted in a decrease in RMB3 expression and an increase in GADD153 expression. In contrast, c-Myc expression was slightly increased in RA-differentiated cells. Collectively, these data provide new insights into the molecular mechanisms of MPP+ toxicity and show that MPP+ can elicit distinct patterns of gene expression in undifferentiated and RA-differentiated SH-SY5Y cells.

Low-risk palpable breast masses removed using a vacuum-assisted hand-held device

BACKGROUND

This study evaluates the safety, efficacy, and patient acceptance of a vacuum-assisted, hand-held biopsy device (Mammatome) in the percutaneous removal of breast masses using ultrasound guidance.

METHODS

A multicenter, nonrandomized study evaluated 216 women with low-risk palpable lesions. Lesions 1.5 to 3.0 cm in size were removed using an 8-gauge probe. Those lesions <1.5 cm were removed with the 11-gauge probe. Follow-up evaluation was performed at 10 days and 6 months after biopsy.

RESULTS

A total of 127 patients had biopsies using the 8-gauge probe, and 89 patients had biopsies using the 11-gauge probe. At 6-month follow-up, 98% of the lesions remained nonpalpable, 73% with no ultrasonographically visible evidence of the original lesion. Most complications were mild and anticipated. Most patients (98%) were satisfied with incision appearance, and 92% of patients would recommend the procedure to others.

CONCLUSIONS

Percutaneous removal of palpable benign breast masses using the Mammotome system is feasible and safe, and yields high patient satisfaction. The results at 6 months after biopsy demonstrated the effectiveness of benign lesion removal, with correlative clinical data demonstrating lack of palpability and no need for additional procedures. Continuing evaluation of long-term efficacy is ongoing.

Percutaneous removal of benign breast masses using a vacuum-assisted hand-held device with ultrasound guidance

BACKGROUND

This study evaluates the safety, efficacy, and patient acceptance of a vacuum-assisted, hand-held biopsy device (Mammotome) in percutaneous removal of breast masses using ultrasound guidance.

METHODS

A multicenter, nonrandomized study evaluated 124 women with low-risk palpable lesions. Lesions <or=1.5 cm and those >1.5 cm but <or=3.0 cm were removed using 1-gauge or 8-gauge probes, respectively. Follow-up evaluation was performed at 10 days postbiopsy.

RESULTS

The 8-guage probe was used to obtain biopsies from 75 patients, and the 11-gauge was used for 49 patients. Complete removal of the imaged lesion was similar between groups (99% 8-gauge versus 96% 11-gauge). Most complications were mild and anticipated. Most patients (97%) were satisfied with incision appearance, and 98% of patients would recommend the procedure to others.

CONCLUSIONS

Percutaneous removal of palpable benign breast masses using the Mammotome system is feasible, safe, and yields high patient satisfaction. Long-term efficacy is being evaluated in the ongoing study.

Specific up-regulation of GADD153/CHOP in 1-methyl-4-phenyl-pyridinium-treated SH-SY5Y cells

Growth arrest DNA damage-inducible 153 (GADD153) expression was increased in 1-methyl-4-phenyl-pyridinium (MPP(+))-treated human SH-SY5Y neuroblastoma cells as determined by gene microarray analysis. GADD153 expression increased after 24 hr of MPP(+) (1 mM) exposure and preceded activation of caspase 3. Comparison of GADD153 expression among cultures treated with other toxins whose primary mode of action is either via mitochondrial impairment (rotenone) or via oxidative stress (6-hydroxydopamine or hydrogen peroxide) showed that GADD153 was uniquely up-regulated by MPP(+). Together these data suggest that a cellular mechanism distinct from mitochondrial impairment or oxidative stress contributes significantly to the up-regulation of GADD153 by MPP(+) and that GADD153 may function as an inducer of apoptosis following MPP(+) exposure. Published 2002 Wiley-Liss, Inc.

Amyloid beta binds trimers as well as monomers of the 75-kDa neurotrophin receptor and activates receptor signaling

p75(NTR), a nerve growth factor co-receptor that has been implicated in apoptosis of neurons, is structurally related to Fas and the receptors for tumor necrosis factor-alpha that display ligand independent assembly into trimers. Using embryonic day 17 fetal rat cortical neurons and p75(NTR)-expressing NIH-3T3 cells, we now show that p75(NTR) exists as a trimer as well as a monomer. Furthermore, we have reported and others have confirmed that amyloid beta binds p75(NTR), and that this binding leads to apoptotic cell death. We now report that amyloid beta binds to trimers of p75(NTR) as well as to p75(NTR) monomers but not to the p140(trkA), the nerve growth factor co-receptor that mediates neuronal survival. Furthermore, amyloid beta activates p75(NTR), strongly inducing the transcription of c-Jun mRNA and stimulating the stress-activated c-Jun NH(2)-terminal kinase, as measured by phosphorylation of its substrate (glutathione S-transferase-c-Jun-(1-79)). Our data suggest that p75(NTR) may be present as a preformed trimer that binds amyloid beta to induce receptor activation, and support the hypothesis that p75(NTR) activation by amyloid beta is causally related to Alzheimer's disease.

A prospective study of the removal rate of imaged breast lesions by an 11-gauge vacuum-assisted biopsy probe system

BACKGROUND

More than 1,000,000 breast biopsies are performed each year as a result of abnormalities identified by imaging techniques. This prospective study was designed to determine whether complete removal of the imaged evidence of an abnormal mammogram or ultrasonogram could be achieved with percutaneous image-guided procedures using an 11-gauge vacuum-assisted biopsy probe.

METHODS

Forty-five women over the age of 18 years entered the study; 50 breast lesions were identified by ultrasonography or mammography. Biopsies were obtained using an 11-gauge vacuum-assisted probe. At 6 months after biopsy, ultrasonography or mammography examinations of the biopsy site were performed.

RESULTS

Forty-five lesions (90%) were completely removed. At 6 months after biopsy, 82% of the sites were lesion free. The percentage of nonrecurring lesions at 6 months after surgery was inversely related to the size of the original lesion.

CONCLUSION

This device allows biopsies to be successfully combined with complete removal of the imaged lesion in a one-step minimally invasive procedure.

Decreased expression of the NADH:ubiquinone oxidoreductase (complex I) subunit 4 in 1-methyl-4-phenylpyridinium -treated human neuroblastoma SH-SY5Y cells

Oxidative stress and mitochondrial dysfunction have been implicated in Parkinson's disease (PD) pathology. NADH:ubiquinone oxidoreductase (complex I) (EC 1.6.99.3) enzyme activity is aberrant in both PD and 1-methyl-4-phenylpyridinium (MPP(+)) models of PD. Reverse transcription polymerase chain reaction of RNA isolated from MPP(+)-treated human neuroblastoma SH-SY5Y cells identified changes in steady-state mRNA levels of the mitochondrial transcript for subunit 4 of complex I (ND4). Expression of ND4 decreased to nearly 50% after 72 h of MPP(+) (1 mM) exposure. The expression of other mitochondrial transcripts did not change significantly under the same conditions. Pre-incubation of cells with the free-radical spin-trap, N-tert-butyl-alpha-(2-sulfophenyl)-nitrone prior to MPP(+) exposure, prevented decreases in cell viability and ND4 expression. This suggests that functional defects in complex I enzyme activity in PD and MPP(+) toxicity may result from changes in steady-state mRNA levels and that free radicals may be important in this process.

Calreticulin functions as a molecular chaperone for the β-amyloid precursor protein 1 1Abbreviations used: Aβ, β-amyloid peptide; AD, Alzheimer’s disease; APP, β-amyloid precursor protein; CHAPS, 3-[(3-Cholamidopropyl)-dimethylammonio]-1-propanesulfonate; Crt, calreticulin; DMEM, Dulbecco’s Modified Eagle Medium; DMJ, deoxymannojirimycin; DTSSP, 3,3′-Dithio bis (sulfosuccinimidylpropionate); ECL, Enhanced Chemiluminescence; ER, endoplasmic reticulum; FBS, fetal bovine serum; HRP, horseradish peroxidase; kDa, kiloDaltons; MES, 2-(N-Morpholino) ethane sulfonic acid; NRS, normal rabbit serum; PBS, PBS; PMSF, phenymethylsulfonyl fluoride; PVDF, polyvinylidene fluoride

Processing of the beta-amyloid precursor protein (APP) in the endoplasmic reticulum and the Golgi apparatus may be critical in generating the beta-amyloid molecules linked to the pathogenesis of Alzheimer's disease. Since chaperone molecules such as calreticulin (Crt) have been shown to be important in the maturation of many glycoproteins, we investigated the interaction between Crt and APP. We show that APP binds transiently to Crt in a manner that is pH, divalent cation, and N-linked glycosylation-dependent. Both immature APP (containing only N-linked sugars) and mature APP (containing both N-linked and O-linked sugars) bind to Crt. Both proteins are part of a complex that appears to be large enough to accommodate other proteins as well. However, while most of the immature form is associated with the complexes, very little of the mature form is. The interaction between APP and Crt is likely to be of physiological significance with respect to APP maturation since Crt is involved in quality control of nascent glycoproteins in the secretory pathway.

Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology

OBJECTIVE

To determine indications for the use of postmastectomy radiotherapy (PMRT) for patients with invasive breast cancer with involved axillary lymph nodes or locally advanced disease who receive systemic therapy. These guidelines are intended for use in the care of patients outside of clinical trials.

POTENTIAL INTERVENTION

The benefits and risks of PMRT in such patients, as well as subgroups of these patients, were considered. The details of the PMRT technique were also evaluated.

OUTCOMES

The outcomes considered included freedom from local-regional recurrence, survival (disease-free and overall), and long-term toxicity.

EVIDENCE

An expert multidisciplinary panel reviewed pertinent information from the published literature through July 2000; certain investigators were contacted for more recent and, in some cases, unpublished information. A computerized search was performed of MEDLINE data; directed searches based on the bibliographies of primary articles were also performed.

VALUES

Levels of evidence and guideline grades were assigned by the Panel using standard criteria. A "recommendation" was made when level I or II evidence was available and there was consensus as to its meaning. A "suggestion" was made based on level III, IV, or V evidence and there was consensus as to its meaning. Areas of clinical importance were pointed out where guidelines could not be formulated due to insufficient evidence or lack of consensus.

RECOMMENDATIONS

The recommendations, suggestions, and expert opinions of the Panel are described in this article.

VALIDATION

Seven outside reviewers, the American Society of Clinical Oncology (ASCO) Health Services Research Committee members, and the ASCO Board of Directors reviewed this document.

Tumor necrosis factor alpha increases human cerebral endothelial cell Gb3 and sensitivity to Shiga toxin

Hemolytic uremic syndrome (HUS) is associated with intestinal infection by enterohemorrhagic Escherichia coli strains that produce Shiga toxins. Globotriaosylceramide (Gb3) is the functional receptor for Shiga toxin, and tumor necrosis factor alpha (TNF-alpha) upregulates Gb3 in both human macrovascular umbilical vein endothelial cells and human microvascular brain endothelial cells. TNF-alpha treatment enhanced Shiga toxin binding and sensitivity to toxin. This upregulation was specific for Gb3 species containing normal fatty acids (NFA). Central nervous system (CNS) pathology in HUS could involve cytokine-stimulated elevation of endothelial NFA-Gb3 levels. Differential expression of Gb3 species may be a critical determinant of Shiga toxin toxicity and of CNS involvement in HUS.

Isolation and characterization of substance P-containing dense core vesicles from rabbit optic nerve and termini

In neurons, neuropeptides and other synaptic components are transported down the axon to the synapse in vesicles using molecular motors of the kinesin family. In the synapse, these neuropeptides are found in dense core vesicles (DCVs), and, following calcium-mediated exocytosis, they interact with receptors on the target cell. We have developed a rapid, large-scale technique for purifying peptide-containing DCVs from specific nuclei in the central nervous system. By using differential velocity gradient and equilibrium gradient centrifugation, neuropeptide-containing DCVs can be separated by size and density from optic nerve (ON) and its termini, the lateral geniculate nuclei and the superior colliculi. Isolated DCVs contain neuropeptides (substance P and brain-derived neurotrophic factor), synaptic vesicle (SV) membrane proteins (SV2, synaptotagmins, synaptophysin, Rab3 and synaptobrevin), SV-associated proteins (alpha-synuclein), secretory markers for DCVs previously isolated (secretogranin II), and beta-amyloid precursor protein. By using electron microscopic techniques, DCV were also visualized and shown to be immunoreactive for neuropeptides, neurotrophins, and SV membrane proteins. Because of the interesting group of physiological and potentially pathophysiological proteins associated with these vesicles; this isolation procedure, applicable to other CNS nuclei, should represent an important research tool.

Beta amyloid fragments derived from activated platelets deposit in cerebrovascular endothelium: usage of a novel blood brain barrier endothelial cell model system

Amyloid precursor protein (A betaPP) processing results in generation of amyloid beta peptide (A beta) which deposits in the brain parenchyma and cerebrovasculature of patients with Alzheimer's disease (AD). Evidence that the vascular deposits derive in part from A betaPP fragments originating from activated platelets includes findings that individuals who have had multiple small strokes have a higher prevalence of AD compared to individuals who have taken anti-platelet drugs. Thus, determination of whether platelet A betaPP fragments are capable of traversing the blood-brain barrier (BBB) is critical. We have established that activated platelets from patients with AD retain more surface transmembrane-bound A betaPP (mA betaPP) than control platelets. We report here that this mA betaPP can be cleaved to A beta-containing fragments which pass through a novel BBB model system. This model utilizes human BBB endothelial cells (BEC) isolated from brains of patients with AD. These BEC, after exposure to activated platelets which have been surface-labeled with fluorescein and express surface-retained mA betaPP, cleave fluorescein-tagged surface proteins, including mA betaPP, resulting in passage to the BEC layer The data confirm that BEC contribute to processing of platelet-derived mA betaPP and show that the processing yields A beta containing fragments which could potentially contribute to cerebrovascular A beta deposition.

Antisense oligonucleotide sequences targeting the muscarinic type 2 acetylcholine receptor enhance performance in the Morris water maze

Blocking autoinhibitory muscarinic type 2 (m2) acetylcholine receptors in the central nervous system may increase the release of acetylcholine and improve learning and memory. Antisense oligonucleotides (OGNs) complementary to m2 receptor mRNA were synthesized and evaluated for their efficacy at decreasing receptor number and reversing deficits in a cognitive task. Three antisense OGNs, which decreased m2 receptor binding in NG108-15 cells, were continuously infused into the lateral cerebral ventricle of rats for 6 days at a rate of 0.5 micro1/h and a daily dose of 72 microg. Performance in the Morris water maze was compared to groups receiving control OGNs or vehicle alone. Decrements induced by 0.2 mg/kg of scopolamine i.p. were significantly reversed by 2 of the 3 antisense OGNs. Use of antisense OGNs targeting the m2 receptor may be a new strategy to increase cholinergic neurotransmission and improve learning and memory.

Toxicity of various amyloid beta peptide species in cultured human blood-brain barrier endothelial cells: increased toxicity of dutch-type mutant

The amyloid beta peptide (A beta) is the major component of the neuritic and cerebrovascular amyloid plaques that are one of the characteristic features of Alzheimer's disease (AD). This peptide has been shown to be toxic to several relevant cell types, including neurons, cerebrovascular smooth muscle cells, and endothelial cells. We have studied the toxic effects of both soluble and aggregated species of A beta(1-40) and the mutation A beta(1-40)Glu-->Gln(22), which is the major species deposited in the cerebrovascular blood vessels of victims of hereditary cerebral hemorrhage with amyloidosis, Dutch type. We find that aggregates of both peptides, as well as of A beta(1-42) and A beta(25-35), are toxic to cultured human cerebrovascular endothelial cells (hBEC) obtained from the brain of a victim of AD (at doses lower than those that are toxic to CNS neurons or leptomeningeal smooth muscle cells). Soluble A beta(1-40) Gln(22) is equally toxic to hBEC, whereas wild-type A beta(1-40) is toxic only at higher doses. This toxicity is seen at the lowest dose of A beta(1-40) Gln (22) used, 20 nM. The soluble A beta(1-40)Gln(22) aggregates on the surface of the cells, in contrast to A beta(1-40), and its toxicity can be blocked both by an inhibitor of free radical formation and by Congo red, which inhibits amyloid fibril formation. We discuss the possibility that the enhanced toxicity of A beta(1-40)Gln(22) is mediated by a A beta receptor on the endothelial cells.

Serum amyloid A is present in the capillaries and microinfarcts of hypertensive monkey brain: an immunohistochemical study

Serum amyloid A (SAA) is a major inducible acute phase protein characterized as a transient injury specific constituent of high density lipoprotein. We investigated whether the acute phase SAA (A-apoSAA), as a marker of inflammation, is present in the brain of monkeys with surgically induced hypertension of 39 months duration. Sections from brains of normotensive monkeys (systolic blood pressure < 124 mmHg) and hypertensive monkeys (systolic blood pressure > 185 mmHg) were processed for immunohistochemistry with a rabbit polyclonal antiserum to human A-apoSAA. We found that A-apoSAA was present in hypertensive but not in normotensive brain sections. Staining was localized to capillary endothelial cells and occasionally to the entire vessel wall of the prefrontal cortex. Staining was also observed in the capillaries and in medium size vessels of the corona radiata, the head of the caudate and, to a smaller extent, in the putamen. Additionally, the A-apoSAA was present in cells forming a circular configuration within microinfarcts. These findings suggest that high blood pressure in the brain can result in either local production of A-apoSAA in the capillaries and within microinfarcts or uptake of A-apoSAA from the blood

Serum amyloid A in Alzheimer's disease brain is predominantly localized to myelin sheaths and axonal membrane

Immunohistochemical localization of the injury specific apolipoprotein, acute phase serum amyloid A (A-apoSAA), was compared in brains of patients with neuropathologically confirmed Alzheimer's disease (AD), multiple sclerosis (MS), Parkinson's disease (PD); Pick's disease (Pick's), dementia with Lewy bodies (DLB), coronary artery disease (CAD), and schizophrenia. Affected regions of both AD and MS brains showed intense staining for A-apoSAA in comparison to an unaffected region and non-AD/MS brains. The major site of A-apoSAA staining in both diseases was the myelin sheaths of axons in layers V and VI of affected cortex. A-apoSAA contains a cholesterol binding site near its amino terminus and is likely to have a high affinity for cholesterol-rich myelin. These findings, along with our recent evidence that A-apoSAA can inhibit lipid synthesis in vascular smooth muscle cells suggest that A-apoSAA plays a role in the neuronal loss and white matter damage occurring in AD and MS.

Kinesin participates in melanosomal movement along melanocyte dendrites

Movement of melanosomes along melanocyte dendrites is necessary for the transfer of melanin pigment from melanocytes to basal and suprabasal keratinocytes, an event critical to epidermal photoprotection and maintenance of normal skin color. Recent murine data suggest that in melanocyte dendrites the microtubule-associated melanosome movement is bidirectional and that actin-associated myosin V secures the peripheral melanosomes, preparing them to be transferred to surrounding keratinocytes. We now report that human melanocytes express high levels of kinesin, a molecule that participates in microtubule-associated transport of organelles in other cell types, and that ultrastructurally kinesin molecules are closely associated with melanosomes. To determine whether kinesin participates in melanosomal transport, cultured melanocytes were treated with sense or antisense oligonucleotides complementary to kinesin heavy chain sequences. Antisense oligonucleotides decreased kinesin protein levels and inhibited the bidirectional movement of the melanosomes, promoting their backward movement. Furthermore, guinea pigs were exposed to ultraviolet B irradiation, known to enhance transport of melanosomes from melanocytes to epidermal keratinocytes, and then were treated with kinesin sense or antisense oligonucleotides. The areas that were treated with kinesin antisense oligonucleotides showed significantly less pigmentation clinically and histologically than control (sense) oligonucleotide-treated areas. As observed ultrastructurally, in antisense-treated areas melanosomes remained in melanocyte dendrites but over several days were not transferred to the surrounding keratinocytes. Our study supports a major role for kinesin in microtubule-associated anterograde melanosomal transport in human melanocyte dendrites.