Tumour bed clip localisation for targeted breast radiotherapy: compliance is proportional to trial-related research activity: tumour bed clip localisation in breast radiotherapy.

BACKGROUND: In breast cancer, with the increasing use of intensity-modulated radiotherapy (IMRT), the need for accurate tumour bed localisation is paramount. We determined current practice of clip usage in patients referred to a regional centre for radiotherapy following breast conserving surgery. We also investigated whether participation of surgical units in IMRT trials, where tumour bed clip use is emphasised, was associated with clip insertion. METHODS: A retrospective cohort study of consecutive CT planning images (n = 205), of breast cancer patients treated with radiotherapy following breast conserving surgery. Presence and number of clips; referring hospital and referring surgeon of the patient was recorded. This was correlated to previous participation of referring hospital to IMRT trials. RESULTS: Of 196 eligible patients, 126 (64%) had clips sited, of which 15 (12%) had two or fewer clips. Five referring hospitals were high recruiters (≥14 patients), and five hospitals were low/non-recruiters (≤1 patient) to IMRT trials. Of patients from low/non-recruiting centres, 29 of 43 (67%) had clips omitted, compared to 41 of 153 (27%) from high-recruiting centres (p < 0.001). Median number of clips used in centres recruiting high numbers of patients was four, compared to zero in low recruiting centres. Ten of 31 referring surgeons routinely omitted clips. CONCLUSION: Despite inclusion in national guidelines, clip insertion has not become routine in the UK in patients undergoing breast conserving surgery. However, hospitals involved in breast radiotherapy randomised controlled trials are more compliant with clip usage recommendations. Auditing of clip insertion should be considered as a quality control marker in breast surgery.

Evidence of a tumour suppressor function for DLEC1 in human breast cancer.

UNLABELLED: DLEC1 (deleted in lung and oesophageal cancer), located on 3p22.3, is a candidate tumour suppressor gene in lung, esophageal, and renal cancer. The aim of this study was determine whether the mRNA expression levels of DLEC1 were consistent with a tumour suppressive function. MATERIALS AND METHODS: A total of 153 samples were analysed. The levels of transcription of DLEC1 were determined using quantitative PCR and normalised against (CK19). Transcript levels within breast cancer specimens were compared to normal background tissues. RESULTS: Levels of transcription were lower [corrected] in tumour samples compared to adjacent non cancerous tissue (ANCT) samples but this was not statistically significant (median 0.167 vs. 0.03; p=0.138). DLEC1 expression levels were significantly lower in samples from patients who developed metastasis, local recurrence, or died of breast cancer when compared to those who were disease free for >10 years (p=0.041). DISCUSSION: These findings are consistent with a possible tumour suppressor function of DLEC1 in breast cancer.

The mRNA expression of SETD2 in human breast cancer: correlation with clinico-pathological parameters.

BACKGROUND: SET domain containing protein 2 (SETD2) is a histone methyltransferase that is involved in transcriptional elongation. There is evidence that SETD2 interacts with p53 and selectively regulates its downstream genes. Therefore, it could be implicated in the process of carcinogenesis. Furthermore, this gene is located on the short arm of chromosome 3p and we previously demonstrated that the 3p21.31 region of chromosome 3 was associated with permanent growth arrest of breast cancer cells. This region includes closely related genes namely: MYL3, CCDC12, KIF9, KLHL18 and SETD2. Based on the biological function of these genes, SETD2 is the most likely gene to play a tumour suppressor role and explain our previous findings. Our objective was to determine, using quantitative PCR, whether the mRNA expression levels of SETD2 were consistent with a tumour suppressive function in breast cancer. This is the first study in the literature to examine the direct relationship between SETD2 and breast cancer. METHODS: A total of 153 samples were analysed. The levels of transcription of SETD2 were determined using quantitative PCR and normalized against (CK19). Transcript levels within breast cancer specimens were compared to normal background tissues and analyzed against conventional pathological parameters and clinical outcome over a 10 year follow-up period. RESULTS: The levels of SETD2 mRNA were significantly lower in malignant samples (p = 0.0345) and decreased with increasing tumour stage. SETD2 expression levels were significantly lower in samples from patients who developed metastasis, local recurrence, or died of breast cancer when compared to those who were disease free for > 10 years (p = 0.041). CONCLUSION: This study demonstrates a compelling trend for SETD2 transcription levels to be lower in cancerous tissues and in patients who developed progressive disease. These findings are consistent with a possible tumour suppressor function of this gene in breast cancer.

Does mammary ductoscopy have a role in clinical practice?

BACKGROUND: Mammary ductoscopy (MD) is a newly developed endoscopic technique that allows direct visualisation of the mammary ductal epithelium using sub-millimetre fiberoptic microendoscopes inserted through the ductal opening onto the nipple surface. These scopes also provide working channels for insufflation, irrigation, ductal lavage, and possible therapeutic intervention. MD can be performed under local anaesthesia in the office setting. The objective of this study is to assess the technical feasibility of mammary ductoscopy, and examine its role in guiding ductal excision surgery and the early diagnosis of malignancy. METHODS: Mammary ductoscopy (MD) was performed using a 1 mm fiberoptic microendoscope (Mastascope TM) in 26 patients (age range: 14-73 years): 13 patients undergoing mastectomy (n = 12) or lumpectomy (n = 1) for ductal carcinoma (including 12 cases of DCIS and one case of infiltrating ductal carcinoma) and 13 patients with pathological nipple discharge (PND) and benign breast imaging and simple discharge cytology. Of the latter group: 10 procedures were performed under local anaesthesia (LA) in the office setting and 3 procedures were carried out under general anaesthesia (GA) to guide duct excision surgery. The ductoscopic appearances in this group were graded between 0 and 5 (D0-D5) according to the degree of suspicion. RESULTS: Intraoperative MD was accomplished in 11 (84.6%) of 13 patients undergoing surgery for DCIS. MD was unsuccessful in 2 cases: one patient (aged 73 years) had sclerosis of the nipple and one patient had preoperative vital blue injection in the subareolar region as part of the sentinel node biopsy thus resulting in inadequate visualisation. Intraductal pathology was visualised in 8 (80%) of the 10 cases undergoing mastectomy but ductoscopic cytology was positive for malignancy in only 2 cases (sensitivity = 16%, specificity = 100%). In the office setting, MD was accomplished in 9 (90%) out of 10 patients with PND and was well tolerated (mean pain score = 3.8 out of 10: range 0-7). Of these 10 patients; MD was inadequate (D0) in one patient due to complete occlusion of lumen by the lesion, showed a papilloma in 3 patients (D3), duct ectasia (D2) in 3 patients, irregular thickening of the lumen suspicious of DCIS (D4) in one patient and non-specific benign findings (D2) in 2 patients. Three women with benign ductoscopy and ductoscopy-assisted cytology were reassured and treated conservatively. The remaining 7 patients had ductoscopy-guided duct excision which revealed DCIS in one, papilloma in 4 and benign breast disease in 2 patients. Adequate cellular yield was obtained in 7 (70%) out of 10 cases (benign cytology). The three patients who had MD under GA during microdochectomy had benign endoscopic appearances and final histology (one papilloma and 2 cases of duct ectasia). CONCLUSION: MD is technically feasible in most patients and has a potential in the early detection of breast cancer. The procedure can be performed safely in the office setting and should be considered in all patients presenting with a single duct PND. MD has the potential to reduce the number of duct excision procedures and minimise the extent of surgical resection. Ductoscopic cytology is not sufficiently sensitive for the diagnosis of malignancy and the development of a biopsy tool that obtains tissue under direct visualisation is required.

The role of aromatase and 17-beta-hydroxysteroid dehydrogenase type 1 mRNA expression in predicting the clinical outcome of human breast cancer.

INTRODUCTION: There is substantial evidence that breast cancer tissue contains all the enzymes responsible for the local biosynthesis of estrogens from circulating precursors. The cytochrome P-450 aromatase enzyme complex is responsible for the conversion of C19 androgens to estrogens and 17-beta-hydroxysteroid dehydrogenase (17-I(2)-HSD) type 1 catalyses the inter-conversion of estrone to the biologically more potent estradiol. The gene encoding for the cytochrome P-450 aromatase is known as CYP19 (15q21.2). It is well established that increased exposure to local estrogens is an important risk factor in the genesis and growth of breast cancer. The aim of this study is to investigate the relationship between CYP19 and 17-beta-HSD type 1A mRNA expression and clinico-pathological parameters of human breast cancer. METHODS: One hundred and twenty seven tumor tissues and 33 normal tissues were analyzed. The levels of transcription of CYP19 and 17-beta-HSD type 1 were determined using real-time quantitative PCR. The mRNA expression was normalized against CK19. Levels of expression were analyzed against tumorâ's stage, grade, nodal status, local relapse, distant metastasis and survival over a 120A months follow up period. In addition, the levels were analyzed against estrogen receptor (ER) and HER1-4 status. RESULTS: Overall, high tumor levels of mRNA expression of CYP19 and 17-beta-HSD type 1 correlated with poor survival (p=0.0105 and p=0.0182, respectively). Increased levels of CYP19 mRNA expression positively correlated with disease progression as levels were significantly higher in samples of patients who had distant metastasis and local recurrence and/or died of breast related causes when compared to those who were disease free for >10 years (p=0.0015). We also observed higher levels of CYP19 mRNA in tumor samples compared to normal breast tissue. However, this reached statistical significance only when comparing grade 1 tumors with normal tissue (p=0.01). There was no correlation between CYP19á mRNA expression and tumor stage, lymph node status and tumor grade. There was however a trend for a positive correlation between CYP19 and ER mRNA expressions (p=0.06). No significant difference in 17-beta-HSD type 1 expression between normal and cancerous tissues was observed. In tumor samples, we observed an increase in levels correlating with tumor's grade. This correlation was statistically significant when we compared grade 1 with grade 2 and grade 1 with grade 3 (p=0.0031 and 0.0251, respectively). CONCLUSION: Our study shows that higher levels of the enzymes responsible for the local biosynthesis of estrogens especially aromatase are associated with a poor clinical outcome in patients with breast cancer.

Breast papillomas: current management with a focus on a new diagnostic and therapeutic modality.

Breast papilloma is a term that describes an intraductal papillary configuration of the mammary epithelium on macroscopic or microscopic examination. It includes solitary intraductal papillomas, multiple papillomas, papillomatosis, and juvenile papillomatosis (JP).Recent advances in mammary ductoscopy (MD) have raised new possibilities in the diagnosis and treatment of breast papillomas. This technique represents an important diagnostic adjunct in patients with pathological nipple discharge (PND) by allowing direct visualisation and biopsy of intraductal lesions and guiding duct excision surgery. Treatment of breast papillomas often entails surgical duct excision for symptomatic relief and histopathological examination. Recently, more conservative approach has been adapted. MD-assisted microdochectomy should be considered the procedure of choice for a papilloma-related single duct discharge. Furthermore, there is increasing evidence that MD has the potential to reduce the number of duct excision procedures and minimise the extent of surgical resection. Imaging-guided vacuum-assisted core biopsy can be diagnostic and therapeutic for papillomas seen on mammography and/or ultrasound. Patients with multiple papillomas do have an increased risk of developing cancer and should be kept under annual review with regular mammography (preferably digital mammography) if treated conservatively. Magnetic resonance (MR) can be also used in surveillance in view of its high sensitivity. Because the risk is small, long term and affects both breasts, long-term follow-up is more appropriate than prophylactic mastectomy. Patients who prove to have solitary duct papilloma have insufficient increase in the risk of subsequent malignancy to justify routine follow-up.

The role of STS and OATP-B mRNA expression in predicting the clinical outcome in human breast cancer.

BACKGROUND: Steroid sulfatase (STS) is the enzyme responsible for hydrolysing biologically inactive estrogen sulfates to active estrogens. Therefore it plays a significant role in supporting the growth of hormone-dependent tumours of the breast, endometrium and prostate. OATP-B is a member of a family of membrane transporter proteins that regulates the uptake of steroid sulfates through cell membranes. Our objective was to determine, using quantitative PCRA whether the mRNA expression levels from these genes were positively correlated with clinical outcome in human breast cancer. This is the first study in the literature to examine the relationship between STS and OATP-B in human breast cancer and to investigate the potential prognostic value of OATP-B. MATERIALS AND METHODS: A total of 153 samples (120 tumour tissues and 33 normal breast tissues) were analysed. The levels of transcription of STS and OATP-B were determined using real-time quantitative PCR and normalized against cytokeratin 19. The levels of expression were analysed against tumour's stage, grade, nodal status, local relapse, distant metastasis, ERalpha, ERbeta and HER1-4 receptor status and survival over a 10 year follow up period. RESULTS: The levels of STS mRNA were significantly higher in malignant samples (p=0.031) and in node positive disease (p=0.0222). STS mRNA expression increased with increasing tumour grade but this did not reach statistical significance. A significant increase was also noted in levels correlating with tumour stage when stages TNM1 and TNM2, TNM2 and TNM3, and TNM3 and TNM4 (p=0.00001, 0.0017 and 0.02, respectively) were compared. Furthermore, STS expression levels positively correlated with progression of disease, as levels were significantly higher in samples from patients who developed metastasis, local recurrence, or died of breast cancer when compared to those who were disease free for >10 years (p=0.0036). No significant correlation was found between the levels of STS expression and ERalpha/ERbeta/ status. The levels positively correlated with HER1 and HER3 receptors. The levels of mRNA expression of OATP-B were higher in malignant tissue compared to normal tissue; this, however, did not reach statistical significance (p=0.4045). Levels were also higher in node positive disease (p=0.0672). Expression levels increased with increasing tumour grade and this became statistically significant when comparing grade 1 to 2, and grade 2 to 3 (p=0.0271 and 0.0289, respectively). An increase in levels correlating with TNM tumour staging was also observed; this, however, did not reach statistical significance. There was no significant correlation between OATP-B expression levels and clinical progression of breast cancer. No correlation was found between STS and OATP-B expression levels. CONCLUSION: This study demonstrates a compelling trend for STS transcription levels to be higher in cancer tissues and in patients who developed progressive disease. OATP-B expression levels correlated with the grade and stage of the disease, but not with the clinical outcome. These results suggest that STS mRNA has a significant potential as an important predictor of clinical outcome in patients with breast cancer.

Skin and fat necrosis of the breast following methylene blue dye injection for sentinel node biopsy in a patient with breast cancer.

Sentinel lymph node biopsy (SLNB) is a simple technique that uses subdermal or peri-tumoral injection of vital blue dye and/or radioactive isotope to identify the first lymph node(s) draining the primary tumor. It has been shown to accurately predict axillary node status in patients with clinically node negative breast cancer. The SLNB is emerging as a new standard of care in patients with early breast cancer. However, the use of methylene blue (MB) dye can be associated with a number of local complications due to its tissue reactive properties. We report a rare case of skin and fat necrosis followed by a dry gangrene of the skin in a female patient with breast cancer who underwent SLNB localization using peri-tumoral injection of MB dye in another institution. This case and literature review suggest that the use of MB dye for SLNB identification should be avoided and replaced with alternative types of blue dye such as Patent Blue V preferably in conjunction with a radioactive isotope tracer.

Is preoperative core biopsy accurate in determining the hormone receptor status in women with invasive breast cancer?

BACKGROUND: The objective of this study was to determine the concordance rate between core needle biopsy (CNB) and surgical excision of invasive breast cancer regarding the oestrogen receptor (ER) and Progesterone receptor (PgR) status as determined by Immunohistochemistry (IHC). METHODS: Hormone receptor status was established using IHC (using quickscore system 0-8) on preoperative CNB and subsequent surgical excision in 93 patients with invasive breast cancer. Results were compared taking into account tumour's size, grade, and patient's age. RESULTS: The ER concordance rate between CNB and surgical excisions was 95%. The PgR concordance rate was 89%. This shows that CNB has a sensitivity of 97% for ER and 95% for PgR. There is a positive correlation of ER and PgR between CNB and surgical excision (p < 0.000001). There was no significant difference in the number of core biopsies between concordant and discordant cases. CONCLUSION: Preoperative core biopsy is highly sensitive for the IHC detection of ER and PgR in invasive breast cancer. The concordance rate is higher for ER than PgR, which could be due to the fact that ER is more homogeneously distributed.

Pneumothorax after a clinical breast fine-needle aspiration of a lump in a patient with Poland's syndrome.

We report the first case in the medical literature of a pneumothorax complicating fine needle aspiration cytology (FNAC) of a breast lump in a woman with a mild form of Poland's syndrome. The pneumothorax was treated conservatively. This is the first case of breast FNA-related pneumothorax seen in our clinical practice. We believe that the absence of pectoral muscles has increased the risk of this complication. We have also diagnosed an incidental screen-detected breast cancer affecting the ipsilateral breast in the same patient. We conclude that caution should be exercised when performing FNAC of breast lesions in patients with Poland's syndrome. The procedure should be preferably performed under image guidance in such patients in order to minimise the risk of this complication.

The evolving role of the dynamic thermal analysis in the early detection of breast cancer.

It is now recognised that the breast exhibits a circadian rhythm which reflects its physiology. There is increasing evidence that rhythms associated with malignant cells proliferation are largely non-circadian and that a circadian to ultradian shift may be a general correlation to neoplasia.Cancer development appears to generate its own thermal signatures and the complexity of these signatures may be a reflection of its degree of development.The limitations of mammography as a screening modality especially in young women with dense breasts necessitated the development of novel and more effective screening strategies with a high sensitivity and specificity. Dynamic thermal analysis of the breast is a safe, non invasive approach that seems to be sensitive for the early detection of breast cancer.This article focuses on dynamic thermal analysis as an evolving method in breast cancer detection in pre-menopausal women with dense breast tissue. Prospective multi-centre trials are required to validate this promising modality in screening.The issue of false positives require further investigation using molecular genetic markers of malignancy and novel techniques such as mammary ductoscopy.

SYK expression in human breast cancer.

BACKGROUND: Syk (Splenic Tyrosine Kinase) is an intracellular receptor protein kinase involved in cell proliferation, differentiation and phagocytosis. It has been studied in T and B lymphocytes, NK cells and platelets. The strong expression of Syk in mammary gland prompted research into its potential role in mammary carcinogenesis. There have been very few studies about its role in breast cancer with conflicting results. This study aims to investigate the hypothesis that Syk expression is down-regulated in breast cancer compared with ANCT and the association between its expression and clinicopathological parameters. MATERIALS AND METHODS: mRNA was extracted from 48 breast cancer specimens. Relative Syk to ribosomal RNA expression was determined by RT-PCR and Taqman methodology. Mann-Whitney U test was used to examine the association between Syk expression in cancer and ANCT. Spearman's rank correlation test was used to examine the association between Syk expression in tumours and patients' age, tumour size, tumour grade, estrogen and progesterone receptor status, lymph node metastasis, vascular invasion and clinical outcome. RESULTS: The median for the relative value of Syk expression was 0.17 and 0.18 (range: 0.12 - 0.56 and 0.0 - 1.77) for tumours and ANCT respectively. There was no significant association between Syk expression in cancers and ANCT (p= 0.598) nor between Syk expression in tumours and patients' age, tumour size, tumour grade, estrogen and progesterone receptor status, lymph node metastasis, vascular invasion or prognosis. CONCLUSION: This study shows that Syk mRNA expression does not seem to vary between breast tumours and ANCT. Furthermore, we observed no significant association between Syk expression and clinicopathological parameters.

In vitro fertilization and breast cancer risk: a review.

INTRODUCTION: Breast cancer is a classic model of a hormone-dependent malignancy. Since the drugs used for ovulation induction as part of in vitro fertilization (IVF) treatment increase the levels of endogenous gonadal hormones, concerns have arisen regarding a possible association between IVF and the risk of developing breast cancer. The aim of this paper was to review the literature and examine the potential effects of IVF treatment on breast cancer risk. METHODS: Medline search was conducted using the key words below in English-language articles. Further papers were obtained using the bibliographies of relevant articles. Furthermore, a combined analysis of retrieved data was performed. RESULTS: Fifteen studies were identified; of these, 11 were cohort studies and 4 were case-control studies. None of the individual studies showed an overall significant association between IVF and breast cancer and, in fact, one study showed that treatment with hCG significantly reduced the risk of breast cancer in women whose maximum nonpregnant body mass index was less than 27.5. A combined analysis of the cohort studies including a total of 60,050 women treated with ovulation induction/IVF showed no significant association between these treatments and increased risk of breast cancer (observed vs. expected: 601 vs. 568, pooled relative risk [RR] = 1.06, P = 0.337). The case-control studies included a total of 11,303 women in the breast cancer groups and 10,930 controls. Women in the breast cancer groups were slightly less likely to have received IVF (2.2% vs. 2.5%, pooled RR = 0.88, P = 0.231). However, one study showed that infertility treatment was associated with an increased risk of breast cancer of borderline significance among women with a family history of the disease. Another study showed that the incidence of breast cancer within the first year of exposure to fertility drugs was higher than expected, possibly due to the promotion of preexisting cancer lesions caused by superovulation or due to the early diagnosis made in the course of IVF treatment. Conflicting results were reported regarding the type of fertility treatment and breast cancer risk. CONCLUSION: Overall, there is no clear evidence that ovulation induction or IVF increases the risk of breast cancer. However, there may be a transient increase in the incidence of breast cancer in the first year due to earlier diagnosis. Furthermore, the risk may be increased in women with a positive family history. Future research should focus on the type of fertility treatment used and breast cancer risk. Aromatase inhibitors should be evaluated further as an alternative to standard ovulation-inducing drugs.

Dairy products and breast cancer risk: a review of the literature.

BACKGROUND: Dietary elements and, in particular, dairy products have been implicated in the etiology of breast cancer. High saturated fat contents, contaminants such as pesticides, and insulin-like growth factor I (IGF-1) have been hypothesized as possible carcinogenic factors. In contrast, calcium, vitamin D, and conjugated linoleic acid (CLA) all are considered to reduce breast cancer risk. We aim to review the current epidemiological literature on the relationship between the intake of dairy products and breast cancer risk. METHODS: A Medline search was conducted using the key words breast neoplasms and dairy products. Further articles were obtained by cross-matching references of relevant articles. Thirty-nine case-control and 11 cohort studies were identified since 1981. Two meta-analyses and several review articles were also noted. RESULTS: Results from previous studies were analyzed and comparisons were made between each type of study. Controversy exists regarding this subject and we found conflicting evidence in recent literature regarding this hypothesis. CONCLUSION: There is no substantial epidemiological evidence to support a significant link between the intake of dairy products and breast cancer risk.