Tissue microarrays for rapid linking of molecular changes to clinical endpoints.

Advances in genomics and proteomics are dramatically increasing the need to evaluate large numbers of molecular targets for their diagnostic, predictive or prognostic value in clinical oncology. Conventional molecular pathology techniques are often tedious, time-consuming, and require a lot of tissue, thereby limiting both the number of tissues and the number of targets that can be evaluated. Here, we demonstrate the power of our recently described tissue microarray (TMA) technology in analyzing prognostic markers in a series of 553 breast carcinomas. Four independent TMAs were constructed by acquiring 0.6 mm biopsies from one central and from three peripheral regions of each of the formalin-fixed paraffin embedded tumors. Immunostaining of TMA sections and conventional "large" sections were performed for two well- established prognostic markers, estrogen receptor (ER) and progesterone receptor (PR), as well as for p53, another frequently examined protein for which the data on prognostic utility in breast cancer are less unequivocal. Compared with conventional large section analysis, a single sample from each tumor identified about 95% of the information for ER, 75 to 81% for PR, and 70 to 74% for p53. However, all 12 TMA analyses (three antibodies on four different arrays) yielded as significant or more significant associations with tumor-specific survival than large section analyses (p < 0.0015 for each of the 12 comparisons). A single sample from each tumor was sufficient to identify associations between molecular alterations and clinical outcome. It is concluded that, contrary to expectations, tissue heterogeneity did not negatively influence the predictive power of the TMA results. TMA technology will be of substantial value in rapidly translating genomic and proteomics information to clinical applications.

Granulocyte colony-stimulating factor (G-CSF) receptor gene expression of ovarian carcinoma does not correlate with G-CSF caused cell proliferation.

BACKGROUND: Recombinant human granulocyte colony-stimulating factor (rhG-CSF) is a growth factor commonly used to avoid leukopenia after chemotherapy. Endogenous G-CSF is produced by macrophages and granulocytes that infiltrate tumors. It has been reported that rhG-CSF stimulates the proliferation of several cell lines as well as bladder carcinoma cells. Conversely, in some hematopoietic cell lines such as U-937, WEHI-3B, and K-562 no effect or in some cases a differentiation pattern was found. Moreover, the role of rhG-CSF on the proliferation of solid tumors is not well understood. METHODS: In this study, 10 ovarian carcinoma biopsies were characterized for the presence of G-CSF and G-CSF receptor by reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemical analysis. Proliferation was analyzed by ATP viability assays. RESULTS: Performing RT-PCR, these biopsies and four ovarian carcinoma cell lines were analyzed for endogenous G-CSF production, which was found in some biopsies and in all cell lines. Despite the presence of the G-CSF receptor in all biopsies and cell lines, no proliferation was found after rhG-CSF incubation of the cell lines or the tumor samples for 3 and for 6 days, respectively. CONCLUSIONS: Summarizing the authors' in vitro studies, rhG-CSF does not affect the proliferation of ovarian carcinoma cells in vitro.

Advanced breast biopsy instrumentation for the evaluation of impalpable lesions: a reliable diagnostic tool with little therapeutic potential.

OBJECTIVE: To assess the potential of advanced breast biopsy instrumentation (ABBI) to clarify the diagnosis of impalpable mammographic lesions and to remove the entire malignant lesions with clear margins. DESIGN: Prospective assessment in a consecutive series of patients. SETTING: University hospital, Basel, Switzerland. SUBJECTS: 139 patients presenting with 144 impalpable microcalcifications or solid nodular densities evident on screening and follow-up mammograms that were suspicious of malignancy. MAIN OUTCOME MEASURES: Feasibility, sensitivity, efficiency in obtaining definitive diagnoses in an outpatient clinic under local anaesthesia, feasibility of complete removal of a primary malignancy, and intervention-related morbidity. RESULTS: The ABBI procedure was successful in 135/144 (94%); an accurate diagnosis was made in 129/130 patients followed up (99%), sensitivity for malignant lesions was 31/32 (97%) and there were 2 complications (2%). Margins of the biopsy cylinder contained a malignant lesion in 26/31 (84%). CONCLUSIONS: Excisional biopsy using the ABBI system is a reliable diagnostic tool with a low morbidity. As in other published series margins were often not clear of tumour and therefore the therapeutic use of the ABBI procedure is limited.

[The Advanced Breast Biopsy Instrumentation (ABBI) for evaluation of mammographically suspicious, non-palpable findings of the breast: a reliable diagnosis with minor therapeutic potential]. / Die Advanced Breast Biopsy Instrumentation (ABBI) für die Evaluation mammographisch verdächtiger, nicht-palpabler Befunde der Brustdrüse: Eine zuverlässige Diagnostik mit geringem therapeutischen Potential.

BACKGROUND: Stereotactic biopsy techniques supersede conventional hook-wire localization followed by open excision to clarify the dignity of nonpalpable mammographic lesions. The advanced breast biopsy instrumentation (ABBI) allows stereotactically guided excision of a specimen up to 20 mm in diameter on an outpatient basis under local anaesthesia. METHODS: Demographic information, mammographic and pathological findings, complications, subsequent interventions and sensitivity as well as efficiency of a series of 144 planned ABBI procedures were documented (largest published single institution series). RESULTS: The ABBI procedure was successfully performed in 93.8% (135/144); accurate diagnosis was made in 99.3% (134/135), sensitivity for malignant lesions was 96.9% (31/32) and morbidity was 1.5%. Consistent with other published series margins of the biopsy cylinder containing a malignant lesion were involved in 83.9% (26/31). CONCLUSIONS: Excisional biopsy using the ABBI system is a reliable diagnostic tool with a low incidence of morbidity. The therapeutic use is of limited potential.

[Validation study of the sentinel lymph node (SLN) method in invasive breast carcinoma. Personal data and review of the literature]. / Validierungsstudie des Sentinel Lymph Node (SLN) Verfahrens beim invasiven Mammakarzinom. Eigene Daten und Review der Literatur.

BACKGROUND: Axillary lymph node dissection (ALND) is an integral part in the therapy of breast cancer. Axillary lymph node involvement and tumour size are the most important prognostic factors. Restriction of ALND to level I and II (Berg) reduced high morbidity. The increasing proportion of patients with early breast cancer and negative axillary nodes led to a more selective method to avoid unnecessary ALND. The sentinel lymph node (SLN)--the first draining lymph node of a tumour--represents the status of the axilla. A negative SLN prevents from further completion ALND. PATIENTS AND METHODS: From 9/97 to 1/99 44 patients with invasive breast cancer underwent a prospective trial of lymphatic mapping with isosulfanblue and/or lymphoscintigraphy with 99m technetium-labelled human colloid. During the operation a hand-held gamma probe was used for detection. The SLN was removed selectively and examined by routine histopathology (H&E) and immunohistochemistry (IHC). ALND of level I and II was performed in all patients for correlation. RESULTS: The SLN were identified in 41 of 44 patients (93%). 2.4 SLN per patient were harvested, overall 17.6 axillary lymph nodes. Of the 41 patients, 21 patients had positive, 20 patients negative SLN. In the 20 patients with negative SLN only one patient (5%) had metastatic disease on complete dissection (negative predictive value of 95%). In 17 patients with positive axillary lymph nodes 16 were found to have positive SLN, only one SLN was negative (false negative rate of 5.9%). In two of 41 patients micrometastases were detected by IHC. Lymphoscintigraphy revealed drainage to the axilla and internal mammary nodes in two of 28 cases (7%). SUMMARY: Our validation study proves the reproducibility and reliability of the SLN procedure. A multidisciplinary approach is indispensable. The SLN procedure has the potency for becoming the selection criterion whether to perform an ALND or not. Multiple sections and IHC staining improve the detection rate of metastatic disease. Ongoing long time investigations will determine the impact on overall survival. Our own data are discussed in an extended review of the literature.

[Neoadjuvant therapy in breast carcinoma]. / Die neoadjuvante Therapie beim Mammakarzinom.

The preoperative or neoadjuvant chemo- or endocrine therapy in the treatment of locally advanced breast cancer is a new therapy option. Clinical Studies could show, that there is no difference in overall survival between patients, who received a preoperative chemotherapy and patients, treated with the conventionally postoperative, adjuvant chemotherapy. There is an increased rate of breast conserving therapy for the locally advanced breast cancer because of tumor shrinking. Neoadjuvant chemotherapy is also a good in-vivo-model for chemosensitivity-testing. For elderly patients with comorbidity, the primary treatment with endocrine therapy with tamoxifen or aromatase inhibitors could even avoid an operation in some cases. The most effective drugs for preoperative chemotherapy are anthracyclines and taxanes. The assessment of predictive factors like S-phase, Ki67, ploidy, c-erb-B2, in-vitro-chemosensitivity-testing results and others could help to differentiate patients who will have a benefit from chemotherapy. It is important to have more results from studies with a long term follow-up, before we declare primary systemic chemo- or hormone therapy as standard therapy for breast cancer patients with locally advanced breast cancer.

[Developments in minimally invasive breast surgery - overview and our own experience: new diagnostic and therapeutic challenges in breast cancer]. / Entwicklung der minimal-invasiven Mammachirurgie - Ubersicht und eigene Erfahrungen. Neue chirurgische Herausforderungen in der Diagnostik und Therapie des Brustkrebses.

New diagnostic and therapeutic modalities in breast cancer are necessary because nowadays an increased number of suspicious breast lesions are referred to breast clinics for a histological diagnosis. In the future more than one quarter of patients might present with a preinvasive lesion and more than half of the patients will have tumors less than 2 cm. Mammography screening helps to find more preinvasive lesions. Therefore we need new tools for exact stereotactic breast biopsies in the outpatient setting, such as the advanced breast biopsy instrumentation (ABBI((R))) or the Mammotome((R)) system. For axillary clearance we need methods that lead to less morbidity. The detection of the sentinel lymph node is one of these new techniques. Endoscopic axillary clearance after liposuction also helps to reduce morbidity. Due to better visualization of the anatomic structures with axilloscopy less traumatic surgery is possible. We also combined these two new methods and described the endoscopic clearance of the sentinel lymph node in the axilla with the additional help of isosulfan blue. However, this combined method is not only time-consuming but also more expensive and shows no obvious advantage compared to the open sentinel technique. Therefore we stopped using the endoscopic sentinel technique and we now promote open sentinel lymph node biopsy without full axillary clearance when frozen section shows sentinel node-negative lymph nodes.

Value of (18F)-FDG positron emission tomography, computed tomography, and magnetic resonance imaging in diagnosing primary and recurrent ovarian carcinoma.

The aim of this study was to compare prospectively the accuracy of whole-body positron emission tomography (PET), CT and MRI in diagnosing primary and recurrent ovarian cancer. Nineteen patients (age range 23-76 years) were recruited with suspicious ovarian lesions at presentation (n = 8) or follow-up for recurrence (n = 11). All patients were scheduled for laparotomy and histological confirmation. Whole-body PET with FDG, contrast-enhanced spiral CT of the abdomen, including the pelvis, and MRI of the entire abdomen were performed. Each imaging study was evaluated separately. Imaging findings were correlated with histopathological diagnosis. The sensitivity, specificity and accuracy for lesion characterization in patients with suspicious ovarian lesions (n = 7) were, respectively: 100, 67 and 86% for PET; 100, 67 and 86% for CT; and 100, 100 and 100% for MRI. For the diagnosis of recurrent disease (n = 10), PET had a sensitivity of 100%, specificity of 50% and accuracy of 90%. The PET technique was the only technique which correctly identified a single transverse colon metastasis. Results for CT were 40, 50 and 43%, and for MRI 86, 100 and 89%, respectively. No statistically significant difference was seen. Neither FDG PET nor CT nor MRI can replace surgery in the detection of microscopic peritoneal disease. No statistically significant difference was observed for the investigated imaging modalities with regard to lesion characterization or detection of recurrent disease; thus, the methods are permissible alternatives. The PET technique, however, has the drawback of less accurate spatial assignment of small lesions compared with CT and MRI.

[Hereditary cancer syndromes in gynecology: what the practitioner needs to know!]. / Hereditäre Karzinomsyndrome in der Frauenheilkunde: Was der Praktiker wissen sollte!

During the last 5 years progress in molecular genetics has offered the possibility of genetic testing for inherited mutations of cancer-predisposing genes. The exact cellular function and carcinogenic potential of these genes is yet not completely understood. Only in 5-20% of all cancers inherited genetic mutations play an important role in the polygenic and multifactorial nature of the disease. Identification of inherited cancer syndromes, predictive genetic testing, and counselling of women and family members at increased risk is of clinical importance. The debate surrounding presymptomatic diagnostic testing and adequate programmes for early cancer detection, prevention or clinical follow-up continues.

Endobag extractor to remove masses during laparoscopy.

BACKGROUND: Intra-abdominal masses are removed during laparoscopy using different types of endobags. However, in many cases the specimens are larger than the trocar or the incision in the abdomen, with a potential risk of endobag rupture. INSTRUMENT: We developed an instrument to facilitate extraction of an endobag during laparoscopy without the need for a conventional minilaparotomy. The endobag extractor has three removable diverging blades that symmetrically enlarge the operative canal in the abdominal wall if spread after sharp extension of the skin incision. The full endobag can be drawn through the canal without the risk of endobag rupture because the size of the canal can be individualized, building a funnel. EXPERIENCE: We removed various kinds of ovarian tumors, specimens from salpingo-oophorectomies, and other specimens in 22 cases. CONCLUSION: This new instrument allows easy removal of surgical specimens during laparoscopy without conventional minilaparotomy, regardless of the type of endobag used. We believe this instrument lessens the risk of endobag rupture.

Differentiation and management of endometrium abnormalities and leiomyomas by hydrosonography.

Transvaginal sonography is an established method for numerous clinical indications in the assessment of endometrium pathology. The investigation of the endometrium consists of the measurement of the thickness, the visualization of the echogenity and echotexture and of the demonstration of focal masses. However, evaluation of the uterine cavity by transvaginal sonography is limited and an abnormal ultrasound of the endometrium may reflect benign or malignant conditions. Furthermore, small structures can be missed or overlooked. If indicated, hydrosonography offers various advantages compared to dilatation and curettage and hysteroscopy in terms of costs, availability and risks. Additional informations obtained after hydrosonography may influence the management before consideration of curettage or hysteroscopy.

Endometrial ablation in the year 2000--do we have more methods than indications?

Approximately 20-25% of hysterectomies are done for the relief of menorrhagia, excessive menstrual bleeding without gynecologic pathology. Menorrhagia represents a widespread clinical problem, and it is one of the leading causes of elective hysterectomy in women with a normal uterus in the US as well as in Europe. The current management of dysfunctional bleeding includes medical or different types of surgical therapies. When patients wish a nonsurgical therapy for menorrhagia we can offer them different medical treatments, a IUD releasing levonorgestrel or a therapeutic dilatation and curettage (D&C). Until recently, women who did not respond to medication were limited to either hysterectomy or continued cycles of heavy menstrual bleeding. Methods for hysteroscopic endometrial ablation were introduced in the 1980s including Nd:YAG laser ablation, transcervical resection of the endometrium (TCRE) and 'rollerball' electrocoagulation (RBE). These first-generation procedures are nowadays the gold standard for the hysteroscopic treatment of menorrhagia. In the 1990s different types of therapeutic alternatives were introduced. The second generation of hysteroscopic ablation techniques include: balloon heating methods, methods with intrauterine instillation of heated saline, the endometrial laser intrauterine thermal therapy procedure ELITT using a diode laser, global 3-D bipolar ablation method, punctual vaporizing methods, photodynamic endometrial ablation method, microwave endometrial ablation method, the radiofrequency method menostat and a cryotherapy method.

m-THPC-mediated photodynamic therapy (PDT) does not induce resistance to chemotherapy, radiotherapy or PDT on human breast cancer cells in vitro.

Photodynamic therapy (PDT) uses laser light to activate a photosensitizer that has been absorbed preferentially by cancer cells after systemic administration. A phototoxic reaction ensues resulting in cell death and tissue necrosis. Some cells, however, may survive PDT. This study was performed to determine if surviving human breast cancer cells (MCF-7) can become resistant to PDT, chemotherapy or radiotherapy. The MCF-7 cells were cultured under standard conditions prior to being exposed to the photosensitizer, 5,10,15,20-meta-tetra(hydroxyphenyl)chlorin (m-THPC), for 24 h and then irradiated with laser light (652 nm). Surviving cells were allowed to regrow by allowing a 2 week interval between each additional PDT. After the third and final treatment, colony formation assays were used to evaluate the sensitivity of cultured cells to ionizing radiation and PDT and the ATP cell viability assay tested in vitro chemosensitivity. Flow cytometry was used to analyze the cell cycle. No alterations in the cell cycle were observed after three cycles of PDT with m-THPC. Similar responses to chemotherapy and ionizing radiation were seen in control and treatment groups. The m-THPC-sensitized PDT did not induce resistance to subsequent cycles of PDT, chemo- or radiotherapy. Photodynamic therapy with m-THPC may represent a novel adjunctive treatment of breast cancer that may be combined with surgery, chemotherapy or ionizing radiation.

[The Advanced Breast Biopsy Instrumentation (ABBI), a system for stereotactic excision of mammographically suspect nonpalpable findings in the breast]. / Die Advanced Breast Biopsy Instrumentation (ABBI), ein System zur stereotaktischen Exzision mammographisch verdächtiger nicht-palpabler Befunde der Brustdrüse.

Advanced Breast Biopsy Instrumentation (ABBI) allows radiologically guided stereotactic excision of non-palpable radiodense lesions with high accuracy. Tissue cylinders of 5, 10, 15 or 20 mm diameter and of variable lengths can be removed very accurately under local anaesthesia and on an outpatient basis. Thirty-six patients with suspicious clusters of microcalcifications (n = 29) and with round lesions (n = 7) of the breast were qualified for ABBI. We were able to perform the excisional biopsy in a total of 34 patients. The breast of one woman was too small to safely fit into the system and in another woman the lesion could not be visualized by the system. In 2/34 cases (6%), the excision was imprecise due to slight dislocation of the breast parenchyma by the advancing cylinder knife. In one case (3%), ABBI missed the target within a dense mastopathic breast. In all cases the excisions were well tolerated. No wound complications occurred and the cosmetic result was excellent. Histology revealed 28 benign (82%) and 6 malignant (18%) lesions. Among the 27 small microcalcifications there were 3 invasive carcinomas, 3 ductal carcinomas in situ (DCIS), 1 lobular hyperplasia, 14 mastopathies, 1 fibroadenoma, 1 duct papilloma and 4 calcifications in scars. Four of the 7 round-shaped lesions were found to be fibroadenomas, 1 lobular hyperplasia, and 2 mastopathies. With the ABBI system, non-palpable breast lesions can be precisely localized and excised.

Measurement of intraocular pressure during laparoscopy and its relationship to central venous pressure.

UNLABELLED: STUDY OBJECTIVE. To determine the effect of different positional degrees on hemodynamics, especially central venous pressure and intraocular pressure, and a possible interrelationship, during laparoscopic surgery. SETTING. University teaching hospital (Canadian Task Force classification II-1). PATIENTS: Seven women undergoing elective gynecologic laparoscopy. INTERVENTIONS: The women were monitored for heart rate, partial pressure of oxygen, end-tidal carbon dioxide, arterial blood pressure, central venous pressure, end-tidal isoflurane concentration, and intraocular pressure in several body positions during general anesthesia. MEASUREMENTS AND MAIN RESULTS: Intraocular pressure depends on body position (r2 = 0.58) related to central venous pressure (r2 = 0.7). Heart rate and arterial blood pressure are also dependent on the body position, but to a lesser degree. CONCLUSION: Continuous monitoring of intraocular pressure may help detect alterations in central venous pressure during general anesthesia for laparoscopic surgery. Undesirable alterations caused by degree of Trendelenburg position may negatively affect patients with high cardiac or ophthalmic risk.

[Initial experiences with the Advanced Breast Biopsy Instrumentation (ABBI), a system for stereotactic excision of non-palpable breast lesions]. / Erste Erfahrungen mit der Advanced Breast Biopsy Instrumentation (ABBI), einem System zur stereotaktischen Exzision nicht-palpabler Mammabefunde.

The advanced breast biopsy instrumentation (ABBI) allows the radiologically guided stereotactic excision of non-palpable radiodense lesions with high accuracy. Forty-six patients with suspicious clusters of microcalcifications (n = 37) and with round lesions (n = 9) of the breast were investigated using the ABBI. Tissue cylinders were successfully removed in 98% of cases. No wound complications occurred and cosmesis was excellent. Histopathology revealed 35 benign (76%) and 11 malignant (24%) lesions. With the ABBI system, non-palpable breast lesions can be precisely localized and excised.

[Bladder and rectal infiltration by uterine carcinomas: the accuracy of CT and MRI compared to endoscopic procedures]. / Blasen- und Rektuminfiltration durch Uteruskarzinome: Treffsicherheit der CT und der MRT im Vergleich zu endoskopischen Verfahren.

PURPOSE: To establish the value of computed tomography (CT) and magnetic resonance imaging (MRI) in predicting bladder and rectum involvement in uterine carcinoma. MATERIAL AND METHODS: 6 different imaging signs (focal obliteration of perivesical or perirectal fat planes, area and angle of contact between uterus and bladder or rectum, asymmetric bladder or rectum wall thickening, evidence of intraluminal masses, and signal intensity of bladder or rectum wall on T2-weighted or contrast-enhanced MR images) were analysed retrospectively in 129 patients who underwent 92 CT and/or 64 MRI examinations. The data were correlated with intraoperative findings and the results of cystoscopy and rectoscopy. RESULTS: Asymmetric wall thickening, evidence of intraluminal masses and increased signal intensities of the bladder wall or rectum wall were valuable signs of infiltration (sensitivity 71-100%, specificity 91-96% and accuracy 89-97%). In 27 patients submitted to both imaging examinations MRI was somewhat superior compared to CT (p > 0.1) and yielded similar results as endoscopic procedures (accuracy of cystoscopy and rectoscopy of 90% and 94%, respectively). CONCLUSION: CT and MRI allow to predict involvement of bladder or rectum wall in carcinoma of the uterus with a similar accuracy as endoscopic procedures.