Prognostic evaluation of proliferative activity and DNA content in the phyllodes tumor of the breast: immunohistochemical and flow cytometric study of 118 cases

The goal of this study was the prognostic evaluation of histology, mitotic rate, S-phase fraction (SPF) and expression of proliferative antigen Ki67 and p53 protein in phyllodes tumor of the breast. The study was performed in the group of 118 patients with phyllodes tumor treated by surgery from 1952 to 1998. Mitotic rate was assessed on the representative histological specimens. Expressions of Ki67 and p53 were evaluated by immunohistochemistry on a section from the corresponding paraffin blocks which were also used for flow cytometric DNA evaluation. Histologically, 52 tumors were benign (LGM), 24 borderline malignancies (BM) while among 42 malignant tumors, 20 were monomorphous (HGM) and the remaining 22 revealed heterologic elements (HGH). Tumor recurrencies occurred in 17 patients, predominantly during the first three years after surgery, and 13 patients died of the tumor (1 BM, 12 both malignant variants). Multivariate analysis demonstrated mitotic rate, SPF and p53 expression as independent prognostic parameters for the disease-free survival. Histological tumor type and expression of Ki67 influenced independently the overall survival. In conclusion, the histological type of tumor phyllodes forms the basis for the prognosis of clinical outcome, but the indicators of the proliferative activity, especially Ki67 index, are valuable prognostic factors among patients with malignant variant of phyllodes tumor of the breast. Expression of the p53 protein in tumor cells could be also useful when the percentage of cells and intensity of expression are considered.

Typical medullary carcinoma of the breast: a clinical and pathological analysis of 52 cases

Fifty-two women with typical medullary breast carcinoma, diagnosed according to criteria of Ridolfi et al. [Cancer 40:1365-1385, 1977] are described. At the time of diagnosis, 90% of the patients were stages I and II. The primary tumor size was < or = to 4 cm in 46 (88.5%) and > 4 cm in 6 (11.5%) patients. Axillary lymph nodes were microscopically negative in 35 (67.3%) and positive in 17 (32.7%) patients. All 52 women underwent the Patey operation. Seventeen patients with microscopically positive axillary lymph nodes received postoperative irradiation. Of the 52 treated patients, 44 (84.6%) survived 10 years NED. The only prognostic factor was the microscopical axillary lymph nodes status. In the group of pNO patients, 97.1% survived 10 years NED, pN+ 58.8% only. The sole causes of unsuccessful treatment were distant metastases to lungs, hepar, and bones. Typical medullary carcinoma is a favorable histological type of breast carcinoma with very good prognosis for pNO patients.

Monocyte chemoattractant protein-induced protein 1 impairs adipogenesis in 3T3-L1 cells

Monocyte chemoattractant protein-induced protein 1 (MCPIP1) encoded by the ZC3H12a gene (also known as Regnase-1) is involved in the regulation of degradation of mRNA of inflammatory modulators and for processing of pre-miRNA. These functions depend on the presence of the PIN domain. Moreover, MCPIP1 was described as a negative regulator of NF-κB and AP-1 signaling pathways although mechanisms underlying such activity remain unknown. We aimed at determining the role of MCPIP1 in adipogenesis. Here, we present evidence that Mcpip1 transcription is transiently activated during 3T3-L1 transition from pre- to adipocytes. However Mcpip1 protein expression is also strongly decreased at day one after induction of adipogenesis. Knockdown of Mcpip1 results in an upregulation of C/EBPβ and PPARγ mRNAs, whereas overexpression of MCPIP1 reduces the level of both transcription factors and impairs adipogenesis. MCPIP1-dependend modulation of C/EBPβ and PPARγ levels results in a modulation of the expression of downstream controlled genes. In addition, decreased C/EBPβ, but not PPARγ, depends on the activity of the MCPIP1 PIN domain, which is responsible for RNase properties of this protein. Together, these data confirm that MCPIP1 is a key regulator of adipogenesis.

Risk and surrogate benefit for pediatric Phase I trials in oncology: A systematic review with meta-analysis

BACKGROUND

Pediatric Phase I cancer trials are critical for establishing the safety and dosing of anti-cancer treatments in children. Their implementation, however, must contend with the rarity of many pediatric cancers and limits on allowable risk in minors. The aim of this study is to describe the risk and benefit for pediatric cancer Phase I trials.

METHODS AND FINDINGS

Our protocol was prospectively registered in PROSPERO (CRD42015015961). We systematically searched Embase and PubMed for solid and hematological malignancy Phase I pediatric trials published between 1 January 2004 and 1 March 2015. We included pediatric cancer Phase I studies, defined as "small sample size, non‑randomized, dose escalation studies that defined the recommended dose for subsequent study of a new drug in each schedule tested." We measured risk using grade 3, 4, and 5 (fatal) drug-related adverse events (AEs) and benefit using objective response rates. When possible, data were meta-analyzed. We identified 170 studies meeting our eligibility criteria, accounting for 4,604 patients. The pooled overall objective response rate was 10.29% (95% CI 8.33% to 12.25%), and was lower in solid tumors, 3.17% (95% CI 2.62% to 3.72%), compared with hematological malignancies, 27.90% (95% CI 20.53% to 35.27%); p < 0.001. The overall fatal (grade 5) AE rate was 2.09% (95% CI 1.45% to 2.72%). Across the 4,604 evaluated patients, there were 4,675 grade 3 and 4 drug-related AEs, with an average grade 3/4 AE rate per person equal to 1.32. Our study had the following limitations: trials included in our review were heterogeneous (to minimize heterogeneity, we separated types of therapy and cancer types), and we relied on published data only and encountered challenges with the quality of reporting.

CONCLUSIONS

Our meta-analysis suggests that, on the whole, AE and response rates in pediatric Phase I trials are similar to those in adult Phase I trials. Our findings provide an empirical basis for the refinement and review of pediatric Phase I trials, and for communication about their risk and benefit.

Phyllodes tumors of the breast. The treatment results for 340 patients from a single cancer centre

PURPOSE

The primary treatment of choice for patients with phyllodes tumor of the breast (PTB) is surgery. Two major problems regarding the treatment of such patients remain unclear: what is the appropriate surgical margin and what role is played by adjuvant radiotherapy (ART).

METHODS

The study provides a retrospective review of all patients with PTB treated between 1952 and 2013 at a single institute. The histology slides were re-examined based on WHO criteria. The clinical characteristics and therapy outcomes were obtained. The five-year survival with no evidence of disease (NED) was used as the end point.

RESULTS

The study population comprised 340 women with PTB. Fifty-five percent of the patients were diagnosed with the benign, 11.8% with borderline and 33.2% with malignant PTB. All the patients received primary treatment with surgery (mastectomy-27.1%, and BCS- 72.9%). Local recurrence (LR) was found in 28 (9.1%) of these patients. Four patients with borderline and 8 with malignant PTB who were treated with BCS and had tumor-free margins < 1 cm received ART. None of these patients had LR and all survived 5 years NED. Of the 340 patients from our group, 294 (86.4%) survived five-years NED.

CONCLUSION

The prognosis for benign PTB is excellent and can be cured with surgery alone. A sufficient margin would be 0.1 cm (data from the literature) or 0.2-0.4 cm (our study). We recommend application of ART for such patients but the role of ART in patients with borderline and malignant PTB treated with BCS and with surgical margin < 1 cm remains uncertain.

Transarterial (chemo)embolisation versus no intervention or placebo for liver metastases

BACKGROUND

The liver is affected by two of the most common groups of malignant tumours: primary liver tumours and liver metastases from colorectal carcinoma or other extrahepatic primary cancers. Liver metastases are significantly more common than primary liver cancer, and long-term survival rate after radical surgical treatment is approximately 50%. However, R0 resection (resection for cure) is not feasible in the majority of people; therefore, other treatments have to be considered. One possible option is based on the concept that the blood supply to hepatic tumours originates predominantly from the hepatic artery. Transarterial chemoembolisation (TACE) of the hepatic artery can be achieved by administering a chemotherapeutic drug followed by vascular occlusive agents, and can lead to selective necrosis of the liver tumour while it may leave normal parenchyma virtually unaffected. This can also be performed without chemotherapy, which is called bland transarterial embolisation (TAE).

OBJECTIVES

To assess the beneficial and harmful effects of TAE or TACE compared with no intervention or placebo in people with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and four more databases (December 2019). We also searched two trials registers and the US Food and Drug Administration database (September 2019).

SELECTION CRITERIA

Randomised clinical trials assessing beneficial and harmful effects of TAE or TACE compared with no intervention or placebo for liver metastases.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodological procedures. We extracted information on participant characteristics, interventions, study outcomes, study design, and trial methods. Two review authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence with GRADE. We resolved disagreements by discussion.

MAIN RESULTS

We included one randomised clinical trial with 61 participants (43 male and 18 female) with colorectal cancer with liver metastases: 22 received transarterial embolisation (TAE; hepatic artery embolisation), 19 received transarterial chemoembolisation (TACE; 5-fluorouracil hepatic artery infusion chemotherapy with degradable microspheres), and 20 received 'no active therapeutic intervention' as a control. Most tumours were synchronous, unresectable metastases involving up to 75% of the liver. Participants were followed for a minimum of seven months. The trial was at high risk of bias. Very-low-certainty evidence found inconclusive results for mortality at 44 months between the TAE and TACE versus no intervention groups (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.06; 61 participants). Local recurrence was reported in 10 participants without any details about the group allocation. Very-low-certainty evidence found little or no difference in mortality between the TAE and no intervention groups (RR 0.91, 95% CI 0.75 to 1.10; 42 participants). Median survival was 7 months from trial entry (range 2 to 44 months) in the TAE group and 7.9 months (range 1 to 26 months) in the control group, and 8.7 months after diagnosis (range 2 to 49 months) in the TAE group and 9.6 months (range 1 to 27 months) in the control group. The trial authors reported the differences were not statistically significant. There were no reported side effects in the control group. In the TAE group, 18 participants experienced short-term symptoms of 'post-embolisation syndrome', which were relieved with symptomatic treatment; one participant also had a local puncture site haematoma. Very-low-certainty evidence found little or no difference in mortality between the TACE and no intervention groups (RR 0.83, 95% CI 0.65 to 1.07; 39 participants). Median survival in the TACE group was 10.7 months (range 3 to 38 months) from trial entry, and 13.0 months (range 3 to 38 months) after diagnosis. The trial authors reported that differences between groups were not statistically significant. All participants experienced short-term nausea, with or without vomiting, immediately after treatment; one participant developed a wound infection, and one developed deep vein thrombosis. The trial did not measure failure to clear liver metastases, time to progression of liver metastases, tumour response measures, or health-related quality of life. Cancer Research Campaign, a non-profit organisation, provided a grant for the trial; Pharmacia Ltd. delivered the Port-a-Cath arterial delivery systems and degradable starch microspheres. We identified one ongoing trial comparing TACE plus chemotherapy versus chemotherapy alone in people with unresectable colorectal liver metastases who failed with first-line chemotherapy (NCT03783559).

AUTHORS' CONCLUSIONS

Based on one, small randomised trial at high risk of bias, the evidence is very uncertain about the effect of TAE or TACE versus no active therapeutic intervention on mortality for people with liver metastases as the true effect may be substantially different. The trial did not measure failure to clear liver metastases, time to progression of liver metastases, tumour response measures, or health-related quality of life. Short-term, minor adverse events were recorded in the intervention groups only. Large trials, following current standards of conduct and reporting, are required to explore the benefits and harms of TAE or TACE compared with no intervention or placebo in people with resectable and unresectable liver metastasis.

Cryotherapy for liver metastases

BACKGROUND

The liver is affected by two of the most common groups of malignant tumours: primary liver tumours and liver metastases from colorectal carcinoma. Liver metastases are significantly more common than primary liver cancer and long-term survival rates reported for patients after radical surgical treatment is approximately 50%. However, R0 resection (resection for cure) is not feasible in the majority of patients. Cryotherapy is performed with the use of an image-guided cryoprobe which delivers liquid nitrogen or argon gas to the tumour tissue. The subsequent process of freezing is associated with formation of ice crystals, which directly damage exposed tissue, including cancer cells.

OBJECTIVES

To assess the beneficial and harmful effects of cryotherapy compared with no intervention, other ablation methods, or systemic treatments in people with liver metastases.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, and six other databases up to June 2018.

SELECTION CRITERIA

Randomised clinical trials assessing beneficial and harmful effects of cryotherapy and its comparators for liver metastases, irrespective of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We extracted information on participant characteristics, interventions, study outcomes, and data on the outcomes important for our review, as well as information on the design and methodology of the trials. Two review authors independently assessed risk of bias in each study. One review author performed data extraction and a second review author checked entries.

MAIN RESULTS

We found no randomised clinical trials comparing cryotherapy versus no intervention or versus systemic treatments; however, we identified one randomised clinical trial comparing cryotherapy with conventional surgery. The trial was conducted in Ukraine. The trial included 123 participants with solitary, or multiple unilobar or bilobar liver metastases; 63 participants received cryotherapy and 60 received conventional surgery. There were 36 women and 87 men. The primary sites for the metastases were colon and rectum (66.6%), stomach (7.3%), breast (6.5%), skin (4.9%), ovaries (4.1%), uterus (3.3%), kidney (3.3%), intestines (1.6%), pancreas (1.6%), and unknown (0.8%). The trial was not reported sufficiently enough to assess the risk of bias of the randomisation process, allocation concealment, or presence of blinding. It was also not possible to assess incomplete outcome data and selective outcome reporting bias. The certainty of evidence was low because of risk of bias and imprecision.The participants were followed for up to 10 years (minimum five months). The trial reported that the mortality at 10 years was 81% (51/63) in the cryotherapy group and 92% (55/60) in the conventional surgery group. The calculated by us relative risk (RR) with 95% Confidence Interval (CI) was: RR 0.88, 95% CI 0.77 to 1.02. We judged the evidence as low-certainty evidence. Regarding adverse events and complications, separately and in total, our calculation showed no evidence of a difference in recurrence of the malignancy in the liver: 86% (54/63) of the participants in the cryotherapy group and 95% (57/60) of the participants in the conventional surgery group developed a new malignancy (RR 0.90, 95% CI 0.80 to 1.01; low-certainty evidence). The frequency of reported complications was similar between the cryotherapy group and the conventional surgery group, except for postoperative pain. Both insignificant and pronounced pain were reported to be more common in the cryotherapy group while intense pain was reported to be more common in the conventional surgery group. However, the authors did not report whether there was any evidence of a difference. There were no intervention-related mortality or bile leakages.We identified no evidence for health-related quality of life, cancer mortality, or time to progression of liver metastases. The study reported tumour response in terms of the carcinoembryonic antigen level in 69% of participants, and reported results in the form of a graph for 30% of participants. The carcinoembryonic antigen level was lower in the cryotherapy group, and decreased to normal values faster in comparison with the control group (P < 0.05).

FUNDING

the trial did not provide information on funding.

AUTHORS' CONCLUSIONS

The evidence for the effectiveness of cryotherapy versus conventional surgery in people with liver metastases is of low certainty. We are uncertain about our estimate and cannot determine whether cryotherapy compared with conventional surgery is beneficial or harmful. We found no evidence for the benefits or harms of cryotherapy compared with no intervention, or versus systemic treatments.

Multimodality treatment of noninflammatory stage IIIb breast cancer

BACKGROUND AND OBJECTIVES

The 1990s have established the contribution of multimodality therapy in the management of IIIb noninflammatory breast cancer (IIIb NIBC), by reducing the odds of recurrence and death.

METHODS

A total of 300 women with IIIb NIBC received a multimodality therapy. The treatment consisted of neoadjuvant chemotherapy [FAC (5-fluorouracil, Adriamycin, cyclophosphamide) regimen], radical (Halsted) mastectomy or modified (Patey mastectomy), postoperative radiotherapy, and adjuvant chemohormone therapy [FAC regimen + cyclophosphamide, 5-fluorouracil and methotrexate (CMF) regimen or Tamoxifen].

RESULTS

Complete or partial clinical response (CR or PR) after neoadjuvant chemotherapy was obtained in 83% patients. Ninety-nine patients (33%) survived 5 years without evidence of disease (NED). The uni- and multivariate analyses factors that had significant influence on the treatment results were: clinical response to neoadjuvant chemotherapy, pathological tumor size, and microscopical status of the axillary lymph nodes.

CONCLUSIONS

We conclude that neoadjuvant FAC regimen chemotherapy is very effective in producing objective tumor regression and offers the benefit of radical mastectomy to patients with previously unresectable IIIb NIBC.

Intensity and Pattern of Enhancement on CESM: Prognostic Significance and its Relation to Expression of Podoplanin in Tumor Stroma - A Preliminary Report

BACKGROUND/AIM

It is possible that the degree of enhancement on contrast-enhanced spectral mammography (CESM), a new diagnostic method, might provide prognostic information for breast cancer patients. Therefore, in a group of 82 breast cancer patients, we analyzed the prognostic significance of degree and pattern of enhancement on CESM as well as its relation to: (a) breast cancer immunophenotype (based on ER/PR/HER2 status) (b) podoplanin expression in cancer stroma (lymphatic vessel density plus podoplanin-positivity of cancer-associated fibroblasts), and (c) other histological parameters.

MATERIALS AND METHODS

For each tumor the intensity of enhancement on CESM was qualitatively assessed as strong or weak/medium, while the pattern - as homogenous and heterogenous.

RESULTS

Herein we report, for the first time, that strong and heterogenous enhancement on CESM was related to unfavorable disease-free survival of breast cancer patients (p=0.005). Moreover, the strong enhancement was more frequent in large and node-positive tumors (pT>1, pN>0) (p=0.002), as well as in carcinomas with podoplanin-sparse stroma (p=0.008).

CONCLUSION

Intensity and pattern of enhancement on CESM might provide (together with the results of other diagnostic imaging methods) not only the confirmation of presence or absence of tumor, but also prognostic information.

Usefulness of scoring systems in outcome prediction for older cancer patients undergoing abdominal surgery

BACKGROUND

Several postoperative outcome scoring systems have been developed and validated, combining both pre- and intraoperative factors. Among others are the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), the Estimation of Physiologic Ability and Stress (E-PASS) and the Surgical Apgar Score combined with the American Society of Anesthesiologists physical status classification (SASA). The aim of this study was to compare the above scoring systems in the prediction of 30-day postoperative outcome in older patients with cancer undergoing abdominal surgery.

METHODS

Consecutive patients ≥70 years were prospectively enrolled. Pre- and intraoperative variables were used to calculate the scores, the ROC and perform logistic regression analysis.

RESULTS

The study sample comprised 201 patients with a median age of 77 (range 70-93) years. The most common surgical procedure was for colorectal (75%), followed by gastric (10.4%) pancreas (7.0%), gall bladder (3.5%), small bowel (2.5%), and other (1.5%) types of cancer. All scores were independent predictors of 30-day postoperative mortality. In case of 30-day morbidity only SASA turned to be significant. The ROC curves were highly valid and area under the curve showed fair to good discriminatory ability (0.60-0.77) for 30-day postoperative mortality and fair (AUC 0.6) in case of SASA for the 30-day postoperative.

CONCLUSION

The SASA, E-PASS, and P-POSSUM were confirmed to be predictive of 30-day postoperative mortality in older patients undergoing abdominal elective cancer surgery. Only SASA demonstrated as independent factor predicting postoperative 30-day major morbidity.

[Follow-up of 70 patients with advanced ovarian cancer after negative second-look laparotomy]

OBJECTIVES

To analyze the results of treatment of 70 patients with stage III and IV ovarian cancer after second look laparotomy with negative findings and to identify causes of failure and prognostic factors.

MATERIALS AND METHODS

Between 1985 and 1998, seventy patients with ovarian cancer stage III and IV were treated with surgery and at least six courses of chemotherapy with cisplatin doxarubicin and cyclophosphamide. Then a second look laparotomy was performed.

RESULTS

The actuarial survival rate without evidence of disease was 50% at 5 years. Locoregional failure was observed in 31 patients (88%) and distant metastases in 9, but they were the sole reason for unsuccessful treatment in only 4 (12%). Adverse prognostic factors were: grade 3 differentiation, primary stage IIIC and IV, and residual infiltration exceeding 2 cm after first laparotomy.

CONCLUSION

Our results are comparable with reports in the literature. The actuarial survival rate without evidence of disease at 5 years in patients with advanced ovarian cancer after second look negative laparotomy is 50%.

Percutaneous ethanol injection for liver metastases

BACKGROUND

The liver is affected by two of the most common groups of malignant tumours: primary liver tumours and liver metastases from colorectal carcinoma or other extrahepatic primary cancers. Liver metastases are significantly more common than primary liver cancer, and the reported long-term survival rate after radical surgical treatment is approximately 50%. However, R0 resection (resection for cure) is not feasible in the majority of patients; therefore, other treatments have to be considered. One of these is percutaneous ethanol injection (PEI), which causes dehydration and necrosis of tumour cells, accompanied by small-vessel thrombosis, leading to tumour ischaemia and destruction of the tumour.

OBJECTIVES

To assess the beneficial and harmful effects of percutaneous ethanol injection (PEI) compared with no intervention, other ablation methods, or systemic treatments in people with liver metastases.

SEARCH METHODS

We searched the following databases up to 10 September 2019: the Cochrane Hepato-Biliary Group Controlled Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE Ovid; Embase Ovid; Science Citation Index Expanded; Conference Proceedings Citation Index - Science; Latin American Caribbean Health Sciences Literature (LILACS); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched clinical trials registers such as ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), and the US Food and Drug Administration (FDA) (17 September 2019).

SELECTION CRITERIA

Randomised clinical trials assessing beneficial and harmful effects of percutaneous ethanol injection and its comparators (no intervention, other ablation methods, systemic treatments) for liver metastases.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures as outlined by Cochrane. We extracted information on participant characteristics, interventions, study outcomes, study design, and trial methods. Two review authors performed data extraction and assessed risk of bias independently. We assessed the certainty of evidence by using GRADE. We resolved disagreements by discussion.

MAIN RESULTS

We identified only one randomised clinical trial comparing percutaneous intratumour ethanol injection (PEI) in addition to transcatheter arterial chemoembolisation (TACE) versus TACE alone. The trial was conducted in China and included 48 trial participants with liver metastases: 25 received PEI plus TACE, and 23 received TACE alone. The trial included 37 male and 11 female participants. Mean participant age was 49.3 years. Sites of primary tumours included colon (27 cases), stomach (12 cases), pancreas (3 cases), lung (3 cases), breast (2 cases), and ovary (1 case). Seven participants had a single tumour, 15 had two tumours, and 26 had three or more tumours in the liver. The bulk diameter of the tumour on average was 3.9 cm, ranging from 1.2 cm to 7.6 cm. Participants were followed for 10 months to 43 months. The trial reported survival data after one, two, and three years. In the PEI + TACE group, 92%, 80%, and 64% of participants survived after one year, two years, and three years; in the TACE alone group, these percentages were 78.3%, 65.2%, and 47.8%, respectively. Upon conversion of these data to mortality rates, the calculated risk ratio (RR) for mortality at last follow-up when PEI plus TACE was compared with TACE alone was 0.69 (95% confidence interval (CI) 0.36 to 1.33; very low-certainty evidence) after three years of follow-up. Local recurrence was 16% in the PEI plus TACE group and 39.1% in the TACE group, resulting in an RR of 0.41 (95% CI 0.15 to 1.15; very low-certainty evidence). Forty-five out of a total of 68 tumours (66.2%) shrunk by at least 25% in the PEI plus TACE group versus 31 out of a total of 64 tumours (48.4%) in the TACE group. Trial authors reported some adverse events but provided very few details. We did not find data on time to mortality, failure to clear liver metastases, recurrence of liver metastases, health-related quality of life, or time to progression of liver metastases. The single included trial did not provide information on funding nor on conflict of interest.

AUTHORS' CONCLUSIONS

Evidence for the effectiveness of PEI plus TACE versus TACE in people with liver metastases is of very low certainty and is based on one small randomised clinical trial at high risk of bias. Currently, it cannot be determined whether adding PEI to TACE makes a difference in comparison to using TACE alone. Evidence for benefits or harms of PEI compared with no intervention, other ablation methods, or systemic treatments is lacking.

Electrocoagulation for liver metastases

BACKGROUND

Primary liver tumours and liver metastases from colorectal carcinoma are two of the most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of the people with metastatic liver disease will die from metastatic complications. Electrocoagulation by diathermy is a method used to destroy tumour tissue, using a high-frequency electric current generating high temperatures, applied locally with an electrode (needle, blade, or ball). The objective of this method is to destroy the tumour completely, if possible, in a single session. With the time, electrocoagulation by diathermy has been replaced by other techniques, but the evidence is unclear.

OBJECTIVES

To assess the beneficial and harmful effects of electrocoagulation by diathermy, administered alone or with another intervention, versus no intervention, other ablation methods, or systemic treatments in people with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, CINAHL, ClinicalTrials.gov, ICTRP, and FDA to October 2020.

SELECTION CRITERIA

We considered all randomised trials that assessed beneficial and harmful effects of electrocoagulation by diathermy, administered alone or with another intervention, versus comparators, in people with liver metastases, regardless of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed risk of bias of the included trial using predefined risk of bias domains, and presented the review results incorporating the certainty of the evidence using GRADE.

MAIN RESULTS

We included one randomised clinical trial with 306 participants (175 males; 131 females) who had undergone resection of the sigmoid colon, and who had five or more visible and palpable hepatic metastases. The diagnosis was confirmed by histological assessment (biopsy) and by carcinoembryonic antigen (CEA) level. The trial was conducted in Iraq. The age of participants ranged between 38 and 79 years. The participants were randomised to four different study groups. The liver metastases were biopsied and treated (only once) in three of the groups: 75 received electrocoagulation by diathermy alone, 76 received electrocoagulation plus allopurinol, 78 received electrocoagulation plus dimethyl sulphoxide. In the fourth intervention group, 77 participants functioning as controls received a vehicle solution of allopurinol 5 mL 4 x a day by mouth; the metastases were left untouched. The status of the liver and lungs was followed by ultrasound investigations, without the use of a contrast agent. Participants were followed for five years. The analyses are based on per-protocol data only analysing 223 participants. We judged the trial to be at high risk of bias. After excluding 'nonevaluable patients', the groups seemed comparable for baseline characteristics. Mortality due to disease spread at five-year follow-up was 98% in the electrocoagulation group (57/58 evaluable people); 87% in the electrocoagulation plus allopurinol group (46/53 evaluable people); 86% in the electrocoagulation plus dimethyl sulphoxide group (49/57 evaluable people); and 100% in the control group (55/55 evaluable people). We observed no difference in mortality between the electrocoagulation alone group versus the control group (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.94 to 1.03; 113 participants; very low-certainty evidence). We observed lower mortality in the electrocoagulation combined with allopurinol or dimethyl sulphoxide group versus the control group (RR 0.87, 95% CI 0.80 to 0.95; 165 participants; low-certainty evidence). We are very uncertain regarding post-operative deaths between the electrocoagulation alone group versus the control group (RR 1.03, 95% CI 0.07 to 16.12; 152 participants; very low-certainty evidence) and between the electrocoagulation combined with allopurinol or dimethyl sulphoxide groups versus the control group (RR 1.00, 95% CI 0.09 to 10.86; 231 participants; very low-certainty evidence). The trial authors did not report data on number of participants with other adverse events and complications, recurrence of liver metastases, time to progression of liver metastases, tumour response measures, and health-related quality of life. Data on failure to clear liver metastases were not provided for the control group. There was no information on funding or conflict of interest. We identified no ongoing trials.

AUTHORS' CONCLUSIONS

The evidence on the beneficial and harmful effects of electrocoagulation alone or in combination with allopurinol or dimethyl sulphoxide in people with liver metastases is insufficient, as it is based on one randomised clinical trial at low to very low certainty. It is very uncertain if there is a difference in all-cause mortality and post-operative mortality between electrocoagulation alone versus control. It is also uncertain if electrocoagulation in combination with allopurinol or dimethyl sulphoxide may result in a slight reduction of all-cause mortality in comparison with a vehicle solution of allopurinol (control). It is very uncertain if there is a difference in post-operative mortality between the electrocoagulation combined with allopurinol or dimethyl sulphoxide group versus control. Data on other adverse events and complications, failure to clear liver metastases or recurrence of liver metastases, time to progression of liver metastases, tumour response measures, and health-related quality of life were most lacking or insufficiently reported for analysis. Electrocoagulation by diathermy is no longer used in the described way, and this may explain the lack of further trials.

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk

BACKGROUND

Screening mammography can detect breast cancer at an early stage. Supporters of adding ultrasonography to the screening regimen consider it a safe and inexpensive approach to reduce false-negative rates during screening. However, those opposed to it argue that performing supplemental ultrasonography will also increase the rate of false-positive findings and can lead to unnecessary biopsies and treatments.

OBJECTIVES

To assess the comparative effectiveness and safety of mammography in combination with breast ultrasonography versus mammography alone for breast cancer screening for women at average risk of breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov up until 3 May 2021.

SELECTION CRITERIA

For efficacy and harms, we considered randomised controlled trials (RCTs) and controlled non-randomised studies enrolling at least 500 women at average risk for breast cancer between the ages of 40 and 75. We also included studies where 80% of the population met our age and breast cancer risk inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full texts, assessed risk of bias, and applied the GRADE approach. We calculated the risk ratio (RR) with 95% confidence intervals (CI) based on available event rates. We conducted a random-effects meta-analysis.

MAIN RESULTS

We included eight studies: one RCT, two prospective cohort studies, and five retrospective cohort studies, enrolling 209,207 women with a follow-up duration from one to three years. The proportion of women with dense breasts ranged from 48% to 100%. Five studies used digital mammography; one study used breast tomosynthesis; and two studies used automated breast ultrasonography (ABUS) in addition to mammography screening. One study used digital mammography alone or in combination with breast tomosynthesis and ABUS or handheld ultrasonography. Six of the eight studies evaluated the rate of cancer cases detected after one screening round, whilst two studies screened women once, twice, or more. None of the studies assessed whether mammography screening in combination with ultrasonography led to lower mortality from breast cancer or all-cause mortality. High certainty evidence from one trial showed that screening with a combination of mammography and ultrasonography detects more breast cancer than mammography alone. The J-START (Japan Strategic Anti-cancer Randomised Trial), enrolling 72,717 asymptomatic women, had a low risk of bias and found that two additional breast cancers per 1000 women were detected over two years with one additional ultrasonography than with mammography alone (5 versus 3 per 1000; RR 1.54, 95% CI 1.22 to 1.94). Low certainty evidence showed that the percentage of invasive tumours was similar, with no statistically significant difference between the two groups (69.6% (128 of 184) versus 73.5% (86 of 117); RR 0.95, 95% CI 0.82 to 1.09). However, positive lymph node status was detected less frequently in women with invasive cancer who underwent mammography screening in combination with ultrasonography than in women who underwent mammography alone (18% (23 of 128) versus 34% (29 of 86); RR 0.53, 95% CI 0.33 to 0.86; moderate certainty evidence). Further, interval carcinomas occurred less frequently in the group screened by mammography and ultrasonography compared with mammography alone (5 versus 10 in 10,000 women; RR 0.50, 95% CI 0.29 to 0.89; 72,717 participants; high certainty evidence). False-negative results were less common when ultrasonography was used in addition to mammography than with mammography alone: 9% (18 of 202) versus 23% (35 of 152; RR 0.39, 95% CI 0.23 to 0.66; moderate certainty evidence). However, the number of false-positive results and necessary biopsies were higher in the group with additional ultrasonography screening. Amongst 1000 women who do not have cancer, 37 more received a false-positive result when they participated in screening with a combination of mammography and ultrasonography than with mammography alone (RR 1.43, 95% CI 1.37 to 1.50; high certainty evidence). Compared to mammography alone, for every 1000 women participating in screening with a combination of mammography and ultrasonography, 27 more women will have a biopsy (RR 2.49, 95% CI 2.28 to 2.72; high certainty evidence). Results from cohort studies with methodological limitations confirmed these findings. A secondary analysis of the J-START provided results from 19,213 women with dense and non-dense breasts. In women with dense breasts, the combination of mammography and ultrasonography detected three more cancer cases (0 fewer to 7 more) per 1000 women screened than mammography alone (RR 1.65, 95% CI 1.0 to 2.72; 11,390 participants; high certainty evidence). A meta-analysis of three cohort studies with data from 50,327 women with dense breasts supported this finding, showing that mammography and ultrasonography combined led to statistically significantly more diagnosed cancer cases compared to mammography alone (RR 1.78, 95% CI 1.23 to 2.56; 50,327 participants; moderate certainty evidence). For women with non-dense breasts, the secondary analysis of the J-START study demonstrated that more cancer cases were detected when adding ultrasound to mammography screening compared to mammography alone (RR 1.93, 95% CI 1.01 to 3.68; 7823 participants; moderate certainty evidence), whilst two cohort studies with data from 40,636 women found no statistically significant difference between the two screening methods (RR 1.13, 95% CI 0.85 to 1.49; low certainty evidence).

AUTHORS' CONCLUSIONS

Based on one study in women at average risk of breast cancer, ultrasonography in addition to mammography leads to more screening-detected breast cancer cases. For women with dense breasts, cohort studies more in line with real-life clinical practice confirmed this finding, whilst cohort studies for women with non-dense breasts showed no statistically significant difference between the two screening interventions. However, the number of false-positive results and biopsy rates were higher in women receiving additional ultrasonography for breast cancer screening. None of the included studies analysed whether the higher number of screen-detected cancers in the intervention group resulted in a lower mortality rate compared to mammography alone. Randomised controlled trials or prospective cohort studies with a longer observation period are needed to assess the effects of the two screening interventions on morbidity and mortality.

Vascular structure of outer myometrial uterine leiomyomata - a preliminary SEM and immunohistochemical study

AIM

The main goal of this study was assessment of vascular structure of uterine leiomyomata localized between outer myometrium and endometrium.

MATERIALS AND METHODS

The study was carried out on thirty two human uteri collected upon autopsy. Vessels were injected with synthetic resin, next corroded and coated with gold, finally observed using scanning electron microscope. Next ten uteri were injected with acrylic emulsion and studies using immunohistochemical staining for von Willebrandt's factor.

RESULTS

Vascular structure of outer myometrial leiomyomata was quite similar to those observed in the middle of muscular layer of uterus, characterized by relatively dense 'vascular capsule', consisted of flattened vein, arterioles and capillaries.

CONCLUSIONS

Structure of outer myometrial uterine leiomyomata was similar to those observed during growth within myometrium.

Blood vessels of the intratumoral septa in uterine leiomyomata

The angioarchitecture of fibroid intratumoral septa was studied using 32 uteri obtained during necropsies of the females aged between 35-57. The whole vascular bed of 16 uteri was injected with synthetic resin Mercox CL-2R and then the uteri were corroded in potassium hydroxide. Next 16 uteri were injected with acrylic emulsion, Liquitex R. Their vascular bed was studied using immunohistochemistry for von Willebrandt's factor. Immunohistochemistry allowed to visualize the vessels within the intratumoral septa, while SEM allowed to differentiate the vessels, which were mainly the venules and the veins. Apart from the veins the intratumoral septa were consisted of small arteries and capillaries.

Acute monocytic leukemia in children and its response to vinblastine (NSC-49842)

Seventeen children with acute monocytic leukemia were treated with (a) vinblatine (with or without prednisone), 0.2 mg/kg of body weight twice a week (13 patients); (b) 6-mercaptopurine plus prednisone patient). Four patients died within the 1st week, before having an adequate chemotherapeutic trial, and a fifth patient died of spesis at 12 days. Five patients achieved complete remissions and two achieved in this study was 41%. For the 13 patients who survived more than 1 week, the remission rate was 53.8%. Remission occurred with vinblastine inall but one patient. Of the ten patients who recieved more than one dose of vinblastine, 60% achieved a remission, indicating that vinblastine is an active agent in this rare form of leukemia.

Metastasis to the breast--a clinical challenge in outpatient

Metastatic tumours of the breast are often misdiagnosed as a primary breast malignancy. This erroneous diagnosis can lead to unnecessary mutilating surgery and to delays in applying appropriate treatment. We have analyzed the clinical features of seven patients presenting initially with a breast mass which, after further investigation, proved to be metastasis from a non-breast primary tumour. The treatment of metastatic breast tumours depends on the nature of the primary tumour. Metastases of solid tumours are treated with local excision. Lymphomas are treated with appropriate systemic therapy. The prognosis for patients with metastatic tumours in the breast is poor.

Clinical analysis of metaplastic breast carcinoma with distant metastases: A multi‑centre experience

Metaplastic breast cancer (BC-Mp), which includes a range of epithelial and mixed epithelial-mesenchymal tumours, are rare malignancies with an unfavourable prognosis. The limited literature on BC-Mp focuses mainly on retrospective data for radically treated patients. Notably absent are studies dedicated to the palliative treatment of BC-Mp with distant metastases. The present retrospective study investigated treatment modalities and prognosis in a multi-centre cohort of 31 female participants diagnosed with distant metastatic BC-Mp, including 7 patients with de novo metastatic disease. The median age of the patients was 61 years (range, 33-87 years), with 38.7% presenting local lymph node involvement. Lungs were the most common site for the metastatic disease (61.3%). Median Ki-67 index was 50% (range, 35-70%), and 80.7% of cases were classified as grade 3. Human epidermal growth factor receptor 2 (HER2)+ and estrogen receptor+ were detected in 12.9 and 6.5% of cases, respectively. A total of 62.4% of patients received first-line palliative systemic treatment. The 1- and 2-year overall survival (OS) were 38.5 and 19.2%, respectively. Receiving ≥1 line of palliative treatment was significantly associated with improved OS (P<0.001). Factors such as age, Ki-67 index, HER2 or hormonal status, presence of specific epithelial or mesenchymal components, location of metastases or chemotherapy regimen type did not influence OS. The present study provided insights into the clinicopathological profile, systemic treatment experience, prognostic factors and OS data of BC-Mp with distant metastases, emphasizing the imperative for clinical trials in this population.

Phyllodes tumor of the breast

PURPOSE

Presentation of the microscopical and clinical findings, prognostic factors and principles of treatment of the phyllodes tumor of the breast.

PATIENTS AND METHODS

This paper reviews the published data on this rare and intriguing tumor of the breast.

RESULTS AND CONCLUSIONS

The main prognostic factor is the histotype of the phyllodes tumor (benign, borderline, malignant) assessed on the basis of the criteria proposed by Azzopardi [3] and Salvadori et al. [50]. Wide local excision with an adequate marg in of normal breast tissue is the preferred initial therapy for phyllodes tumor. Mastectomy is indicated only for very large tumors compared with breast morphologic size and for recurrences of borderline and malignant tumors.

Angioarchitecture of uterine cervical leiomyomata - a SEM study

AIM

he main goal of this study was assessment of vascular structure of cervical uterine leiomyomata.

MATERIALS AND METHODS

The study was carried out on ten human uteri collected upon autopsy. Vessels were injected with synthetic resin, next corroded and coated with gold, finally observed using scanning electron microscope.

RESULTS

Most of cervical fibroids were observed in the middle third of the wall of cervix. They were surrounded by relatively dense 'vascular capsule'. consisted of flattened vein, arterioles and capillaries.

CONCLUSIONS

Structure of cervical uterine leiomyomata was similar to those observed in initial stage of growth of myometrial fibroids.

Comparison of the Mammography, Contrast-Enhanced Spectral Mammography and Ultrasonography in a Group of 116 patients

Mammography (MG) is the gold-standard in breast cancer detection - the only method documented to reduce breast cancer mortality. Breast ultrasound (US) has been shown to increase sensitivity to breast cancers in screening women with dense breasts. Contrast-enhanced spectral mammography (CESM) is a novel technique intensively developed in the last few years. The goal of this study was to compare the sensitivity, specificity and accuracy of MG, US and CESM in detecting malignant breast lesions. The study included 116 patients. All patients were symptomatic and underwent MG, US and CESM. A radiologist with 20 years of experience in US and MG breast imaging and 1 year of experience in CESM reviewed images acquired in each of the three modalities separately, within an interval of 14-30 days. All identified lesions were confirmed at core biopsy. BI-RADS classifications on US, MG and CESM were compared to histopathology. MG, CESM and US were compared among 116 patients with 137 lesions encountered. Sensitivity of CESM was 100%, significantly higher than that of MG (90%, p<0.004) or US (92%, p<0.01). CESM accuracy was 78%, also higher than MG (69%, p<0.004) and US (70%, p=0.03). There was no statistically significant difference between AUCs for CESM and US (both 0.83). The AUCs of both US and CESM, however, were significantly larger than that of MG (p<0.0004 for each). CESM permitted better detection of malignant lesions than both MG and US, read individually. CESM found lesion enhancement in some benign lesions, as well, yielding a rate of false-positive diagnoses similar to that of MG and US.