The role of infiltrating lymphocytes in the neo-adjuvant treatment of women with HER2-positive breast cancer

Background

Pre-treatment tumour-associated lymphocytes (TILs) and stromal lymphocytes (SLs) are independent predictive markers of future pathological complete response (pCR) in HER2-positive breast cancer. Whilst studies have correlated baseline lymphocyte levels with subsequent pCR, few have studied the impact of neoadjuvant therapy on the immune environment.

Methods

We performed TIL analysis and T-cell analysis by IHC on the pretreatment and ‘On-treatment’ samples from patients recruited on the Phase-II TCHL (NCT01485926) clinical trial. Data were analysed using the Wilcoxon signed-rank test and the Spearman rank correlation.

Results

In our sample cohort (n = 66), patients who achieved a pCR at surgery, post-chemotherapy, had significantly higher counts of TILs (p = 0.05) but not SLs (p = 0.08) in their pre-treatment tumour samples. Patients who achieved a subsequent pCR after completing neo-adjuvant chemotherapy had significantly higher SLs (p = 9.09 × 10^–3) but not TILs (p = 0.1) in their ‘On-treatment’ tumour biopsies. In a small cohort of samples (n = 16), infiltrating lymphocyte counts increased after 1 cycle of neo-adjuvant chemotherapy only in those tumours of patients who did not achieve a subsequent pCR. Finally, reduced CD3 + (p = 0.04, rho = 0.60) and CD4 + (p = 0.01, rho = 0.72) T-cell counts in 'On-treatment' biopsies were associated with decreased residual tumour content post-1 cycle of treatment; the latter being significantly associated with increased likelihood of subsequent pCR (p < 0.01).

Conclusions

The immune system may be ‘primed’ prior to neoadjuvant treatment in those patients who subsequently achieve a pCR. In those patients who achieve a pCR, their immune response may return to baseline after only 1 cycle of treatment. However, in those who did not achieve a pCR, neo-adjuvant treatment may stimulate lymphocyte influx into the tumour.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06244-1.

O12: IHC ANALYSIS OF RESIDUAL DISEASE POST NEOADJUVANT TRASTUZUMAB FOR EARLY STAGE BREAST CANCER REVEALS ER/HER2 CROSSTALK THROUGH INCREASED ER SIGNALLING

Introduction

Therapeutic pressure functionally affects oncogenes and related signalling pathways through dynamic alterations in transcriptional and epigenetic alterations. Altered receptor status occurs throughout tumour progression and may be influenced by adjuvant and neoadjuvant therapies. Recurrent transcriptional remodelling events have been described in the progression of primary breast cancer to metastasis, including increased tyrosine kinase signalling, specifically Her2, and loss of ESR1 gene expression. We hypothesise that in the setting of tyrosine kinase inhibition, an increase in estrogen receptor (ER) signalling is observed.

Method

A database of patients recruited to ICORG trial 07/09 was queried to identify patients with histologically confirmed, Her2-overexpressing or Her2 amplified, nonmetastatic, invasive breast cancer who received neoadjuvant trastuzumab, alone or in combination with neoadjuvant systemic chemotherapy. Clinicopathological characteristics recorded include age at diagnosis, clinical stage, receptor status and percentage positivity, and pathological complete response.

Result

A total of 55 patients identified on ICORG trial 09/07 received neoadjuvant trastuzumab. Of these, 27 achieved a complete pathological response (49%; n=27/55). In those with residual disease, a gain in mean ER staining percentage positivity was observed in the residual disease compared to diagnostic biopsy staining (59.22 vs 45.11; p=0.03). A corresponding loss in Her2 percentage staining positivity was also observed (p=0.006).

Conclusion

An inverse correlation was observed between loss of Her2 positivity and percentage gain in ER staining in patients with residual disease following treatment with neoadjuvant trastuzumab. Further study is needed to elucidate the regulatory mechanism of ER/Her2 crosstalk, which may be epigenetically regulated through DNA methylation.

Take-home message

ER/Her2 crosstalk can be demonstrated clinically in IHC analysis of patients with residual disease post neoadjuvant trastuzumab. Tyrosine kinase inhibition in the form of neoadjuvant trastuzumab results in loss of Her2 signalling and corresponding gain in ER signalling.

Abstract P3-04-03: S100β as a predictive biomarker and monitoring tool in endocrine resistant breast cancer

In estrogen receptor positive breast cancer, endocrine therapy is the standard line of treatment and even though it results in reduced recurrence and mortality, a significant number of patients will eventually relapse. Early detection of metastatic disease would significantly enhance management of endocrine resistant breast cancer. Here we investigate the potential of the calcium-binding protein S100β as a predictive biomarker and monitoring tool in endocrine treated patients. Furthermore, the efficacy of S100β inhibition as therapy in patients that fail first line endocrine therapy was examined.

Primary tumor tissue expression of S100β protein was assessed in a retrospective cohort of endocrine treated breast cancer patients. Expression of S100β indicated a significant reduction in time to disease recurrence (n=509, Wilcoxon p&lt;0.0001, hazard ratio 2.43, 95% C.I. is 1.607 to 3.69, p&lt;0.0001, Cox proportional hazard model).

S100β protein is also detectable in serum of breast cancer patients and elevated levels of serum S100β prior to removal of primary tumor is associated with poor disease free survival in endocrine treated patients (n=190, Wilcoxon p=0.0367, hazard ratio 2.68, 95% C.I. is 1.12 to 6.41, p=0.026, Cox proportional hazard model). Serum levels of S100β are significantly reduced after primary tumor resection (n=19, p=0.0003). In serial samples taken during the treatment period, elevated levels of S100β significantly associated with disease progression and with the emergence of metastatic disease (p=0.0031).

In an in-vivo model of endocrine resistant breast cancer, raised levels of S100β marked the emergence of disease progression. The oncogene steroid receptor co-activator 1 (SRC1) and its interaction with homeobox protein (HOXC11) regulates S100β production in a src-kinase dependent manner. Here, src-kinase inhibition reduced tumor burden with a concomitant reduction in serum S100β. We also observed a marked reduction in expression of proliferative marker Ki67 and S100β protein following the treatment of endocrine resistant patient tumor explants with src-kinase inhibitor.

Associations between elevated levels of serum S100β and subsequent disease progression in endocrine treated patients, suggests S100β as a monitoring tool for early detection of disease progression. Additionally high level of S100β can be used as a potential companion diagnostic tool for stratifying patients on endocrine therapy suitable for treatment with small molecule src-kinase inhibitor.

Citation Format: Charmsaz S, Hughes É, Byrne C, Bane F, Tibbitts P, McIlroy M, Hill AD, Young LS. S100β as a predictive biomarker and monitoring tool in endocrine resistant breast cancer [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 P3-04-03.

Long-term outcomes and healthcare utilization following critical illness--a population-based study

BACKGROUND

The purpose of this study was to examine hospital mortality, long-term mortality, and health service utilization among critically ill patients. We also determined whether these outcomes differed according to demographic and clinical characteristics.

METHODS

We conducted a retrospective cohort study of adults (age ≥ 18 years) who survived admission to an intensive care unit (ICU) in Ontario, Canada, between 1 April 2002 and 31 March 2012, excluding isolated admissions to step-down or intermediate ICUs, coronary care ICUs, or cardiac surgery ICUs. Adults (age ≥ 18 years) who survived an acute hospitalization that did not include an ICU stay formed the comparator group. The primary outcome was mortality following hospital discharge. Secondary outcomes were healthcare utilization, including emergency room admissions and hospital readmissions during follow-up.

RESULTS

Over the study interval, 500,124 patients were admitted to ICUs and 420,187 (84%) survived to hospital discharge. Median follow-up for survivors was 5.3 (interquartile range 2.5, 8.2) years. Patients admitted to an ICU were more likely to subsequently visit the emergency department, be readmitted to the hospital and ICU, receive home care support, require rehabilitation, and be admitted for long-term care. Those requiring more resources within the ICU required more resources after discharge. One-third of patients admitted to the ICU died during long-term follow-up, with overall probabilities of death of 11% and 29% at 1 year and 5 years, respectively. In the adjusted analysis, there was an increasing hazard of death with increasing age, reaching a hazard ratio of 18.08 (95 % confidence interval 16.60-19.68) for those ≥ 85 years of age compared with those aged 18-24 years.

CONCLUSIONS

Healthcare utilization after hospital discharge was higher among ICU patients, and also among those requiring more healthcare resources during their ICU admission, than among all hospitalized patients as a group. One-third of ICU patients died within the 5 years following discharge, and age was the most influential determinant of outcome. These findings should help target post-ICU discharge services for high-risk groups and better inform goals-of-care discussions for elderly critically ill patients.

A standardized autopsy procurement allows for the comprehensive study of DIPG biology

Diffuse intrinsic pontine glioma (DIPG) is one of the least understood and most deadly childhood cancers. Historically, there has been a paucity of DIPG specimens for molecular analysis. However, due to the generous participation of DIPG families in programs for postmortem specimen donation, there has been a recent surge in molecular analysis of newly available tumor specimens. Collaborative efforts to share data and tumor specimens have resulted in rapid discoveries in other pediatric brain tumors, such as medulloblastoma, and therefore have the potential to shed light on the biology of DIPG. Given the generous gift of postmortem tissue donation from DIPG patients, there is a need for standardized postmortem specimen accrual to facilitate rapid and effective multi-institutional molecular studies.

We developed and implemented an autopsy protocol for rapid procurement, documenting and storing these specimens. Sixteen autopsies were performed throughout the United States and Canada and processed using a standard protocol and inventory method, including specimen imaging, fixation, snap freezing, orthotopic injection, or preservation. This allowed for comparative clinical and biological studies of rare postmortem DIPG tissue specimens, generation of in vivo and in vitro models of DIPG, and detailed records to facilitate collaborative analysis.

Identification of novel ALK rearrangement A2M-ALK in a neonate with fetal lung interstitial tumor

Fetal lung interstitial tumor (FLIT) is a recently reported type of congenital lung lesion comprising solid and cystic components. The pathological features include unique interstitial mesenchyme-based cell proliferation, and differ from other neoplasms represented by pleuropulmonary blastoma or congenital peribronchial myofibroblastic tumor. FLIT is extremely rare and its gene expression profile has not yet been reported. We provide the first report of a novel chromosomal rearrangement resulting in α-2-macroglobulin (A2M) and anaplastic lymphoma kinase (ALK) gene fusion in a patient with FLIT. The tumor cells contained a t(2;12)(p23;p13) and were mesenchymal in origin (e.g., inflammatory myofibroblastic tumors), suggesting the involvement of ALK in this case of FLIT. Break apart fluorescence in situ hybridization demonstrated chromosomal rearrangement at ALK 2p23. Using 5'-rapid amplification of cDNA ends, we further identified a novel transcript fusing exon 22 of A2M to exon 19 of ALK, which was confirmed by reverse-transcription polymerase chain reaction. The corresponding chimeric gene was subsequently confirmed by sequencing, including the genomic break point between intron 22 and 18 of A2M and ALK, respectively. Discovery of A2M as a novel ALK fusion partner, together with the involvement of ALK, provides new insights into the pathogenesis of FLIT, and suggests the potential for new therapeutic strategies based on ALK inhibitors.

From theater to the world wide web--a new online era for surgical education

INTRODUCTION

Traditionally, surgical education has been confined to operating and lecture theaters. Access to the World Wide Web and services, such as YouTube and iTunes has expanded enormously. Each week throughout Ireland, nonconsultant hospital doctors work hard to create presentations for surgical teaching. Once presented, these valuable presentations are often never used again.

AIMS

We aimed to compile surgical presentations online and establish a new online surgical education tool. We also sought to measure the effect of this educational tool on surgical presentation quality.

METHODS

Surgical presentations from Cork University Hospital and Beaumont Hospital presented between January 2010 and April 2011 were uploaded to http://www.pilgrimshospital.com/presentations. A YouTube channel and iTunes application were created. Web site hits were monitored. Quality of presentations was assessed by 4 independent senior surgical judges using a validated PowerPoint assessment form. Judges were randomly given 6 presentations; 3 presentations were pre-web site setup and 3 were post-web site setup. Once uploading commenced, presenters were informed.

RESULTS

A total of 89 presentations have been uploaded to date. This includes 55 cases, 17 journal club, and 17 short bullet presentations. This has been associated with 46,037 web site page views. Establishment of the web site was associated with a significant improvement in the quality of presentations. Mean scores for pre- and post-web site group were 6.2 vs 7.7 out of 9 respectively, p = 0.037.

CONCLUSIONS

This novel educational tool provides a unique method to enable surgical education become more accessible to trainees, while also improving the overall quality of surgical teaching PowerPoint presentations.

P5-12-01: Aromatase Inhibitor Specific Metastasis Is Driven by the Steroid Receptor Coactivator SRC-1

Aromatase Inhibitors are currently one of the most promising therapies of estrogen-receptor positive breast cancer in postmenopausal women. Even though many women initially respond to the treatment, approximately 30–40% will acquire resistance and relapse within 5 years. The mechanisms involved in the development of resistance to AIs however are poorly understood as long term follow up is only now becoming available. To investigate the mechanisms involved in AI-specific tumour recurrence, we generated a cell line resistant to the AI Letrozole (LetR) and examined a cohort of endocrine treated breast cancer patients (n=150). In patients treated with a first-line AI (n=89), we found that hormone receptor switching between the primary tumour and the resistant metastasis was a common feature of disease recurrence. More so, this switch accompanied the development of a phenotype displaying an increase in migratory capacity and loss of organisation. Both the resistant cell model and AI resistant tumour samples expressed high levels of the steroid receptor coactivator SRC-1. We also found that the interaction between SRC-1 and the transcription factor Ets2 was involved in the regulation of Myc and MMP9 expression and that SRC-1 was required for the aggressive AI resistant phenotype. Expression of SRC-1 in the primary and/or recurrent tumour associated with poor disease free survival (p=0.01, n=89) in the AI treated population. A significant coassociation between SRC-1 and Ets2 in the nucleus of the recurrent tissue compared with the matched primary tumour was also observed (p=0.0004, n=3). These data describe a novel signaling mechanism of AI-specific metastatic progression where SRC-1 utilizes Ets2 to promote de-differentiation and migration to drive disease progression.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-12-01.

Clinical observed performance evaluation: a prospective study in final year students of surgery

We report a prospective study of clinical observed performance evaluation (COPE) for 197 medical students in the pre-qualification year of clinical education. Psychometric quality was the main endpoint. Students were assessed in groups of 5 in 40-min patient encounters, with each student the focus of evaluation for 8 min. Each student had a series of assessments in a 25-week teaching programme. Over time, several clinicians from a pool of 16 surgical consultants and registrars evaluated each student by direct observation. A structured rating form was used for assessment data. Variance component analysis (VCA), internal consistency and inter-rater agreement were used to estimate reliability. The predictive and convergent validity of COPE in relation to summative OSCE, long case, and overall final examination was estimated. Median number of COPE assessments per student was 7. Generalisability of a mean score over 7 COPE assessments was 0.66, equal to that of an 8 × 7.5 min station final OSCE. Internal consistency was 0.88-0.97 and inter-rater agreement 0.82. Significant correlations were observed with OSCE performance (R = 0.55 disattenuated) and long case (R = 0.47 disattenuated). Convergent validity was 0.81 by VCA. Overall final examination performance was linearly related to mean COPE score with standard error 3.7%. COPE permitted efficient serial assessment of a large cohort of final year students in a real world setting. Its psychometric quality compared well with conventional assessments and with other direct observation instruments as reported in the literature. Effect on learning, and translation to clinical care, are directions for future research.

The management of rectal cancer in Ireland in 2007--room for improvement?

INTRODUCTION

Effective management of rectal cancer relies on accurate pre-operative assessment, surgical technical excellence and integrated neoadjuvant and adjuvant chemo and/or radiotherapy. The aim of this study was to examine the management of rectal cancer in Ireland.

METHODS

This was a retrospective chart review. All cases of rectal cancer (15 cm or less from the anal verge) diagnosed in Ireland in the year 2007 were included in the audit.

RESULTS

In total data for 585 patients were included, under the care of 87 consultant surgeons operating in 48 hospitals. Only data recorded in medical charts were included. Pre-operative investigations were less utilised than recommended by current guidelines and consequently many cancers were inadequately staged. In total 52.5% of cases were discussed at a multi-disciplinary meeting. Overall, 88% of the patients had surgery, and the 30-day mortality rate was 1.7%. The quality of post-operative pathology reporting was variable, with adequacy of total mesorectal excision status unclear or unknown in 74% of cases. Cases were managed in a large number of centres, and in lower volume centres (<5 cases per annum) patients appeared to be less adequately investigated.

CONCLUSION

This study gives a snapshot of recent practice in the management of rectal cancer in Ireland but is of necessity limited as the audit was retrospective and long term outcomes have not been assessed. In 2007 rectal cancer was managed in a large number of centres and best practice was frequently not adhered to. The impending centralisation of cancer services is likely to impact on the management of rectal cancer in Ireland.

Sentinel lymph node biopsy in patients with a needle core biopsy diagnosis of ductal carcinoma in situ: is it justified?

BACKGROUND

The incidence of ductal carcinoma in situ (DCIS) has increased markedly with the introduction of population-based mammographic screening. DCIS is usually diagnosed non-operatively. Although sentinel lymph node biopsy (SNB) has become the standard of care for patients with invasive breast carcinoma, its use in patients with DCIS is controversial.

AIM

To examine the justification for offering SNB at the time of primary surgery to patients with a needle core biopsy (NCB) diagnosis of DCIS.

METHODS

A retrospective analysis was performed of 145 patients with an NCB diagnosis of DCIS who had SNB performed at the time of primary surgery. The study focused on rates of SNB positivity and underestimation of invasive carcinoma by NCB, and sought to identify factors that might predict the presence of invasive carcinoma in the excision specimen.

RESULTS

7/145 patients (4.8%) had a positive sentinel lymph node, four macrometastases and three micrometastases. 6/7 patients had invasive carcinoma in the final excision specimen. 55/145 patients (37.9%) with an NCB diagnosis of DCIS had invasive carcinoma in the excision specimen. The median invasive tumour size was 6 mm. A radiological mass and areas of invasion <1 mm, amounting to "at least microinvasion" on NCB were predictive of invasive carcinoma in the excision specimen.

CONCLUSIONS

SNB positivity in pure DCIS is rare. In view of the high rate of underestimation of invasive carcinoma in patients with an NCB diagnosis of DCIS in this study, SNB appears justified in this group of patients.

Novel non-steroidal p160 coactivator interactions in tamoxifen resistant breast cancer

Abstract #3038

While most breast cancer patients initially respond to endocrine therapy, 30-40% of cases relapse within 5 years of treatment. Translational studies from our group and others have provided substantial evidence of a significant role for p160 family of Steroid Receptor Co-activator (SRC) proteins in the development of resistance to endocrine therapy. In this study we have investigated novel non-steroidal SRC-1 interactions in endocrine resistant breast cancer.&#x2028; A mass-spectrometry-based screen was used to identify proteins which differentially interact with SRC-1 in endocrine resistant compared with endocrine sensitive breast cancer cells. The developmental protein, HOXC11, was confirmed as an SRC-1 interacting partner. HOXC11 was shown to be over-expressed in tamoxifen-resistant cells using immunocytochemistry and was observed to translocate to the nucleus and peri-nuclear region when cells were treated with tamoxifen. In a breast cancer TMA (n=560) HOXC11 was found to correlate with disease recurrence and metastasis (local and distant). Moreover, in addition to associating with SRC-1, HOXC11 was found to be a strong predictor of reduced disease-free survival on endocrine treatment (Hazard ratio: 5.79; p&lt;0.0001).&#x2028; Bioinformatic analysis identified S100β as a target gene of the HOXC11 transcription factor. Interestingly, the s100 family of calcium binding proteins has been associated with poor outcome and reduced disease-free survival in melanoma. Reporter assays were used to confirm HOXC11 as a mediator of S100β transcription. Regulation of the target gene in the presence of tamoxifen was shown to be modified by activation of protein kinase A (PKA) which has previously been implicated in the enhancement of tamoxifenÂs agonist profile. Here we have defined HOXC11 as a non-steroidal interacting partner of SRC-1; furthermore, this interaction appears to be regulated by the activation of PKA. HOXC11 expression in our breast cancer patient cohort associated with poor survival and the development of metastatic disease. This study provides evidence of a novel mechanism at play in endocrine resistant breast cancer cells.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3038.

Coassociation of ERα and p160 proteins predicts resistance to endocrine treatment; SRC-1 is an independent predictor of breast cancer recurrence

Abstract #3032

The p160 coactivators AIB1 and SRC-1 are known to play a critical role in modulating transcription in breast cancer cells in conjunction with ligand-bound estrogen receptor. The interactions of the p160 proteins with this nuclear receptor are also important in the development of resistance to endocrine treatments. Using quantitative coassociation immunofluorescent microscopy, the colocalisation of the p160s and ERα was increased in the LY2 endocrine resistant cell line following treatment with the anti-estrogen tamoxifen in comparison to the endocrine sensitive MCF-7 cell line. In cell cultures derived from patient tumours at the time of primary surgery prior to treatment, there was an increase in association of the coactivators with ERα following treatment with estrogen but dissociation was evident in the presence of tamoxifen. Immunohistochemical staining of a tissue microarray, constructed from 560 breast cancer patients, revealed that SRC-1 was a strong predictor of reduced disease-free survival, both in patients receiving adjuvant tamoxifen treatment and untreated patients (p&lt;0.0001 and p=0.0111 respectively). AIB1 was not a significant independent predictor of disease recurrence. SRC-1 was assigned a hazard ratio of 2.12 when survival analysis using a Cox proportional hazards model was applied. Quantitative coassociation analysis of the p160 coactivators with ERα in the patient TMA revealed significantly stronger colocalisation of SRC-1 and ERα in patients who are known to have relapsed than those patients who did not recur (p=0.00001). This data suggests SRC-1 is pivotal in tumour aggressiveness and is a powerful predictor of progression of disease in breast cancer patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3032.

The reactivity of 1,3-butadiene with butadiene-derived popcorn polymer

Adiabatic calorimetry performed on butadiene-derived popcorn polymer samples from industrial facilities has revealed exothermic behavior accompanied by non-condensible gas production, indicative of possible decomposition, at elevated temperatures. In the presence of low concentrations of 1,3-butadiene, reactivity is observed at temperatures of 60-70 degrees C; that is, 20-30 degrees C below those usually seen for butadiene alone. Once the butadiene is consumed, the reaction behavior reverts to that of the popcorn polymer alone. At higher butadiene concentrations, the low temperature reaction persists, eventually merging with typical butadiene behavior. The butadiene reactivity with popcorn polymer is attributed to polymerization reaction at free radical sites in the popcorn polymer. Different popcorn polymer samples exhibit distinct extents of reactivity, presumably depending on the nature and concentration of the free radical sites and the structure of the material. Uninhibited butadiene exposed to 100 psia air, which may act to generate peroxide species, shows a small, additional exotherm around 50-80 degrees C. Contact of butadiene with lauroyl peroxide, providing free radicals upon decomposition, generates an exotherm at temperatures as low as 60 degrees C.

Expression and prognostic relevance of Mcl-1 in breast cancer

BACKGROUND

Bcl-2, an anti-apoptotic protein, is frequently associated with favourable prognosis in breast cancer. The potential role of mcl-1, another bcl-2 family member, in breast cancer has not yet been defined.

PATIENTS AND METHODS

This study examined the expression of mcl-1 and bcl-2 in 170 cases of invasive primary breast carcinoma, using reverse-transcriptase polymerase chain reaction and immunohistochemical analyses.

RESULTS

Expression of bcl-2 mRNA and protein were found to be favourably associated with outcome for patients, supporting a prognostic role for bcl-2 in breast cancer, whereas mcl-1 expression, at the mRNA or protein level, did not correlate with tumour size, grade, lymph node or ER status, age of patient at diagnosis, or disease outcome.

CONCLUSION

As these analyses of mcl-1 expression may have co-detected mcl-1(S/deltaTM) (a more recently identified, shorter variant, that may be pro-apoptotic) with the anti-apoptotic wild-type of mcl-1, it is possible that future studies may indicate some significant clinical correlations if the isoforms can be independently investigated.

Pathological axillary lymph nodes detected at mammographic screening

AIM

To investigate the significance of abnormal axillary lymph nodes detected at mammographic screening in the absence of a concomitant breast lesion.

METHODS

Twenty-three thousand, seven hundred and seven women were screened at the Merrion Unit as part of the Irish National Breast Screening Programme ("BreastCheck") in the period June 2000 to July 2002. Nine women (0.4 per 1000 women screened) were found to have an abnormal axillary lymph node(s) in the absence of a mammographic breast lesion and were recalled for assessment. The radiological criteria for recall included: size greater than or equal to 15 mm, round or irregular shape, increased node density and absence of hilar lucency. Each woman underwent further mammographic views, ultrasound examination of axilla and breast, clinical examination and lymph node biopsy either by 14G needle core biopsy (NCB) or open excision.

RESULTS

The final pathological diagnoses in the nine patients were oestrogen receptor (OR) positive metastatic breast carcinoma (two patients), metastatic malignant melanoma (one patient), malignant lymphoma (two patients), caseating granulomatous lymphadenitis suggestive of tuberculosis (one patient), and other benign conditions (three patients).

CONCLUSION

Abnormal axillary lymph nodes, in the absence of an accompanying breast lesion, are rarely identified on screening mammogram, but may harbour significant pathology and their presence on screening mammogram merits further investigation including biopsy.

Prognostic importance of survivin in breast cancer

Survivin is a member of the inhibitor of apoptosis (IAP) family, and is also involved in the regulation of cell division. Survivin is widely expressed in foetal tissues and in human cancers, but generally not in normal adult tissue. This study examined the expression of surviving protein in a series of 293 cases of invasive primary breast carcinoma. Survivin immunoreactivity was assessed using two different polyclonal antibodies, and evaluated semiquantitatively according to the percentage of cells demonstrating distinct nuclear and/or diffuse cytoplasmic staining. Overall, 60% of tumours were positive for survivin: 31% demonstrated nuclear staining only, 13% cytoplasmic only, and 16% of tumour cells demonstrated both nuclear and cytoplasmic staining. Statistical analysis revealed that survivin expression was independent of patient's age, tumour size, histological grade, nodal status, and oestrogen receptor status. In multivariate analysis, nuclear survivin expression was a significant independent prognostic indicator of favourable outcome both in relapse-free and overall survival (P<0.001 and P=0.01, respectively). In conclusion, our results show that survivin is frequently overexpressed in primary breast cancer. Nuclear expression is most common and is an independent prognostic indicator of good prognosis.

Elevated expression and altered processing of fibulin-1 protein in human breast cancer

The extracellular matrix protein fibulin-1 suppresses the motility and invasiveness of a variety of tumour cell types in vitro as well as the growth of fibrosarcoma tumours in nude mice. In this study, fibulin-1 protein expression in breast carcinoma specimens and normal breast tissue was evaluated immunohistologically. Fibulin-1 protein expression was also semiquantitatively assessed by immunoblot analysis in a collection of normal breast tissues (n=18), benign tumours (n=5) and breast carcinomas (n=39). In normal breast tissue, fibulin-1 protein expression predominated in the ductal epithelium and underlying myoepithelium, with weaker staining evident in the loose connective surrounding the ducts. Examination of breast carcinomas revealed that the tumour cells also expressed fibulin-1 protein. The level of mature fibulin-1 polypeptide (100 kDa) was higher in the breast carcinoma specimens as compared to normal breast tissue (Mann-Whitney U-test, P=0.0005). In addition to the mature fibulin-1 polypeptide, several smaller sized polypeptides of 55, 50 and 25 kDa were detected using monoclonal antibodies reactive towards an epitope located at the N-terminus of fibulin-1. The immunoreactive 50 kDa polypeptide was detected more frequently in breast carcinoma specimens than in normal breast tissue (chi(2)=17.22, P<0.0001). Furthermore, the ratio of the 50 kDa fragment to the mature fibulin-1 polypeptide correlated with the level of oestrogen receptor alpha (Spearman correlation coefficient, rs=0.49, P<0.003, n=36) and progesterone receptor (rs=0.43, P=0.008, n=36) expression in the tumour specimens. Taken together, these findings indicate that elevated expression and altered processing of fibulin-1 is associated with human breast cancer.

Value of sentinel node biopsy in the management of breast cancer

AIMS

To determine the rate of detection of the sentinel node using both blue dye and radioisotope, and the accuracy with which the sentinel node histology reflects the nodal status of the axilla in a series of patients with clinically node-negative breast cancer.

PATIENTS AND METHODS

During a 32-month period from May 1998 to December 2000, 73 patients with clinically node-negative breast cancer underwent sentinel node biopsy immediately followed by formal axillary lymphadenectomy. The sentinel node(s) was identified using a combination of lymphoscintigraphy, blue dye and an intraoperative hand-held gamma probe.

RESULTS

The mean age of the 73 patients was 58 years (range 32-83 years). Twenty-six per cent (19/73) had previous surgical/excisional biopsy. Pre-operative lymphoscintigraphy was positive in 74% (54/73) of patients. Combination of blue dye and radioisotope was better than either method in isolation for identifying the sentinel node, yielding a success rate of 96% (70/73). A total of 32 cases proved to have positive nodal disease on histological examination. In 44% (14/32) of patients, the sentinel node was the only positive node. Forty-seven per cent (15/32) of patients in whom the sentinel node was positive also had positive nodes in the axillary nodal basin. There were 3/32 false negative cases, giving a false negative rate of 9.4%.

CONCLUSION

Sentinel node biopsy will have a role in the management of breast cancer. However, widespread adaptation of this technique awaits the results of prospective, randomised trials.

Safety guidelines for radiolocalised sentinel node resection

BACKGROUND

Sentinel node radiolocalisation procedures are associated with low levels of radiation exposure. Radioactive material is present in the operating theatre and pathology laboratory. In most hospitals there are no official regulations in place for sentinel node radiation exposure.

AIM

To establish guidelines on the safety of sentinel node mapping with emphasis on the management of radioisotopes.

METHODS

The current literature regarding sentinel node procedures and radiation safety was reviewed. EU and US radiation safety regulations were scrutinised.

RESULTS

Personnel involved in sentinel node procedures are exposed to low levels of radiation. These levels are not high enough to require designated radiation workers in the theatre and pathology laboratory. Awareness of radiation safety and certain precautions during the procedure and processing of the specimen can further reduce levels of exposure.

CONCLUSION

Although low levels of radiation exposure are associated with sentinel node procedures, awareness of radiation safety and adherence to regulations, along with close interdepartmental co-operation, are recommended for further reduction in radiation exposure and safe application of this technique.

Immunohistochemical analysis of sentinel lymph nodes from patients with Merkel cell carcinoma

BACKGROUND

Immunohistochemical analysis of sentinel lymph nodes from patients with breast carcinoma and melanoma has been shown to increase the sensitivity for detecting lymph node metastases. To the authors' knowledge, this technique has not been described in patients with Merkel cell carcinoma.

METHODS

Lymphatic mapping and sentinel lymph node biopsy was performed on 26 patients with Merkel cell carcinoma between 1997 and 1999. All sentinel lymph nodes were analyzed with conventional hematoxylin and eosin (H&E) staining and then analyzed with immunohistochemical staining to evaluate whether this additional technique would increase the number of patients found to have lymph node metastasis.

RESULTS

The median age of the patients in the current study was 67 years and the median tumor size at the time of presentation was 2 cm. Lymph node metastases were identified in 5 of the 26 patients (19%). Three of these five lymph node positive patients were identified with H&E staining. The remaining two patients were identified only after immunohistochemical analysis. The median follow-up in this group of lymph node positive patients was 14 months, with 2 of the 5 lymph node positive patients developing a recurrence. The median follow-up in the 21 patients who were lymph node negative was 19 months, with only 1 patient having developed a recurrence at the time of last follow-up.

CONCLUSIONS

Immunohistochemical analysis of sentinel lymph nodes from patients with Merkel cell carcinoma appears to increase the sensitivity of detecting clinically occult lymph node metastases.

Calcium fractional absorption and metabolism assessed using stable isotopes differ between postpartum and never pregnant women

Determining the fractional absorption (FA) of calcium using the incorporation into urine of stable isotopes given intravenously (IV) and orally has become a routine procedure. We investigated the FA of calcium in two groups of (2-3 mo) postpartum women lactating (LACT) (n = 6) and nonlactating (PPNL) (n = 6), and in never pregnant (NP) women (n = 7). The women consumed a controlled diet containing 30-33 mmol/d calcium (Ca) for 21 d. On d 7 of the controlled diet, the women received 0.05 mmol of 42Ca IV and 0.25 mmol 44Ca orally in milk. Urine samples (24-h) were collected for the next 14 d and morning blood samples were collected from fasting subjects before dosing and at 24 and 48 h after receiving the isotopes. Milk samples from the LACT women were collected from each feeding beginning 24 h before to 72 h after dosing. There were no significant differences in the FA of calcium as measured by stable isotope incorporation into urine (23.8 +/- 2.9%), serum (24.0 +/- 3.4%) or milk (23.6 +/- 3.6%) of LACT women. The fractional calcium absorption measured in urine of the postpartum women (LACT and PPNL, 23.8 +/- 2.9% and 25.0 +/- 3.3%, respectively) did not differ but was greater (P < 0.028) than that of the NP women (17.3 +/- 1.3%). The postpartum LACT and PPNL women had a reduced urinary excretion of calcium (P < 0.01) compared with the NP women. There was a significantly greater incorporation (P < 0.001) by LACT women of the oral isotope dose into milk than into urine. Calcium FA can be determined from incorporation of stable isotopes into breast milk and serum as well as urine.

Post-partum ovarian vein thrombosis

Post-partum ovarian vein thrombosis (POVT) is uncommon, but the true incidence is not known. Ninety per cent of cases present as right iliac fossa pain within 10 days of delivery. Anti-coagulation and intravenous antibiotics are the mainstay of treatment. We report three cases that were referred to our unit. These cases illustrate the difficulty in the clinical diagnosis of POVT and highlight the importance of its inclusion in the differential diagnoses of an acute abdomen in post-partum patients. POVT can be accurately diagnosed by appropriate noninvasive investigations and a laparotomy avoided.

Suppression of macrophage nitric oxide production by melanoma: mediation by a melanoma-derived product

The tumour-bearing state is known to induce immune dysfunction that contributes to increased infectious complications and tumour progression. However, the mechanisms underlying this immunosuppression remain unclear. This study investigated in a murine model the effects of melanoma growth on nitric oxide (NO) production by peritoneal macrophages in vivo and in vitro. B16 and K1735 melanoma cells were inoculated subcutaneously into C57BL/6 and C3H/HeN mice, respectively. Stimulated NO production by elicited peritoneal macrophages was examined in control and melanoma- bearing mice. An in vitro system was established to assess the effects of co-culturing melanoma cells (B16 and K1735) or melanoma-conditioned medium with normal peritoneal macrophages on subsequent NO production. NO production was significantly suppressed in macrophages from melanoma-bearing mice. Co-culture of normal macrophages with melanoma cells in a transwell system or with melanoma-conditioned media in vitro reproduced the defects observed in vivo without affecting macrophage viability, pointing to a melanoma-derived product as the basis for the observed suppression of NO production. This inhibition required RNA and protein synthesis and was dose and time dependent. Using inhibition profiles and neutralizing antibodies, it was demonstrated that this melanoma inhibitory activity was distinct from known NO inhibitors. Preliminary characterization attributed this activity to a melanoma-secreted protein moiety.

Studies on oestrogen receptor-α and -β mRNA in breast cancer

The oestrogen receptor (ER) is widely used to predict response to tamoxifen in patients with breast cancer. Recently a new form of ER known as ER-beta was discovered, the original ER is now designated ER-alpha. In this investigation, ER-alpha and ER-beta were measured in 107 breast carcinomas and 22 fibroadenomas. Using reverse transcriptase-polymerase chain reaction (RT-PCR), ER-beta mRNA, but not ER-alpha mRNA was expressed more frequently in fibroadenomas than carcinomas. In the carcinomas, ER-beta mRNA was present in a greater proportion of samples positive for ER-alpha mRNA than in those lacking this form of the receptor. ER-alpha, but not ER-beta mRNA, was significantly associated with ER protein-positivity in the cancers. ER-alpha mRNA was also positively related to progesterone receptors (PR), but ER-beta mRNA showed an inverse relationship with PR. We conclude that the presently used enzyme-linked immunosorbent assay (ELISA) for ER appears to be mostly measuring ER-alpha and is unlikely to be detecting ER-beta.

Parathyroid carcinoma: diagnosis and management

Parathyroid carcinoma is a rare and difficult diagnosis to make based on the histological features alone. We review five cases of parathyroid carcinoma in the past 30 years and the clinical and biochemical features that facilitate the making of the diagnosis. A favourable outcome can be expected with adequate surgical treatment.

Prospective evaluation of the morbidity of axillary clearance for breast cancer

BACKGROUND

Axillary clearance, despite its morbidity, retains an essential role in the management of patients with breast cancer. The aim of this prospective study was to document the development of arm swelling and limitation of shoulder movement following complete axillary clearance.

METHODS

One hundred patients who had axillary clearance to level III, for treatment of breast cancer, were followed prospectively for over 1 year. Arm volumes were measured using an optoelectronic volometer and shoulder movements with a goniometer.

RESULTS

Ten patients had significant arm swelling at 1 year. The swelling was mild in eight and moderate in two. No patient developed severe swelling. Reduced arm movements were noted in the first week after operation but had returned to normal at 6 months.

CONCLUSION

This study provided accurate documentation of the morbidity associated with axillary clearance, together with a reproducible method of arm volume measurement.

Bone-related mineral content of water samples collected on the Navajo reservation

Although dairy food intake is low among the Navajo people, hip fracture rates are lower than in Caucasians. Genetic differences in bone density have been cited as the reasons for low fracture rates among Native Americans and other segments of the population. However, more detailed examination of mineral intakes suggests that environmental factors may provide part of the explanation for the lower fracture rates. Cultural practices such as the addition of ash to traditional foods and the high mineral content of water may provide much higher intakes of bone-related minerals than food intake surveys have previously reported. As part of a larger study to assess overall intake of minerals related to bone health and other conditions, water samples were collected from the Navajo reservation. Duplicates were collected at least one week apart from 53 sites including wells, springs, taps, and storage barrels and analyzed by atomic absorption and inductively coupled plasma spectrometry for a number of minerals. For average intakes of 2 l/day, water could provide up to 212 mg of calcium, 150 mg of magnesium and 8 mg of zinc. The combined contribution of mineral intakes provided by the addition of juniper ash to traditional foods, not genetic differences, may partially explain the lower fracture rates of the Navajo people. Further research in this area is required to confirm this hypothesis.

Tumour micrometastases: the influence of angiogenesis

INTRODUCTION

Many cancer patients have undetected micrometastatic disease at first presentation which ultimately progresses. Angiogenesis-the development of an independent blood supply-is a key event in the growth of metastases. Improved understanding of the influence of angiogenesis on micrometastatic growth may lead to new therapeutic intervention.

METHODS

This study examines current concepts of the significance of micrometastases and the role of angiogenesis in their development and destruction. A comprehensive review of the literature on micrometastasis and angiogenesis was performed using the Medline database between 1966 and 1999.

CONCLUSIONS

Advances in technology have improved our ability to diagnose metastatic disease, but micrometastases in loco-regional lymph nodes and at distant sites can only be detected by sophisticated histological techniques. While the significance of micrometastases remains controversial, there is increasing evidence that micrometastatic status provides useful prognostic information and should be part of standard staging techniques. Anti-angiogenic therapy has the potential to favourably influence management of certain cancers by manipulating a number of key events in the metastatic process.

Intradermal radiocolloid and intraparenchymal blue dye injection optimize sentinel node identification in breast cancer patients

BACKGROUND

Radiotracer and blue dye mapping of sentinel lymph nodes (SLN) have been advocated as accurate methods to stage the clinically negative axilla in breast cancer patients. The technical aspects of SLN biopsy are not fully characterized. In this study we compare the results of intraparenchymal (IP) and intradermal (ID) injection of Tc-99m sulfur colloid, to establish an optimal method for SLN localization.

METHODS

200 consecutive patients had SLN biopsy performed by a single surgeon. Of these, 100 (Group I) had IP injection and 100 (Group II) had ID injection of Tc-99m sulfur colloid. All patients had IP injection of blue dye as well. Endpoints included (1) successful SLN localization by lymphoscintigraphy, (2) successful SLN localization at surgery, and (3) blue dye-isotope concordance (uptake of dye and isotope by the same SLN).

RESULTS

Isotope SLN localization was successful in 78% of Group I and 97% of group II patients (P < .001). When isotope was combined with blue dye, SLN were found in 92% of group I and 100% of Group II (P < .01). In cases where both dye and isotope were found in the axilla, dye mapped the same SLN as radiotracer in 97% of Group I and 95% of Group II patients.

CONCLUSIONS

The dermal and parenchymal lymphatics of the breast drain to the same SLN in most patients. Because ID injection is easier to perform and more effective, this technique may simplify and optimize SLN localization.

Sentinel lymph node biopsy after percutaneous diagnosis of nonpalpable breast cancer

PURPOSE

To determine the technical success rate of sentinel lymph node biopsy in women with nonpalpable infiltrating breast cancer diagnosed by using percutaneous core biopsy and to determine the frequency with which sentinel lymph node biopsy obviated axillary dissection.

MATERIALS AND METHODS

Retrospective review revealed 33 women who underwent sentinel node biopsy after percutaneous core biopsy diagnosis of nonpalpable infiltrating breast cancer. Sentinel nodes were identified with radioisotope and blue dye; the procedure was technically successful if sentinel nodes were found at surgery. All sentinel nodes were excised. Axillary dissection was performed if tumor was present in sentinel nodes.

RESULTS

Sentinel nodes were found at surgery in 30 women (91%). Sentinel nodes were identified with both radioisotope and blue dye in 22 (73%) of these women, with only radioisotope in six (20%), and with only blue dye in two (7%). Sentinel nodes were found in 12 (80%) of 15 women in the first half of the study versus all 18 (100%) women in the second half (P = .08). Sentinel nodes were free of tumor in 23 (77%) of 30 women. In six (86%) of seven women with tumor in sentinel nodes, the sentinel nodes were the only nodes with tumor.

CONCLUSION

Sentinel node biopsy was successful in 30 women (91%) with nonpalpable infiltrating carcinoma diagnosed with percutaneous core biopsy and obviated axillary dissection in 23 women (70%). Using both radioisotope and blue dye may increase the success rate. A learning curve exists, and success improves with experience.

Credentialing for breast lymphatic mapping: how many cases are enough?

OBJECTIVE

To evaluate credentialing issues for sentinel lymphatic mapping for breast cancer.

SUMMARY BACKGROUND DATA

The sentinel lymph node (SLN) is defined as the first lymph node receiving lymphatic drainage from a tumor. The SLN accurately reflects the status of the axillary nodes in patients with early-stage breast cancer, and SLN mapping is gaining widespread acceptance. Few of the many published feasibility studies of lymphatic mapping for breast cancer have adequate numbers to assess credentialing issues for this new procedure.

METHODS

Five hundred consecutive SLN biopsies were performed at one institution, over a 20-month period, by eight surgeons, using isosulfan blue dye and technetium-labeled sulfur colloid. The authors reviewed each surgeon's success rate in finding the SLN, and false-negative rate, relative to level of experience with the technique.

RESULTS

Lymphatic mapping performed by an experienced surgeon (surgeon A, B, or C) was associated with a higher success rate (94%) than when it was performed by one with less experience (86%). Ten failed mapping procedures occurred in the first 100 cases. For each of the ensuing 100 cases, there were eight, six, six, and four failed mapping procedures, suggesting that increasing experience does not eradicate failed mapping procedures completely. The false-negative rate among 104 patients in whom axillary dissection was planned in advance was 10.6% (5/47). Most false-negative results occurred early in the surgeon's experience: when the first six cases of every surgeon were excluded, the false-negative rate fell to 5.2% (2/38).

CONCLUSIONS

With increasing experience, failed SLN localizations and false-negative SLN biopsies occur less often. Combined dye and isotope localization, enhanced histopathology, a backup axillary dissection, and judicious case selection are required to avoid the high false-negative rate of one's early experience.

Sentinel lymph node biopsy in breast cancer: unfiltered radioisotope is superior to filtered

BACKGROUND

The combination of gamma-probe radiolocalization and blue-dye mapping of sentinel lymph nodes (SLNs) has been advocated as the most accurate method for staging the clinically negative axilla in breast cancer patients, but the technical aspects of these procedures are not fully characterized in the literature. In this study, we compared the success of SLN localization in 134 consecutive breast cancer patients using blue dye plus two different preparations of radiocolloid.

STUDY DESIGN

A retrospective analysis of a prospectively maintained data base was performed to assess SLN localization in two cohorts of patients. Unfiltered technetium-99m (Tc-99m) sulfur colloid (in 77 patients; group I) was compared with filtered Tc-99m sulfur colloid (in 57 patients; group II). All patients had a peritumoral injection of blue dye and isotope, followed immediately by lymphoscintigraphy to confirm radioactivity at the injection site and to image the SLN. Statistical analysis was performed using the Pearson chi-square test.

RESULTS

Unfiltered Tc-99m sulfur colloid was superior to the filtered radiocolloid in localizing the SLN (88% versus 73%; p = 0.03). SLN imaging by lymphoscintigraphy was also more successful in the unfiltered group. Using the combination of blue dye and radiolocalization, SLNs were identified in 94% of patients.

CONCLUSIONS

For optimal localization of the SLN in breast cancer patients, surgeons should use the combined technique of blue-dye mapping and gamma-probe localization using unfiltered Tc-99m sulfur colloid.

Lessons learned from 500 cases of lymphatic mapping for breast cancer

OBJECTIVE

To evaluate the factors affecting the identification and accuracy of the sentinel node in breast cancer in a single institutional experience.

SUMMARY BACKGROUND DATA

Few of the many published feasibility studies of lymphatic mapping for breast cancer have adequate numbers to assess in detail the factors affecting failed and falsely negative mapping procedures.

METHODS

Five hundred consecutive sentinel lymph node biopsies were performed using isosulfan blue dye and technetium-labeled sulfur colloid. A planned conventional axillary dissection was performed in 104 cases.

RESULTS

Sentinel nodes were identified in 458 of 492 (92%) evaluable cases. The mean number of sentinel nodes removed was 2.1. The sentinel node was successfully identified by blue dye in 80% (393/492), by isotope in 85% (419/492), and by the combination of blue dye and isotope in 93% (458/492) of patients. Success in locating the sentinel node was unrelated to tumor size, type, location, or multicentricity; the presence of lymphovascular invasion; histologic or nuclear grade; or a previous surgical biopsy. The false-negative rate of 10.6% (5/47) was calculated using only those 104 cases where a conventional axillary dissection was planned before surgery.

CONCLUSIONS

Sentinel node biopsy in patients with early breast cancer is a safe and effective alternative to routine axillary dissection for patients with negative nodes. Because of a small but definite rate of false-negative results, this procedure is most valuable in patients with a low risk of axillary nodal metastases. Both blue dye and radioisotope should be used to maximize the yield and accuracy of successful localizations.

Intraoperative lymphatic mapping and sentinel lymph node biopsy for Merkel cell carcinoma

BACKGROUND

Merkel cell carcinoma is a rare cutaneous neoplasm which commonly spreads to the regional lymph nodes. The feasibility of identifying the sentinel node in patients with clinically node-negative Merkel cell carcinoma was evaluated.

METHODS

Sentinel lymphatic mapping was performed in 18 patients with stage 1 Merkel cell carcinoma using the combination of isosulphan blue dye and 99mTc-radiolabelled sulphur colloid. Patients with tumour metastasis in the sentinel node underwent complete dissection of the remainder of the lymph node basin.

RESULTS

Eighteen patients underwent removal of 35 sentinel nodes. Two patients demonstrated metastatic disease in the sentinel lymph nodes; complete dissection of the involved nodal basin revealed no additional positive nodes suggesting that the sentinel lymph node had been identified. The node-negative patients received no further surgical therapy, with no evidence of recurrent disease in the sentinel nodal basin at a median of 7 months' follow-up.

CONCLUSION

Sentinel node biopsy is feasible in patients with Merkel cell carcinoma. It can be used to stage patients and provides important prognostic information. In those with subclinical nodal disease, it may direct early regional lymphadenectomy but the effect of such surgery on survival remains unclear.

Ret-proto-oncogene analysis in medullary thyroid carcinoma

INTRODUCTION

Medullary carcinoma of the thyroid (MTC) is a rare tumour which occurs in both sporadic and hereditary forms. Mutations of the RET proto-oncogene have been identified in hereditary forms. The aim of our study was to confirm or exclude familial disease by examining for germline mutations in the RET proto-oncogene in patients with medullary thyroid carcinoma.

METHODS

Nine patients with medullary thyroid carcinoma and 4 of their children were studied. Peripheral blood was used to examine for mutations in the RET proto-oncogene. When this was not available, archival thyroid tissue was used.

RESULTS

Seven patients had clinically sporadic tumours confirmed by mutational analysis of RET. Four children were at risk of being carriers of a mutated gene, as their fathers had histologically proven MTC and had tested positive for the mutation at codon 618 on exon 10 of the RET proto-oncogene. Three of these children carried the 618 mutation. To date, 2 have had a prophylactic thyroidectomy, the pathology of which revealed C-cell hyperplasia. One child had familial disease excluded by mutational analysis. One patient had a clinical diagnosis of MEN2B confirmed by detection of the 918 mutation on exon 16 of the RET proto-oncogene.

CONCLUSIONS

RET proto-oncogene analysis is a reliable method of differentiating familial from sporadic MTC. Mutational information determines which family members of affected kindreds are at risk of developing the disease and can be used to affect clinical management.

Patient regrets after bilateral prophylactic mastectomy

BACKGROUND

The discovery of a cadre of breast cancer susceptibility genes has resulted in an increase in the number of women seeking information about prophylactic breast surgery, but virtually no large-scale prospective databases exist to assist women considering prophylactic mastectomy.

METHODS

The authors constructed a National Prophylactic Mastectomy Registry comprised of a volunteer population of 817 women from 43 states who have undergone prophylactic mastectomy.

RESULTS

In the registry, 370 women had undergone bilateral prophylactic mastectomy. Twenty-one (5%) women expressed regrets about the procedure. The median follow-up was 14.6 years (mean 14.8 years; range 0.2-51 years). Those with regrets were subsetted into those with major (n = 10) or minor (n = 7) regrets. Regrets were more common in those women with whom discussion about prophylactic mastectomy was initiated by a physician (19/255), compared with patients who initiated the discussion themselves (2/108; P < .05).

CONCLUSIONS

The overall satisfaction rate of 95% reported here may be explained by the voluntary nature of this registry. The most important factor that predicts an unfavorable outcome following bilateral prophylactic mastectomy is a physician-initiated discussion.

Sentinel lymph node biopsy in breast cancer: initial experience at Memorial Sloan-Kettering Cancer Center

BACKGROUND

Sentinel node biopsy (SNB) has emerged as a potential alternative to routine axillary dissection in clinically node-negative breast cancer.

STUDY DESIGN

From September 1995 to June 1996 at Memorial Sloan-Kettering Cancer Center, 60 patients with clinically node-negative cancer underwent SNB, which was immediately followed by standard axillary dissection. Both blue dye and radioisotope were used to identify the sentinel node. SNB was compared with standard axillary dissection for its ability to accurately reflect the final pathologic status of the axillary nodes.

RESULTS

The sentinel node was successfully identified by lymphoscintigraphy in 75% (42 of 56), by blue dye in 75% (44 of 59), by isotope in 88% (52 of 59), and by the combination of blue dye and isotope in 93% (55 of 59) of all 59 evaluable patients. Of the 55 patients in this study where sentinel nodes were identified, 20 (36%) were histologically positive. The sentinel node was falsely negative in three patients, yielding an accuracy of 95%. SNB was more accurate for T1 (98%) than for T2-T3 tumors (82%).

CONCLUSIONS

Lymphatic mapping is technically feasible, reliably identifies a sentinel node in most cases, and appears more accurate for T1 tumors than for larger lesions. Blue dye and radioisotope are complementary techniques, and the overall success of the procedure is maximized when the two are used together.

A 25 year review of parotid surgery

At a single institution over 25 years, 110 patients were operated upon for a mixture of parotid disease. The mean duration of symptoms for benign disease was 40.8 months compared with 15.6 months for malignant disease. Pain was a significant feature of malignant parotid disorders (46.1% compared with 17.8% for benign conditions). The pathology of these masses was diverse, with pleomorphic adenoma being the commonest (44%). Superficial parotidectomy was the commonest procedure employed (69/110) with local excision being performed only prior to 1984 (15/110). There were five cases of permanent facial palsy, all following radical resection for malignancy. One patient developed Frey's syndrome. Recurrence rate for pleomorphic adenomas was 7/48 (15%), three following enucleations prior to 1984. In primary malignancy of the parotid, 3/21 (14%) developed recurrences. Parotid tumours have a low incidence. Surgery for these tumours can be safely performed by those with a special interest in parotid surgery.

Hereditary breast cancer

BACKGROUND

Hereditary breast cancer is thought to account for less than 10 per cent of all breast cancers. Recently there have been significant advances in understanding of the genetics, with the sequencing of the genes BRCA1 and BRCA2 which are associated with hereditary breast cancer.

METHODS AND RESULTS

Current understanding of hereditary breast cancer and its impact on the management of women with this disease is reviewed.

CONCLUSION

Problems in accurate testing for breast cancer-associated genes remain. No reliable simple test exists because of the large number of mutations present in these genes. The implications of different mutations remain poorly understood. Guidelines for the management of carriers of the breast cancer-associated genes remain controversial.

Cervical exploration for primary hyperparathyroidism--A 25 year experience

Parathyroidectomy should be considered in every patient with hypercalcaemia and primary hyperparathyroidism even if the symptoms are vague. Cervical exploration is a safe operation with very satisfactory results. Our experience in 214 patients over 25 years shows permanent postoperative normocalcaemia in 95% of cases with a complication rate of 2.8%. All patients with primary HPT, regardless of age or the severity of symptoms should be candidates for cervical exploration.

Ductal carcinoma in situ of the breast--current management

The management options in the treatment of patients with ductal carcinoma in situ of the breast are reviewed. Results of treatment by mastectomy, wide local excision, and local surgery followed by radiotherapy are analysed. Factors which incline the surgeon towards recommending mastectomy and the conditions which should be fulfilled for breast conservation are discussed.

Granulocyte-macrophage colony-stimulating factor inhibits tumor growth during the postoperative period

BACKGROUND

Granulocyte-macrophage colony-stimulating factor (GM-CSF) may have important antineoplastic properties because it induces macrophage tumoricidal activity in vitro. We examined the inhibitory effect of GM-CSF on tumor growth in a murine carcinoma model and whether this inhibitory effect would persist during the postoperative period. Potential macrophage-mediated mechanisms were studied.

METHODS

The effect of GM-CSF on macrophage function in vitro was assessed by measuring superoxide anion and interleukin-6 production, percentage phagocytosis of Candida albicans, and percentage Ia expression. GM-CSF's effect on tumor volume was assessed first in a murine tumor model and second to examine whether these effects also occurred during the postoperative period in the same model after laparotomy. Macrophage function in the latter study was assessed by measuring superoxide anion, cytotoxicity, and tumor necrosis factor production.

RESULTS

GM-CSF treatment was associated with a decrease in tumor volume on day 4 after the initiation of GM-CSF treatment (0.93 +/- 0.08 cm3 for control versus 0.34 +/- 0.08 cm3 for GM-CSF; p < 0.05). This effect was also seen after laparotomy (1.07 +/- 0.2 cm3 for laparotomy+saline versus 0.16 +/- 0.04 cm3 for laparotomy+GM-CSF, p < 0.05). In vivo macrophage function showed increased superoxide anion, cytotoxicity, and tumor necrosis factor-alpha production from macrophages obtained from GM-CSF treated animals compared with saline treated controls.

CONCLUSIONS

Tumor growth is inhibited by GM-CSF treatment, and this effect also occurs after laparotomy. Thus, GM-CSF may have a therapeutic role in the treatment of the tumor bearing host after operation.

Antimicrobial effects of granulocyte-macrophage colony-stimulating factor in protein-energy malnutrition

OBJECTIVES

To evaluate, in a murine model of protein-energy malnutrition, whether granulocyte-macrophage colony-stimulating factor (GM-CSF) improves the host response to a septic challenge and to determine the potential mechanisms involved.

DESIGN

Nonblinded study of GM-CSF in mice with protein-energy malnutrition.

SETTING

A university-based surgical laboratory and animal facility.

INTERVENTION

In study 1, malnourished mice were randomized to receive either GM-CSF (120 micrograms/kg subcutaneously to receive either GM-CSF (120 micrograms/kg subcutaneously from day 4 to 7 of the protein-free diet) or saline vehicle as a control. On day 7, all mice were given Candida albicans (5 x 10(5) organisms intravenously). In study 2, malnourished mice received the same dose of GM-CSF or saline vehicle for 7 days of the protein-free diet.

MAIN OUTCOME MEASURES

In study 1 mice were followed up for survival. In study 2, after 7 days of diets, splenic macrophages were harvested and were assayed for interleukin-6, superoxide anion, and nitric oxide production. Splenocytes were stimulated with concanavalin A (5 micrograms/mL) for interleukin-4, interleukin-10, and interferon-gamma production.

RESULTS

Treatment with GM-CSF significantly enhanced survival in malnourished mice infected with C albicans. Treatment with GM-CSF was associated with increased production from splenic macrophages of interleukin-6, superoxide anion, and nitric oxide as well as decreased interleukin-4 production from splenocytes.

CONCLUSIONS

This study suggests a beneficial role for GM-CSF in the malnourished host predisposed to infection. The antimicrobial properties of GM-CSF may function through enhanced production of nitric oxide and superoxide anion.

The effect of granulocyte-macrophage colony-stimulating factor on myeloid cells and its clinical applications

Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a naturally occurring growth factor produced by several cell types in response to a variety of stimuli. GM-CSF has potent stimulatory effects on the growth and maturation of hematopoietic cells and has profound effects on mature circulating effector cells. Clinical applications of GM-CSF include ameliorating chemotherapy-induced neutropenia and enhancing hematopoietic recovery after bone marrow transplantation. This review evaluates the effect of GM-CSF on myeloid cells and its clinical applications.