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Du H, Wang Q, Zhang B, Liang Z, Huang C, Shi D, Li F, Ling D. Structural Defect-Enabled Magnetic Neutrality Nanoprobes for Ultra-High-Field Magnetic Resonance Imaging of Isolated Tumor Cells in Vivo. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024:e2401538. [PMID: 38738793 DOI: 10.1002/adma.202401538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/12/2024] [Indexed: 05/14/2024]
Abstract
The identification of metastasis "seeds," isolated tumor cells (ITCs), is of paramount importance for the prognosis and tailored treatment of metastatic diseases. The conventional approach to clinical ITCs diagnosis through invasive biopsies is encumbered by the inherent risks of overdiagnosis and overtreatment. This underscores the pressing need for noninvasive ITCs detection methods that provide histopathological-level insights. Recent advancements in ultra-high-field (UHF) magnetic resonance imaging (MRI) have ignited hope for the revelation of minute lesions, including the elusive ITCs. Nevertheless, currently available MRI contrast agents are susceptible to magnetization-induced strong T2-decaying effects under UHF conditions, which compromises T1 MRI capability and further impedes the precise imaging of small lesions. Herein, this study reports a structural defect-enabled magnetic neutrality nanoprobe (MNN) distinguished by its paramagnetic properties featuring an exceptionally low magnetic susceptibility through atomic modulation, rendering it almost nonmagnetic. This unique characteristic effectively mitigates T2-decaying effect while concurrently enhancing UHF T1 contrast. Under 9 T MRI, the MNN demonstrates an unprecedentedly low r2/r1 value (≈1.06), enabling noninvasive visualization of ITCs with an exceptional detection threshold of ≈0.16 mm. These high-performance MNNs unveil the domain of hitherto undetectable minute lesions, representing a significant advancement in UHF-MRI for diagnostic purposes and fostering comprehensive metastasis research.
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Affiliation(s)
- Hui Du
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, School of Biomedical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Qiyue Wang
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, School of Biomedical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai, 200240, China
- World Laureates Association (WLA) Laboratories, Shanghai, 201203, China
| | - Bo Zhang
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, School of Biomedical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai, 200240, China
- World Laureates Association (WLA) Laboratories, Shanghai, 201203, China
| | - Zeyu Liang
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, School of Biomedical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai, 200240, China
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, 310058, China
| | - Canyu Huang
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, School of Biomedical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Dao Shi
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, School of Biomedical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Fangyuan Li
- World Laureates Association (WLA) Laboratories, Shanghai, 201203, China
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, 310058, China
- Songjiang Research Institute, Songjiang Hospital, Shanghai Key Laboratory of Emotions and Affective Disorder, Shanghai Jiao Tong University School of Medicine, Shanghai, 201600, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, 310009, China
| | - Daishun Ling
- Frontiers Science Center for Transformative Molecules, School of Chemistry and Chemical Engineering, School of Biomedical Engineering, National Center for Translational Medicine, Shanghai Jiao Tong University, Shanghai, 200240, China
- World Laureates Association (WLA) Laboratories, Shanghai, 201203, China
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, 310058, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, 310009, China
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Zhou J, Sun X, Zhang X, Yang H, Jiang Z, Luo Q, Liu Y, Wang G. miR-107 is involved in the regulation of NEDD9-mediated invasion and metastasis in breast cancer. BMC Cancer 2022; 22:533. [PMID: 35549691 PMCID: PMC9097419 DOI: 10.1186/s12885-022-09603-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background As a metastasis-related protein, NEDD9 has been reported in breast cancer (BC) metastasis research. However, there are few studies on the upstream regulators of NEDD9, especially involving the potential role of miRNAs. The purpose of this study was to explain whether miR-107 potentially regulates NEDD9, which may lead to invasion and metastasis of BC. Methods MCF-7 and MDA-MB-231 cells were transduced with lentiviruses to construct stably transduced cells with miR-107 overexpression, miR-107 silencing or empty vectors. A luciferase reporter assay was performed to verify the binding of miR-107 and NEDD9. The scratch test and Transwell assay were used to measure cell migration and invasion ability, respectively. For the study of metastasis in vivo, we injected MDA-MB-231 cells into the fat pad of nude mice to develop an orthotopic breast cancer model. Results We found that NEDD9 expression correlates with the prognosis of BC patients. In BC cell lines, NEDD9 was positively correlated with cell migration ability. Further research revealed that miR-107 inhibited NEDD9 expression by targeting the 3′-untranslated region of NEDD9. Overexpression of miR-107 suppressed the expression of NEDD9, thereby inhibiting the invasion, migration and proliferation of BC cells, but interference with miR-107 promoted the expression of NEDD9 as well as invasion, migration and proliferation. In an in vivo model, overexpression of miR-107 decreased the expression of NEDD9 and inhibited tumour growth, invasion and metastasis; however, these effects were reversed by inhibiting miR-107. Conclusions These findings indicated the potential role of miR-107 in regulating NEDD9 in the invasion, migration and proliferation of BC. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09603-3.
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Affiliation(s)
- Jiamin Zhou
- Department of Physiology and Hypoxic Biomedicine, Institute of Special Environmental Medicine, Nantong University, 9 Seyuan Road, Chongchuan District, Nantong, 226019, Jiangsu, China
| | - Xianglin Sun
- Department of Physiology and Hypoxic Biomedicine, Institute of Special Environmental Medicine, Nantong University, 9 Seyuan Road, Chongchuan District, Nantong, 226019, Jiangsu, China
| | - Xinyu Zhang
- Department of Physiology and Hypoxic Biomedicine, Institute of Special Environmental Medicine, Nantong University, 9 Seyuan Road, Chongchuan District, Nantong, 226019, Jiangsu, China
| | - Huan Yang
- Department of Physiology and Hypoxic Biomedicine, Institute of Special Environmental Medicine, Nantong University, 9 Seyuan Road, Chongchuan District, Nantong, 226019, Jiangsu, China.
| | - Zhenglin Jiang
- Department of Physiology and Hypoxic Biomedicine, Institute of Special Environmental Medicine, Nantong University, 9 Seyuan Road, Chongchuan District, Nantong, 226019, Jiangsu, China
| | - Qianqian Luo
- Department of Physiology and Hypoxic Biomedicine, Institute of Special Environmental Medicine, Nantong University, 9 Seyuan Road, Chongchuan District, Nantong, 226019, Jiangsu, China
| | - Yifei Liu
- Department of Pathology, Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong, 226001, China
| | - Guohua Wang
- Department of Physiology and Hypoxic Biomedicine, Institute of Special Environmental Medicine, Nantong University, 9 Seyuan Road, Chongchuan District, Nantong, 226019, Jiangsu, China.
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Amin A, Yasmeen S, Jeyachandran D, Khoury T, Desouki MM. Diagnostic Utility and Significance of Performing Multistep Level Sections in Breast and Gynecologic Biopsy Specimens. Am J Clin Pathol 2021; 156:620-624. [PMID: 33769440 DOI: 10.1093/ajcp/aqaa277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The significance of performing multistep level sections, including preparation of unstained sections in breast and gynecologic biopsy specimens, has been studied. METHODS Consecutive H&E-stained level sections of 785 atypical and malignant biopsy specimens were included. The diagnostic material was categorized into present, absent, increased in size, or depleted. If the multistep level sections helped in establishing the diagnosis after a nondiagnostic material or the tissue significantly increased in size, this was considered a positive impact. RESULTS No effect and positive impact of performing multistep level sections were obtained in 84.8% and 15.2% by preparing a second level and 97.2% and 2.8% by preparing a third level, respectively. Eighteen (2.3%) of the diagnoses could have been missed without performing a second level, while 8 (1%) could have been missed without performing a third level. The intervening unstained sections were used in 27 of 785 (3.4%) of the cases. CONCLUSIONS Staining two level sections with H&E significantly affected the diagnosis. However, preparing a third level did not improve the diagnosis. A universal protocol should be considered to standardize the handling of biopsy specimens among laboratories.
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Affiliation(s)
- Al Amin
- Department of Pathology and Anatomical Sciences, State University of New York, Buffalo, NY, USA
| | - Sayeeda Yasmeen
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Devi Jeyachandran
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Thaer Khoury
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY, USA
| | - Mohamed Mokhtar Desouki
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY, USA
- Department of Pathology, Microbiology and Immunology, University of South Carolina, Columbia, SC, USA
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Lago V, Montero B, López S, Padilla-Iserte P, Matute L, Marina T, Gurrea M, Montoliu G, Bello P, Domingo S. Ultrastaging protocol in sentinel lymph node for apparent early stage ovarian cancer. Gynecol Oncol 2021; 161:408-413. [PMID: 33712275 DOI: 10.1016/j.ygyno.2021.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/01/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The objective of the present study is to determine the role of sentinel lymph node (SLN) ultrastaging in apparent early-stage ovarian cancer. METHODS We previously demonstrated the feasibility of SLN in early-stage ovarian cancer in a pilot study and in a clinical trial (NCT03452982). The SLN of the 30 patients involved in both were processed following an ultrastaging protocol. The cost of ultrastaging processing was also reported. RESULTS A SLN was detected in up to 91.3% and 90% in the pelvic and para-aortic region, respectively. In all cases, a SLN was detected at least in one field, pelvic or para-aortic. The mean time from injection to SLN resection was 53.3 ± 20.3 min. Two of 30 (6.6%) patients had a contralateral SLN in the para-aortic field, but no patients had contralateral SLN within the pelvic field after injection. The mean number of harvested SLN was 2.1 ± 1.4 (range: 0-5) and 2.7 ± 1.5 (range: 0-7) in the pelvic and para-aortic region, respectively. Two patients were upgraded to stage IIIA1 because of lymph node metastasis. In the first case, based on single sections and haematoxylin and eosin (H&E) examination, a pelvic SLN micrometastasis (1 mm) was found on the first H&E section. By using the ultrastaging protocol, the size of the metastasis was increased to 2.1 mm (macrometastasis). In the same patient, the ultrastaging study of the inframesenteric para-cava SLNs found isolated tumour cells in the subcapsular and interfollicular lymph nodes sinus in one of the two SLN harvested (in one of the sections at the fourth and fifth ultrastage levels). The other upstaged case was a para-aortic macrometastasis in a patient in whom the SLN was not identified in the para-aortic field because of the absence of migration from the infundibulo-pelvic stump injection. The cost of ultrastaging in each patient depended on the total number of SLN retrieved, averaging 96.8 € (range: 0-230.5) and 124.5 € (range: 0-322.7€) for pelvic and para-aortic SLN, respectively. CONCLUSIONS A uniform protocol for ultrastaging is essential for lower-volume metastasis detection and to provide reproducible information between upcoming studies, as evidence about SLN in ovarian cancer is growing.
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Affiliation(s)
- Víctor Lago
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain; Woman's Health Research Group, Medical Research Institute La Fe (IISLAFE), Valencia, Spain; Spanish Clinical Research Network, SCReN-IIS La Fe (PT17/0017/0035), Valencia, Spain.
| | - Beatriz Montero
- Department of Pathology, University Hospital La Fe, Valencia, Spain
| | - Susana López
- Department of Pathology, University Hospital La Fe, Valencia, Spain
| | | | - Luis Matute
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain
| | - Tiermes Marina
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain
| | - Marta Gurrea
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain
| | | | - Pilar Bello
- Department of Nuclear Medicine, University Hospital La Fe, Valencia, Spain
| | - Santiago Domingo
- Department of Gynecologic Oncology, University Hospital La Fe, Valencia, Spain
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Predictive factors of lymph node metastasis and effectiveness of intraoperative examination of sentinel lymph node in breast carcinoma: A retrospective Belgian study. Ann Diagn Pathol 2020; 49:151607. [PMID: 32949894 DOI: 10.1016/j.anndiagpath.2020.151607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/17/2020] [Accepted: 08/17/2020] [Indexed: 11/22/2022]
Abstract
Recently, several trials demonstrated the safety of omitting axillary lymph node dissection in clinically N0 patients with positive sentinel nodes in select subgroups. However, this fact is still troublesome to clarify to surgeons and clinicians, as they used to perform intraoperative examination of the sentinel node and axillary dissection for many years. Hence, we decided to review our practice. This is to firstly highlight the predictive factors of node metastasis and secondly, to evaluate the effectiveness of intraoperative examination of the sentinel node. There were 406 total procedures. The rate of positive lymph nodes in the final diagnosis was 27%. Factors associated with metastasis were age, tumour size, TNM classification, tumour grade, vascular invasion, molecular classification and KI-67 index. The rate of reoperation was 6.2% in cases with final positive nodes, however, the complementary ALND was justified in only 2.7%. Forty-nine percent of SLN were examined during surgery (IOESLN), whereby the false negative rate was 11.8%. Sixty-three intraoperative examinations were necessary to prevent a second operation on a patient. We recommend changing the clinical management of the axilla, resulting in fewer ALNDs in selected cN0, SLN-positive patients. In keeping with recent large clinical trial (ACOSOG Z0011, AMAROS and OTOASOR) data, our results support that intraoperative exam in selected cN0, SLN-positive Belgian patients is no longer effective.
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Cytomorphological Characterization of Individual Metastatic Tumor Cells from Gastrointestinal Cancer Patient Lymph Nodes with Imaging Flow Cytometry. GASTROINTESTINAL DISORDERS 2019. [DOI: 10.3390/gidisord1040030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The presence or absence of tumor cells within patient lymph nodes is an important prognostic indicator in a number of cancer types and an essential element of the staging process. However, patients with the same pathological stage will not necessarily have the same outcome. Therefore, additional factors may aid in identifying patients at a greater risk of developing metastasis. In this proof of principle study, initially, spiked tumor cells in rat lymph nodes were used to mimic a node with a small cancer deposit. Next, human lymph nodes were obtained from cancer patients for morphological characterization. Nodes were dissociated with a manual tissue homogenizer and stained with fluorescent antibodies against CD45 and Pan-Cytokeratin and then imaging flow cytometry (AMNIS ImageStreamX Mark II) was performed. We show here that imaging flow cytometry can be used for the detection and characterization of small numbers of cancer cells in lymph nodes and we also demonstrate the phenotypical and morphological characterization of cancer cells in gastrointestinal cancer patient lymph nodes. When used in addition to conventional histological techniques, this high throughput detection of tumor cells in lymph nodes may offer additional information assisting in the staging process with therapeutic and prognostic applications.
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Chen JY, Lai YS, Chu PY, Chan SH, Wang LH, Hung WC. Cancer-Derived VEGF-C Increases Chemokine Production in Lymphatic Endothelial Cells to Promote CXCR2-Dependent Cancer Invasion and MDSC Recruitment. Cancers (Basel) 2019; 11:cancers11081120. [PMID: 31390756 PMCID: PMC6721484 DOI: 10.3390/cancers11081120] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 08/01/2019] [Accepted: 08/03/2019] [Indexed: 12/19/2022] Open
Abstract
Breast cancer-derived vascular endothelial growth factor-C (VEGF-C) has been shown to enhance lymphangiogenesis in lymph nodes to accelerate cancer metastasis. However, the remodeling of lymph node microenvironments by VEGF-C remains elusive. By in vivo selection, we established a subline (named as “LC”) with strong lymphatic tropism and high VEGF-C expression from the human MDA-MB-231 breast cancer cell line. Co-culture with LC cells or treatment with LC-conditioned medium upregulated the expression of CXC chemokines in lymphatic endothelial cells (LECs), which could be inhibited by pre-incubation with VEGF-C-neutralizing antibodies and VEGFR3 inhibitors. The chemokines produced by LECs enhanced recruitment of myeloid-derived suppressor cells (MDSCs) to tumor-draining and distant lymph nodes in tumor-bearing mice. Treatment with a CXCR2 inhibitor after tumor cell inoculation dramatically decreased the number of MDSCs in lymph nodes, suggesting the importance of the chemokine/CXCR2 signaling axis in MDSC recruitment. In addition, LEC-released chemokines also stimulated the expression of serum amyloid A1 (SAA1) in cancer cells, enhancing their lymphatic invasion by increasing VE-cadherin phosphorylation, junction disruption, and vascular permeability of LECs. Clinical sample validation confirmed that SAA1 expression was associated with increased lymph node metastasis. Collectively, we reveal a novel mechanism by which cancer cell-derived VEGF-C remodels lymphovascular microenvironments by regulating chemokine production in LECs to promote cancer invasion and MDSC recruitment. Our results also suggest that inhibition of CXCR2 is effective in treating lymphatic metastasis.
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Affiliation(s)
- Jing-Yi Chen
- National Institute of Cancer Research, National Health Research Institutes, Tainan 704, Taiwan
| | - You-Syuan Lai
- National Institute of Cancer Research, National Health Research Institutes, Tainan 704, Taiwan
| | - Pei-Yi Chu
- Department of Pathology, Show Chwan Memorial Hospital, Changhua City 500, Taiwan
| | - Shih-Hsuan Chan
- Chinese Medicine Research Center and Graduate Institute of Integrated Medicine, China Medical University, Taichung 404, Taiwan
| | - Lu-Hai Wang
- Chinese Medicine Research Center and Graduate Institute of Integrated Medicine, China Medical University, Taichung 404, Taiwan
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli 350, Taiwan
| | - Wen-Chun Hung
- National Institute of Cancer Research, National Health Research Institutes, Tainan 704, Taiwan.
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
- Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
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Gera R, Kasem A, Mokbel K. Can Complete Axillary Node Dissection Be Safely Omitted in Patients with Early Breast Cancer When the Sentinel Node Biopsy Is Positive for Malignancy? An Update for Clinical Practice. In Vivo 2019; 32:1301-1307. [PMID: 30348682 DOI: 10.21873/invivo.11380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/16/2018] [Accepted: 09/19/2018] [Indexed: 02/07/2023]
Abstract
The sentinel lymph node biopsy (SLNB) has become the new standard-of-care for patients with clinically node-negative invasive breast cancer. The focused examination of fewer lymph nodes in addition to improvements in histopathological and molecular analysis have increased the rate at which micrometastases and isolated tumor cells are identified. We reviewed the literature and summarized the evidence regarding the need for complete axillary lymph node dissection (ALND) following the finding of a positive sentinel node biopsy through the identification of the most important outcomes and evaluation of quality of evidence. The article focuses on the safe omission of complete ALND when the axillary lymph nodes contain macrometastases and provides an overview of the topic primarily based on level 1 evidence derived from randomized clinical trials with a critical appraisal of the ACOSOG Z0011 trial.
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Affiliation(s)
- Ritika Gera
- The London Breast Institute, Princess Grace Hospital, London, U.K
| | - Abdul Kasem
- The London Breast Institute, Princess Grace Hospital, London, U.K
| | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, London, U.K.
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Presumed early ovarian cancer with isolated tumor cells in para-aortic sentinel nodes. Int J Gynecol Cancer 2019; 29:216-220. [DOI: 10.1136/ijgc-2018-000005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Shin ET, Joehlin-Price AS, Agnese DM, Zynger DL. Minimal Clinical Impact of Intraoperative Examination of Sentinel Lymph Nodes in Patients With Ductal Carcinoma In Situ: An Opportunity for Improved Resource Utilization. Am J Clin Pathol 2017; 148:374-379. [PMID: 29016707 DOI: 10.1093/ajcp/aqx089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES There is little information regarding sentinel lymph node (SLN) frozen-section examination in patients with a history of ductal carcinoma in situ (DCIS). We evaluated the usage, clinical impact, and pathology resources used for SLN cryosectioning in mastectomy cases with a DCIS history. METHODS Mastectomies with SLNs submitted from 2012 to 2013 at a tertiary care center were analyzed. Medicare reimbursement was used to estimate pathology health care expenditures of intraoperative frozen sections. RESULTS There was no difference in the rate of SLN frozen-section examination or parts submitted, total blocks frozen, total blocks submitted, or total SLNs identified per case between the DCIS (n = 139) and invasive (n = 369) groups. Nine patients with DCIS had SLN metastases (three macrometastases, two micrometastases, and four isolated tumor cells), all of which were examined by frozen section. Only the macrometastases were identified by cryosectioning, which led to two synchronous axillary lymph node dissections that did not yield any additional positive nodes. A total of $19,313 was spent for pathology per DCIS patient with surgical management affected, whereas only $1,019 was spent per invasive carcinoma patient affected. CONCLUSIONS Decreasing SLN frozen-section use in patients with a history of DCIS represents an opportunity for pathology cost containment.
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Affiliation(s)
| | | | - Doreen M Agnese
- Surgical Oncology, The Ohio State University Medical Center, Columbus
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Holten-Rossing H, Talman MLM, Jylling AMB, Laenkholm AV, Kristensson M, Vainer B. Application of automated image analysis reduces the workload of manual screening of sentinel lymph node biopsies in breast cancer. Histopathology 2017; 71:866-873. [DOI: 10.1111/his.13305] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Henrik Holten-Rossing
- Department of Pathology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Maj-Lis Møller Talman
- Department of Pathology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | | | | | | | - Ben Vainer
- Department of Pathology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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A new molecular-based lymph node staging classification determines the prognosis of breast cancer patients. Br J Cancer 2017; 117:1470-1477. [PMID: 28910822 PMCID: PMC5680460 DOI: 10.1038/bjc.2017.311] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 08/01/2017] [Accepted: 08/18/2017] [Indexed: 11/28/2022] Open
Abstract
Background: The one-step nucleic acid amplification (OSNA) assay is a novel molecular method that can detect metastasis in a whole lymph node based on cytokeratin 19 mRNA copy number. This cohort study aimed to establish an OSNA-based nodal staging (pN(mol)) classification for breast cancer. Methods: The cohort consisted of 1039 breast cancer patients who underwent sentinel node (SN) biopsy using the OSNA assay. Cutoff value of the SN tumour burden stratifying distant disease-free survival (DDFS) was determined, and predictive factors for DDFS and breast cancer-specific survival (BCSS) were investigated. pN(mol) classification of the SN status was defined as: pN0(mol)(sn), SN negative; pN1mi(mol)(sn), SN positive and tumour burden <cutoff-value; and pN1(mol)(sn), tumour burden ⩾cutoff-value. Median follow-up time; 68.3 months. Results: Cutoff value of the SN tumour burden was 2810 copies per μl. Of the 1039 patients, 798, 95, and 146 had pN0(mol)(sn), pN1mi(mol)(sn), and pN1(mol)(sn) status, respectively. Five-year DDFS and BCSS rates were lower for pN1(mol)(sn) patients than for pN1mi(mol)(sn) patients (87.7% vs 98.8%, P=0.001 and 93.1% vs 98.8%, P=0.044, respectively). Multivariate analyses revealed the pN(mol) classification was most significant predictor for DDFS and BCSS. Conclusions: The molecular-based pN classification determines the prognosis of breast cancer patients and could guide therapeutic decision making.
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Dürst M, Hoyer H, Altgassen C, Greinke C, Häfner N, Fishta A, Gajda M, Mahnert U, Hillemanns P, Dimpfl T, Lenhard M, Petry KU, Runnebaum IB, Schneider A. Prognostic value of HPV-mRNA in sentinel lymph nodes of cervical cancer patients with pN0-status. Oncotarget 2016; 6:23015-25. [PMID: 26008982 PMCID: PMC4673218 DOI: 10.18632/oncotarget.4132] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 04/20/2015] [Indexed: 02/06/2023] Open
Abstract
Up to 15% of patients with cervical cancer and pN0-status develop recurrent-disease. This may be due to occult metastatic spread of tumor cells. We evaluated the use of human-papillomavirus-(HPV)-mRNA as a molecular marker for disseminated tumor cells to predict the risk of recurrence. For this prospective, multi-center prognostic study, 189 patients free of lymphnode metastases by conventional histopathology could be analyzed. All patients underwent complete lymphadenectomy. Of each sentinel node (SLN) a biopsy was taken for the detection of HPV-E6-E7-mRNA. Median follow-up time after surgery was 8.1 years. HPV-mRNA could be detected in SLN of 52 patients (27.5%). Recurrence was observed in 22 patients. Recurrence-free-survival was significantly longer for patients with HPV-negative SLN (log rank p = 0.002). By Cox regression analysis the hazard ratio (95%CI) for disease-recurrence was 3.8 (1.5 - 9.3, p = 0.004) for HPV-mRNA-positive compared to HPV-mRNA-negative patients. After adjustment for tumor size as the most influential covariate the HR was still 2.8 (1.1 - 7.0, p = 0.030). In patients with cervical cancer and tumor-free lymph nodes by conventional histopathology HPV-mRNA-positive SLN were of prognostic value independent of tumor size. Particularly, patients with tumors larger than 20mm diameter could possibly benefit from further risk stratification using HPV-mRNA as a molecular marker.
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Affiliation(s)
- Matthias Dürst
- Department of Gynecology, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Heike Hoyer
- Institute of Medical Statistics, Information Sciences and Documentation, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Christoph Altgassen
- Department of Gynecology and Obstetrics, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Christiane Greinke
- Department of Gynecology, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Norman Häfner
- Department of Gynecology, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Alba Fishta
- Department of Gynecology, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Mieczyslaw Gajda
- Institute of Pathology, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Ute Mahnert
- Department of Gynecology and Obstetrics, Helios Klinikum Erfurt GmbH, Erfurt, Germany
| | - Peter Hillemanns
- Department of Gynecology and Obstetrics, Medizinische Hochschule Hannover, Hannover, Germany
| | - Thomas Dimpfl
- Department of Gynecology and Obstetrics, Klinikum Kassel GmbH, Kassel, Germany
| | - Miriam Lenhard
- Department of Gynecology and Obstetrics, Ludwig-Maximilians-University Munich, Munich, Germany
| | - K Ulrich Petry
- Department of Gynecology and Obstetrics, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Ingo B Runnebaum
- Department of Gynecology, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Achim Schneider
- Institute for Cytology and Dysplasia, Fürstenbergkarree, Berlin, Germany
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14
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Abbassi-Ghadi N, Golf O, Kumar S, Antonowicz S, McKenzie JS, Huang J, Strittmatter N, Kudo H, Jones EA, Veselkov K, Goldin R, Takats Z, Hanna GB. Imaging of Esophageal Lymph Node Metastases by Desorption Electrospray Ionization Mass Spectrometry. Cancer Res 2016; 76:5647-5656. [DOI: 10.1158/0008-5472.can-16-0699] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/31/2016] [Indexed: 11/16/2022]
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15
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Khoo JJ, Ng CS, Sabaratnam S, Arulanantham S. Sentinel Node Biopsy Examination for Breast Cancer in a Routine Laboratory Practice: Results of a Pilot Study. Asian Pac J Cancer Prev 2016; 17:1149-55. [DOI: 10.7314/apjcp.2016.17.3.1149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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16
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Mantel HTJ, Wiggers JK, Verheij J, Doff JJ, Sieders E, van Gulik TM, Gouw ASH, Porte RJ. Lymph Node Micrometastases are Associated with Worse Survival in Patients with Otherwise Node-Negative Hilar Cholangiocarcinoma. Ann Surg Oncol 2015; 22 Suppl 3:S1107-15. [PMID: 26178761 PMCID: PMC4686550 DOI: 10.1245/s10434-015-4723-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Indexed: 12/18/2022]
Abstract
Background Lymph node metastases on routine histology are a strong negative predictor for survival after resection of hilar cholangiocarcinoma. Additional immunohistochemistry can detect lymph node micrometastases in patients who are otherwise node negative, but the prognostic value is unsure. The objective of this study was to assess the effect on survival of immunohistochemically detected lymph node micrometastases in patients with node-negative (pN0) hilar cholangiocarcinoma on routine histology. Methods Between 1990 and 2010, a total of 146 patients underwent curative-intent resection of hilar cholangiocarcinoma with regional lymphadenectomy at two university medical centers in the Netherlands.
Ninety-one patients (62 %) without lymph node metastases at routine histology were included. Micrometastases were identified by multiple sectioning of all lymph nodes and additional immunostaining with an antibody against cytokeratin 19 (K19). The association with overall survival was assessed in univariable and multivariable analysis. Median follow-up was 48 months. Results Micrometastases were identified in 16 (5 %) of 324 lymph nodes, corresponding to 11 (12 %) of 91 patients. There were no differences in clinical variables between K19 lymph node-positive and -negative patients. Five-year survival rates in patients with lymph node micrometastases were significantly lower compared to patients without micrometastases (27 vs. 54 %, P = 0.01). Multivariable analysis confirmed micrometastases as an independent prognostic factor for survival (adjusted Hazard ratio 2.4, P = 0.02). Conclusions Lymph node micrometastases are associated with worse survival after resection of hilar cholangiocarcinoma. Immunohistochemical detection of lymph node micrometastases leads to better staging of patients who were initially diagnosed with node-negative (pN0) hilar cholangiocarcinoma on routine histology.
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Affiliation(s)
- Hendrik T J Mantel
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Jim K Wiggers
- Department of Hepato-Pancreatico-Biliary Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J Doff
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Egbert Sieders
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thomas M van Gulik
- Department of Hepato-Pancreatico-Biliary Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Annette S H Gouw
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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17
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de Araújo MR, Campos LC, Ferreira E, Cassali GD. Quantitation of the Regional Lymph Node Metastatic Burden and Prognosis in Malignant Mammary Tumors of Dogs. J Vet Intern Med 2015; 29:1360-7. [PMID: 26130166 PMCID: PMC4858035 DOI: 10.1111/jvim.13576] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 02/19/2015] [Accepted: 06/10/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND As in women, regional lymph node status impacts survival in dogs with malignant mammary tumors. However, few studies have evaluated regional lymph node metastases in dogs with malignant mammary gland tumors. OBJECTIVES To estimate overall survival based on the assessments of the lymph node status and the morphologic and morphometric features in female dogs with malignant mammary gland tumors. MATERIALS AND METHODS In total, 178 lymph nodes from 97 female dogs were assessed and reviewed, and after confirmation by immunohistochemistry (IHC), 161 lymph nodes were selected for analysis of metastases. Animals were considered metastasis-free (negative lymph nodes) only after IHC analysis for cytokeratin AE1/AE3. The number of positive lymph nodes, the number of metastatic foci, the maximum diameter and the area of metastasis were analyzed, and estimates of overall survival were made. RESULTS Dogs with metastasis had lower mean survival than those with metastasis-free regional lymph nodes, showing a direct relationship between the number of affected lymph nodes and shorter survival. However, histologic analysis of the lymph nodes identified lower survival rates in animals with macrometastases and isolated tumor cells, areas of metastasis >20.11 mm², and metastatic diameters >7.32 mm. CONCLUSION The identification of ≥1 lymph nodes positive for metastasis and morphometric characterization of lymphatic metastases indicate the prognostic relevance of lymph nodes status in dogs with mammary tumors.
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Affiliation(s)
- M R de Araújo
- Departamento de Patologia Geral, Instituto de Ciências Biológicas, UFMG, Belo Horizonte, Brazil
| | - L C Campos
- Departamento de Patologia Geral, Instituto de Ciências Biológicas, UFMG, Belo Horizonte, Brazil
| | - E Ferreira
- Departamento de Patologia Geral, Instituto de Ciências Biológicas, UFMG, Belo Horizonte, Brazil
| | - G D Cassali
- Departamento de Patologia Geral, Instituto de Ciências Biológicas, UFMG, Belo Horizonte, Brazil
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18
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Wazir U, Manson A, Mokbel K. Towards optimal management of the axilla in the context of a positive sentinel node biopsy in early breast cancer. World J Clin Oncol 2014; 5:792-794. [PMID: 25493217 PMCID: PMC4259941 DOI: 10.5306/wjco.v5.i5.792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/22/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
The sentinel lymph node biopsy (SLNB) was initially pioneered for staging melanoma in 1994 and it has been subsequently validated by several trials, and has become the new standard of care for patients with clinically node negative invasive breast cancer. The focussed examination of fewer lymph nodes in addition to improvements in histopathological and molecular analysis has increased the rate at which micrometastases and isolated tumour cells are identified. In this article we review the literature regarding the optimal management of the axilla when the SLNB is positive for metastatic disease based on level 1 evidence derived from randomised clinical trials.
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19
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German, Austrian and Swiss consensus conference on the diagnosis and local treatment of the axilla in breast cancer. Eur J Cancer 2013; 49:2277-83. [DOI: 10.1016/j.ejca.2013.01.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Revised: 01/02/2013] [Accepted: 01/19/2013] [Indexed: 11/22/2022]
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20
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Accuracy of intraoperative pathological examination of SLN in cervical cancer. Gynecol Oncol 2013; 130:525-9. [PMID: 23500089 DOI: 10.1016/j.ygyno.2013.01.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 01/17/2013] [Accepted: 01/24/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Early cervical cancer patients with pelvic lymph node metastasis do not benefit from radical hysterectomy. Assessment of the SLN status is thus crucial before deciding to perform a radical hysterectomy as opposed to aortic dissection only followed by definitive radiation therapy. Accuracy of frozen section of SLN has been questioned and deserves further investigation. METHODS Stage IA-IB1 cervical cancer patients who underwent SLN then full pelvic dissection at the Claudius Regaud Cancer Center in Toulouse, France, were included. RESULTS At least one SLN was identified in all 94 patients. Bilateral detection rate was 80.8%. Ectopic drainage area was found in 19 patients (20.2%). Sentinel lymph node involvement was found in 11 patients (11.7%). Sensitivity and NPV of frozen section pathological examination for the detection of macrometastatic disease was 100%, sensitivity for the detection of macro and micrometastatic disease, excluding ITC, was 88.9%, and NPV was 98.8%. Micrometastasis and isolated tumor cells (ITC) undetected at frozen section examination were found in 1 patient (1.06%) and 2 lymph nodes (1.24%), and in 2 patients (2.13%) and 2 lymph nodes (1.24%), respectively. Final pathology sensitivity of SLN was 100% for both macro and micrometastatic disease, including ITC. CONCLUSION In our institution, intraoperative frozen examination of SLN accurately predicts the status of pelvic lymph nodes and is effective for selecting intraoperatively the group of patients who benefit from radical hysterectomy. In addition, our results suggest that patients with small tumors and bilateral detection of SLN can be spared full pelvic lymphadenectomy.
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Uehiro N, Horii R, Iwase T, Tanabe M, Sakai T, Morizono H, Kimura K, Iijima K, Miyagi Y, Nishimura S, Makita M, Ito Y, Akiyama F. Validation study of the UICC TNM classification of malignant tumors, seventh edition, in breast cancer. Breast Cancer 2013; 21:748-53. [DOI: 10.1007/s12282-013-0453-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 02/01/2013] [Indexed: 10/27/2022]
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22
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Provenzano E, Brown JP, Pinder SE. Pathological controversies in breast cancer: classification of ductal carcinoma in situ, sentinel lymph nodes and low volume metastatic disease and reporting of neoadjuvant chemotherapy specimens. Clin Oncol (R Coll Radiol) 2012. [PMID: 23199579 DOI: 10.1016/j.clon.2012.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The pathological classification of breast cancer is constantly being updated to reflect the advances in our clinical and biological understanding of the disease. This overview examines new insights into the classification and molecular biology of ductal carcinoma in situ, the pathological handling of sentinel lymph node biopsies and the identification of low volume disease (micrometastases and isolated tumour cells) and the handling and reporting of specimens after neoadjuvant therapy. The molecular subtypes of invasive breast cancer are also represented in ductal carcinoma in situ. It is hoped that alongside traditional histological features, such as cytological grade and the presence of necrosis, this will lead to better classification systems with improved prediction of clinical behaviour, in particular the risk of progression to invasive cancer, and enable more targeted management. Sentinel lymph node biopsy is now the standard of care for early stage breast cancer in clinically node-negative patients. However, the handling and reporting of these specimens remains controversial, largely related to the uncertainties regarding the clinical significance of micrometastases and isolated tumour cells. The increasing use of neoadjuvant therapies has introduced challenges for the pathologist in the handling and interpretation of these specimens. Grading the tumour response, particularly the identification of a complete pathological response, is prognostically important. However, there is still marked variability in reporting these specimens in routine practice, and consensus guidelines for the histopathology reporting of breast cancers after neoadjuvant chemotherapy based on robust, validated evidence are presently lacking.
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Affiliation(s)
- E Provenzano
- Department of Pathology, University of Melbourne, Parkville, Victoria, Australia.
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23
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Tot T. Axillary lymph node status in unifocal, multifocal, and diffuse breast carcinomas: differences are related to macrometastatic disease. Ann Surg Oncol 2012; 19:3395-401. [PMID: 22476758 DOI: 10.1245/s10434-012-2346-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Multifocality in breast carcinoma is associated with an increased propensity to metastasis. However, it is not clear whether this propensity manifests in the form of macrometastases or as presumably less-significant low-volume metastatic disease. METHODS A total of 948 cases of invasive breast carcinoma documented in large-format histology sections and assessed with detailed radiologic-pathologic correlation were categorized as unifocal, multifocal, or diffuse on the basis of the subgross distribution of the invasive component. Rates of macrometastases (>2 mm), micrometastases (0.2-2 mm), and isolated tumor cells (<0.2 mm) in these categories were compared. The influence of tumor size and histology grade on lymph node positivity rates was also tested. RESULTS Macrometastases were present in 20.4% (112 of 550) of unifocal, 48.3% (172 of 356) of multifocal, and 61.9% (26 of 42) of diffuse cases (P < 0.0001). Among the macrometastatic cases, more than three nodes were involved in 18.9% (21 of 112) of unifocal, 35.5% (61 of 172) of multifocal, and 50.0% (13 of 26) of diffuse cases. The rates of micrometastases (5.1, 5.1, and 2.4% unifocal, multifocal, and diffuse, respectively) and isolated tumor cells (4.5, 3.7, and 2.4% unifocal, multifocal, and diffuse, respectively) were low and similar in all examined categories. The relative risk (RR) of having macrometastatic disease was approximately doubled (RR 2.3726, P < 0.0001) in multifocal and tripled (RR 3.0562, P < 0.0001) in diffuse compared to unifocal cases. The findings were similar for all size categories, tumor grade categories, and sentinel lymph nodes, as well as all examined lymph nodes. CONCLUSIONS The significantly increased lymph node positivity rates in multifocal and diffuse invasive breast carcinomas results from large-volume macrometastatic disease.
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Affiliation(s)
- Tibor Tot
- Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden.
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