Breast cancer section analysis correlates with sentinel lymph node biopsies: Precision and topographic anatomy

BACKGROUND

The mainstream treatment of breast cancer is radical mastectomy accompanied with Axillary Lymph Node Dissection (ALND). Lately, more conservative methods accompanied by adjuvant radiotherapy have been gradually replacing radical modalities. The Sentinel Lymph Node Biopsy (SLNB) has been considered such a valuable alternative to surgery conservative approach.

OBJECTIVE

To assess the agreement between SLNB in breast cancer patients and pathology results following ALND and to provide correlation between the sentinel lymph nodes (SLN) anatomical topography and biopsy positivity according to SLNBs.

METHODS

Two hundred female breast cancer patients (31 to 83 years of age) underwent partial or simple mastectomy with or without subsequent ALND. All patients were randomized against selection criteria and underwent SLNB.

RESULTS

In a set of 200 patients, 96.3% presented identical results between SLNB and pathology. 36% of them were confirmed with positive SLN through both approaches. Regarding the SLN topographic anatomical position, 67.3% of samples were located in the front axillary position, 24.5% in the front thoracic position, whereas 6.1% was located in the central axillary position.

CONCLUSIONS

The correlation between the SLN topographic anatomical position and the pathology results, revealed that the majority of the SLN accumulates in the front axillary region. A larger patient population will statistically support this association.

Expression of estrogen receptors in melanoma and sentinel lymph nodes; a "female" clinical entity or a possible treatment modality?

PURPOSE

The natural history of human malignant melanoma suggests that steroid hormones may affect the biological behavior of this tumor. The purpose of the current study was to investigate the specific immunostaining patterns of estrogen receptors in malignant melanomas and their sentinel lymph nodes (SLNs), as well as to examine any possible association with patients' prognosis and overall survival.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected data was conducted during a 12-year period (2001-2012). Sixty patients with mean age of 54.4 ± 14.5 years diagnosed with melanomas of varying depth (Clark) and thickness (Breslow) after excision biopsy of pre-existing melanocytic lesions, were included in the study. All patients underwent wide excision of the primary tumor and SLN identification. Determination of estrogen receptor alpha (ERa) and beta (ERb) status by immunohistochemistry on tumor and nodal paraffin blocks was performed in all feasible cases.

RESULTS

ERb but not ERa was the predominant estrogen receptor found in all primary tumors and SLNs examined. The most intense ERb immunostaining was seen in negative SLNs associated with thinner, less invading melanomas. ERb expression in the primary tumor seems to correlate with the cellular microenvironment, possibly altering the process of SLN invasion.

CONCLUSIONS

ERb expression is down-regulated in aggressive melanomas with sentinel nodal metastatic disease, suggesting its possible usefulness as a surrogate marker for metastatic potential and prognosis in malignant melanoma.

Multi-modality curative treatment of salivary gland cancer liver metastases with drug-eluting bead chemoembolization, radiofrequency ablation, and surgical resection: a case report

INTRODUCTION

Liver metastases are rare in salivary gland tumors and have been reported only once to be the first manifestation of the disease. They are usually treated with surgical resection of the primary tumor and systemic chemotherapy. Drug-eluting bead chemoembolization has an evolving role in the treatment of hepatocellular carcinoma, as well as in the treatment of metastatic disease of the liver. Nevertheless, it has never been used in a patient with salivary gland liver metastases.

CASE PRESENTATION

We report a case of a 51-year-old Caucasian Greek woman who presented to our hospital with liver metastases as the first manifestation of an adenoid cystic carcinoma of the left submandibular gland. The liver lesions were deemed inoperable because of their size and multi-focality and proved resistant to systemic chemotherapy. She was curatively treated with a combination of doxorubicin eluting bead (DC Beads) chemoembolization, intra-operative and percutaneous radiofrequency ablation, and radiofrequency-assisted surgical resection. The patient remained disease-free one year after the surgical resection.

CONCLUSION

In conclusion, this complex case is an example of inoperable liver metastatic disease from the salivary glands that was refractory to systemic chemotherapy but was curatively treated with a combination of locoregional therapies and surgery. A multi-disciplinary approach and the adoption of modern radiological techniques produced good results after conventional therapies failed and there were no other available treatment modalities.

Is sentinel node biopsy reliable in large breast tumors?

PURPOSE

The value of sentinel lymph node biopsy (SNB) in patients with larger breast tumors (diameter > 3 cm) has been questioned due to high false-negative rates reported from initial studies. The aim of this study was to analyze the safety and prognostic reliability of SNB in this group of patients.

METHODS

During a 6-year period (2001-2007), 84 women with mean age 51.7 +/- 11.6 years diagnosed with a breast tumor larger than 3 cm in diameter on pathological analysis were retrospectively identified from the database of our institution. Sentinel node identification was performed after injection of blue dye subcutaneously at the subareolar area. The sentinel node specimen was sent for frozen section analysis. Regardless of the SNB results, all patients underwent completion axillary clearance.

RESULTS

Breast surgery consisted of mastectomy in 62 patients (73.8%) and partial mastectomy in 22 patients (26.2%). There were 69 invasive ductal cancers (82.1%), 14 lobular cancers (16.6%) and one case of anaplastic carcinoma (1.3%). Nine tumors (10.7%) were identified to be multifocal after the histopathological report. The mean number of sentinel nodes removed was 1.5 +/- 0.7 (range 1-4) while SNB detection was not feasible in three patients (3.6%). Of 56 positive SNBs, seven (12.5%) were not identified by routine hematoxylin and eosin staining during frozen section analysis but were detected by subsequent immunohistochemistry on the final histopathological report. All patients with multifocal tumors presented nodal metastases on pathological analysis (100%), while the rate of nodal metastatic disease in patients with unifocal tumors was 16% (12 patients), although no statistical significance was documented. The overall false-negative rate, defined as the percentage of all node-positive tumors in which the SNB was negative, was 14.3%. The false-negative rate was significantly higher for the group of patients with multifocal tumors (55.5%) compared to the group with unifocal tumors (9.3%) (p < 0.001).

CONCLUSIONS

The present study indicates that sentinel node biopsy is feasible in patients with larger breast tumors (max. diameter > 3 cm), with comparable false-negative and sentinel detection rates (14.3% and 96.4%, respectively). Larger tumor size seems to be associated with increased incidence of nodal metastases while multifocality appears to be related to increased false-negative rates; hence completion axillary clearance should be initially considered for these cases.

Management of bone loss in breast cancer patients: 24-month results from the ARBI trial of anastrozole with risedronate

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Background: The management of bone mineral density (BMD) in postmenopausal, breast cancer (BC) patients (pts) receiveing anastrozole was investigated in this phase III, multicenter, open label trial. Methods: Pretreatment BMD of 217 eligible pts with hormone receptor-positive BC scheduled to receive anastrozole was evaluated at lumbar spine (LS) and hip (HP). Pts with T-score<-2.0 in LS or HP, received anastrozole 1mg/day plus oral risedronate 35 mg/week (A+R) and pts with T-score>-1 in both sites received anastrozole only (A). Pts with T-score<-1 in either site but T-score>-2.0 in both sites were randomized to receive A+R or A alone. All pts received Calcium and Vit D daily. BMD was then assessed at 12 and 24 months. Results: Comparison of randomized arms (A = 33 pts, A+R = 37 pts): T-score change from baseline was significantly different only for LS at 24 months (-0.23 in A vs 0.41 in A+R, Wilcoxon test p = 0.007) and was significantly higher from baseline for the A+R arm (Signed rank test p = 0.01). At 12 months, among A only pts, 4 (12.1%) had a T-score<-2.0 without becoming osteoporotic, while 2(6.1%) moved to the normal BMD region; from A+R pts, only 2(5.4%) had a T-score<-2.0 without becoming osteoporotic, while 9 (24.3%) moved to the normal BMD region. The same trend in BMD changes was also observed at the 24 month evaluation. Group with T-score<-2.0 in either LS or HP (A+R, n = 99): a significant increase for LS both at 12 and 24 months was detected (median increase of T-score by 0.45 and 0.37, p<0.01 for both time points) with a corresponding non-significant change in HP (p = 0.91 and p = 0.15). BMD in 13(13.3%) pts improved to the osteopenic region (-2.0<T-score<-1.0). Group with T-score>-1 in both sites (A, n = 48): significant decrease was detected for HP and LS, both at 12 and 24 months; however, only 11 (22%) pts became osteopenic and 1(2%) became osteoporotic. Conclusions: The addition of oral risedronate in postmenopausal BC patients with osteopenia receiving anastrozole has a favourable effect in BMD at lumbar spine at 24 months.

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Evaluation of Smad2/3 and Smad4 as inhibitors of estrogens and Ski protein as a predictive factor in T1, T2 N0 breast carcinomas

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Background: Smad proteins are TGF-β intracellular substrates, and Ski protein is a negative regulator of TGF-pathway. Tamoxifen's inhibition in breast cancer cells is mediated through TGF-β and Smad proteins. The purpose of our study was to investigate the activation of Smad2/3, Smad4, and Ski proteins in breast carcinomas and correlate their expression with each other and with hormonal receptors, as well as with other clinicopathological parameters such as the tumor size and grade, and the Distant Disease Free and the Overall Survival. Methods: One hundred forty-seven paraffin-embedded specimens from 22 in situ and 125 invasive ductal node-negative carcinomas were used, for which we had a mean follow-up time of 96 months. ER and PR status, as well as the expression of Smad2/3, Smad4, and Ski proteins were evaluated using immunohistochemistry. Staining of 5% of the tumor cells was adopted as a threshold. SPSS13 for windows was used for the statistical analysis of the results. Results: Smad2/3 and Smad4 were strongly correlated with each other (p < 0,001) and inversely correlated with patients’ DDFS (Kaplan-Meier plots, p = 0,004 for Smad2/3 and p = 0,026 for Smad4) and OS (Kaplan-Meier plots, p = 0,034 for Smad2/3 and p = 0,017 for Smad4). Smad2/3 was proved to be an independent prognostic factor in grade 1 tumors, while Smad4 was inversely correlated with PR expression (p = 0,028) and had a strong prognostic value in ER+ tumors (p = 0,02). Ski protein had a strong association with tumor grade (p < 0.001) and was found to be an independent prognostic factor in Cox regression analysis (p = 0,006, exp(B) = 4,98). Conclusions: Smad 2/3 and Smad 4 not only are tumor suppressor molecules, but also inhibit ER dependent gene expression. This inhibition is lost when Smad's expression is reduced, and that is a potent explanation for Smad 4 prognostic value in ER positive tumors. Moreover the correlation with PR expression, may be due to the fact that PR is an indicator of ER pathway's integrity and also to PR's enallaktiki activation by ER-β. From the other hand, Ski protein acts as an oncogene in breast carcinogenesis and contributes to the development of a more aggressive tumor phenotype.

No significant financial relationships to disclose.

Correlation of mammographic appearance and molecular prognostic factors in high-grade breast carcinomas

The aim of our study was to evaluate the association between the mammographic appearance and the biologic characteristics of high-grade breast carcinomas. Three hundred and twenty patients with breast carcinomas were studied. Histological examination showed 83 (26%) high-grade ductal carcinomas. Immunohistochemistry was carried out by using antibodies against estrogen receptor (ER), progesterone receptor (PR), HER-2/neu, p53 and cathepsin D. In 60/83 high-grade carcinomas we studied the mammographic appearance. Asymmetric density with poorly defined margins without microcalcifications was the major mammographic finding in 49/60 (approximately 82%) high-grade ductal carcinomas. HER-2/neu positivity (68.7%) and p53 positivity (48.2%) were statistically correlated with asymmetric density with poorly defined margins without microcalcifications in high-grade carcinomas. We observed loss of ER and PR receptors in 50%, whereas loss of PR receptors was observed in 65% of high-grade breast carcinomas. Cathepsin D (> 20%) was detected in 38.5% of high-grade carcinomas. Our findings suggest a significant relationship between mammographic appearance and biologic markers in high-grade breast carcinomas.

Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy: transcatheter intraarterial embolization

We present a case of hepatic artery injury with pseudoaneurysm formation following laparoscopic cholecystectomy. A 29-year-old man was referred to our hospital with right upper quadrant pain, jaundice and upper gastrointestinal bleeding one month after laparoscopic cholecystectomy. Gastroscopy showed mucosal erosions at the gastroesophageal junction. The patient did well after medical treatment only and was discharged one week later. However, ten days later he was readmitted with recurrent upper gastrointestinal bleeding. Usual laboratory tests, routine imagine diagnostic procedures and selective hepatic arteriogram were performed. Usual laboratory tests and routine imagine diagnostic procedures were inconclusive, but selective hepatic arteriogram showed a right hepatic artery pseudoaneurysm. The diagnosis of hemobilia was established. Embolization of the aneurysm with coils was carried out. Bleeding was controlled, the patient was discharged one week later and since then he remains under close follow up without any evidence of bleeding recurrence. We believe that the intraarterial embolization of a pseudoaneurysm is a safe and effective method to manage some complications such as bleeding or hemobilia.