RNA analysis of tape strips to rule out melanoma in lesions clinically assessed as cutaneous malignant melanoma: A diagnostic study

BACKGROUND

Distinguishing cutaneous malignant melanoma (CMM) from nevi can be clinically challenging. Suspicious lesions are therefore excised, resulting in many benign lesions being removed surgically to find 1 CMM. It has been proposed to use tape strip derived ribonucleic acid (RNA) to distinguish CMM from nevi.

OBJECTIVE

To develop this technique further and validate if RNA profiles can rule out CMM in clinically suspicious lesions with 100% sensitivity.

METHODS

Before surgical excision, 200 lesions clinically assessed as CMM were tape stripped. Expression levels of 11 genes on the tapes were investigated by RNA measurement and used in a rule-out test.

RESULTS

Histopathology showed that 73 CMMs and 127 non-CMMs were included. Our test correctly identified all CMMs (100% sensitivity) based on the expression levels of 2 oncogenes, PRAME and KIT, relative to a housekeeping gene. Patient age and sample storage time were also significant. Simultaneously, our test correctly excluded CMM in 32% of non-CMM lesions (32% specificity).

LIMITATIONS

Our sample contained a very high proportion of CMMs, perhaps due to inclusion during COVID-19 shutdown. Validation in a separate trial must be performed.

CONCLUSION

Our results demonstrate that the technique can reduce removal of benign lesions by one-third without overlooking any CMMs.

Detection of cutaneous malignant melanoma using RNA sampled by tape strips: A study protocol

Background

Cutaneous malignant melanoma (CMM) is curable if detected in its early stages. However, the clinical recognition of CMM is challenging. An American research group has shown promising results in detecting CMM based on RNA profiles sampled from suspicious lesions with tape strips. We aim to further develop this technique and validate if RNA profiles sampled with tape strips can detect CMM.

Methods

This prospective cohort study will include approximately 200 lesions clinically suspected of CMM requiring surgical removal. Tape stripping of the lesions will be performed just before surgical excision. Subsequently, RNA on the tape strips is analyzed using quantitative real-time polymerase chain reaction with TaqMan technology. The results are combined into a binary outcome where positive indicates CMM and negative indicates no CMM. The histopathological diagnosis of the lesions will be used as the gold standard. The main outcome is the results of the RNA test and the histopathological diagnosis, which, combined, provide the sensitivity and specificity of the test.

Discussion

The accuracy of the clinical examination in CMM diagnostics is limited. This clinical trial will explore the ability to use RNA analysis to improve the management of suspicious lesions by enhancing early diagnostic accuracy. Hopefully, it can reduce the number of benign lesions being surgically removed to rule out CMM and decrease patient morbidity.

Trial registration

The project was approved by The Committee on Health Research Ethics of the Capital Region of Denmark (H-15010559) and registered at the Danish Data Protection Agency (BFH-2015-065).

Study protocol for a 10-year prospective observational study, examining lymphoedema and patient-reported outcome after breast reconstruction

INTRODUCTION

Over the last decades, treatment of breast cancer has become increasingly more effective. Consequently, an increasing number of women are living with late effects of breast cancer treatment, including disfiguring scars, deformity or asymmetry of the breast, secondary lymphoedema and other physical and psychosocial late effects. Data from this study will provide knowledge on how to guide breast reconstruction in the future towards outcomes with fewer complications, higher long-term quality of life (QoL) and satisfaction with the aesthetic outcome. The development of secondary lymphoedema, for which the effect of breast reconstruction has yet to be established, will be thoroughly examined.

METHODS AND ANALYSIS

Women receiving breast reconstruction (autologous and implant based) at the Department of Plastic Surgery and Burns Treatment, Rigshospitalet, will be invited to participate. The patients will be followed for 10 years postoperatively. Demographic, health-related, oncological characteristics and treatment data will be registered. Validated assessment tools, such as the BREAST-Q and Beck Depression Inventory, will be used to measure an extensive range of clinical outcomes, including QoL, life and aesthetic satisfaction and depression. Arm range of motion will be measured with a goniometer and lymphoedema by bioimpedance spectroscopy, compared with circular arm measurements.

ETHICS AND DISSEMINATION

This study will be conducted according to the 5th version of the Helsinki Declaration. The regional ethical committee for Capital Region Denmark did not find the study notifiable, according to the law of the committee § 1, part 4. All data will be anonymised before its publication. This study will be conducted according to the Danish data protection regulation and is catalogued and approved by the Capital Region Head of Knowledge Centre. According to the Danish health law § 46, part 2, this study does not need the Danish Patient Safety Authority's approval. The findings of this study will be submitted to international peer-reviewed journals.

[Ductal carcinoma in situ]

Ductal carcinoma in situ (DCIS) is a premalignant lesion in the breast. It is often asymptomatic and diagnosed by screening mammography. DCIS is treated in line with low-risk invasive breast cancer including mastectomy or breast-conserving treatment plus radiotherapy, implicating a risk of both physical and psychological side effects. Since only a part of DCIS lesions develop into invasive cancer, some women suffer from overtreatment. However, it remains yet to be identified, in which subgroup of women with DCIS treatment can safely be omitted. We need to know more about the natural course of DCIS and develop tools to tailor treatment individually.

Reoperation Rates in Ductal Carcinoma In Situ vs Invasive Breast Cancer After Wire-Guided Breast-Conserving Surgery

Importance

New techniques for preoperative localization of nonpalpable breast lesions may decrease the reoperation rate in breast-conserving surgery (BCS) compared with rates after surgery with the standard wire-guided localization. However, a valid reoperation rate for this procedure needs to be established for comparison, as previous studies on this procedure include a variety of malignant and benign breast lesions.

Objectives

To determine the reoperation rate after wire-guided BCS in patients with histologically verified nonpalpable invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) and to examine whether the risk of reoperation is associated with DCIS or histologic type of the IBC.

Design, Setting, and Participants

This nationwide study including women with histologically verified IBC or DCIS having wire-guided BCS performed between January 1, 2010, and December 31, 2013, used data from the Danish National Patient Registry that were cross-checked with the Danish Breast Cancer Group database and the Danish Pathology Register.

Main Outcomes and Measures

Reoperation rate after wire-guided BCS in patients with IBC or DCIS.

Results

Wire-guided BCS was performed in 4118 women (mean [SD] age, 60.9 [8.7] years). A total of 725 patients (17.6%) underwent a reoperation: 593 were reexcisions (14.4%) and 132 were mastectomies (3.2%). Significantly more patients with DCIS (271 of 727 [37.3%]) than with IBC (454 of 3391 [13.4%]) underwent a reoperation (adjusted odds ratio, 3.82; 95% CI, 3.19-4.58; P < .001). After the first reexcision, positive margins were still present in 97 patients (16.4%). The risk of repeated positive margins was significantly higher in patients with DCIS vs those with IBC (unadjusted odds ratio, 2.21; 95% CI, 1.42-3.43; P < .001). The risk of reoperation was significantly increased in patients with lobular carcinoma vs those with ductal carcinoma (adjusted odds ratio, 1.44; 95% CI 1.06-1.95; P = .02). A total of 202 patients (4.9%) had a subsequent completion mastectomy, but no difference was found in the type of reoperation between patients with DCIS and those with IBC.

Conclusions and Relevance

A lower reoperation rate after wire-guided BCS was found in this study than those shown in previous studies. However, the risk of reoperation in patients with DCIS was 3 times higher than in those with IBC. The widespread use of mammographic screening will increase the number of patients diagnosed with DCIS, making a precise localization of nonpalpable DCIS lesions even more important.

Radioactive seed localization of renal cell carcinoma in a patient with Von Hippel-Lindau disease

This report describes the case of a patient, who had successful radioactive seed localization (RSL) performed to improve the identification and excision of a renal cell carcinoma. RSL is a new method of preoperative localization, which can ease the surgical procedure, minimize tissue trauma, and ultimately benefit the patient.

Radioguided Surgery for Localization of Nonpalpable Breast Lesions A Mini-Review

The majority of patients with nonpalpable breast lesions are eligible for breast conserving surgery guided by some kind of lesion localization. The current standard is wire-guided localization (WGL) even though it has several disadvantages, the most important one being the considerable proportion of patients with insufficient resection margin. These patients require a reoperation. New methods in the field of radioguided surgery (RGS) have been developed including radioguided occult lesion localization (ROLL) and radioactive seed localization (RSL). Especially RSL is a very promising technique. Guided by ultrasound a small titanium seed containing typically 1-10 MBq of radioactive iodine-125 is placed in the centre of the nonpalpable breast lesion. During the operation the seed is located with a hand-held gamma probe. To date, only few cohort studies exist on the feasibility of RSL, and the method has only been tested in one randomized trial. The results are either equal to or superior to those obtained with WGL, with regards to achieving free margins and low reoperation rates. Additionally, the RSL technique is less unpleasant for the patient and more flexible regarding preoperative logistics. The seed can be placed a few days before surgery, in contrast to the wire used in WGL, which has to be placed within few hours of surgery. RSL has quickly become popular in surgical and radiological teams that have used the technique and will probably become an important tool for preoperative localization of nonpalpable breast lesions in the near future.

Preparation and Administration of I-125 Labeled Seeds for Localization of Nonpalpable Breast Lesions

Radioactive seed localization (RSL) is a new technique for surgical identification of non-palpable breast lesions. We describe the preparation of the needle with I-125 seeds for ultrasound-guided deposition in breast lesions. In a feasibility study we investigated the minimum activity amount needed for reliable gamma probe identification of the seeds and the levels of exposure to the staff.

METHODS

11 patients received a seed, which was manually placed in an 18 gauge needle with bone wax occluding the tip, and the radiologist introduced it into the breast tissue guided by ultra-sound. The seed was located during the operation with a handheld gamma probe. The activity amount required was studied in a water bath. Radiation exposure to the fingertips of pathologists was measured by a thermoluminescent dosemeter.

RESULTS

All seeds were successfully prepared, positioned in the breast lesion, and easily identified. The surgeon removed the seeds together with the breast lesions, and they were identified by the pathologist. There were no unexpected adverse drug reactions. Water bath studies suggest that 1-3 MBq I-125 was sufficient for precise identification, regardless of the presence of conventional Tc- 99m activity from sentinel node injection. The total finger dose exposure to the pathologists for the 8 procedures was below the detection limit of 0.1 mSv.

CONCLUSION

I-125 seeds for ultrasound-guided deployment and surgical identification of breast lesions were successfully prepared and identified for this promising new radioguided surgical technique. The radiation exposure to staff involved is considerably below the permissible limits and almost negligible.

[Marking of non-palpable changes in breast tissue]

The Danish national mammography screening programme leads to identification of an increased number of small non-palpable breast tumours, suitable for breast-conserving surgery. Accurate lesion localization is therefore important. The current standard is wire-guided localization and although effective it involves a risk of high rates of positive margin and re-operations. New methods are emerging and radioactive seed localization (RSL) seems promising with regards to re-operation rates and logistics. In RSL a small titanium seed containing radioactive iodine is used to mark the lesion.

The influence of age and other risk factors on the results of coronary reoperation

In a retrospective analysis of 115 patients who underwent a coronary reoperation between 1984 and 1989, we studied the influence of age and other risk factors on the perioperative morbidity and mortality and on the long-term results. The mean age of the population was 59.4 years, 55 patients were below 60, 52 between 60 and 70 and 8 patients over 70 years, respectively. The distribution of risk factors was similar to other populations suffering from coronary heart disease. The mean time between first and second coronary operation was 7.1 years. Complete revascularisation at the reoperation could be achieved in only 20.9% (n = 24) of the patients. A mean of 1.9 vein grafts were implanted. The perioperative mortality (within 30 days) was 5.2% (n = 6) for the whole group, whereas the highest mortality rate could be observed in the patients aged over 70 with 25% (n = 2). The incidence of perioperative complications was also higher in the elderly patients, comparing them to the whole group. Mean follow-up time was 39 months. During follow up 14 patients (12.4%) died, most of the deaths were cardiac related. The cumulative survival rate was 91% after one, 90% after three, and 88% after five years. We found no statistically significant differences in the survival rates and the myocardial infarction rates regarding the different age groups. The exercise capacity and functional status at the time of follow up were quite acceptable.(ABSTRACT TRUNCATED AT 250 WORDS)