Combined pathologic-genomic algorithm for early-stage breast cancer improves cost-effective use of the 21-gene recurrence score assay.

Background: The 21-gene recurrence score (RS) (Oncotype DX®; Genomic Health, Redwood City, CA) partitions hormone receptor positive, node negative breast cancers into three risk groups for recurrence. The Anne Arundel Medical Center (AAMC) model has previously been shown to accurately predict RS risk categories using standard pathology data. A pathologic-genomic (P-G) algorithm then is presented using the AAMC model and reserving the RS assay only for AAMC intermediate-risk patients. Patients and methods: A survival analysis was done using a prospectively collected institutional database of newly diagnosed invasive breast cancers that underwent RS assay testing from February 2005 to May 2015. Patients were assigned to risk categories based on the AAMC model. Using Kaplan-Meier methods, 5-year distant recurrence rates (DRR) were evaluated within each risk group and compared between AAMC and RS-defined risk groups. Five-year DRR were calculated for the P-G algorithm and compared with DRR for RS risk groups and the AAMC model's risk groups. Results: A total of 1268 cases were included. Five-year DRR were similar between the AAMC low-risk group (2.7%, n = 322) and the RS < 18 low-risk group (3.4%, n = 703), as well as between the AAMC high-risk group (22.8%, n = 230) and the RS > 30 high-risk group (23.0%, n = 141). Using the P-G algorithm, more patients were categorized as either low or high risk and the distant metastasis rate was 3.3% for the low-risk group (n = 739) and 24.2% for the high-risk group (n = 272). Using the P-G algorithm, 44% (552/1268) of patients would have avoided RS testing. Conclusions: AAMC model is capable of predicting 5-year recurrences in high- and low-risk groups similar to RS. Further, using the P-G algorithm, reserving RS for AAMC intermediate cases, results in larger low- and high-risk groups with similar prognostic accuracy. Thus, the P-G algorithm reliably identifies a significant portion of patients unlikely to benefit from RS assay and with improved ability to categorize risk.

Sentinel node biopsy for breast cancer.

Sentinel node biopsy is more frequently being used as a replacement for axillary node dissection as single and multicenter trials confirm its ability to predict the presence of disease in the remaining lymph nodes. There have been a variety of techniques used with varying success and data supporting each of these techniques is presented. In addition, a number of factors have been found to influence the identification and false negative rates, and these are discussed as well. There remain many areas of controversy surrounding this new surgical technique, including: the appropriate method of pathological analysis of the sentinel node, use of lymphoscintigraphy, usefulness of internal mammary sentinel node biopsy, and use of sentinel node biopsy for ductal carcinoma in situ. The Literature is reviewed on these controversial areas.

Preoperative chemotherapy and sentinel lymphadenectomy for breast cancer.

BACKGROUND: Sentinel lymphadenectomy (SL) for breast cancer is becoming the standard of care for selected patients treated by experienced surgeons. One of the few contraindications for performing SL alone is prior chemotherapy (PC). There are, however, no data to support that PC interferes with the ability of the sentinel node to predict the presence of disease in the remaining axillary lymph nodes. The goal of this study was to determine the effect of PC on patients undergoing SL for breast cancer. METHODS: A multicenter trial was organized in 1997 to evaluate the diagnostic accuracy of SL in patients with breast cancer. Investigators were recruited after attending a course on the technique of SL. Technetium-99 and isosulfan blue were injected into the peritumor region and a gamma probe was used to aid identification of the sentinel nodes. The only exclusion criteria for entrance into the trial were palpable or suspicious axillary lymph nodes. A total of 968 patients were enrolled in the trial. Twenty-nine patients were treated with PC and compared with 939 patients not receiving PC. RESULTS: The overall, sentinel node identification rate for the PC patients was 93% (27 of 29) compared with 88% (822 of 939) for patients not treated with PC. There were no false negatives in those patients receiving PC compared with a 13% (25 of 193) false negative rate in those patients not receiving PC. The mean tumor size was 1.4 cm for the PC group and 0.6 cm for the remaining patients (P <0.005). The mean number of sentinel nodes found was 2.0 for the non-PC group and 2.5 for the PC group (not significant). As expected, a higher proportion of patients had positive axillary nodes in the PC group (52%, 15 of 29) compared with the remaining patients (21%, 200 of 939). CONCLUSION: In this small group of patients, PC did not adversely impact the false negative or identification rate. Most patients receiving chemotherapy have larger tumors and a higher chance of harboring metastatic disease but a significant group of these patients (48%) without metastases can potentially be spared an axillary node dissection.

The learning curve and sentinel node biopsy.

BACKGROUND: The ability of sentinel node biopsy (SNB) to replace axillary node dissection for accurate breast cancer staging is absolutely dependent on the consistent and accurate determination and removal of the "true" sentinel node. There are a wide variety of variables that affect the ability of the physician to achieve this goal. One important and potentially controllable variable is physician training and competence to employ the available techniques successfully. There is a large diversity of opinion regarding the minimum number of cases required under supervision prior to independent utilization of the technique but there are data to support at least 20 cases done in conjunction with axillary dissection or under direct supervision. METHODS: Data from single institution and multicenter trials are reviewed and the learning curves are described. An overview of surgical education methods, testing, and credentialing is also addressed. RESULTS: A review of single institution series show that the false negative rate and identification rates vary considerably. In all cases where authors published a second series success rate improved compared with their initial series. Of the four multicenter trials only two can provide reliable learning curves and these have shown a decrease in the false negative rate to < or = 5% after 20 to 30 procedures are performed. CONCLUSIONS: There are data to show that there is a definite learning curve for SNB that cannot be ignored. It is possible that other factors, (ie, a skin injection with technetium-99, Sappeys plexus injection, and mentoring) could decrease this learning curve but until compelling evidence to suggest otherwise is available, surgeons should obtain a minimum experience of 20 cases.

Comparison of intradermal and subcutaneous injections in lymphatic mapping.

BACKGROUND: Sentinel node biopsy (SNB) for melanoma, with its intradermal (ID) injection, has a higher success rate than SNB for breast cancer, which is typically performed with a subcutaneous (SC) or peritumor injection. It is hypothesized that this is in part due to a slower transit time of lymphatic mapping agents through the parenchymal lymphatics of the breast. No study has investigated differences in transit time between different tissues to account for this clinical observation. The goal of the study was to compare transit time between ID and SC injections with common agents used in lymphatic mapping. METHODS: Four injection sites on five domestic pigs were used. Sites were bilateral and included cervical, forelimb, hindlimb, and flank areas. Agents included technetium sulfur colloid (Tc99, filtered and unfiltered), isosulfan blue (IB) dye, and fluorescein (FL) dye. At each site both ID and SC injections were made and the transit time to reach the sentinel node was recorded. The transit time differences were calculated per centimeter distance from the draining lymph node basin. RESULTS: Sentinel nodes were identified draining all sites and found to be hot, blue, or fluorescent (using a Wood's lamp for identification). The cervical and forelimb injection sites drained to the same cervical lymph node basin and both SC and ID injection sites drained to the same sentinel node. Similarly, the hindlimb and flank injection sites both drained to inguinal lymph node basins. The slowest transit time occurred with Tc99 injected SC and the fastest occurred with Tc99 injected ID, whereas both FL dye and IB traveled rapidly to the sentinel node whether injected SC or ID. Large differences were found using unfiltered Tc99 depending on its injection ID (2.7 s/cm +/- 0.5) vs SC (249 s/cm +/- 14.7, P = 0.008). CONCLUSIONS: Tc99 ID injections were significantly faster than SC injection. The slowest and fastest SC injection agents were unfiltered Tc99 and IB, respectively. Dermal injections provide faster transit of lymphatic agents and may improve the identification rate when applied to patients with breast cancer.

Multicenter trial of sentinel node biopsy for breast cancer using both technetium sulfur colloid and isosulfan blue dye.

OBJECTIVE: To determine the factors associated with false-negative results on sentinel node biopsy and sentinel node localization (identification rate) in patients with breast cancer enrolled in a multicenter trial using a combination technique of isosulfan blue with technetium sulfur colloid (Tc99). SUMMARY BACKGROUND DATA: Sentinel node biopsy is a diagnostic test used to detect breast cancer metastases. To test the reliability of this method, a complete lymph node dissection must be performed to determine the false-negative rate. Single-institution series have reported excellent results, although one multicenter trial reported a false-negative rate as high as 29% using radioisotope alone. A multicenter trial was initiated to test combined use of Tc99 and isosulfan blue. METHODS: Investigators (both private-practice and academic surgeons) were recruited after attending a course on the technique of sentinel node biopsy. No investigator participated in a learning trial before entering patients. Tc99 and isosulfan blue were injected into the peritumoral region. RESULTS: Five hundred twenty-nine patients underwent 535 sentinel node biopsy procedures for an overall identification rate in finding a sentinel node of 87% and a false-negative rate of 13%. The identification rate increased and the false-negative rate decreased to 90% and 4.3%, respectively, after investigators had performed more than 30 cases. Univariate analysis of tumor showed the poorest success rate with older patients and inexperienced surgeons. Multivariate analysis identified both age and experience as independent predictors of failure. However, with older patients, inexperienced surgeons, and patients with five or more metastatic axillary nodes, the false-negative rate was consistently greater. CONCLUSIONS: This multicenter trial, from both private practice and academic institutions, is an excellent indicator of the general utility of sentinel node biopsy. It establishes the factors that play an important role (patient age, surgical experience, tumor location) and those that are irrelevant (prior surgery, tumor size, Tc99 timing). This widens the applicability of the technique and identifies factors that require further investigation.

The details of successful sentinel lymph node staging for breast cancer.

Sentinel lymphadenectomy is an effective and accurate tool for staging breast cancer. In recent years the details of a successful program have become better defined. The authors outline practical considerations for the performance of successful sentinel lymph node staging from a multidisciplinary perspective.

State-of-the-art lymph node staging for breast cancer in the year 2000.

Axillary staging for breast cancer is vitally important for determining appropriate adjuvant hormone and chemotherapy. In the absence of distant metastases, axillary lymph node status remains the most accurate predictor of clinical outcome. Sentinel lymph node biopsy is a minimally invasive approach with enhanced accuracy and less morbidity than conventional axillary dissection. The stage is now set for the sentinel lymphadenectomy staging to move from state-of-the-art care to the standard care in coming years.

Credentialing issues with sentinel lymph node staging for breast cancer.

Sentinel lymphadenectomy (SL) is a minimally invasive approach for staging patients with breast cancer. SL, when performed in lieu of axillary dissection, is associated with less morbidity and is potentially more cost effective and more accurate than the historical axillary dissection in the detection of regional nodal metastases. The credentialing and privileging of SL, as with any surgical procedure, is by the policies of the local hospital or institution. The suggested credentialing criteria for local hospitals has been an area of controversy. Herein the authors outline the credentialing controversy and suggest criteria for the implementation of sentinel lymph node staging for breast cancer.

Fine-needle aspiration cytology of metastatic squamous-cell carcinoma arising in a pilonidal sinus, with literature review.

Fewer than 50 cases of carcinoma arising in a pilonidal sinus have been reported, with only 5 patients having documented inguinal lymph node metastases. This is the first report of the fine-needle aspiration (FNA) diagnosis of this uncommon clinical situation of squamous-cell carcinoma arising in a pilonidal sinus, metastatic to an inguinal lymph node. We report on a 59-yr-old male with squamous-cell carcinoma arising in a pilonidal sinus who presented with inguinal adenopathy. FNA biopsy of a lymph node was performed, resulting in a diagnosis of metastatic squamous-cell carcinoma. FNA biopsy is useful in the evaluation of patients with inguinal adenopathy and a history of malignancy arising in a pilonidal sinus. The possibility of this rare complication should also be considered when metastatic squamous-cell carcinoma to an inguinal lymph node is diagnosed by FNA cytology in patients having an unknown primary except for a change in a long-standing pilonidal cyst.

Filtered versus unfiltered technetium sulfur colloid in lymphatic mapping: a significant variable in a pig model.

BACKGROUND: Lymphatic mapping with sentinel node biopsy is becoming a standard diagnostic test for melanoma and is being extensively investigated for use with other soft tissue tumors. Both filtered and unfiltered technetium sulfur colloid (Tc 99) have been used for preoperative lymphoscintigraphy, as well as intraoperative lymphatic mapping, and it is not clear if one is preferable over the other. The purpose of this study was to compare these two preparations to determine whether the form of Tc 99 used affects the results of lymphatic mapping. METHODS: Mock skin sites were placed on each extremity of 12 domestic pigs totaling 48 skin sites. Twenty-four of the lesions were injected with unfiltered Tc 99; the remaining 24 were injected with Tc 99 passed over a 0.2-microm filter. Both preparations of Tc 99 were mixed with 1 mL of isosulfan blue before injection. Sentinel node dissection was performed using a gamma probe, with counts recorded over a 10-second period and timed to begin 5 minutes after injection. RESULTS: Sentinel nodes were identified in all 48 lymph node basins draining the mock sites and characterized as hot (10x background), blue, or both. Significantly more sentinel nodes were found in the filtered (105 total, X = 4.4/basin), than in the unfiltered group (total 53, X = 2.2/basin, P <.0001). The filtered group had both a higher number of nodes that were hot (35 vs. 6) and more nodes that were hot and blue (69 vs. 43). In addition, hot secondary level lymph nodes (iliac and deep cervical) were found in 11 of 24 of the basins (46%) in the filtered group compared to 1 of 24 (4%) in the unfiltered group (P <.003). There was no significant difference in injection site or residual basin counts between the two groups, but in vivo counts over the sentinel node sites were significantly lower in the unfiltered group (X = 2670+/-1829 vs. X = 6027+/-4333; P = .003). CONCLUSION: Use of filtered Tc 99 results in more sentinel nodes (both hot/blue and hot non-blue) and a higher proportion of secondary lymph nodes. These findings indicate that the Tc 99 preparation used is a significant variable in the results of lymphatic mapping. It is critical that future clinical studies document which preparation of Tc 99 was used. Only large clinical trials will be able to determine whether the additional nodes found with filtered Tc 99 increase the sensitivity of the technique or merely increase the number of nodes that must be removed unnecessarily.

Identification of superior markers for polymerase chain reaction detection of breast cancer metastases in sentinel lymph nodes.

Sentinel lymph node biopsy (SLNB) is being evaluated in breast cancer patients to improve detection of metastases and to guide therapy with minimal morbidity. The use of reverse transcription-PCR analysis to increase detection of tumor cells in SLN of breast cancer patients is hampered by the lack of specific markers. In this study, seven markers were evaluated by reverse transcription-PCR for expression in human breast adenocarcinoma lines (BrCa) and in normal nodes from non-cancer patients. Two markers yielded exceptional results; mammaglobin and carcinoembryonic antigen transcripts were detected in 100 and 71% BrCa, respectively, and were absent from all normal lymph nodes. These markers will be used as components of a multimarker panel to evaluate sentinel nodes in an on-going, multicenter clinical trial.

Nonpalpable versus palpable invasive breast tumors treated with breast-conserving surgical management.

Most mammographically detected breast cancers are small, nonpalpable malignancies that should be amenable to cure by definitive breast-conserving therapy (BCT) consisting of tumor excision and postoperative radiation. We examined this hypothesis by retrospectively comparing the incidence of local recurrence and the rate of survival in breast cancer patients undergoing BCT for nonpalpable versus palpable lesions. Between 1982 and 1991, 345 patients at the John Wayne Cancer Institute, a large referral center for breast diseases, underwent BCT for invasive ductal and/or invasive lobular breast carcinomas: 120 (35%) had nonpalpable lesions detected by mammography (MG group), and 225 (65%) had palpable lesions detected by physical exam (PE group). The clinical and pathologic tumor status and the clinical outcome were recorded in each case. Median tumor size was significantly larger in PE than MG patients (2 cm versus 1 cm, P < 0.001). Only 29 percent of MG patients were premenopausal, compared with 51 percent of PE patients (P < 0.05). Axillary node involvement was more frequent in PE than MG patients (46% versus 19%, P < 0.01). Over a median follow-up of 58 months, local recurrence rates were 8 per cent for both MG and PE patients. In both groups, the incidence of local recurrence increased significantly when tumor was found in the margins of the resected breast specimen. In the MG group, the risk of local recurrence was significantly higher in premenopausal patients (P < 0.05). Survival was similar in both groups. The rate of local recurrence after BCT is the same for nonpalpable and palpable breast tumors. However, nonpalpable lesions have a lower rate of regional node metastases, which may improve survival. Both local recurrence and metastases seem to be related to tumor size. Tumor-free operative margins are the best predictor of local control.

Resection and adjuvant immunotherapy for melanoma metastatic to the lung and thorax.

Although melanoma that metastasizes to distant sites is generally associated with a median survival of only 6 to 8 months, certain metastatic sites including the lung may carry a better prognosis than others. Surgical therapy for pulmonary metastases remains controversial because of the variable survival rates reported for previous small series. To determine the prognosis and optimal management of patients with melanoma with pulmonary metastases, we reviewed our 22-year melanoma database of over 6100 patients. Of 984 patients with metastatic melanoma involving the lung or thorax, 106 underwent resection by posterior lateral thoracotomy or median sternotomy. There were no operative deaths, and the median follow-up period for surgical patients was 55 months. The remaining 878 patients were treated without operation with immunotherapy, chemotherapy, radiation therapy, or a combination. In both treatment groups the male/female ratio was approximately 2:1. The primary lesion's Clark level of invasion and Breslow thickness and the patient's age at diagnosis of metastatic disease were not significantly different between the two groups. The 1-year, 3-year, and 5-year survival rates for surgical patients were 77%, 37%, and 27%, respectively, compared with 32%, 7%, and 3% for nonsurgical patients; these differences were highly significant (p = 0.0001). The highest 5-year survival rate (39%) occurred in those patients with a single metastatic lesion. Sixty-three percent of the surgical patients received some form of immunotherapy, compared with 34% of the nonsurgical patients. Multivariate analysis showed that resection and immunotherapy with a melanoma cell vaccine were both independent predictors of survival (p < 0.0001). These results indicate that the prognosis associated with metastatic melanoma may be less dismal than previously thought when distant metastases involve thoracic sites. We believe that surgical resection is the treatment of choice for patients with melanoma with pulmonary metastases; when combined with immunotherapy, this regimen offers the best chance for long-term survival.

Intraportal delivery of immunosuppression to intrahepatic islet allograft recipients.

Local delivery of immunosuppressive agents may dampen local alloreactive events with avoidance of systemic toxicity. We investigated the innovative strategy of intraportal (IPO) delivery of three immunosuppressive agents in streptozotocin diabetic rat recipients of islet allografts (Lewis to Wistar-Furth) transplanted intrahepatically. IPO budesonide (BUD, 240 or 360 micrograms/kg per day), a potent steroid, and cyclosporin (CyA, 2 or 4 mg/kg per day) did not prolong graft mean survival time [MST +/- standard deviation (SD)] as compared to nonimmunosuppressed recipients. Fourteen days of IPO FK 506 (0.16 mg/kg per day) significantly increased MST as compared with untreated controls (49 +/- 29 vs 7 +/- 1 days, P < 0.01) and was more effective than intravenous (IV) FK 506 (17 +/- 7 days, P < 0.01). When FK 506 was given for 28 days, the benefit of IPO over IV delivery was reaffirmed (MST 81 +/- 32 vs 34 +/- 4 days, P < 0.01). The potential for toxicity was lessened by lower mean systemic levels in the IPO group as compared to the IV group (1.3 +/- 0.6 vs 3.5 +/- 0.9 ng/mg, P < 0.02). The strategy of continuous IPO FK 506 was effective in the prevention of rejection of intrahepatic islet allografts.

Margin status and local recurrence after breast-conserving surgery.

OBJECTIVE: To examine the effect of microscopic tumor at the margins on local recurrence after breast-conserving surgery for invasive carcinoma. DESIGN: Retrospective review of patients treated with surgical resection followed by radiation therapy. SETTING: A university-based radiation department and a community-based cancer referral center. PATIENTS: A consecutive series of 272 women treated between 1982 and 1990. MAIN OUTCOME MEASURE: Local recurrence according to the histopathologic status of excised margins and the total dose of radiation. RESULTS: During a mean follow-up period of 48 months, the overall rate of local recurrence was 6.3%. Local recurrence was more frequent (P = .0001) in patients with histologically positive margins (18.2%) than in those with unknown margins (7.1%) or negative margins (3.7%). In the 44 patients with positive margins, the local recurrence rate was 8.3% after radiation doses of 66 Gy or more compared with 21.9% following lower doses. CONCLUSIONS: Microscopic involvement of resection margins increases the risk of local recurrence following breast-conserving surgery for invasive carcinoma. Therefore, every effort should be made to achieve negative margins intraoperatively.

Planned segmentectomy. A necessity for breast carcinoma.

OBJECTIVE AND DESIGN: Some surgeons consider excisional biopsy with gross negative margins to be adequate surgical therapy for breast carcinomas, if followed by axillary dissection and radiation. To test our hypothesis that breast carcinoma necessitates planned operation, we reviewed the incidence of residual cancer tissue (RCT) and the significance of positive margins following excisional breast biopsy and segmentectomy. SETTING, PATIENTS, AND INTERVENTION/OUTCOME MEASURES: Using the clinical database of our multidisciplinary cancer center, we examined the tumor status of segmentectomy specimens from 375 patients treated for breast carcinoma during the past 10 years. All patients underwent excisional biopsy of the tumor mass before definitive treatment with segmentectomy and axillary dissection. Median follow-up was 32 months. RESULTS: The 284 patients (76%) whose segmentectomy specimens contained residual tumor (RCT-positive patients) had a larger median tumor diameter than RCT-negative patients (2 vs 1 cm, P < .01). Patients with tumor-positive axillary lymph nodes were more likely to be RCT positive (P < .001). Tumors of RCT-positive patients were more frequently identified by physical examination, whereas those of RCT-negative patients were more frequently identified by mammography (P < .001). Overall recurrence rate was 7% (26/384). Recurrence-free survival rates were statistically related to tumor status of the segmentectomy margins (P < .025) but not to RCT in the segmentectomy specimen. CONCLUSION: Diagnostic breast biopsy is not a substitute for planned excision to remove all malignant tissue. Anything less than a preconceived surgical procedure may leave a significant amount of malignant tissue.

Effects of cotransplanted fetal liver on fetal pancreas isografts.

Ricordi et al. described a hepatotrophic effect mediated by pancreatic islets on cotransplanted hepatocytes. We found a reciprocal salutary effect of fetal liver (FL) on fetal pancreas (FP) in the intramural small bowel (ISB) site. To further investigate this intriguing finding, composite FP/FL isografts were transplanted to the conventional renal subcapsular (RSC) site and the accessible but historically inhospitable intramuscular site in streptozotocin-diabetic Lewis rats. A comparison of recipients of FP/FL and FP alone found the proportion rendered normoglycemic was site dependent. All recipients of either composite FP/FL grafts or FP alone transplanted in the ISB site became normoglycemic. The proportion of normoglycemic recipients was lower in the RSC site (71% FP and 40% FP/FL) and the i.m. site (14% FP and 67% FP/FL). Importantly, regardless of site, normoglycemia was established with an accelerated time course in recipients of FP/FL versus FP alone (24 +/- 8 vs. 67 +/- 43 days; P = 0.001). Normal (or more rapid) glucose clearance after challenge was achieved in all normoglycemic recipients except those transplanted in the RSC site. On histological examination of excised FP/FL grafts, hepatocytes were present in association with islets. Cyclosporine-induced islet toxicity could not be overcome in 6 recipients of FP alone, but 6 of 8 recipients of FP/FL became normoglycemic (P less than 0.01). To assess the effect of FP on hepatocytes, allografts (Wistar donors) of FP or FP/FL were cotransplanted in the ISB of enzyme-deficient jaundiced Gunn rats. Immunosuppression consisted of rapamycin (0.8 mg/kg/day) infused intravenously for 4 weeks. In the FP/FL group (n = 4), the mean serum bilirubin level decreased from 8.6 to 4.9 mg/dl at 6 weeks after transplantation. This was a significant difference as compared with the increased mean serum bilirubin from 6.9 to 7.8 mg/dl (P less than 0.05; paired Student's t test) in recipients of FL alone (n = 4). In conclusion, we found a mutual paracrine effect on islets and hepatocytes transplanted as a composite FP/FL graft. FL hastened the establishment of normoglycemia following transplantation of FP in diabetic rats, and FP enhanced FL transplant function in Gunn rats.