Selective application of routine preoperative axillary ultrasonography reduces costs for invasive breast cancers.

PURPOSE: Preoperative axillary sonography with fine needle aspiration (FNA) in patients with invasive breast cancer identifies patients with nodal metastasis who can be spared further surgery. Indiscriminate use of the diagnostic modality can increase costs and yield inaccurate results. We evaluate the costs associated with the use of highly sensitive axillary ultrasonography in patients with stage ≥T2 tumors. PATIENTS AND METHODS: We constructed a decision analysis tree using TreeAge Pro 2009 software comparing direct hospital charges between patients with and without routine use of axillary ultrasound. Base case estimates were derived from our institutional data and compared with those derived from the literature. One- and two-way sensitivity analyses were performed to check the validity of our inferences. RESULTS: We found that, for the base case estimate with 35% lymph node positivity in stage ≥T2 tumors and sensitivity of the axillary ultrasound set at 86% with a specificity of 40%, the strategy to perform preoperative axillary ultrasound yielded rollback costs of $15,215, compared with $15,940 for surgery plus sentinel lymph node biopsy (cost difference, $725 per patient favoring axillary ultrasound). On two-way sensitivity analysis, the cost benefit for axillary ultrasound was not seen in patients with a low risk for nodal metastasis. CONCLUSION: The adoption of routine preoperative axillary sonography with FNA is a lower-cost strategy than conventional strategies in patients with stage ≥T2 invasive breast cancer.

Optimization of a dendritic cell-based assay for the in vitro priming of naïve human CD4+ T cells.

Methods to prime human CD4(+) T cells in vitro would be of significant value for the pre-clinical evaluation of vaccine candidates and other immunotherapeutics. However, to date, there is no reliable method for the induction of primary human T cell responses in the laboratory. Here, we optimized a culture strategy incorporating highly purified lymphocytes and dendritic cells, in the absence of any exogenous growth factors, for the in vitro sensitization of naïve CD4(+) T cells against a variety of protein antigens. This fully autologous approach, which was superior to the more traditional PBMC assay for supporting the induction of primary human T helper cell responses in culture, elicited effector cells capable of producing a variety of Th cytokines, including IFNgamma, TNFalpha, IL-2, IL-5, IL-17 and IL-21, and memory cells that could be restimulated multiple times with a specific antigen. Through simple modifications to this culture method, we evaluated the role of dendritic cell maturation state and regulatory T cells on the sensitization of naïve T helper cells, which highlights its utility for addressing basic questions of human immunobiology. Finally, using the formulated yellow fever vaccine, YF-VAX (R), we provide a proof-of-concept demonstration of the utility of the system for evaluating the T cell immunogenicity of vaccine candidates in a pre-clinical setting.