Multicentre evaluation of intraoperative molecular analysis of sentinel lymph nodes in breast carcinoma

Background

Ideally, intraoperative sentinel lymph node (SLN) analysis in breast cancer should be automated, have high concordance with extensive histopathology, and be applicable in any hospital setting. A prospective multicentre evaluation of the one-step nucleic acid amplification (OSNA) automated molecular diagnostic system of SLN analysis was undertaken.

Methods

Intraoperative examination of SLNs from 204 patients with breast cancer was performed by OSNA at four sites in the UK. Half of each SLN was assessed by OSNA (for cytokeratin 19 mRNA) and the remaining half was paraffin embedded for intensive histological examination at ten levels. Discordant cases were reanalysed by further molecular biological techniques and by additional histological examination of all remaining nodal material to ascertain whether the discordance was due to an uneven distribution of metastases, known as tissue allocation bias (TAB).

Results

After exclusion of samples affected by TAB, the overall concordance rate for OSNA versus histopathology was 96·0 per cent, with a sensitivity of 91·7 per cent and a specificity of 96·9 per cent. The median time to process a single SLN was 32 (range 22–97) min, and that for two nodes 42 (30–73) min.

Conclusion

OSNA enables accurate automated intraoperative diagnosis and can be used successfully in different UK hospitals. When the SLN is shown to be positive, the patient can undergo immediate axillary clearance under the same anaesthetic rather than having a delayed second procedure.

Mucosal lichen sclerosus/lichen planus overlap syndromes

Lichen sclerosus and lichen planus affecting cutaneous sites are easily distinguishable clinical. Clinical signs on mucosal sites, however, may not allow differentiation between these diseases, and reliance is frequently placed on histopathological findings. We report a series of seven patients with clinical evidence of coexisting vulval lichen sclerosus and lichenoid oral lesions. All patients had vulval biopsies, and four had oral biopsies. Histology of all the vulval biopsy specimens showed features consistent with lichen sclerosus. Two of these patients developed vulval intraepithelial neoplasia during the course of their disease, and one progressed to a well-differentiated squamous carcinoma. Histology of the oral lesions showed features that were predominantly those of lichen planus. There are, however, few reports of histologically proven oral lichen sclerosus. Variations in histopathological descriptions of lichen sclerosus, depending on duration of disease, have been reported, particularly with regard to the position of the inflammatory infiltrate in relation to the dermo-epidermal junction. We believe that these patients may have oral lichen sclerosus, or at the very least make up a distinctive group who need to be identified and followed up, as their risk of oral dysplasia is unknown.

Fast neutron therapy for soft tissue sarcoma

Seventy-nine patients with soft tissue sarcoma were treated with fast neutron therapy at the Hammersmith Hospital, MRC Cyclotron Unit. Sixty-six of these, treated between 1971 and 1983 were assessable. The histology was reviewed and graded in 82% of cases and tumors divided into groups according to maximum diameter. In sixteen patients, who were irradiated following complete macroscopic removal of tumor, there was 94% local control and 86% survived 5 years. Of the 50 patients who had gross tumors present 62% were greater than 10 cm in diameter, and 20 were recurrent after previous radiotherapy or surgery or both. Sixty-eight per cent of gross tumors completely regressed and local control was 52%. The main cause of death was metastatic spread, and median survival was 63 months for Grade 1 patients, 9 months for Grade 2, and 7 months for Grade 3. Thus, there was a significant advantage to patients with Grade 1 tumor but little difference between Grades 2 and 3. Twenty-seven patients experienced late complications of treatment, 67% of which involved the skin predominantly and were related to the low energy of neutrons used. Seventeen of the 27 had received previous radiotherapy. Neutron therapy given in this dose and fractionation produced a higher local control rate than photon therapy, but complications were more frequent. Since these mainly involved the skin a lower level of complications may be anticipated using higher energy neutrons which will have a more even distribution of dose and lower skin dosage. Forty-eight per cent of patients developed metastatic disease, indicating the need for effective systemic therapy, especially in Grades 2 and 3 tumors.

Identification of HEXIM1 as a positive regulator of p53

Hexamethylene bisacetamide-inducible protein 1 (HEXIM1) is best known as the inhibitor of positive transcription elongation factor b (P-TEFb), which regulates the transcription elongation of RNA polymerase II and controls 60-70% of mRNA synthesis. Our previous studies show that HEXIM1 interacts with two key p53 regulators, nucleophosmin and human double minute-2 protein (HDM2), implying a possible connection between HEXIM1 and the p53 signaling pathway. Here we report the interaction between p53 and HEXIM1 in breast cancer, acute myeloid leukemia, and colorectal carcinoma cells. The C-terminal regions of p53 and HEXIM1 are required for the protein-protein interaction. Overexpression of HEXIM1 prevents the ubiquitination of p53 by HDM2 and enhances the protein stability of p53, resulting in up-regulation of p53 target genes, such as Puma and p21. Induction of p53 can be achieved by several means, such as UV radiation and treatment with anti-cancer agents (including doxorubicin, etoposide, roscovitine, flavopiridol, and nutlin-3). Under all the conditions examined, elevated protein levels of p53 are found to associate with the increased p53-HEXIM1 interaction. In addition, knockdown of HEXIM1 significantly inhibits the induction of p53 and releases the cell cycle arrest caused by p53. Finally, the transcription of the p53 target genes is regulated by HEXIM1 in a p53-dependent fashion. Our results not only identify HEXIM1 as a positive regulator of p53, but also propose a novel molecular mechanism of p53 activation caused by the anti-cancer drugs and compounds.

The association of squamous cell carcinoma of the vulva and lichen sclerosus: implications for management and follow up

All cases of biopsy proven squamous cell carcinoma (SCC) of the vulva and of lichen sclerosus (LS) presenting to a district general hospital between 1984 and 1993 were studied. Twenty-eight cases of squamous cell carcinoma of the vulva were identified from histological specimens. Histological evidence of LS was found in 28.5% and clinical LS in 57%. There was poor correlation between clinical and histological findings when SCC arose on a background of LS. A second study of all cases of histological LS over the same period showed the incidence of SCC in vulval LS to be 7%.

Amoxycillin-induced flexural exanthem

We describe a 37-year-old man who developed an acute, inflammatory flexural eruption shortly after taking amoxycillin, then erythema multiforme-like lesions on the palms and soles. The eruption resolved with systemic corticosteroids, and positive patch tests with amoxycillin supported a drug-induced aetiology. A few similar cases have been described as the 'baboon syndrome' or intertriginous drug eruptions. We draw attention to this rare, distinctive drug eruption.

HEXIM1, a New Player in the p53 Pathway

Hexamethylene bisacetamide-inducible protein 1 (HEXIM1) is best known as the inhibitor of positive transcription elongation factor b (P-TEFb), which controls transcription elongation of RNA polymerase II and Tat transactivation of human immunodeficiency virus. Besides P-TEFb, several proteins have been identified as HEXIM1 binding proteins. It is noteworthy that more than half of the HEXIM1 binding partners are involved in cancers. P53 and two key regulators of the p53 pathway, nucleophosmin (NPM) and human double minute-2 protein (HDM2), are among the factors identified. This review will focus on the functional importance of the interactions between HEXIM1 and p53/NPM/HDM2. NPM and the cytoplasmic mutant of NPM, NPMc+, were found to regulate P-TEFb activity and RNA polymerase II transcription through the interaction with HEXIM1. Importantly, more than one-third of acute myeloid leukemia (AML) patients carry NPMc+, suggesting the involvement of HEXIM1 in tumorigenesis of AML. HDM2 was found to ubiquitinate HEXIM1. The HDM2-mediated ubiquitination of HEXIM1 did not lead to protein degradation of HEXIM1 but enhanced its inhibitory activity on P-TEFb. Recently, HEXIM1 was identified as a novel positive regulator of p53. HEXIM1 prevented p53 ubiquitination by competing with HDM2 in binding to p53. Taken together, the new evidence suggests a role of HEXIM1 in regulating the p53 pathway and tumorigenesis.

Fine needle aspiration biopsy in the diagnosis and management of fibroadenoma of the breast

Cytological and histological biopsies were obtained on 75 breast lumps clinically diagnosed as fibroadenomas. Of these, 95 per cent of lesions were benign. In 51 (68 per cent) confirmed as fibroadenomas histologically, cytology was benign in 78 per cent, but inadequate for diagnosis in 16 per cent. The remaining 24 lesions included three breast cancers and one lymph node with Hodgkin's disease. In this group cytology was inadequate for diagnosis in 54 per cent, including one breast cancer. No lesion with benign cytology was subsequently shown to be malignant. The study supports the view that clinical diagnosis and cytology are accurate in the diagnosis of benign breast disease of this type. Breast cancer may rarely present with the clinical features of a fibroadenoma and too few lesions have been studied to assess fully the performance of cytological biopsy in detecting these small mobile lesions. A non-excisional policy should therefore include prolonged follow-up and repeat biopsy.

GCN5 inhibits XBP-1S-mediated transcription by antagonizing PCAF action

Cellular unfolded protein response (UPR) is induced when endoplasmic reticulum (ER) is under stress. XBP-1S, the active isoform of X-box binding protein 1 (XBP-1), is a key regulator of UPR. Previously, we showed that a histone acetyltransferase (HAT), p300/CBP-associated factor (PCAF), binds to XBP-1S and functions as an activator of XBP-1S. Here, we identify general control nonderepressible 5 (GCN5), a HAT with 73% identity to PCAF, as a novel XBP-1S regulator. Both PCAF and GCN5 bind to the same domain of XBP-1S. Surprisingly, GCN5 potently blocks the XBP-1S-mediated transcription, including cellular UPR genes and latent membrane protein 1 of Epstein-Barr virus. Unlike PCAF, GCN5 acetylates XBP-1S and enhances nuclear retention and protein stability of XBP-1S. However, such GCN5-mediated acetylation of XBP-1S shows no effects on XBP-1S activity. In addition, the HAT activity of GCN5 is not required for repression of XBP-1S target genes. We further demonstrate that GCN5 inhibits XBP-1S-mediated transcription by disrupting the PCAF-XBP-1S interaction and preventing the recruitment of XBP-1S to its target genes. Taken together, our results represent the first work demonstrating that GCN5 and PCAF exhibit different functions and antagonistically regulate the XBP-1S-mediated transcription.

Inhibition of human cytomegalovirus replication by overexpression of CREB1

Expression of the human cytomegalovirus (HCMV) major immediate-early (MIE) genes is regulated by a strong enhancer-containing promoter with multiple binding sites for various transcription factors, including cyclic AMP response element binding protein 1 (CREB1). Here we show that overexpression of CREB1 potently blocked MIE transcription and HCMV replication. Surprisingly, CREB1 still exhibited strong inhibition of the MIE promoter when all five CREB binding sites within the enhancer were mutated, suggesting that CREB1 regulated the MIE gene expression indirectly. Promoter deletion analysis and site-directed mutagenesis identified the region between -130 and -50 upstream of the transcription start site of the MIE gene as the "CREB1 responsive region". Mutations of SP1/3 and NF-κB binding sites within this region interrupted the inhibitory effect induced by CREB1 overexpression. Our findings suggest that overexpression of CREB1 can cause repression of HCMV replication and may contribute to the development of new anti-HCMV strategies.

Myocarditis complicating ethylene glycol poisoning in the absence of neurological features

The consequences of ethylene glycol intoxication are described in a 42 year old man who presented with a profound metabolic acidosis, cardiogenic shock and renal failure. The clinical and electrocardiographic findings suggested a myocarditis and this was confirmed by endomyocardial biopsy. The striking absence of neurological features in this patient delayed diagnosis, which was not suspected until calcium oxalate crystals were demonstrated at renal biopsy. Retrospective analysis of serum retained at his admission to hospital confirmed toxic levels of ethylene glycol. Following a period of intensive cardio-respiratory support and peritoneal dialysis he made a good recovery with cardiac and renal function returning to normal.

Influence of endotoxin on graft-versus-host disease after bone marrow transplantation across major histocompatibility barriers in mice

Much clinical and experimental data suggest that infection and graft-versus-host disease (GVHD) are intimately associated, and that bacterial endotoxin (ET), a potent immunostimulant, influences the severity of GVHD. We have used a cell-wall-deficient mutant of Escherichia coli (E coli J5) to study the effect of active and passive immunization against ET in a murine model of GVHD induced by major histocompatibility antigens. CBA/Ca (H-2k) mice were irradiated and grafted with 1 X 10(7) bone marrow cells from C57BL/B6 (H-2b) donors. Groups of mice were immunized against J5: either actively immunized with killed J5 cells or pure J5 lipopolysaccharide, or passively immunized with rabbit anti-J5 antiserum (R alpha J5). Controls included irradiation controls, negative controls (syngeneic graft), positive controls (conventional mice receiving allogeneic graft), mice immunized with normal rabbit serum, Freund's adjuvant (FA), or human serum albumin (HSA) in FA. Active immunization with J5 exacerbated the effects of GVHD as indicated by increased weight loss (P = 0.002) and earlier death (P = 0.043). In contrast, immunization with HSA protected against weight loss (P = 0.028), and improved survival (P = 0.008). Passive immunization with J5 had no effect. These observations support the hypothesis that ET influences the pathogenesis of GVHD, and provide a useful model for studying the effects of ET in a well-defined immunological system.

Collaborative approach to improve the detection and management of trichomoniasis in a low prevalence district

We describe a simple collaborative approach developed by the departments of cytology, microbiology and genitourinary (GU) medicine for the detection, diagnosis and management of microbiologically confirmed Trichomonas vaginalis (TV) infection. Over a 2-year period, 54 (0.1%) of 52,440 cervical smears were reported to show TV, but microbiological confirmation was made in only 76% of 34 patients from whom a vaginal swab was subsequently taken. Trichomoniasis should not be diagnosed by cytology alone and clinicians need further education on the role of cytology in diagnosing sexually transmitted diseases (STDs). Over the same period, from a total of 96 cases of TV identified in the district, only 12 (13%) were first diagnosed in the department of GU medicine. Forty per cent of the other 84 patients were subsequently seen in the GU clinic for test of cure, contact tracing and screening for other STDs. Collaborations between departments may improve the management of trichomoniasis and other conditions in the community and their development should be encouraged.

Effect of immunization with Escherichia coli J5 on graft-versus-host disease induced by minor histocompatibility antigens in mice

We have used a cell-wall-deficient mutant of Escherichia coli (E coli J5) to study the effect of active and passive immunization against bacterial endotoxin (ET) in a murine model of acute graft-versus-host disease (GVHD) induced by minor histocompatibility antigens. C57BL/B6 (H-2b) mice were irradiated and grafted with 1 X 10(7) anti-Thy-1.2 and complement-treated bone marrow cells and 5 X 10(7) spleen cells from LP/J (H-2b) donors. Groups of mice were immunized against J5--either actively immunized with killed J5 cells or pure J5 lipopolysaccharide or passively immunized with rabbit anti-J5 antiserum (R alpha J5). Controls included irradiation controls, negative controls (conventional mice grafted with depleted bone marrow only), positive controls (conventional mice grafted with bone marrow and spleen cells), and mice passively immunized with normal rabbit serum (NRS). Positive control mice developed GVHD and all died by day +77. Active immunization partially protected against the rapid weight loss due to GVHD (P less than 0.05) but mice had an earlier onset of GVHD (P less than 0.05) and a shortened survival after onset (P less than 0.05). Median survival time (MST) and overall survival were unchanged. Passive immunization with R alpha J5 delayed death (P less than 0.01), increased MST (P = 0.01), increased overall survival (P less than 0.01), and protected against weight loss (P = 0.01). NRS had no beneficial effect.

Total gastrointestinal endoscopy in the management of Peutz-Jeghers syndrome

Peutz-Jeghers syndrome was diagnosed in a 51-year-old woman presenting with iron deficiency anaemia. Upper gastrointestinal endoscopy and colonoscopy revealed several hamartomatous polyps in the stomach, duodenum and colon, which were removed. At a combined surgical-endoscopic procedure, 42 hamartomatous polyps were removed from the small intestine by snare polypectomy. This enteroscopic procedure reduces symptoms, may protect against future intestinal obstructive episodes and their associated surgery, and may reduce the risk of developing gastrointestinal malignancy.

Traditional and Complementary Medicine (TCM) among Study Population with Cardiovascular Risk; use and Substitution for Conventional Medicine in Pahang, Malaysia

INTRODUCTION

Cardiovascular diseases are the main cause of morbidity and mortality in Malaysia. There is evidence of high traditional and complementary medicine (TCM) use among population with cardiovascular risk and there have been anecdotal reports about substitution of conventional medicines with TCM. We investigated the prevalence of TCM use, treatment preference and substitution of conventional medicines in study population with cardiovascular risk factors in Pahang, Malaysia.

METHODS

A cross-sectional survey was conducted using an interviewer-administered questionnaire in five districts of Pahang. A total of 1250 households were chosen through proportionate and systematic sampling. Respondents aged 18 years and above were selected.

RESULTS

The study population with cardiovascular risk factors who used TCM was higher than the general population (31.7% versus 25.9%). There were no clear preferences in using TCM by gender, age groups, educational level and income even though other bumiputeras showed a slight inclination towards TCM use. Among the study population with cardiovascular risk factors who consumed TCM, 20-30% of them were using TCM as a substitute for their conventional medications. Respondents from the younger age group (18-40 years) (57.1%), highest educational level (43.2%), other bumiputeras (38.4%) and highest income group (31.4%) preferred the combination of both conventional and traditional medicine.

CONCLUSION

TCM use among population with cardiovascular risk factors is high. The high preference for combination therapy of TCM and conventional medications among young adults and the use of TCM to substitute conventional medications show that much research is needed to provide proven TCM therapies to avoid self-mismanagement of cardiovascular risk in Malaysia.

'Good prognosis tumours' in breast cancer screening

The Forrest Report led to the introduction of the breast screening programme with the aim of reducing mortality from breast cancer. In 1989 a breast screening programme was introduced to the South Bucks District and now two cycles have been completed. The findings are of a high yield of good prognosis tumours 71% and 72%, respectively. These encouraging figures are reflected in a high response rate and with a fall in the incidence of non-screen-detected tumours.

Clinical-radiological features and diagnostic modalities for mediastinal melioidosis

Melioidosis is a potentially life-threatening infection caused by the Gram-negative bacillus Burkholderia pseudomallei. Mediastinal melioidosis has a range of clinical presentations, making it difficult to diagnose: we therefore reviewed the evidence on the clinical characteristics, radiological features and invasive diagnostic modalities or interventions. An electronic search was conducted on three databases (PubMed, SCOPUS, Google Scholar) from November to December 2022. The initial search yielded 120 results, of which 34 studies met the inclusion criteria, but only 31 full-texts were retrievable. Among these, 4 were cohort studies, 26 case reports or series and 1 a conference abstract. The four main themes covered were mediastinal melioidosis as a diagnostic dilemma, unexpected complications, invasive interventions or an accompanying thoracic feature. Radiological manifestations included matting, necrosis and abscess-like collection. Severe presentations of mediastinal melioidosis included superior vena cava obstruction, sinus tract formation and pericardial tamponade. Transbronchial needle aspiration was the most common invasive diagnostic modality. Further research is needed to understand the relationship between the thoracic features of melioidosis on patient prognosis, its relationship to melioidosis transmission and potential preventive measures.

Minimal change nephropathy and pemphigus vulgaris associated with penicillamine treatment of rheumatoid arthritis

A 51-year-old man developed pemphigus vulgaris, minimal change nephropathy and acute tubular necrosis after 11 months of treatment with penicillamine for rheumatoid arthritis associated with features of Reiter's syndrome. Penicillamine is a polyclonal B lymphocyte activator in animals and precipitates a variety of autoimmune reactions in man. The pathogenesis of minimal change nephropathy is obscure, but our observations support the possibility that autoimmune mechanisms play a role.

Abstract P3-06-31: Etirinotecan pegol in patients with metastatic breast cancer (mBC): Modeling CA27.29 response and its correlation with tumor response

Background: Etirinotecan pegol (NKTR-102) is a unique topoisomerase 1 inhibitor that provides continuous exposure to SN38. In a Phase 2 study in pts with mBC whose disease had failed prior taxane-based treatment (Tx) etirinotecan pegol given q14d or q21d demonstrated a 29% overall response rate (J Clin Oncol 29: 2011 (suppl; abstr 1034)). Here we present the relationship between the dynamics of serum tumor marker CA27.29, etirinotecan pegol pharmacokinetics, and tumor response.

Methods: Data from 45 pts with at least two CA27.29 measurements (pre- & post-first dose), were fitted with a PK/PD model developed to correlate CA27.29 dynamics with SN38 exposure predicted from individual pt dosing history: d[CA27.29]/dt = Kin*exp(beta*t)*(1−[SN38]/(IC50+[SN38]))-Kout*[CA27.29]. Correlation of CA27.29 and RECIST response was investigated; % change of CA27.29 from baseline was also correlated with progression-free survival (PFS).

Results: CA27.29 vs time profiles were well described by the model, with a population mean plasma SN38 IC50 of 1.6 ng/mL. Typical minimum/maximum SN38 concentrations during Tx were 1.5/ 3 ng/mL for q14d and 0.9/ 2.4 ng/mL for q21d, indicating that both schedules resulted in SN38 exposure near the IC50. The half-life of CA27.29 decline was 15 days. 41 pts had pre- and post-Tx tumor measurements for correlation of CA27.29 response with tumor size. Of the 15 pts with RECIST CR or PR, 14 (93%) exhibited at least 10% declines in CA27.29 during Tx; all 5 pts with RECIST SD ≥ 6 months (mths) also manifested ≥10% declines, whereas only 45% (5/11) of pts with SD < 6 mths showed ≥10% decline in CA27.29. Among the 10 pts with RECIST progressive disease (PD), 80% showed ≥10% CA27.29 elevations during Tx. The median maximum % reduction in observed CA27.29 from baseline during the course of Tx ranged from −55% to +30% and correlated with responder status as tabulated below.