Integrated digital pathology at scale: A solution for clinical diagnostics and cancer research at a large academic medical center

OBJECTIVE

Broad adoption of digital pathology (DP) is still lacking, and examples for DP connecting diagnostic, research, and educational use cases are missing. We blueprint a holistic DP solution at a large academic medical center ubiquitously integrated into clinical workflows; researchapplications including molecular, genetic, and tissue databases; and educational processes.

MATERIALS AND METHODS

We built a vendor-agnostic, integrated viewer for reviewing, annotating, sharing, and quality assurance of digital slides in a clinical or research context. It is the first homegrown viewer cleared by New York State provisional approval in 2020 for primary diagnosis and remote sign-out during the COVID-19 (coronavirus disease 2019) pandemic. We further introduce an interconnected Honest Broker for BioInformatics Technology (HoBBIT) to systematically compile and share large-scale DP research datasets including anonymized images, redacted pathology reports, and clinical data of patients with consent.

RESULTS

The solution has been operationally used over 3 years by 926 pathologists and researchers evaluating 288 903 digital slides. A total of 51% of these were reviewed within 1 month after scanning. Seamless integration of the viewer into 4 hospital systems clearly increases the adoption of DP. HoBBIT directly impacts the translation of knowledge in pathology into effective new health measures, including artificial intelligence-driven detection models for prostate cancer, basal cell carcinoma, and breast cancer metastases, developed and validated on thousands of cases.

CONCLUSIONS

We highlight major challenges and lessons learned when going digital to provide orientation for other pathologists. Building interconnected solutions will not only increase adoption of DP, but also facilitate next-generation computational pathology at scale for enhanced cancer research.

Morphologic and immunohistochemical features of carcinoma involving microglandular adenosis of the breast following neoadjuvant chemotherapy

Microglandular adenosis (MGA)-related lesions, including atypical MGA (AMGA) and carcinoma involving MGA (C-MGA), are characterized by epithelial atypia, negative hormone receptors, and HER2 status, and can mimic invasive triple negative breast cancer (TNBC) in core needle biopsies (CNB) resulting in selection for treatment with neoadjuvant chemotherapy (NAC). We identified 12 cases of AMGA and/or C-MGA in post-NAC excision specimens (EXC) and analyzed their morphologic and immunohistochemical (IHC) features. All CNBs were initially diagnosed as containing TNBC. Upon re-review, TNBC was confirmed in nine cases. In three CNBs AMGA and/or C-MGA had been interpreted as TNBC. AMGA was initially recognized in only one case but AMGA and/or C-MGA were present in an additional nine CNBs. At EXC, no residual TNBC was present in 5 of 9 EXCs and all 12 cases showed residual AMGA and/or C-MGA. Similar to conventional MGA, AMGA, and C-MGA were positive for S-100, laminin and collagen IV and negative for calponin and p63. Following NAC, these lesions retained their typical staining pattern despite acquiring treatment-related morphologic alterations, most notably of which were areas of single cell growth pattern seen in eight EXCs. This study is the first to report the effects of NAC on AMGA and C-MGA. Our data showed no response of the AMGA and/or C-MGA following NAC in contrast to the high response rate of conventional TNBC. In particular, the infiltrative single cell pattern of post-NAC MGA-related lesions closely mimicked residual TNBC. The persistence of AMGA and C-MGA following NAC supports the notion that these lesions are distinct from conventional TNBC. Our findings also highlight the challenges in recognizing AMGA and C-MGA in CNBs which may lead to unwarranted treatment with NAC in the absence of conventional TNBC.

Deep Multi-Magnification Networks for multi-class breast cancer image segmentation

Pathologic analysis of surgical excision specimens for breast carcinoma is important to evaluate the completeness of surgical excision and has implications for future treatment. This analysis is performed manually by pathologists reviewing histologic slides prepared from formalin-fixed tissue. In this paper, we present Deep Multi-Magnification Network trained by partial annotation for automated multi-class tissue segmentation by a set of patches from multiple magnifications in digitized whole slide images. Our proposed architecture with multi-encoder, multi-decoder, and multi-concatenation outperforms other single and multi-magnification-based architectures by achieving the highest mean intersection-over-union, and can be used to facilitate pathologists' assessments of breast cancer.

E-cadherin immunohistochemical expression in invasive lobular carcinoma of the breast: correlation with morphology and CDH1 somatic alterations

E-cadherin (ECAD) immunohistochemical (IHC) expression is lost in ∼90% of invasive lobular carcinomas (ILCs) owing to genomic alterations of CDH1. We examined morphologic features and ECAD IHC expression in invasive breast carcinomas (BCs) with known CDH1 alterations. Between January 2014 and May 2018, 202 cases of BC with a CDH1 somatic alteration were identified. ECAD expression was lost in 77% (155/202) of cases and was retained in 23% (47/202) cases. Most (90%, 139/155) ECAD-negative cases were morphologically classified as ILC, while the remaining (10%, 16/155) were invasive mammary carcinoma with mixed ductal and lobular features (IMC). Of 47 cases with ECAD staining, 62% (29/47) were classified as ILC, 23% (11/47) were classified as IMC, and 15% (7/47) were classified as invasive ductal carcinoma (IDC). Of note, 51% (24/47) of ECAD-positive cases were initially diagnosed as IDC or IMC based on ECAD expression alone. For ECAD-negative BCs, 98% (152/155) of CDH1 alterations were truncating, and 2% (3/155) were variants of unknown significance (VUS). Truncating CDH1 alterations were identified in the majority of ECAD-positive BCs (72%, 34/47); however, VUS-type CDH1 alterations were more prevalent (28%, 13/47) in ECAD-positive BCs than in ECAD-negative BCs. Although 90% of ECAD-negative tumors were compatible with ILC in this study, 17% (29/168) of ILC cases were ECAD positive. In addition, CDH1 truncating alterations were seen in ECAD-positive ILC, supporting the notion of aberrant ECAD staining. Therefore, ECAD IHC expression must be interpreted in conjunction with morphology, and BC with classic histologic features of ILC should not be reclassified as IDC/IMC based solely on the status of ECAD IHC expression.

Abstract P5-02-09: The prevalence of invasive lobular carcinomas with unconventional immunohistochemical phenotypes

Background The prognosis of invasive lobular carcinoma (ILC) is controversial. Some studies report equivalent or better outcomes than invasive ductal carcinoma, likely due to ILC’s favorable prognostic phenotype. Classic ILC (CL) is typically of low histologic grade, estrogen receptor (ER) positive and human epidermal growth factor receptor-2 (HER2) negative. However, worse long term outcomes have been observed because ILC tends to be multicentric, bilateral, and to show higher rates of late metastases in uncommon sites. Additionally, subtypes of ILC, including solid (SOL) and pleomorphic (PL), have been reported to display more aggressive behavior. Yet current treatment paradigms are distinguished by hormone receptor profile and stage, not by tumor morphology. This study aimed to evaluate the clinicopathologic and immunohistochemical (IHC) characteristics of ILC, particularly those with unusual patterns.

Methods

From 2009-2018, consecutive in-house biopsy and resection specimens with the diagnosis of ILC were identified by a retrospective review of our institutional database. Demographic, morphologic, and IHC data were obtained from pathology reports. Cases with equivocal HER2 IHC results are sent for fluorescence in situ hybridization analysis at our Center. CL ILC was defined by small cells with low nuclear grade and discohesive growth arranged in single file or cords. PL ILC is composed of larger, more atypical cells, which still exhibit discohesion typical of lobular phenotype. SOL ILC consists of tumors growing in large sheets with minimal intervening stroma.

Results

Over the nine year study period, a total of 3,028 ILCs from 2,322 patients were identified. Most (74%, 2229/3028) cases were classified as CL while 22% (665/3028) were PL and 4% (134/3028) SOL (Table 1). The median patient age was 60 years (range 32-95). The median tumor size was larger for PL (2.3 cm) and SOL (2.4 cm) subtypes than CL (1.1 cm). IHC results were available for 896 specimens. The majority of all ILCs showed an expected phenotype: ER positive and HER2 negative (99% CL, 84% PL, 97% SOL). A smaller subset of ER positive ILC were also HER2 positive (1% CL, 8% PL, 3% SOL). No CL or SOL ILC were ER negative; in contrast 8% (21/270) of PL ILC were ER negative. Twelve (5%) PL ER negative cases were also HER2 negative. Overall, 15% of ILC were HER2 positive, with the PL variant showing the highest incidence (11%, 30/270). Lymph node (LN) metastases were seen in 22% (66/291) of CL cases, 55% (53/96) PL and 29% (17/58) SOL. Metastases in 10 or more LN (N3) was seen only in PL and SOL cases (13% and 5%, respectively).

Conclusions

In this study, up to 8% of ILC cases were found to be ER negative, a finding unique to the PL variant. No CL or SOL ILC was ER negative. HER2 positivity, not typically expected in ILC, was seen in 15% of cases, most commonly in the PL type. ILC that was both negative for ER and HER2 was observed in 5% of cases, and only within the PL subgroup. PL ILC showed higher median tumor size at presentation than CL and nodal metastases were also more common in PL than in CL or SOL ILC (55% vs 22% and 29%, respectively). Our findings are in keeping with prior observations that compared to CL ILC. PL ILC exhibits features associated with unfavorable clinicopathologic features, such as higher tumor and nodal stage at presentation. Additionally, this is the first study to systematically examine the prevalence of unconventional IHC phenotypes of ILC (ER negativity and/or HER2 positivity) in a large series from one institution.

Table 1. Summary of Clinicopathologic FeaturesClassicPleomorphicSolidILC types (n=3028)2229665134Median age, (range)60 yrs (32-94)61 yrs (31-95)66 yrs (44-93)Median size, cm 1.12.32.4Immunophenotype (n=896)ER+/HER2-99% (551/559)84% (228/270)97% (65/67)ER+/HER2+1% (8/559)8% (21/270)3% (2/67)ER-/HER2+0% (0/559)3% (9/270)0% (0/67)ER-/HER2-0% (0/559)5% (12/270)0% (0/67)Lymph node status (n=445)N077% (225/291)45% (43/96)71% (41/58)N120% (59/291)31% (30/96)19% (11/58)N22% (7/291)11% (11/96)5% (3/58)N30% (0/291)13% (12/96)5% (3/58)

Citation Format: Matthew G Hanna, Anne Grabenstetter, Dara S Ross, Lee K Tan. The prevalence of invasive lobular carcinomas with unconventional immunohistochemical phenotypes [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-02-09.

P884 Rare case of primary cardiac lymphoma in immunocompetent patient

Primary cardiac lymphoma is a rare tumour especially in immunocompetent person. It is invariably fatal unless diagnosed and treated early. Our patient was a 76 year old Chinese gentlemen, known case diabetes mellitus and hypertension, who presented with 3 months history of failure symptoms. He also had loss of appetite.

His vital signs were stable. There was bibasal crepitation, raised JVP with normal heart sounds and bilateral pedal edema. Chest X-ray showed bilateral pleural effusion.He was admitted for stabilization of heart failure and started on diuretics.

Echocardiography showed the LV ejection fraction was 50% with grade 1 diastolic dysfunction. There was a global pericardial effusion with effusion size 2.52cm maximum at posterior to LV. There was partial RA collapse .Patient was otherwise hemodynamically stable. Patient was observed closely and diuretics continued. Echocardiography on the third day of admission showed a suspicious looking mass in the right atrial (RA) and right ventricular (RV) wall near the AV groove. It become apparent after pericardial effusion became less. Patient was counselled and agreed for pericardial tapping but procedure had to be abandoned as effusion has reduced compared to before (<20mm).

MRI cardiac showed an infiltrating mass around the right atrio-ventricular groove extending to the right ventricular free wall and around the pericardial lining around the ascending aorta and pulmonary trunks. There is inhomogenous signal in STIR with iso-intensity on T1 weighted images. First pass metabolism revealed some vascularity. There was a patchy myocardial enhancement on late gadolinium enhancement. pericardium was thickened with global pericardial effusion- 16mm. Large right pleural effusion seen and minimal left pleural effusion. Mediastinal lymphadenopathy was seen. The finding were suggestive of cardiac lymphoma with differential sarcoma.

Subsequent day, patient develop acute ischemic stroke which was complicated by aspiration pneumonia and septic shock. Fortunately he recovered after 1 week of antibiotics and non-invasive ventilatory support.

FDG PET- CT scan showed FDG-avid primary cardiac lymphoma with pericardial involvement and conglomerate of multiple group of mediastinal and supra clavicular lymph nodes . Bilateral hypermetabolic adrenal nodule were seen but unable to determine its relevance to the primary pathology(lymphoma). No marrow or other organ involvement. Stage is likely IIE.

We were unable to harvest the lymph node because they were too deep. Patient"s family was counselled for cardiac biopsy but family did not want to take the risk as patient was bedridden and fragile. They were also not keen for any chemotherapy or invasive procedure. Once patient was out of infection, they requested to bring back patient to home. He was sent to nursing home for full time care but succumbed to another bout of aspiration pneumonia one week after discharge.

Abstract P884 Figure. Echo, MRI, Pet CT scan

P1342 Secondary cardiac tumour -a metastasis from renal cell carcinoma via transvenous extension

Secondary cardiac tumour is 20-40 times more common than primary cardiac tumour. Most common tumour that metastasize to the heart are lung cancer, breast cancer and hematologic malignancy. Melanoma and pleural mesothelioma has high inclination to metastasize. Other cancer with high rate of cardiac metastasis include gastric, ovarian, renal and pancreatic cancer. The presentation of cardiac metastasis is usually non-specific and sometimes mimic other cardiac condition. We would like to present one such case where we used multimodality approach for proper evaluation.

A 57 year old lady presented with intermittent chest discomfort for one month which worsen on day of admission. Otherwise she had good effort tolerance. Electrocardiogram had no acute ischemic changes and Troponin T was not elevated. Bedside echocardiography revealed a large cardiac mass in right atrium around 66mm x 29mm, protruding to right ventricle. Apart from that noted aneurysm of interatrial septum towards LA.

MRI cardiac showed an inhomogenous mass extending from the right renal vein and inferior vena cava(IVC) into the right atrium(RA). The tumour mass in the right atrium a highly mobile and flops across the tricuspid valve into the right ventricle during ventricular diastole causing right ventricular outflow tract obstruction. The mass was hyperintense on T2- and isointense on T1-weighted images. There was vascularity within the mass with inhomogenous gadolinium enhancement. There was also 2 masses in right kidney , a larger inhomogenous encapsulated mass at the right lower pole and smaller at lower pole. The findings were suggestive of a primary renal cell carcinoma with tumour mass extension into right renal vein, inferior vena cava and into the right atrium.

A staging CT scan thorax , abdomen and pelvis did not show any other possible primary source of cancer and reconfirm the extracardiac finding of the MRI. No evidence of tumour extension into hepatic veins and left renal vein. There was however small nodular opacities in both right and left lung suggesting lung metastasis.

A combined operation was done with our cardiothoracic surgeon and urologist from nearby tertiery hospital. Nephrectomy and removal of tumour thrombus from IVC and RA was done with 18 degree Celcius circulatory arrest with cardiopulmonary bypass.

Section of renal mass showed a poorly circumscribed lobulated tumour with areas of hemorrhage and necrosis. The tumour was close to capsule but has not breached it. The tumour was mainly clear cell carcinoma variant, nuclear grade III. Section from IVC that extend to RA appeared elongated sausage-like measuring 150mm in length and 30mm in diameter had tumour embolus. Pulmonary artery and perirenal blood vessel also had tumour emboli. The hilar nodes however were free from tumour.

Patient recovered well and was discharged home day 9 post operation. Follow-up echocardiogram 3weeks post-op showed no recurrence of the mass and good LV function.

Abstract P1342 Figure. Echo, CTscan, MRI and Pathology images

Echocardiographic and electrocardiographic presentations of patients with endomyocardial biopsy-proven cardiac amyloidosis

OBJECTIVE

Cardiac amyloidosis is under diagnosed and its prevalence is unknown. This is a retrospective, nonrandomised, single centre study of patients with endomyocardial biopsy-proven cardiac amyloidosis focusing on their echocardiographic and electrocardiogram (ECG) presentations. This is the first case series in Malaysia on this subject.

METHODS

We identified all of our endomyocardial biopsyproven cardiac amyloidosis patients from January 2010 to January 2018 and reviewed their medical records. All patients echocardiographic and ECG findings reviewed and analysed comparing to basic mean population value.

RESULTS

In total there are 13 biopsy-proven cardiac amyloidosis patients. All of the biopsies shows light chain (AL) amyloid. Majority of the patients (8, 61.5%) is male, and most of our patients (8, 61.5%) is Chinese. All seven patients on whom we performed deformation imaging have apical sparing pattern on longitudinal strain echocardiogram. Mean ejection fraction is 49.3%, (SD=7.9). All patients have concentric left ventricular hypertrophy and right ventricular hypertrophy. Diastolic dysfunction was present in all of our patients with nine out of 13 patients (69.2%) having restrictive filling patterns (E/A ≥2.0 E/e' ≥15). On electrocardiogram, 12 (92%) patients have prolonged PR interval (median 200ms, IQR 76.50ms) and 9 (69.2%) patients have pseudoinfarct pattern.

CONCLUSION

Echocardiography plays an important role in diagnosing cardiac amyloidosis. The findings of concentric left ventricular hypertrophy with preserved ejection fraction without increased in loading condition should alert the clinician towards its possibility. This is further supported by right ventricular hypertrophy and particularly longitudinal strain imaging showing apical sparing pattern.

Sentinel lymph node B cells can predict disease-free survival in breast cancer patients

Tumor invasion into draining lymph nodes, especially sentinel lymph nodes (SLNs), is a key determinant of prognosis and treatment in breast cancer as part of the TNM staging system. Using multicolor histology and quantitative image analysis, we quantified immune cells within SLNs from a discovery cohort of 76 breast cancer patients. We found statistically more in situ CD3⁺ T cells in tumor negative vs. tumor positive nodes (mean of 8878 vs. 6704, respectively, p = 0.006), but no statistical difference in CD20⁺ B cells or CD1a⁺ dendritic cells. In univariate analysis, a reduced hazard was seen with a unit increase in log CD3 with HR 0.49 (95% CI 0.30–0.80) and log CD20 with HR 0.37 (95% CI 0.22–0.62). In multivariate analysis, log CD20 remained significant with HR 0.42 (95% CI 0.25–0.69). When restricted to SLN tumor negative patients, increased log CD20 was still associated with improved DFS (HR = 0.26, 95% CI 0.08–0.90). The CD20 results were validated in a separate cohort of 21 patients (n = 11 good outcome, n = 10 poor outcome) with SLN negative triple-negative breast cancer (TNBC) (“good” mean of 7011 vs. “poor” mean of 4656, p = 0.002). Our study demonstrates that analysis of immune cells within SLNs, regardless of tumor invasion status, may provide additional prognostic information, and highlights B cells within SLNs as important in preventing future recurrence.

B cells within the tumor-draining lymph nodes may have an important biological role in preventing relapse of breast cancer. A team led by Peter Lee from City of Hope in Duarte, California, USA, quantified the levels of three populations of immune cells—T cells, B cells and dendritic cells—within sentinel lymph nodes biopsied from a cohort of 76 patients. They found that larger numbers of T cells and B cells were both linked to longer progression-free survival in the women. However, after statistically accounting for correlations between the two immune cell types, the researchers concluded that B cells had the dominant beneficial effect on survival times. They validated the finding that high B-cell counts are a prognostic indicator of better outcomes in a separate cohort of 21 women with triple-negative breast cancer.

A case of successfully managed pregnancy in a patient with complex cyanotic congenital heart disease

Medical advances have increased survival of patients with congenital heart disease. However, cardiac disease in pregnancy carries significant maternal and fetal risks, posing enormous challenges to obstetricians. Cyanotic congenital heart disease is associated with maternal complications such as arrhythmias, thromboembolic events and death. Fetal complications include small for gestational age, miscarriage and prematurity. Cyanotic congenital heart disease patients who continue their pregnancies require holistic multidisciplinary team care with early and coordinated planning for delivery. Management of such patients include early counseling regarding pregnancy-associated risks, close monitoring of their cardiac function and regular scanning for fetal assessment. Choice of anesthesia for these patients requires meticulous planning to achieve a favorable balance between systemic and pulmonary vascular resistance, ensuring minimal change in right-to-left shunting. We report a case of a successfully managed pregnancy in a patient with complex congenital heart disease and a single ventricle of left ventricle morphology.

Repeated failed non-invasive prenatal testing in a woman with immune thrombocytopenia and antiphospholipid syndrome: lessons learnt

We present a case of a 37-year-old Chinese woman (gravida 4 para 0) with a history of immune thrombocytopenia and type IIb antiphospholipid syndrome. She was started on 100 mg of aspirin, 20 mg of prednisolone and 20 mg of subcutaneous low-molecular-weight heparin daily for her fourth pregnancy. She opted for non-invasive prenatal testing for aneuploidy screening but had failed results three times consecutively from insufficient fetal cfDNA initially or high variance in cfDNA counts on redraws. She declined invasive karyotyping. Her pregnancy was complicated by severe pre-eclampsia and fetal growth restriction at 19+6 weeks of gestation and was terminated. Subsequent fetal karyotyping revealed a normal karyotype of 46XY with no apparent abnormalities.

The value of secondary pathology review

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Background: Improving the value of cancer care is a major focus for the Alliance of Dedicated Cancer Centers (ADCC). Looking to align with the Institute of Medicine’s (IOM) initiative to “Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice,” the ADCC implemented a study to examine the clinical impact of expert secondary pathology review. The goal of this project was to: 1) demonstrate the value of secondary review of outside pathological specimens by ADCC subspecialty pathologists in identifying significant errors that can potentially impact treatment; and 2) create an opportunity to improve patient cancer care. Methods: All consult slides from patients referred to each ADCC center were reviewed by designated pathologists. Patient-level data for original and revised diagnoses were collected for two months in 2014. Discrepancies were classified as: 1) major - diagnosis changes treatment or surveillance; or, 2) minor - diagnosis does not change affect treatment or surveillance. To verify these assessments, disease-specific, multi-center teams of clinical experts reviewed each discrepant case and provided treatment recommendations for the original and revised diagnoses. Results: A total of 13,109 cases were collected across all ADCC centers and the discrepancy rate was 11% (1,488/1309); 3% (359/13,109) were major and 9% (1,129/13,109) were minor. The most common discrepancy was reclassification of the neoplasm cell type. The highest discrepancy rate was shown in the neuro-oncology and head and neck cases, with a 7% and 4% major discrepancy rate respectively. Conclusions: We identified an overall discrepancy rate of 11%, with 3% of cases leading to a change in treatment or surveillance. This demonstrates the importance of expert pathology review and that secondary pathology review can significantly improve clinical outcomes through precise and accurate pathological diagnoses. As indicated in the recent IOM report, this project further demonstrates that “diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions.”

Breast Carcinoma in Young Women: No Evidence of Increasing Rates of Metastatic Breast Carcinoma in a Single Tertiary Center Review

Breast carcinoma in young women aged less than 40 years attracts a high level of mainstream media coverage, and there is a gap between societal perceptions of the disease as a growing problem and epidemiological trends. Several population studies have reported that the overall incidence of breast carcinoma in young women is stable, while one recent article suggested that the relative proportion of breast carcinoma in young women that is metastatic at diagnosis is growing. We sought to establish whether these trends were apparent at our institution. In this study, the clinical database at a breast carcinoma tertiary center was reviewed in terms of clinicopathologic data on patient age, diagnosis, clinical and pathologic stage, hormone receptor status, and HER-2 overexpression status for the period 2000-2011. Over the study period, young patients represented a decreasing proportion of all breast carcinoma cases (10.8% [2000-2003] to 8.7% [2008-2011]; p < 0.0001) treated at our institution. Young patients were more likely than patients aged 40 years or older to present with metastatic (M1) disease (5.4% versus 4.4%; p = 0.009), to be triple negative (21.6% versus 13%; p < 0.001), or to be HER-2 positive (24.3% versus 14.8%; p < 0.01). Young patients with HER-2-positive cancers were significantly more likely to present with metastatic disease (8.3% versus 4.8%; p = 0.004). This study showed no demonstrable increase in the relative proportion of breast cancer occurring in patients aged <40 years over the 12-year period 2000-2011 and no increase in the proportion of young patients presenting with metastatic disease.

Acinic cell carcinoma of breast: morphologic and immunohistochemical review of a rare breast cancer subtype

Acinic cell carcinoma of breast is a rare subtype of triple-negative breast carcinoma and demonstrates extensive morphologic overlap with acinic cell carcinoma of the salivary gland. In this study, we perform a detailed morphologic and immunohistochemical description of 2 cases of this rare entity and undertake a comprehensive review of all reported cases of breast acinic cell carcinoma in the English language literature to date. One-third of reported cases of breast acinic cell carcinoma have been associated with the presence of a ductal carcinoma not otherwise specified component, which is frequently poorly differentiated. Breast acinic cell carcinoma can demonstrate focal morphologic features similar to microglandular adenosis; these areas are frequently negative for collagen IV and laminin on immunohistochemistry. The true relationship between these 2 entities remains unclear, but we advocate that microglandular adenosis-like areas at the periphery of a breast acinic cell carcinoma should be considered part of the carcinomatous process and re-excised if this process extends to the initial surgical margins.

Is There a Role for Oncotype Dx Testing in Invasive Lobular Carcinoma?

Oncotype Dx Breast Cancer Assay is a 21-gene assay used in estrogen receptor (ER)-positive breast cancer to predict benefit from chemotherapy (CT). Tumors are placed into one of three risk categories based on their recurrence score (RS). This paper explores the impact of tumor histopathologic features and Oncotype Dx RS on the treatment plan for invasive lobular carcinoma (ILC). Invasive lobular carcinoma cases submitted for Oncotype Dx testing were identified from a clinical data base. The histopathologic and immunohistochemical features and RS subcategory of each tumor, and treatment regimen and medical oncologic assessments of each patient were reviewed. A total of 135 cases of ILC had RS testing, which represented 15% of all ILC diagnosed at the institution over the time period. 80% of ILC was of the classical subtype and all tumors were ER positive and human epidermal growth factor receptor 2 (HER-2) negative by immunohistochemistry. Sixty three percent of cases were low risk (LR), 35.5% were intermediate risk (IR) and 1.5% were high risk (HR). Both HR cases were pleomorphic ILC. Sixty eight percent of classical ILC had a LR score, while 70% of pleomorphic ILC had an IR score. Patients in the IR category were significantly more likely to undergo CT than patients in the LR category (54% versus 18%; p < 0.0001). In the LR category, those undergoing CT were significantly younger and more likely to have positive lymph nodes (p < 0.05). Qualitative analysis of medical oncologic assessments showed that RS played a role in decision-making on CT in 74% of cases overall. At our institution, Oncotype Dx RS currently plays a role in the management of a proportion of ILC and impacts on treatment decisions.

A national common massive transfusion protocol (MTP) is a feasible and advantageous option for centralized blood services and hospitals

BACKGROUND

A common national MTP was jointly implemented in 2011 by the national blood service (Blood Services Group) and seven participating acute hospitals to provide rapid access to transfusion support for massively haemorrhaging patients treated in all acute care hospitals.

METHODS

Through a systematic clinical workflow, blood components are transfused in a ratio of 1:1:1 (pRBC: whole blood-derived platelets: FFP), together with cryoprecipitate for fibrinogen replacement. The composition of components for the MTP is fixed, although operational aspects of the MTP can be adapted by individual hospitals to suit local hospital workflow. The MTP could be activated in support of any patient with critical bleeding and at risk of massive transfusion, including trauma and non-trauma general medical, surgical and obstetric patients.

RESULTS

There were 434 activations of the MTP from October 2011 to October 2013. Thirty-nine per cent were for trauma patients, and 30% were for surgical patients with heavy intra-operative bleeding, with 25% and 6% for patients with gastrointestinal bleeding and peri-partum haemorrhage, respectively. Several hospitals reported reduction in mean time between request and arrival of blood. Mean transfusion ratio achieved was one red cell unit: 0·8 FFP units: 0·8 whole blood-derived platelet units: 0·4 units of cryoprecipitate. Although cryoprecipitate usage more than doubled after introduction of MTP, there was no significant rise in overall red cells, platelet and FFP usage following implementation.

CONCLUSION

This successful collaboration shows that shared transfusion protocols are feasible and potentially advantageous for hospitals sharing a central blood provider.

Glaucoma severity affects diffusion tensor imaging (DTI) parameters of the optic nerve and optic radiation

OBJECTIVES

To evaluate whether MR diffusion tensor imaging (DTI) of the optic nerve and optic radiation in glaucoma patients provides parameters to discriminate between mild and severe glaucoma and to determine whether DTI derived indices correlate with retinal nerve fibre layer (RNFL) thickness.

METHODS

3-Tesla DTI was performed on 90 subjects (30 normal, 30 mild glaucoma and 30 severe glaucoma subjects) and the FA and MD of the optic nerve and optic radiation were measured. The categorisation into mild and severe glaucoma was done using the Hodapp-Parrish-Anderson (HPA) classification. RNFL thickness was also assessed on all subjects using OCT. Receiver operating characteristic (ROC) analysis and Spearman's correlation coefficient was carried out.

RESULTS

FA and MD values in the optic nerve and optic radiation decreased and increased respectively as the disease progressed. FA at the optic nerve had the highest sensitivity (87%) and specificity (80%). FA values displayed the strongest correlation with RNFL thickness in the optic nerve (r=0.684, p ≤ 0.001) while MD at the optic radiation showed the weakest correlation with RNFL thickness (r=-0.360, p ≤ 0.001).

CONCLUSIONS

The high sensitivity and specificity of DTI-derived FA values in the optic nerve and the strong correlation between DTI-FA and RNFL thickness suggest that these parameters could serve as indicators of disease severity.

Abstract P1-02-09: Positive predictive value (PPV) of the diagnosis of atypia in breast core biopsies: An audit of MSKCC breast pathology service

Percutaneous needle core biopsy is the standard of care in the assessment of suspicious breast lesions. The diagnostic term “Atypia” is used in breast biopsy reporting when histologic appearances are suspicious but not diagnostic of malignancy. Multiple histopathological appearances are encompassed by the umbrella term “atypia”, including atypical ductal hyperplasia (ADH), columnar cell change with atypia (CCCWA), which is also known as flat epithelial atypia (FEA), and a miscellaneous group of diagnoses, known as atypia NOS.

A pathologic diagnosis of “atypia” in breast core biopsies usually leads to a recommendation to surgically excise the lesion. Many studies have correlated the diagnosis of “atypia” in core biopsies with the subsequent finding of carcinoma in the surgical excisions, and the percentage of carcinoma found represents the positive predictive value (PPV) of the diagnosis. To date, there is no agreed target PPV for the diagnosis of breast atypia on biopsy, but the most studies have demonstrated a PPV of 20- 40%. Individual “atypia” diagnoses such as CCCWA have an even lower PPV of 10-15%.

One method of performance review is an audit of the average breast-atypia PPV within individual pathology departments, which then can be monitored and studied over time, to detect trends and “diagnostic drift” at an early stage. In addition, assessment of the individual PPV of each breast pathologist allows for analysis of the consistency of the diagnostic practice of each individual with their colleagues. Surprisingly, there have been no major studies assessing the intradepartmental range of PPVs for breast atypia diagnoses to date. In contrast, the American College of Radiology has designed the BIRADS classification system in order to audit and monitor the PPV of breast imaging in diagnosing malignancy.

We undertook to measure the departmental PPV for malignancy following a biopsy diagnosis of breast atypia, and performed an anonymized subanalysis in order to establish the range of PPVs of atypia diagnoses between the sub-specialized breast pathologists within the department.

This study established that the baseline PPV in our department is comparable to previously reported studies at 24%, while the range of PPV for an atypia diagnosis between pathologists is between 22.8 and 25% for 5 of 6 pathologists, with one pathologist demonstrating a higher PPV of 36.8%. ADH was the most common diagnosis of the atypia subtypes, and the PPV for ADH alone was 29.9%. 15% of ADH diagnoses were described as “ADH bordering on low grade DCIS”; within this subgroup the PPV was 48.5%. The PPV for a diagnosis of CCCWA alone was 10%.

This study demonstrates that the PPV for breast atypia in a major tertiary cancer center is approximately 24%. We have demonstrated very reproducible use of this diagnostic term within the department. We plan to use the findings of this study to identify subgroups of patients with a sufficiently low PPV to justify a decision not to proceed to surgical intervention. We aim to develop an algorithm for use in the clinical setting in order to direct further patient management. The ultimate aim of this research is to reduce the number of patients undergoing unnecessary surgical interventions.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-02-09.

Non-mammary metastases to the breast and axilla: a study of 85 cases

Non-mammary metastases to the breast and axilla are rare occurrences. However, they are important diagnostic considerations as their treatment and prognosis differ significantly from primary breast cancer. Between 1990 and 2010, we identified a total of 85 patients, 72 women and 13 men, with non-mammary malignancies involving the breast, axilla, or both. The tumor types consisted of carcinoma (58%), melanoma (22%) and sarcoma (20%). Ovary was the most common site of origin for carcinoma, and metastatic high-grade ovarian serous carcinoma was most frequently misdiagnosed as a primary breast carcinoma. Melanoma was the single most common non-carcinomatous tumor type to involve the breast and/or axilla, and uterine leiomyosarcoma was the most common type of sarcoma. Most patients (77%) had other metastases at the time of diagnosis of the tumor, but in 11% the breast or axillary lesion was the first presentation. Without a clinical history, non-mammary metastases were difficult to diagnose because the majority of cases presented with a solitary nodule and lacked pathognomonic pathologic features. There were, however, certain recurrent histological findings identified, such as the often relatively well-circumscribed growth pattern of the metastatic lesion surrounded by a fibrous pseudocapsule, and the absence of an in situ carcinoma. Overall, these patients had poor survival; 96% of patients with follow-up available are dead of disease, with a median survival of 15 months after the diagnosis of the breast or axillary lesion. This finding emphasizes the need to accurately identify these tumors as metastases in order to avoid unnecessary procedures and treatments in these patients.

Quantification of diffusion tensor imaging in normal white matter maturation of early childhood using an automated processing pipeline

OBJECTIVES

The degree and status of white matter myelination can be sensitively monitored using diffusion tensor imaging (DTI). This study looks at the measurement of fractional anistropy (FA) and mean diffusivity (MD) using an automated ROI with an existing DTI atlas.

METHODS

Anatomical MRI and structural DTI were performed cross-sectionally on 26 normal children (newborn to 48 months old), using 1.5-T MRI. The automated processing pipeline was implemented to convert diffusion-weighted images into the NIfTI format. DTI-TK software was used to register the processed images to the ICBM DTI-81 atlas, while AFNI software was used for automated atlas-based volumes of interest (VOIs) and statistical value extraction.

RESULTS

DTI exhibited consistent grey-white matter contrast. Triphasic temporal variation of the FA and MD values was noted, with FA increasing and MD decreasing rapidly early in the first 12 months. The second phase lasted 12-24 months during which the rate of FA and MD changes was reduced. After 24 months, the FA and MD values plateaued.

CONCLUSION

DTI is a superior technique to conventional MR imaging in depicting WM maturation. The use of the automated processing pipeline provides a reliable environment for quantitative analysis of high-throughput DTI data.

KEY POINTS

Diffusion tensor imaging outperforms conventional MRI in depicting white matter maturation. • DTI will become an important clinical tool for diagnosing paediatric neurological diseases. • DTI appears especially helpful for developmental abnormalities, tumours and white matter disease. • An automated processing pipeline assists quantitative analysis of high throughput DTI data.

Ministry of health clinical practice guidelines: clinical blood transfusion

The Health Sciences Authority (HSA) and the Ministry of Health (MOH) publish clinical practice guidelines on Clinical Blood Transfusion to provide doctors and patients in Singapore with evidence-based guidance for blood transfusion. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HSA-MOH clinical practice guidelines on Clinical Blood Transfusion, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=25700). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Obstetric outcomes in women with end-stage renal disease on chronic dialysis: a review

Pregnancies in women on chronic dialysis for end-stage renal disease are high risk, but outcomes appear to have improved with increasing experience and advances in dialysis care. This paper reviews the existing data on outcomes in such pregnancies to enable evidence-based preconception counselling and anticipation of antenatal complications.

Molar pregnancy with false negative urine hCG: the hook effect

Urine pregnancy tests are widely used in emergency departments as the first screening test for patients of reproductive age presenting with gynaecological problems in order to rule out pregnancy. Conditions such as complete molar pregnancy, which produces large amounts of beta human chorionic gonadotropin (beta-hCG), may cause a false negative result due to an oversaturation of the assay system, known as the "hook effect". We report a case where the exclusion of pregnancy by urine testing led to the initial misdiagnosis of a molar pregnancy as a degenerative fibroid. Physicians need to be reminded of the possibility of false negative results with this commonly used test. Negative or inconclusive results in patients with a high suspicion of pregnancy should be further evaluated by serum quantification of beta-hCG and appropriate sample dilution.

B-Lynch suture for the treatment of uterine atony

INTRODUCTION

Over 125,000 women die of postpartum haemorrhage (PPH) each year, with the commonest cause being uterine atony (75-90 percent). Failing conservative management, hysterectomy is usually the final resort. In 1997, Christopher B-Lynch devised an innovative technique to treat uterine atony, and it has been widely used around the world since its original report. However, there are hardly any reports of this technique being utilised in East Asian countries, including Singapore. Our study reviews the cases in which the B-Lynch suture was used to treat uterine atony, and the clinical outcomes of these cases.

METHODS

A retrospective study of data of all women who delivered between May 2004 and June 2007 was collected from the department's database, to identify patients who had undergone the B-Lynch procedure. Primary PPH is defined as a blood loss of more than 500 ml at or within 24 hours of delivery.

RESULTS

There were a total of 5,470 deliveries during this period, with primary PPH occurring in 100 cases. The B-Lynch procedure was performed in seven women, avoiding the need for a hysterectomy in five cases.

CONCLUSION

Our series of cases treated with the B-Lynch procedure showed that it is an effective method of containing PPH. It has the advantage of being applied easily and rapidly, and should be taught to all trainees and registrars in obstetrics. It should be attempted when conservative management of PPH fails and before any radical surgery is considered.

Foetal peak systolic velocity in the middle cerebral artery: an Asian reference range

INTRODUCTION

The aim of this study was to establish reference values of peak systolic blood flow velocity measurement in the foetal middle cerebral artery (MCA-PSV) in the local Asian obstetric population and to compare our reference ranges with those of previously-published studies.

METHODS

329 normal pregnant women attending the outpatient antenatal clinics of the Department of Obstetrics and Gynaecology in the Singapore General Hospital underwent Doppler ultrasonography at least once between 16 and 40 weeks' gestation. The blood flow velocity recordings from the foetal middle cerebral artery were obtained. New reference ranges were constructed by regressing each parameter on gestational age.

RESULTS

New reference ranges for foetal middle cerebral artery with gestation were constructed for an Asian population. Our reference curves were compared with that of a previously-constructed one.

CONCLUSION

MCA-PSV increases with advancing gestational age. There appear to be differences between Asian and non-Asian reference ranges for MCA-PSV.

Occult Axillary Node Metastases in Breast Cancer Are Prognostically Significant: Results in 368 Node-Negative Patients With 20-Year Follow-Up

Purpose

In breast cancer, sentinel lymph node (SLN) biopsy allows the routine performance of serial sections and/or immunohistochemical (IHC) staining to detect occult metastases missed by conventional techniques. However, there is no consensus regarding the optimal method for pathologic examination of SLN, or the prognostic significance of SLN micrometastases.

Patients and Methods

In 368 patients with axillary node-negative invasive breast cancer, treated between 1976 and 1978 by mastectomy, axillary dissection, and no systemic therapy, we reexamined the axillary tissue blocks following our current pathologic protocol for SLN. Occult lymph node metastases were categorized by pattern of staining (immunohistochemically positive or negative [IHC±], hematoxylin-eosin staining positive or negative [H & E ±]), number of positive nodes (0, 1, > 1), number of metastatic cells (0, 1 to 20, 21 to 100, > 100), and largest cluster size (≤ 0.2 mm [pN0i+], 0.3 to 2.0 mm [pN1mi], > 2.0 mm [pN1a]). We report 20-year results as overall survival (OS), disease-free survival (DFS), and disease-specific death (DSD).

Results

A total of 23% of patients (83 of 368) were converted to node-positive. Of these, 73% were ≤ 0.2 mm in size (pN0i+), 20% were 0.3 to 2.0 mm (pN1mi), and 6% were more than 2 mm (pN1a). On univariate and multivariate analysis, pattern of staining, number of positive nodes, number of metastatic cells, and cluster size were all significantly related to both DFS and DSD. On multivariate analysis, each of these measures had significance comparable to, or greater than, tumor size, grade or lymphovascular invasion.

Conclusion

In breast cancer patients staged node-negative by conventional single-section pathology, occult axillary node metastases detected by our current pathologic protocol for SLN are prognostically significant.

The association between maternal depression and frequent non-routine visits to the infant's doctor--a cohort study

BACKGROUND

Perinatal depression is common, but women typically do not seek help for it. We studied its association with frequent non-routine physician visits, which may be a form of help-seeking behaviour.

METHODS

A prospective cohort study of women in their 34th to 38th week of pregnancy at the outpatient obstetrics clinic at a Singapore tertiary hospital was done. Screening was done using the Edinburgh Postnatal Depression Scale and diagnosis of major or minor depressive disorder was made using the SCID-IV. At 6 to 12 months' post-partum, women were screened and interviewed again for depression and asked to report the frequencies with which they had brought their infants to the doctor on non-routine visits in the preceding 6 weeks. Four hundred and seventy-one of the 559 patients recruited before delivery were re-interviewed.

RESULTS

After adjusting for confounders, women who had brought their infants for three or more non-routine visits to the infant's doctor had a significantly higher prevalence of depression (32.6%) than those with fewer visits (13.6%) (OR 2.87, 95% CI 1.41 to 5.85, p=0.004). The relative risk reduction for women who did not bring their infants for frequent non-routine visits was 0.583 (95% CI 0.44 to 0.73, p=0.002). They were also more likely to have poorer perceived emotional support from their families.

LIMITATIONS

These included use of self-reported doctor visits, and relatively high educational levels of the participants.

CONCLUSIONS

Doctors should have a high index of suspicion for enquiring about depression and emotional support in mothers who bring their infants for frequent non-routine visits.

Delayed bleeding after liver biopsy: a dreaded complication

We present an unusual case of percutaneous liver biopsy complicated by delayed haemothorax in a 55-year-old Chinese man with hepatitis C cirrhosis and severe haemophilia A. The patient presented ten days after the initial liver biopsy, and was managed with prompt investigations for confirming the diagnosis, infusion of factor VIII and fresh frozen plasma, and early referral to the surgeon for consideration of surgical repair. The importance of early detection and aggressive therapy is emphasised.

Ultrasonographical features of morbidly-adherent placentas

Morbidly-adherent placentas manifest as placenta accreta, increta or percreta, depending on the depth of placental invasion. These conditions present high risks of severe obstetrical haemorrhage at delivery. The underlying pathology is due to defects in the decidua basalis caused by a variety of insults, such as previous surgery, excessive curettage or infection. The incidence of morbidly-adherent placentas is rising as the frequency of caesarean sections increase. Imaging plays an important role in the antenatal detection of this condition. Based on the case series seen at our local institution, we describe the imaging characteristics of this condition as seen on grayscale ultrasonography, colour/power Doppler ultrasonography, three-dimensional ultrasonography and magnetic resonance imaging.

Outcomes for Women With Ductal Carcinoma-in-Situ and a Positive Sentinel Node: A Multi-Institutional Audit

BACKGROUND

A positive sentinel lymph node (SLN) has been reported in 6% to 13% of patients with ductal carcinoma in situ (DCIS). Although it is well established that nodal status for invasive disease is prognostically important, the clinical relevance of a positive SLN in patients with DCIS remains undetermined.

METHODS

SLN biopsy was performed on 470 high-risk patients with DCIS (22% of all patients with DCIS) at 3 institutions. Of these, 43 (9%) had SLN metastases. Pathology findings of positive cases were reviewed, and follow-up was obtained. At 2 of the 3 institutions, data were also collected on DCIS patients who had negative findings on SLN biopsy. For these 414 patients, univariate analyses of tumor characteristics were performed to identify factors associated with node positivity.

RESULTS

Extensive disease requiring mastectomy (p = 0.02) and the presence of necrosis (p = 0.04) were associated with an increased risk of nodal positivity. Three (7%) of the 43 SLN-positive patients had macrometastases (pN1), 4 (9%) had micrometastases (pN1mi), and 36 (84%) had single tumor cells or small clusters (pN0(i+)). Of the 25 women that underwent completion axillary dissection, one was found to have a macrometastasis. On pathological review of the primary lesion, 2 (5%) of 43 patints were found to have microinvasion, and 2 (5%) lymphovascular invasion. Nine of 43 (21%) high-risk DCIS patients with a positive SLN and 9/470 (2%) of all high-risk DCIS patients were upstaged to AJCC stage I or II as a result of the SLN biopsy. At a median (range) follow-up of 27 (3-88) months, 1 patient had developed hepatic metastases. This patient had immunohistochemistry detected isolated tumor cells in her SLN (N0(i+)), and upon pathologic review, was found to have high-grade DCIS with microinvasion.

CONCLUSION

SLN biopsy for high-risk DCIS patients is a mean of detecting those who may have unrecognized invasive disease and therefore are at risk for distant disease.

Perpendicular inked versus tangential shaved margins in breast-conserving surgery: does the method matter?

BACKGROUND

In breast-conserving surgery (BCS), the method of margin assessment and the definition of a negative margin vary widely. The purpose of this study was to compare the incidence of positive margins and rates of reexcision between two methods of margin assessment at a single institution.

STUDY DESIGN

In July 2004, our protocol for margin evaluation changed from perpendicular inked margins (Group A, n=263) to tangential shaved margins (Group B, n=261). In Group A, margins were classified as positive, close, and negative. Margins designated as "close" were further defined as: < or = 1 mm, < or = 2 mm, and < or =3 mm. In Group B, shaved margins (by definition 2 to 3 mm) were reported as positive or negative.

RESULTS

The rate of reported "positive" margins was significantly higher in Group B: 127 of 261 (49%) versus 42 of 263 (16%), p < 0.001. But when patients with "positive, close, or both" kinds of margins were combined in Group A, there was no significant difference between the two techniques. Although the shaved margin was 2- to 3-mm thick, the rate of reexcision in Group B was significantly higher when compared with that in patients with "positive, close, or both" < or =3 mm margins in Group A (75% versus 52%, p < 0.001). The likelihood of finding residual disease remained the same (27% versus 32%, p=NS).

CONCLUSIONS

The tangential shaved-margin technique results in a higher proportion of reported positive margins and limits the ability of the surgeon to discriminate among patients with close margins, resulting in a higher rate of reexcision. The fact that many, but not all, patients with positive or close margins in both groups underwent reexcision emphasizes the role of surgical judgment in this setting. Longer followup is required to determine equivalency in rates of local recurrence between these two methods of margin assessment.

Intrapartum maternal sinus bradycardia with spontaneous resolution following delivery

Pregnancy is a normal physiological state that is characterised by significant adaptive changes, many of which take place in the cardiovascular system. These adaptations are believed to be the cause for the increased incidence in cardiac arrhythmias in pregnancy and particularly, in labour. We report an unusual case of a healthy 32-year-old primigravida who developed profound intrapartum bradycardia which persisted throughout labour. Spontaneous recovery to pre-labour baseline heart rate occurred following spontaneous vaginal delivery. Maternal and foetal statuses remained satisfactory during labour. This case report underscores the importance of recognising that arrhythmias in various forms are common in labour. In the absence of detectable underlying cardiac disease or maternal and foetal compromise, continuation of the labour with a view to vaginal delivery should be the goal.

Tocolytic treatment for the management of preterm labour: a systematic review

Spontaneous preterm labour and delivery accounts for approximately one-third of preterm births, which is the predominant cause of perinatal mortality and morbidity. This review aims to evaluate the evidence on the benefits and harms of five classes of tocolytic therapy, namely: betamimetics, calcium channel blockers, magnesium, non-steroidal anti-inflammatory agents, and atosiban. We performed a systematic review of the effectiveness of tocolytics to stop uterine contractions (first-line therapy). Reports of randomised controlled trials from searches of MEDLINE, bibliographies of review articles, Cochrane Collaboration and its Pregnancy and Childbirth Review Group between 1966 and 2003 were identified, using the search terms "randomised controlled trial" (RCT), "preterm labor", "tocolysis", "betamimetics", "ritodrine", "prostaglandin synthetase inhibitors", "indomethacin", "calcium channel blockers", "nifedipine", "oxytocin receptor blockers", "atosiban", and "magnesium sulphate". Studies on women with preterm labour comparing the effects of a tocolytic with a placebo or no treatment that met our inclusion criteria, were included. To our knowledge, the trials were conducted mainly before 1999 and there were no placebo-controlled trials after that. Of the 86 articles identified and evaluated, 14 first-line studies met more stringent requirements for meta-analyses. Tocolytics were associated with significant decreases in the odds of delivery within 24 hours (odds-ratio [OR] 0.54, 95 percent confidence interval [CI] 0.32-0.91) and 48 hours (OR 0.47, 95 percent CI 0.30-0.75). These effects were significant for beta-agonists, atosiban and indomethacin, but not magnesium sulphate. Maternal side-effects significantly associated with betamimetics were pulmonary oedema, cardiac arrhthymias and hypokalaemia. Although calcium antagonists have not been evaluated against placebo, comparative trials with beta-agonists have shown more favourable neonatal outcomes and better prolongation of gestation. In conclusion, the management of threatened preterm labour with first-line tocolytic therapy can prolong gestation. However, the time gained in-utero need to be optimised. There is no clear first-line tocolytic agent. The use of tocolytic agents should be individualised and based on maternal condition, potential side-effects and gestational age.

Confinement and other psychosocial factors in perinatal depression: a transcultural study in Singapore

BACKGROUND

To investigate the prevalence, socio-cultural and psychosocial risk factors for perinatal depression in Singaporean women.

METHOD

A prospective cohort of 559 women was interviewed antenatally and at six weeks' postpartum at a tertiary hospital. Women were interviewed for diagnosis of depression using a two-stage design, with a screening questionnaire and diagnostic interview.

RESULTS

Postnatally, a negative confinement experience was associated with depression. Other independent factors included poor emotional support, a past history of depression, unplanned pregnancy and perceived potential conflicts with relatives over childcare antenatally and dissatisfaction, poor instrumental support postnatally. The prevalence of depression antenatally and postnatally was 12.2% and 6.8%, respectively.

LIMITATIONS

Measures of satisfaction with social support were based on self-report; there were high dropout rates at six weeks' postpartum; and other modulating social factors such as pre-existing interpersonal conflicts were not studied.

CONCLUSIONS

Perinatal depression in Singaporean women is common. Contrary to expectations, a negative 'confinement' experience is a significant risk factor for postnatal depression, and is not universally welcomed by women. Depression is modulated by dissimilar sets of psychosocial factors antenatally and postnatally.

Expression of WT1, CA 125, and GCDFP-15 as Useful Markers in the Differential Diagnosis of Primary Ovarian Carcinomas Versus Metastatic Breast Cancer to the Ovary

Metastatic breast carcinoma to the ovary is sometimes difficult to differentiate from primary ovarian carcinoma. This problem is often encountered in breast carcinoma patients who develop adnexal masses. ER and PR can be positive in a high percentage of breast and ovarian carcinomas, and therefore cannot be used in the differential diagnosis of these entities. WT1 and CA125 have been identified as possible markers for ovarian cancer. However, no studies have been done that specifically compare the immunophenotype of breast carcinoma metastatic to ovary with that of primary ovarian cancer. Thirty-nine cases of metastatic breast carcinoma to the ovary, 36 primary breast carcinomas, and 42 primary ovarian carcinomas were examined immunohistochemically for the expression of WT1, CA125, carcinoembryonic antigen, MUC2, MUC1, and GCDFP. The percentage of cells stained and the intensity of staining were recorded. Thirty-two ovarian carcinomas (76%) were positive for WT1, including 31 of 33 (94%) serous carcinomas. Most of them had strong and diffuse staining. None of the breast cancers either primary or metastatic to the ovary expressed WT1. Thirty-eight (90%) ovarian carcinomas were positive for CA125, most of them with strong and diffuse staining. Most breast carcinomas were negative for CA125, with only 6 (16%) of the primary ones and 5 (12%) of the metastatic showing weak and focal positivity. All ovarian carcinomas were negative for GCDFP. Five primary breast cancers (14%) and 17 (43%) metastatic to the ovary were positive for GCDFP. Nine (21%) ovarian carcinomas, 8 (22%) primary breast carcinomas, and 13 (33%) metastatic to the ovary were positive for carcinoembryonic antigen. Almost all tumors examined were positive for MUC1 (100% ovarian carcinomas, 100% primary breast carcinomas, and 95% metastatic breast carcinomas to ovary). MUC2 was positive in 10 (24%) ovarian carcinomas, 3 (8%) primary breast cancers, and 12 (30%) metastases to the ovary. The presence of immunoreactivity for WT1 and CA125 in a carcinoma involving ovary strongly favors a primary lesion. Most ovarian carcinomas are positive for both markers, whereas the majority of metastatic breast carcinomas to the ovary are negative. GCDFP can be complementary in this differential diagnosis.

Correlation of HER-2 status with estrogen and progesterone receptors and histologic features in 3,655 invasive breast carcinomas

We studied the inverse relationship between HER-2 and estrogen (ER) and progesterone (PR) receptors using HER-2 testing and correlated HER-2 status with histologic features in 3,655 unselected invasive breast carcinomas. Immunohistochemical analysis for ER, PR, and HER-2 and fluorescence in situ hybridization for HER-2 were performed. ER and PR expression were decreased significantly in HER-2+ tumors compared with HER-2- tumors (ER, 49.1% vs 78.17%; PR, 24.3% vs 53.13%). Even among HER-2+ tumors, the rate of ER or PR expression in high-grade tumors was significantly decreased compared with intermediate-grade tumors. HER-2 was positive in 10.87% of grade 2 and 27.84% of grade 3 ductal carcinomas and negative in all grade 1 ductal carcinomas. HER-2 overexpression or amplification essentially was limited to grades 2 and 3 ductal carcinomas and correlated inversely with ER or PR expression. Although ER or PR expression is decreased in HER-2+ tumors, a substantial proportion of them still express ER or PR.

A phase II trial of imatinib mesylate monotherapy in patients with metastatic breast cancer

BACKGROUND

Imatinib mesylate is a potent inhibitor of Abl, KIT, and PDGFR tyrosine kinases. Breast cancer has variable expression of KIT and PDGFR therefore we conducted a phase II trial to evaluate the safety and efficacy of imatinib in patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

Eligible patients had measurable and progressive MBC, with no limits on prior chemo- or hormonal therapy. Imatinib was initially administered at a dose of 400 mg orally twice a day with provisions for dose reductions based on toxicities. The primary endpoint was clinical benefit based on RECIST criteria. Tumor specimens were tested for expression of KIT and PDGFR tyrosine kinases.

RESULTS

Sixteen patients were enrolled and treated. Median age was 55 years (range: 35-73); median number of prior chemotherapy regimens for MBC was 4 (range 1-8). The main non-hematologic toxicities were (Grades 1/2; Grade 3): fatigue (56%; 6%), edema (38%; 19%), nausea (31%; 19%), vomiting (38%; 0%), anorexia (38%; 0%), diarrhea (19%; 6%), and rash (25%; 6%). Grade 3/4 hematologic and biochemical abnormalities were minimal. There was no evidence of clinical benefit. The median duration of therapy on trial was 28 days (range 2-71). Of the 13 testable cases: 1 was KIT positive and 4 were PDGFR positive.

CONCLUSION

Imatinib therapy at doses of 800 mg/day was associated with significant toxicity in patients with heavily pre-treated MBC. Our results do not indicate activity for imatinib monotherapy in these unselected patients.

The results of frozen section, touch preparation, and cytological smear are comparable for intraoperative examination of sentinel lymph nodes: a study in 133 breast cancer patients

BACKGROUND

The goal of intraoperative sentinel lymph node (SLN) examination is to avoid reoperation for a positive SLN, but the ideal method of intraoperative SLN examination remains unclear, and published results vary widely.

METHODS

We evaluated the sensitivity of intraoperative frozen section (FS), touch preparation (TP), and cytological smear (CS) in 305 SLNs from 133 breast cancer patients. Each SLN was received fresh and cut into 2- to 3-mm slices; TP and CS from each cut surface and an FS of the entire SLN were obtained. Postoperative evaluation of the SLN consisted of 1 hematoxylin and eosin-stained section and of one hematoxylin and eosin-stained and one immunohistochemically stained section for cytokeratin from each of two levels 50 microm apart. Tumor cells found by any method, including immunohistochemistry, identified a positive SLN. Three pathologists blinded to the final SLN diagnosis reviewed all TP, CS, and FS; the consensus diagnosis (concordance of two or more) was used for the study.

RESULTS

FS, TP, and CS had comparable sensitivities (59%, 57%, and 59%, respectively). Each method was more sensitive in detecting macrometastases (>2 mm; 96%, 93%, and 93%, respectively) than micrometastases (< or =2 mm; 27%, 27%, and 30%, respectively). The combination of methods only marginally improved the intraoperative sensitivity. TP and CS were each responsible for a single false-positive result.

CONCLUSIONS

FS, TP, and CS are comparable for the intraoperative detection of SLN metastases, and each method is substantially better at detecting micrometastases than micrometastases. The combination of two or more techniques only marginally improves the sensitivity over that achieved by a single method.

A tool for predicting breast carcinoma mortality in women who do not receive adjuvant therapy

BACKGROUND

Among the several proposed risk classification schemes for predicting survival in women with breast carcinoma, one of the most commonly used is the Nottingham Prognostic Index (NPI). The goal of the current study was to use a continuous prognostic model (similar to those that have already been demonstrated to possess greater predictive accuracy than risk group-based models in other malignancies) to predict breast carcinoma mortality more accurately compared with the NPI.

METHODS

A total of 519 women who had been treated with mastectomy and axillary lymph node dissection at Memorial Sloan-Kettering Cancer Center (New York, NY) between 1976 and 1979 met the following requirements for study inclusion: confirmation of the presence of invasive mammary carcinoma, no receipt of neoadjuvant or adjuvant systemic therapy, no previous history of malignancy, and negative lymph node status as assessed on routine histopathologic examination. Paraffin blocks were available for 368 of the 519 eligible patients. All available axillary lymph node tissue blocks were subjected to enhanced pathologic analysis. The competing-risk method was used to predict disease-specific death, and the accuracy of the novel prognostic model that emerged from this process was evaluated using the concordance index. Jackknife and 10-fold cross-validation predictions yielded by this new model were compared with predictions yielded by the NPI.

RESULTS

Of the 348 women for whom complete data were available, 73 died of disease; the 15-year probability of breast carcinoma-related death was 20%. On the basis of these 348 cases, the authors developed a prognostic model that took patient age, disease multifocality, tumor size, tumor grade, lymphovascular invasion, and enhanced lymph node staining into account, and using competing-risks regression analysis, they found that this new model predicted disease-specific death more accurately compared with the NPI.

CONCLUSIONS

The authors have developed a model for predicting breast carcinoma-specific death with improved accuracy. This tool should be useful in counseling patients with regard to their specific need for adjuvant therapy.

Cytokeratin-positive cells in sentinel lymph nodes in breast cancer are not random events: experience in patients undergoing prophylactic mastectomy

BACKGROUND

The incidence of immunohistochemistry (IHC)-detected epithelial cell displacement in sentinel lymph node (SLN) biopsy is unknown. In the current study, we address this question by examining the pattern of SLN involvement in patients undergoing prophylactic mastectomy (PM) at Memorial Sloan-Kettering Cancer Center (New York, NY).

METHODS

Between January 1999 and January 2003, 5275 patients underwent SLN biopsy. Unilateral or bilateral PM with SLN biopsy was performed in 143 (2.7%) patients, representing 163 PM cases.

RESULTS

Occult carcinoma was identified in 13 of 163 (8.0%) PM specimens. Two patients with occult invasive carcinoma had positive SLNs (hematoxylin and eosin). In the remaining 150 PM cases without occult carcinoma (130 patients), 89% underwent IHC analysis of the SLNs. Of these 130 patients, 43 (33%) had one or more prior biopsies in their "cancer-free" breast, a median of 43 days (range, 3-314 days) before PM. A total of 310 SLNs were examined by IHC (mean, 2.3 lymph nodes per PM case). Only 1 of 130 (0.8%) patients without occult carcinoma had an IHC-positive SLN. This patient had Stage IIIC carcinoma of the contralateral breast. IHC-positive SLNs were not identified in any of the 43 patients with a history of prior biopsy. Therefore, only 1 IHC-positive SLN was detected in 310 (0.3%) lymph nodes examined.

CONCLUSIONS

IHC-positive cells in SLNs are rare in the absence of cancer and are not the result of previous breast instrumentation. Although the prognostic significance of IHC-positive cells remains controversial, the current study suggests that they are not random events.