Outcomes of a population-based series of early breast cancer patients with micrometastases and isolated tumour cells in axillary lymph nodes

Comprehensive Review of Metastatic Breast Carcinoma in Cytology Specimens

Breast carcinomas are known to metastasize to various organs of the human body. Fine needle aspiration cytology or exfoliative cytology often are the standard method for diagnosis at these metastatic sites due to ease of procurement of diagnostic material, accessibility, less complications, high sensitivity, and specificity of diagnosis and evaluation of biomarker status needed to guide future management. This comprehensive review article discusses in detail metastatic patterns, cytomorphology of metastatic breast cancer at different body sites, immunohistochemistry needed for diagnosis of breast carcinoma, sensitivity and specificity of diagnosis and breast biomarker assays in the cytology material.

A Competing Risk Analysis Model to Determine the Prognostic Value of Isolated Tumor Cells in Axillary Lymph Nodes for T1N0M0 Breast Cancer Patients Based on the Surveillance, Epidemiology, and End Results Database

Introduction

Knowledge of the association between isolated tumor cells (ITCs) in breast cancer patients and the outcome is very limited. We aimed to determine the prognostic value of axillary lymph node ITCs for T1N0M0 female breast cancer (FBC) patients.

Methods

Data for T1N0M0 FBC patients staged ITCs negative [pN0(i−)] and positive [pN0(i+)] were extracted from the Surveillance, Epidemiology, and End Results database from 2004 to 2015. Prognostic predictors were identified by Kaplan–Meier analysis, competing risk model, and Fine–Gray multivariable regression model.

Results

A total of 94,599 subjects were included, 88,632 of whom were staged at pN0(i−) and 5,967 were pN0(i+). Patients staged pN0(i+) had worse breast cancer-specific survival (BCSS) [hazard ratio (HR): 1.298, 95% CI = 1.069–1.576, P = 0.003] and higher breast cancer-specific death (BCSD) rate (Gray’s test, P = 0.002) than pN0(i−) group. In the Fine–Gray multivariable regression analysis, the pN0(i+) group had higher BCSD rate (HR: 1.321, 95% CI = 1.109–1.575, P = 0.002) than pN0(i−) group. In subgroup analyses, no significant difference in BCSD was shown between the chemotherapy and non-chemotherapy subgroup (Gray’s test, P = 0.069) or radiotherapy and non-radiotherapy subgroup (Gray’s test, P = 0.096).

Conclusion

ITC was independently related to the increase of the BCSD rate and could be identified as a reliable survival predictor for T1N0M0 FBC patients.

Adjuvant chemotherapy in small node-negative triple-negative breast cancer

BACKGROUND

Recommendations on adjuvant chemotherapy in pT1N0M0 triple-negative breast cancer (TNBC) differ among international guidelines owing to lack of randomized trial data. We evaluated associations of adjuvant chemotherapy with a long-term outcome in a population-based cohort of pT1N0M0 TNBC.

METHODS

All patients diagnosed with pT1N0M0 TNBC in the Netherlands between 2005 and 2016 were identified from the Netherlands Cancer Registry. Patient, tumour and treatment characteristics were recorded. The date and cause of death were obtained from Statistics Netherlands. We used multivariable Cox regression models to evaluate associations of adjuvant chemotherapy with breast cancer-specific survival (BCSS) and overall survival (OS), adjusted for baseline characteristics and performed sensitivity analyses using propensity score (PS) weighting.

RESULTS

We identified 4366 patients: 284 with pT1a, 923 with pT1b and 3159 with pT1c tumours. Adjuvant chemotherapy was administered in 53% of patients. Patients receiving chemotherapy had more unfavourable baseline characteristics including younger age, larger tumours and higher tumour grade. At 8.2 years median follow-up (interquartile range = 5.8-10.9), 671 patients had died, of whom 311 because of breast cancer. After adjustment for baseline characteristics, chemotherapy was associated with improved BCSS (adjusted hazard ratio [aHR] = 0.65; 95% confidence interval [CI] = 0.48-0.89). The effect of chemotherapy differed by tumour size (pT1a: aHR = 4.28, 95% CI = 1.12-16.44; pT1b: aHR = 1.12, 95% CI = 0.51-2.49; pT1c: aHR = 0.60, 95% CI = 0.43-0.82; p_interaction = 0.02). Findings for OS were in line with BCSS results. PS-weighting analysis confirmed the results of the primary analysis.

CONCLUSIONS

Adjuvant chemotherapy is associated with better BCSS and OS in pT1N0M0 TNBC. Better outcome is most evident in pT1c tumours and may not outweigh harm in pT1a/pT1b tumours.

Role of Sentinel Lymph Node Biopsy in Microinvasive Breast Cancer

BACKGROUND

Microinvasive ductal carcinoma (DCISM), defined as DCIS with a focus of invasive carcinoma ≤ 1 mm, can be managed similarly to pure DCIS; however, management of the axilla in DCISM has been a subject of debate. Reports in the literature differ on the utility and necessity of sentinel lymph node biopsy (SLNB) for DCISM. The aim of the present study was to identify risk factors for nodal disease in patients with DCISM, which can help develop a selective approach to SLNB in this patient population.

METHODS

The National Cancer Database was used to select patients with DCISM (pT1mi), diagnosed from 2012 to 2015, who underwent SLNB. Multivariable regression analysis was performed to determine associations between sentinel lymph node metastasis and relevant clinical variables.

RESULTS

Our cohort comprised of 2609 patients with pT1mi who underwent SLNB. Of these, 76 (2.9%) were found to have sentinel lymph node metastases on final pathology. Low/intermediate grade tumors were associated with decreased SLN metastasis (OR 0.50, CI 0.28-0.92). Age and receptor status of the tumor did not have a clear association in predicting SLN metastases.

CONCLUSIONS

The rate of sentinel node metastases in DCISM is low at only 2.9% in this national study. Tumor grade was identified as influencing the risk of SLN metastases. This information can factor into shared decision-making for SLNB in patients with DCISM.

Postmastectomy radiation therapy in early breast cancer: Utility or futility?

Postmastectomy radiation therapy (PMRT) has been shown to reduce the risk of locoregional recurrence (LRR), in patients with locally advanced breast cancer who are considered of high-risk because of large tumors (>5 cm) or presence of axillary lymph-node involvement, as well as to reduce breast cancer mortality. However, controversy still remains with respect to indication of PMRT in case of early-stages invasive tumors. This review aims to analyze the impact that PMRT has on final results in women with breast tumors in different scenarios that would otherwise be considered as early breast cancer, such as extensive DCIS, tumors without axillary lymph-node involvement or with minimal microscopic nodal-involvement. The existence of risk factors including young age, premenopausal status, and presence of lymphovascular invasion (LVI), high grade or tumor size >2 cm has been associated with an increased risk of LRR in these patients at early-stages and advises to consider PMRT in selected cases.

Heme Oxygenase-1 Inhibits Tumor Metastasis Mediated by Notch1 Pathway in Murine Mammary Carcinoma

Heme oxygenase-1 (HO-1) plays an important role in the progression of several malignancies including breast cancer. However, its role in breast cancer metastasis is still ambiguous. In this study, we observed the effect of HO-1 on mouse mammary carcinoma metastasis using the in vivo tumor metastasis model. Our results revealed that overexpression of HO-1 strongly inhibits the lung metastasis of 4T1 cells. In in vitro analysis, associated indices for epithelial-mesenchymal transition (EMT), migration, and proliferation of 4T1 cells were evaluated. The results show that HO-1 inhibits EMT, migration, and proliferation of 4T1 cells. In addition, the Notch1/Slug pathway is found to mediate an antimetastasis role of HO-1 in mouse mammary carcinoma. In conclusion, since HO-1/Notch1/Slug axis plays an important role in breast cancer metastasis, induction of HO-1 could be used as a potential therapeutic strategy for breast cancer treatment.

Ezrin promotes breast cancer progression by modulating AKT signals

Background

Ezrin, which is known as a cytoskeleton linker protein, is closely linked with the metastatic progression of cancer and is frequently abnormally expressed in aggressive cancer types. However, the possible involvement of Ezrin in metastasis and angiogenesis in breast cancer remains unclear.

Methods

Immunohistochemical analysis of Ezrin was performed on both BC samples (n = 117) and normal epithelium samples (n = 47). In vivo and in vitro assays were performed to validate the effect of Ezrin on AKT pathway-mediated BC progression.

Results

In this study, Ezrin was found to be upregulated in BC tissues, which was linked with aggressive tumour characteristics and poor prognosis. Moreover, we showed that Ezrin promotes BC proliferation, migration, invasion, and angiogenesis in vitro and in vivo. Mechanistic analysis showed that Ezrin interacted with AKT, and promoted its kinase activity, thereby regulating the AKT pathway in BC.

Conclusions

In all, we propose a model for an Ezrin/AKT oncoprotein axis, which provides novel insight into how Ezrin contributes to BC progression.

Gamma probe and ultrasound guided fine needle aspiration cytology of the sentinel node (GULF) trial - overview of the literature, pilot and study protocol

BACKGROUND

Sentinel node (SN) biopsy (SNB) detects clinically occult metastases of breast cancer and melanoma in 20-30%. Wound infections, seroma and lymph edema occur in up to 10%. Targeted ultrasound (US) of the SN, (with fine needle aspiration cytology (FNAC) if appropriate) has been investigated as a minimally invasive alternative, but reported sensitivity rates are too low to replace SNB. Our hypothesis is that the use of a handheld gamma probe concomitant with US may improve sensitivity. Our aim is to provide an overview of the current literature on preoperative nodal staging of clinical N0 melanoma patients, report on a pilot, and present a study protocol for a minimally invasive alternative to the SNB: Gamma probe and Ultrasound guided Fine needle aspiration cytology of the sentinel node (GULF trial).

METHODS

The GULF trial is a multicenter open single arm observational trial. Newly diagnosed cT1b-4N0M0 cutaneous melanoma or cT1-3N0M0 breast cancer patients, aged >18 years, presenting for SNB are eligible. 120 patients will be included for preoperative targeted gamma probe guided US and FNAC of the SN. Afterwards all patients proceed to surgical SNB. Primary endpoint is the sensitivity of FNAC. Secondary endpoints include SN identification rate and the histopathological compatibility of Core Needle Biopsy and FNAC vs. SNB. Secondary endpoints were investigated in a pilot with 10 FNACs and marker placements, and 10 FNACs combined with Core Needle Biopsy.

RESULTS

A pilot in 20 patients showed that SN identification rate was 90%, supporting the feasibility of this technique.

DISCUSSION

There is broad experience with US (in combination with FNAC) prior to SNB, but sensitivity and specificity are too low to completely abandon SNB. Promising alternative techniques potentially will replace SNB in the future but more evidence is needed in the form of prospective studies. Accurate identification of the SN for US-FNAC has been proven feasible in our pilot. When adequate sensitivity can be reached, US-FNAC provides a minimally invasive alternative for the surgical SNB procedure.

TRIAL REGISTRATION

The GULF trial is registered in the Netherlands Trial Registry (NTR), ID: NRT5193 . May 1st 2015.

Palbociclib inhibits epithelial-mesenchymal transition and metastasis in breast cancer via c-Jun/COX-2 signaling pathway

Palbociclib, a highly selective CDK4/6 inhibitor, has been shown to be a novel anti-tumor agent that suppresses breast cancer cell proliferation. However, its anti-metastasis activity remains controversial. In the present study, we evaluated whether palbociclib prevented breast cancer cell metastasis and revealed its regulatory mechanism. We found that palbociclib inhibited migration and invasion in the breast cancer cells MDA-MB-231 and T47D. The epithelial-mesenchymal transition (EMT) markers, vimentin and Snail, were down-regulated with palbociclib treatment. Moreover, we revealed that this inhibition was mediated by the c-Jun/COX-2 pathway. COX-2 was decreased after palbociclib treatment. The production of PGE2 was also reduced along with COX-2. Additionally, our data showed that c-Jun, a crucial transcriptional regulator of COX-2, was down-regulated by palbociclib. We found that palbociclib weakened the COX-2 promoter binding activity of c-Jun and prevented its translocation from the cytoplasm to cell nuclei. Bioluminescence imaging and tail intravenous injection were used to evaluate the anti-metastasis effect of palbociclib in vivo. The data demonstrated that palbociclib reduced breast cancer metastasis to the lung. These results therefore demonstrated that the anti-metastasis activity of palbociclib is mediated via the c-Jun/COX-2 signaling pathway by inhibiting EMT in breast cancer cells.

The effect of trastuzumab-based chemotherapy in small node-negative HER2-positive breast cancer

The prognosis of patients with stage II-III Human Epidermal growth factor Receptor 2 (HER2)-positive breast cancer has significantly improved since the addition of trastuzumab to (neo-)adjuvant chemotherapy. Several reports have shown that small (≤2 cm), node-negative, HER2-positive tumors have a relatively poor prognosis and these patients increasingly receive trastuzumab-based chemotherapy. We aimed to provide evidence for this approach in a population-based cohort. All T1N0M0 HER2-positive breast cancer patients diagnosed between 2006 and 2012 were identified from the Netherlands Cancer Registry. Patient, tumor, and treatment characteristics were recorded. Kaplan-Meier statistics were used for overall survival (OS) and breast cancer-specific survival (BCSS) estimations overall and in T1a, T1b, and T1c tumors separately. Cox regression analyses were performed to account for imbalances in baseline characteristics between treated and untreated patients. A total of 3512 patients were identified: 385 with T1a, 800 with T1b, and 2327 with T1c tumors. Forty-five percent of patients received chemotherapy and/or trastuzumab: 92 % received both. Chemotherapy and/or trastuzumab significantly improved 8-year OS (95 vs. 84 %; hazard ratio [HR] 0.29; 95 % confidence interval [CI] 0.21-0.41, P < 0.001). The effect remained significant in multivariable analyses (HR 0.35; 95 % CI 0.23-0.52, P < 0.001). BCSS was also improved with systemic treatment in univariable (96 vs. 92 %; HR 0.41; 95 % CI 0.27-0.63, P < 0.001) and multivariable analyses (HR 0.31; 95 % CI 0.19-0.53, P < 0.001). Treatment effect on OS and BCSS was similar in T1a, T1b, and T1c tumors. Chemotherapy and/or trastuzumab improves OS and BCSS and can be considered in all patients with small node-negative HER2-positive breast cancer.

Detection of disseminated tumor cells in lymph nodes from patients with early stage non-small cell lung cancer

BACKGROUND

The regional lymph node involvement is a major prognostic factor in patients with non-small cell lung cancer (NSCLC) undergoing surgical resection. Disease relapse is common, suggesting that early disseminated disease is already present in the regional lymph nodes at the time of surgery, and that the current nodal staging classification might be suboptimal. Early detection of disseminated tumor cells (DTCs) in lymph nodes could potentially enable identification of subcategories of patients with high risk of disease relapse.

METHOD

Lymph node samples were collected from 128 NSCLC patients at the time of surgery and the presence of DTCs determined by immunomagnetic selection (IMS) using the MOC31 antibody recognizing EpCAM. Results obtained with IMS were compared to the pathological staging obtained by histopathology. Associations between the presence of DTCs and clinicopathological variables and patient outcome were investigated.

RESULTS

DTCs were detected in 40 % of the lymph node samples by IMS. Their presence was significantly associated with pN status as assessed by histopathology, and samples from 83 % of the patients with lymph node metastases (pN1-2) had detectable DTCs. In the group of patients who were negative for lymph node metastases by standard histopathology (pN0) DTCs were detected in 32 %. The presence of DTCs was not associated with any other clinicopathological variables. Patients with IMS-positive samples showed decreased relapse free survival compared to patients with IMS-negative samples, but the difference was not statistically significant. The pN status was significantly associated with both relapse free and overall survival, but the presence of DTCs had no prognostic impact in the subcategory of patients with pN0 status.

CONCLUSION

Our findings do not support further development of lymph node DTC detection for clinical use in early stage NSCLC.

DNA defects, epigenetics, and gene expression in cancer-adjacent breast: a study from The Cancer Genome Atlas

Recurrence rates after breast-conserving therapy may depend on genomic characteristics of cancer-adjacent, benign-appearing tissue. Studies have not evaluated recurrence in association with multiple genomic characteristics of cancer-adjacent breast tissue. To estimate the prevalence of DNA defects and RNA expression subtypes in cancer-adjacent, benign-appearing breast tissue at least 2 cm from the tumor margin, cancer-adjacent, pathologically well-characterized, benign-appearing breast tissue specimens from The Cancer Genome Atlas project were analyzed for DNA sequence, copy-number variation, DNA methylation, messenger RNA (mRNA) sequence, and mRNA/microRNA expression. Additional samples were also analyzed by at least one of these genomic data types and associations between genomic characteristics of normal tissue and overall survival were assessed. Approximately 40% of cancer-adjacent, benign-appearing tissues harbored genomic defects in DNA copy number, sequence, methylation, or in RNA sequence, although these defects did not significantly predict 10-year overall survival. Two mRNA/microRNA expression phenotypes were observed, including an active mRNA subtype that was identified in 40% of samples. Controlling for tumor characteristics and the presence of genomic defects, this active subtype was associated with significantly worse 10-year survival among estrogen receptor (ER)-positive cases. This multi-platform analysis of breast cancer-adjacent samples produced genomic findings consistent with current surgical margin guidelines, and provides evidence that extratumoral RNA expression patterns in cancer-adjacent tissue predict overall survival among patients with ER-positive disease.

Locoregional treatment of early breast cancer with isolated tumor cells or micrometastases on sentinel lymph node biopsy

The advent of sentinel lymph-node technique has led to a shift in lymph-node staging, due to the emergence of new entities namely micrometastases (pN1mi) and isolated tumor cells [pN0(i+)]. The prognostic significance of this low positivity in axillary lymph nodes is currently debated, as is, therefore its management. This article provides updates evidence-based medicine data to take into account for treatment decision-making in this setting, discussing the locoregional treatment in pN0(i+) and pN1mi patients (completion axillary dissection, axillary irradiation with or without regional nodes irradiation, or observation), according to systemic treatment, with the goal to help physicians in their daily practice.

Is breast conservative surgery a reasonable option in multifocal or multicentric tumors?

The incidence of multifocal (MF) and multicentric (MC) carcinomas varies widely among clinical studies, depending on definitions and methods for pathological sampling. Magnetic resonance imaging is increasingly used because it can help identify additional and conventionally occult tumors with high sensitivity. However, false positive lesions might incorrectly influence treatment decisions. Therefore, preoperative biopsies must be performed to avoid unnecessary surgery. Most studies have shown higher lymph node involvement rates in MF/MC tumors than in unifocal tumors. However, the rate of local recurrences is usually low after breast conservative treatment (BCT) of MC/MF tumors. It has been suggested that BCT is a reasonable option for MC/MF tumors in women aged 50-69 years, with small tumors and absence of extensive ductal carcinoma in situ. A meta-analysis showed an apparent decreased overall survival in MC/MF tumors but data are controversial. Surgery should achieve both acceptable cosmetic results and negative margins, which requires thorough preoperative radiological workup and localization of lesions. Boost radiotherapy techniques must be evaluated since double boosts might result in increased toxicity, namely fibrosis. In conclusion, BCT is feasible in selected patients with MC/MF but the choice of surgery must be discussed in a multidisciplinary team comprising at least radiologists, surgeons and radiotherapists.

Assessment of multifocality and axillary nodal involvement in early-stage breast cancer patients using 18F-FDG PET/CT compared to contrast-enhanced and diffusion-weighted magnetic resonance imaging and sentinel node biopsy

BACKGROUND

Non-invasive evaluation of the extent of axillary nodal involvement in early-stage breast cancer (ESBC) patients and accurate assessment of multifocality are both challenging. Few reports have explored whether 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) might be more useful than other diagnostic methods in these contexts.

PURPOSE

To prospectively evaluate the diagnostic utility of FDG PET/CT, contrast-enhanced, and diffusion-weighted magnetic resonance imaging (DCE-MRI and DWI), and sentinel lymph node biopsy (SNB), in detection of axillary metastatic lymph nodes in ESBC patients; and to explore the utilities of FDG PET/CT and DCE-MRI for identification of multifocality.

MATERIAL AND METHODS

Twenty-four female patients (mean age, 47 ± 9.9 years; range, 24-68 years) with ESBC underwent whole-body FDG PET/CT and breast MRI prior to operation. SNB and axillary lymph node dissection (ALND) were performed on all patients, as was mastectomy or wide local tumor excision. Histopathological findings served as the gold standard when evaluating either multifocality or axillary nodal involvement.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy, of PET/CT and DCE-MRI, used to detect multifocality, were as follows: 67% versus 78%, 100% versus 53%, 100% versus 50%, 83% versus 80%, and 88% versus 63%. SNB afforded the highest sensitivity (93%) in terms of detection of axillary metastasis. The sensitivity, NPV, and accuracy of PET/CT were 67%, 62%, and 75% respectively, thus higher than the equivalent values of either DCE-MRI or DWI.

CONCLUSION

For assessment of multifocality in ESBC patients, highly specific results of PET/CT should be taken into account along with DCE-MRI findings. For evaluation of axillary nodal involvement, PET/CT has higher sensitivity, NPV, and accuracy values than DCE-MRI and DWI and may guide a surgical decision to proceed or not to SNB or ALND.

Occult metastases in node-negative breast cancer: A Surveillance, Epidemiology, and End Results-based analysis

INTRODUCTION

The role of immunohistochemistry (IHC) for detecting occult lymph node disease in patients initially found to be node-negative by routine pathology is controversial. In this study, we evaluated trends associated with overall survival in node-negative breast cancer patients staged by IHC.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for all patients with invasive breast adenocarcinoma and negative lymph nodes on routine pathology between 2004 and 2011 who underwent IHC to evaluate for occult nodal disease. Overall survival stratified by N-stage was compared with Kaplan-Meier analysis. Multivariate analysis was performed using a Cox proportional hazards model.

RESULTS

Overall, 93,070 patients were identified, including 4,657 patients with isolated tumor cells (<0.2 mm diameter or <200 cells) and 6,720 patients with micrometastases (0.2-2 mm diameter). Kaplan-Meier curves demonstrated a difference in overall survival across all groups (P < .0001). On multivariate analysis, micrometastases remained an independent predictor for survival compared with IHC-negative patients (hazard ratio 1.40, 95% confidence interval 1.28-1.53), whereas isolated tumor cells were not a significant predictor (hazard ratio 1.05, 95% confidence interval 0.92-1.20).

CONCLUSION

Patients with occult micrometastases in axillary lymph nodes found via IHC demonstrated a significant overall survival difference, but isolated tumor cells have no prognostic significance.

[Regional treatment for axillary lymph node micrometastases of breast cancer]

In patients with breast cancer, axillary lymph node micrometastasis detection has been more frequent with a better definition since the introduction of the sentinel node procedure. In this review, we focus on pN1mi micrometastasis and review the literature in order to determine factors involved in making the decision of a regional treatment.

[Sentinel lymph node-multicentric and multifocal tumors: a valid technique?]

Sentinel node biopsy without complementary axillary lymph node dissection was validated for T1-2 N0 unifocal breast cancer without previous treatment since several years. In the situation of multifocal multicentric breast tumors, this procedure was considered as a contraindication. The aim of this work was to analyse literature results to determine if sentinel lymph node biopsy can be considered as a valid option without complementary axillary lymph node dissection for negative sentinel lymph node.

Quality of pathology reporting is crucial for cancer care and registration: a baseline assessment for breast cancers diagnosed in Belgium in 2008

OBJECTIVES

Given the crucial role of pathology reporting in the management of breast cancers, we aimed to investigate the quality and variability of breast cancer pathology reporting in Belgium.

MATERIALS AND METHODS

Detailed information on non-molecular and molecular parameters was retrieved from the pathology protocols available at the Belgian Cancer Registry for 10,007 breast cancers diagnosed in Belgium in 2008.

RESULTS

Substantial underreporting was shown for several clinically relevant non-molecular parameters, such as lymphovascular invasion. High-volume laboratories performed only slightly better than others, and analyses at the individual laboratory level showed clear inter-laboratory variability in reporting for all volume categories. Information on ER/PR and HER2 IHC was mentioned in respectively 91.7% and 90.8% of evaluative cases. HER2 ISH data were available for 78.5% of the cases judged to be 2+ for HER2 IHC. For cases with different specimens analysed, discordance between these specimens was highest for HER2, followed by PR. For HER2, results obtained from different laboratories were even less concordant. In addition, inter-laboratory differences were noted in the used ER/PR scoring systems, the proportion of ER-/PR+ cases, and the relation between histological grade and ER/PR positivity. Data on Ki67 were only available for 43.8% of the investigated cases, and showed inconsistent use of cut-off values.

CONCLUSION

Breast pathology reporting in Belgium in 2008 was suboptimal and showed considerable inter-laboratory variability. Synoptic reporting has been proposed as a facilitator towards increased reporting quality and harmonization, but the lack of aligned informatics remains a major hurdle in its concrete implementation.

Extent of microinvasion in ductal carcinoma in situ is not associated with sentinel lymph node metastases

BACKGROUND

Ductal carcinoma in situ with microinvasion (DCISM) is a rare diagnosis with a good prognosis. Although nodal metastases are uncommon, sentinel lymph node biopsy (SLNB) remains standard care. Volume of disease in invasive breast cancer is associated with SLNB positivity, and, thus we hypothesized that in a large cohort of patients with DCISM, multiple foci of microinvasion might be associated with a higher risk of positive SLNB.

METHODS

Records from a prospective institutional database were reviewed to identify patients with DCISM who underwent SLNB between June 1997 and December 2010. Pathology reports were reviewed for number of microinvasive foci and categorized as 1 focus or ≥2 foci. Demographic, pathologic, treatment, and outcome data were obtained and analyzed.

RESULTS

Of 414 patients, 235 (57 %) had 1 focus of microinvasion and 179 (43 %) had ≥2 foci. SLNB macrometastases were found in 1.4 %, and micrometastases were found in 6.3 %; neither were significantly different between patients with 1 focus versus ≥2 foci (p = 1.0). Patients with positive SLNB or ≥2 foci of microinvasion were more likely to receive chemotherapy. At median 4.9 years (range 0-16.2 years) follow-up, 18 patients, all in the SLNB negative group, had recurred for an overall 5-year recurrence-free proportion of 95.9 %.

CONCLUSIONS

Even with large numbers, there was no higher risk of nodal involvement with ≥2 foci of microinvasion compared with 1 focus. Number of microinvasive foci and results of SLNB appear to be used in decision making for systemic therapy. Prognosis is excellent.

Metastatic breast cancer: mechanisms and opportunities for cytology

Despite significant advances in diagnosis, surgical techniques, general patient care, and local and systemic adjuvant therapies, metastatic disease remains the most critical condition limiting the survival of patients with breast cancer. Therefore, the development of effective treatment against late-arising metastasis has become the centre of clinical attention and is one of the current challenges in cancer research. A deeper understanding of the metastatic cascade is fundamental, and the need for repetitive tumour assessments for the evaluation of tumour evolution is a relatively new practice in routine medical care. As such, fine needle aspiration cytology (FNAC) is ideally placed to monitor biological changes in metastasis that may affect treatment and response. As FNAC is a minimally invasive method, it can be performed repeatedly with relatively little trauma, and selective ancillary tests can be applied to FNAC specimens, including for tumour whose primary nature is known. Herein, we review how the linear and parallel models explain metastatic dissemination, thus influencing therapeutic and clinical decisions, and how cytology, together with immunocytochemistry and molecular analysis, can be a tool for routine clinical practice and clinical trials aimed at metastatic disease with a special emphasis on breast cancer.

Receptor-interacting protein kinase 2 promotes triple-negative breast cancer cell migration and invasion via activation of nuclear factor-kappaB and c-Jun N-terminal kinase pathways

Introduction

Metastasis is the main cause of breast cancer morbidity and mortality. Processes that allow for tumor cell migration and invasion are important therapeutic targets. Here we demonstrate that receptor-interacting protein kinase 2 (RIP2), a kinase known to be involved in inflammatory processes, also has novel roles in cancer cell migration and invasion.

Methods

A total of six breast cancer expression databases, including The Cancer Genome Atlas, were assessed for RIP2 expression among various clinical subtypes and its role as a prognostic biomarker. mRNA fluorescence in situ hybridization (FISH) for RIP2 was performed on 17 stage III breast cancers to determine if there was a correlation between RIP2 expression and lymph node involvement. RNA-interference was used to knock-down RIP2 expression in MDA-MB-231, Htb126, SUM149PT, MCF7, T47D, and HCC1428 cells. Cell migration and invasion were measured in vitro by scratch/wound healing and transwell migration assays. A xenograft mouse model was used to assess tumor growth and chemosensitivity to docetaxel in vivo in MDA-MB-231 cells with and without RIP2 small hairpin RNA knockdown. Western blot and immunofluorescence imaging were used to evaluate protein expressions.

Results

Interrogation of expression databases showed that RIP2 expression is significantly over-expressed in triple-negative breast cancers (TNBC: estrogen-receptor (ER) negative, progesterone-receptor (PR) negative, Her2/neu- (Her2) negative), compared to other clinical subtypes. High RIP2 expression correlates with worse progression-free survival using a combined breast cancer expression array dataset consisting of 946 patients. Multivariate analysis shows RIP2 as an independent prognostic biomarker. Knock-down of RIP2 significantly decreases migration in both scratch/wound healing and transwell migration assays in MDA-MB-231, Htb126, SUM149PT, MCF7, and T47D cells and is correlated with decreased Nuclear Factor-kappaB and c-Jun N-terminal kinase (JNK) activation. Finally, RIP2 knock-down leads to increased sensitivity to docetaxel and decreased tumor mass and lung metastases in a xenograft mouse model.

Conclusion

These results highlight RIP2 as a pro-metastasis kinase in patients with advanced breast cancer. These results also illustrate a novel role for this kinase in addition to its known role in inflammation, and suggest that targeting RIP2 may improve outcomes in advanced breast cancer patients, in which it is overexpressed.

Sentinel lymph node biopsy in breast cancer: predictors of axillary and non-sentinel lymph node involvement

BACKGROUND

Sentinel lymph node biopsy is a standard method for the evaluation of axillary status in patients with T1-2N0M0 breast cancers.

AIMS

To determine the prognostic significance of primary tumour-related clinico-histopathological factors on axillary and non-sentinel lymph node involvement of patients who underwent sentinel lymph node biopsy.

STUDY DESIGN

Retrospective clinical study.

METHODS

In the present study, 157 sentinel lymph node biopsies were performed in 151 consecutive patients with early stage breast cancer between June 2008 and December 2011.

RESULTS

Successful lymphatic mapping was obtained in 157 of 158 procedures (99.4%). The incidence of larger tumour size (2.543±1.21 vs. 1.974±1.04), lymphatic vessel invasion (70.6% vs. 29.4%), blood vessel invasion (84.2% vs. 15.8%), and invasive lobular carcinoma subtype (72.7% vs. 27.3%) were statistically significantly higher in patients with positive SLNs. Logistic stepwise regression analysis disclosed tumour size (odds ratio: 1.51, p=0.0021) and lymphatic vessel invasion (odds ratio: 4.68, p=0.001) as significant primary tumour-related prognostic determinants of SLN metastasis.

CONCLUSION

A close relationship was identified between tumour size and lymphatic vessel invasion of the primary tumour and axillary lymph node involvement. However, the positive predictive value of these two independent variables is low and there is no compelling evidence to recommend their use in routine clinical practice.