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Hart JK, Michael P, Hawkins R, Bull ER, Farrar A, Baguley C, Turner RR, Byrne-Davis LMT. 'We just need to find space for them to practice so that we can help to make a stronger society': Perceived barriers and facilitators to employing health psychologists in UK public health and clinical health settings. Br J Health Psychol 2023; 28:1206-1221. [PMID: 37455260 DOI: 10.1111/bjhp.12680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/16/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION In recent years, health psychology has received significant attention within the health sector, due to its application to understanding influences on health and well-being and translation of health psychology into interventions to support behaviour change. The number of health psychologists in public health and healthcare settings is growing but remains limited, and is it unclear why. This study aimed to explore the views of potential and current employers of health psychologists, to elucidate barriers and facilitators of employing health psychologists in healthcare settings. METHODS Semi-structured interviews were carried out to explore the experiences of working with and/or employing health psychologists. Opportunities and barriers were explored for increasing access to health psychology expertise in the NHS and public health. Interviews were analysed using inductive thematic analysis. RESULTS Fifteen participants took part in interviews. Participants were mid-senior-level professionals working in varied healthcare settings and/or academic institutions. The majority had experience of health psychology/working with health psychologists, whilst others had limited experience but an interest in employing health psychologists. Three key themes were identified: (1) the organizational fit of health psychologists, (2) perception of competition for roles and (3) ideas for changing hearts, minds and processes. CONCLUSION Barriers exist to employing health psychologists in healthcare settings. These barriers include misunderstandings of the role of health psychologists and the need to preserve other disciplines due to perceived competition. Recommendations for change included showcasing the benefits and skills of health psychologists and having transparent conversations with employees and multi-disciplinary colleagues about roles.
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Affiliation(s)
- J K Hart
- Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
| | - P Michael
- Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
| | - R Hawkins
- Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
| | - E R Bull
- Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust & Derbyshire County Council, Manchester, UK
| | | | | | - R R Turner
- Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
| | - L M T Byrne-Davis
- Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
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Cochran AJ, Wen DR, Huang RR, Abrishami P, Smart C, Binder S, Scolyer RA, Thompson JF, Stern S, Van Kreuningen L, Elashoff DE, Sim MS, Wang HJ, Faries MB, Kirkwood J, Daly J, Kutner M, Mihm M, Smith G, Urist M, Beegun N, Thompson JF, Mozzillo N, Nieweg OE, Roses DF, Hoekstra HJ, Karakousis CP, Reintgen DS, Leong SP, Coventry BJ, Kraybill WG, Smithers BM, Nathanson SD, Huth JF, Wong JH, Fraker DL, McKinnon JG, Paul E, Morton DL, Botti G, Tiebosch A, Strutton GM, Whitehead FJ, Peterse HJ, Epstein HD, Goodloe S, Scolyer RA, McCarthy SW, Melamed J, Messina J, Moffitt HL, Turner RR, Wunsch PH. Sentinel lymph node melanoma metastases: Assessment of tumor burden for clinical prediction of outcome in the first Multicenter Selective Lymphadenectomy Trial (MSLT-I). Eur J Surg Oncol 2022; 48:1280-1287. [DOI: 10.1016/j.ejso.2022.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/22/2021] [Accepted: 01/19/2022] [Indexed: 02/05/2023] Open
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Turner RR, Mitchell CPJ, Kopec AD, Bodaly RA. Tidal fluxes of mercury and methylmercury for Mendall Marsh, Penobscot River estuary, Maine. Sci Total Environ 2018; 637-638:145-154. [PMID: 29751297 DOI: 10.1016/j.scitotenv.2018.04.395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/27/2018] [Accepted: 04/29/2018] [Indexed: 05/28/2023]
Abstract
Tidal marshes are both important sites of in situ methylmercury production and can be landscape sources of methylmercury to adjacent estuarine systems. As part of a regional investigation of the Hg-contaminated Penobscot River and Bay system, the tidal fluxes of total suspended solids, total mercury and methylmercury into and out of a regionally important mesohaline fluvial marsh complex, Mendall Marsh, were intensively measured over several tidal cycles and at two spatial scales to assess the source-sink function of the marsh with respect to the Penobscot River. Over four tidal cycles on the South Marsh River, the main channel through which water enters and exits Mendall Marsh, the marsh was a consistent sink over typical 12-h tidal cycles for total suspended solids (8.2 to 41 g m-2), total Hg (9.2 to 47 μg m-2), total filter-passing Hg (0.4 to 1.1 μg m-2), and total methylmercury (0.2 to 1.4 μg m-2). The marsh's source-sink function was variable for filter-passing methylmercury, acting as a net source during a large spring tide that inundated much of the marsh area and that is likely to occur during approximately 17% of tidal cycles. Additional measurements on a small tidal channel draining approximately 1% of the larger marsh area supported findings at the larger scale, but differences in the flux magnitude of filter-passing fractions suggest a highly non-conservative transport of these fractions through the tidal channels. Overall the results of this investigation demonstrate that Mendall Marsh is not a significant source of mercury or methylmercury to the receiving aquatic systems (Penobscot River and Bay). While there is evidence of a small net export of filter-passing (<0.4 μm pore size) methylmercury under some tidal conditions, the mass involved represents <3% of the mass of filter-passing methylmercury carried by the Penobscot River.
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Affiliation(s)
- R R Turner
- RT Geosciences Inc, 3398 Kingburne Dr., Cobble Hill, B.C. V0R 1L5, Canada.
| | - C P J Mitchell
- Department of Physical & Environmental Sciences, University of Toronto Scarborough, 1265 Military Trail, Toronto, ON M1C 1A4, Canada.
| | - A D Kopec
- Penobscot River Mercury Study, 479 Beechwood Ave., Old Town, ME 04468, USA.
| | - R A Bodaly
- Penobscot River Mercury Study, 115 Oystercatcher Place, Salt Spring Island, B.C. V8K 2W5, Canada
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Turner RR, Kopec AD, Charette MA, Henderson PB. Current and historical rates of input of mercury to the Penobscot River, Maine, from a chlor-alkali plant. Sci Total Environ 2018; 637-638:1175-1186. [PMID: 29801211 DOI: 10.1016/j.scitotenv.2018.05.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 02/28/2018] [Accepted: 05/07/2018] [Indexed: 06/08/2023]
Abstract
Mercury inputs by surface and ground water sources to Penobscot River from a defunct Hg-cell chlor-alkali plant were measured in 2009-10 and estimated for the entire period of operation of this facility. Over the measured interval (422 days) approximately 2.3 kg (5.4 g day-1) of mercury was discharged to the Penobscot River by the two surface streams that drain the site, with most of the combined loading (1.8 kg Hg, 78%) associated with a single storm with rainfall in excess of 100 mm. Groundwater seepage rates from the site, as estimated from both a radon tracer and seepage meter methods were in the range of 3 to 4 cm day-1 and, when combined with a best estimate of the area of groundwater discharge (11,000 m2) and average seepage/porewater mercury concentration (242 ng L-1, UCL95), yielded a loading of 0.11 g day-1 for site groundwater. None of the municipal or other industrial point sources of mercury to the river between Veazie and Bucksport, Maine exceeded 1 g day-1 individually, nor was the aggregate loading of all such sources >3 g day-1 (based on State of Maine data). Mercury loadings for the three largest tributaries downstream of Veazie Dam were estimated to contribute 4.2, 3.7 and 2.5 g day-1, respectively, to the Penobscot River. Based on sampling (total Hg ~ 2 to 4 ng L-1) and historical mean discharge data (340-460 m3 s-1), the Penobscot River upstream of the plant site contributes as much as 160 g day-1 to the downstream reach depending on river discharge. Estimates of historical (1967-2012) mercury loading using both generic emission factors and measured releases ranged from 2.6 to 27 MT while the mass of mercury found in downstream sediments amounted to 9 MT.
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Affiliation(s)
- R R Turner
- RT Geosciences Inc., 3398 Kingburne Dr., Cobble Hill, B.C. V0R 1L5, Canada.
| | - A D Kopec
- Penobscot River Mercury Study, 479 Beechwood Ave., Old Town, ME 04468, USA.
| | - M A Charette
- Department of Marine Chemistry and Geochemistry, Woods Hole Oceanographic Institution, 266 Woods Hole Rd, Woods Hole, MA 02543, USA.
| | - P B Henderson
- Department of Marine Chemistry and Geochemistry, Woods Hole Oceanographic Institution, 266 Woods Hole Rd, Woods Hole, MA 02543, USA.
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Nakhleh RE, Nosé V, Colasacco C, Fatheree LA, Lillemoe TJ, McCrory DC, Meier FA, Otis CN, Owens SR, Raab SS, Turner RR, Ventura CB, Renshaw AA. Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology: Guideline From the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med 2016; 140:29-40. [PMID: 25965939 DOI: 10.5858/arpa.2014-0511-sa] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT Additional reviews of diagnostic surgical and cytology cases have been shown to detect diagnostic discrepancies. OBJECTIVE To develop, through a systematic review of the literature, recommendations for the review of pathology cases to detect or prevent interpretive diagnostic errors. DESIGN The College of American Pathologists Pathology and Laboratory Quality Center in association with the Association of Directors of Anatomic and Surgical Pathology convened an expert panel to develop an evidence-based guideline to help define the role of case reviews in surgical pathology and cytology. A literature search was conducted to gather data on the review of cases in surgical pathology and cytology. RESULTS The panel drafted 5 recommendations, with strong agreement from open comment period participants ranging from 87% to 93%. The recommendations are: (1) anatomic pathologists should develop procedures for the review of selected pathology cases to detect disagreements and potential interpretive errors; (2) anatomic pathologists should perform case reviews in a timely manner to avoid having a negative impact on patient care; (3) anatomic pathologists should have documented case review procedures that are relevant to their practice setting; (4) anatomic pathologists should continuously monitor and document the results of case reviews; and (5) if pathology case reviews show poor agreement within a defined case type, anatomic pathologists should take steps to improve agreement. CONCLUSIONS Evidence exists that case reviews detect errors; therefore, the expert panel recommends that anatomic pathologists develop procedures for the review of pathology cases to detect disagreements and potential interpretive errors, in order to improve the quality of patient care.
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Affiliation(s)
- Raouf E Nakhleh
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida (Dr Nakhleh); the Department of Pathology, Massachusetts General Hospital, Boston (Dr Nosé); Governance (Ms Colasacco) and the Pathology and Laboratory Quality Center (Mss Fatheree and Ventura), College of American Pathologists, Northfield, Illinois; Hospital Pathology Associates, Abbott Northwestern Hospital, Minneapolis, Minnesota (Dr Lillemoe); the Department of Medicine, Duke University, Durham, North Carolina (Dr McCrory); the Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, Michigan (Dr Meier); the Department of Pathology, Baystate Medical Center, Springfield, Massachusetts (Dr Otis); the Department of Pathology, University of Michigan Medical School, Ann Arbor (Dr Owens); the Department of Pathology, Memorial University of Newfoundland/Eastern Health Authority, St John's, Newfoundland, Canada (Dr Raab); the Department of Pathology, St John's Health Center, Santa Monica, California (Dr Turner); and the Department of Pathology, Homestead Hospital, Homestead, Florida (Dr Renshaw). Dr Meier is currently with the Department of Pathology, Massachusetts General Hospital, Boston
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Lyman GH, Temin S, Edge SB, Newman LA, Turner RR, Weaver DL, Benson AB, Bosserman LD, Burstein HJ, Cody H, Hayman J, Perkins CL, Podoloff DA, Giuliano AE. Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2014; 32:1365-83. [DOI: 10.1200/jco.2013.54.1177] [Citation(s) in RCA: 541] [Impact Index Per Article: 54.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PurposeTo provide evidence-based recommendations to practicing oncologists, surgeons, and radiation therapy clinicians to update the 2005 clinical practice guideline on the use of sentinel node biopsy (SNB) for patients with early-stage breast cancer.MethodsThe American Society of Clinical Oncology convened an Update Committee of experts in medical oncology, pathology, radiation oncology, surgical oncology, guideline implementation, and advocacy. A systematic review of the literature was conducted from February 2004 to January 2013 in Medline. Guideline recommendations were based on the review of the evidence by Update Committee.ResultsThis guideline update reflects changes in practice since the 2005 guideline. Nine randomized clinical trials (RCTs) met systematic review criteria for clinical questions 1 and 2; 13 cohort studies informed clinical question 3.RecommendationsWomen without sentinel lymph node (SLN) metastases should not receive axillary lymph node dissection (ALND). Women with one to two metastatic SLNs planning to undergo breast-conserving surgery with whole-breast radiotherapy should not undergo ALND (in most cases). Women with SLN metastases who will undergo mastectomy should be offered ALND. These three recommendation are based on RCTs. Women with operable breast cancer and multicentric tumors, with ductal carcinoma in situ (DCIS) who will undergo mastectomy, who previously underwent breast and/or axillary surgery, or who received preoperative/neoadjuvant systemic therapy may be offered SNB. Women who have large or locally advanced invasive breast cancer (tumor size T3/T4), inflammatory breast cancer, or DCIS (when breast-conserving surgery is planned) or are pregnant should not undergo SNB. These recommendations are based on cohort studies and/or informal consensus. In some cases, updated evidence was insufficient to update previous recommendations.
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Affiliation(s)
- Gary H. Lyman
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Sarah Temin
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Stephen B. Edge
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Lisa A. Newman
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Roderick R. Turner
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Donald L. Weaver
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Al B. Benson
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Linda D. Bosserman
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Harold J. Burstein
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Hiram Cody
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - James Hayman
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Cheryl L. Perkins
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Donald A. Podoloff
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
| | - Armando E. Giuliano
- Gary H. Lyman, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA; Sarah Temin, American Society of Clinical Oncology, Alexandria, VA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; Lisa A. Newman and James Hayman, University of Michigan, Ann Arbor, MI; Roderick R. Turner, John Wayne Cancer Institute, Santa Monica; Linda D. Bosserman, Wilshire Oncology Medical Group, Rancho Cucamonga; Armando E. Giuliano, Cedars-Sinai Medical Center, Los Angeles, CA; Donald L. Weaver,
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Abstract
Comprehensive pathologic evaluation of the sentinel lymph node using step sections and cytokeratin immunohistochemistry enhances detection of micrometastases and optimizes the staging of breast carcinoma. This review discusses our current understanding of the pathologic and molecular techniques for sentinel node examination.
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Affiliation(s)
- R R Turner
- Department of Surgery, John Wayne Cancer Institute, 2200 Santa Monica Boulevard, Santa Monica California 90404, USA.
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Qu Y, Ray PS, Li J, Cai Q, Bagaria SP, Moran C, Sim MS, Zhang J, Turner RR, Zhu Z, Cui X, Liu B. High levels of secreted frizzled-related protein 1 correlate with poor prognosis and promote tumourigenesis in gastric cancer. Eur J Cancer 2013; 49:3718-28. [PMID: 23927957 DOI: 10.1016/j.ejca.2013.07.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 06/17/2013] [Accepted: 07/15/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND Secreted frizzled-related protein 1 (sFRP1), Wnt signalling regulator, can positively or negatively regulate tumourigenesis and progression. We sought to determine the clinical relevance and the role of sFRP1 in gastric cancer development and progression. METHODS We investigated the sFRP1 protein expression levels and its clinicopathological correlations using 85 cases of human gastric samples with survival information (JWCI cohort). mRNA levels of sFRP1 and coexpressed genes were analysed using 131-sample cDNA microarray data (Ruijin cohort). The effects of sFRP1 alteration were investigated using cell proliferation, colony formation, migration, and invasion and xenograft models. RESULTS We show that sFRP1 is overexpressed in some human cancers and is significantly associated with lymph node metastasis and decreased overall survival in gastric cancer patients. Using gastric cancer cell models, we demonstrate that sFRP1 overexpression is correlated with the activation of TGFβ (transforming growth factor-beta) signalling pathway and thereby induces cell proliferation, epithelial-mesenchymal transition (EMT), and invasion. Conversely, sFRP1 knockdown shows the opposite effects. Furthermore, sFRP1 overexpression promotes tumourigenesis and metastasis in a xenograft model. CONCLUSION Our studies demonstrate that sFRP1 is a biomarker for aggressive subgroups of human gastric cancer and a prognostic biomarker for patients with poor survival. Our data provide insight into a crosstalk between Wnt and TGFβ pathways which underlies gastric cancer development and progression.
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Affiliation(s)
- Ying Qu
- Shanghai Key Laboratory of Gastric Neoplasms, Department of Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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van Hoesel AQ, Sato Y, Elashoff DA, Turner RR, Giuliano AE, Shamonki JM, Kuppen PJK, van de Velde CJH, Hoon DSB. Assessment of DNA methylation status in early stages of breast cancer development. Br J Cancer 2013; 108:2033-8. [PMID: 23652305 PMCID: PMC3670495 DOI: 10.1038/bjc.2013.136] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Molecular pathways determining the malignant potential of premalignant breast lesions remain unknown. In this study, alterations in DNA methylation levels were monitored during benign, premalignant and malignant stages of ductal breast cancer development. Methods: To study epigenetic events during breast cancer development, four genomic biomarkers (Methylated-IN-Tumour (MINT)17, MINT31, RARβ2 and RASSF1A) shown to represent DNA hypermethylation in tumours were selected. Laser capture microdissection was employed to isolate DNA from breast lesions, including normal breast epithelia (n=52), ductal hyperplasia (n=23), atypical ductal hyperplasia (n=31), ductal carcinoma in situ (DCIS, n=95) and AJCC stage I invasive ductal carcinoma (IDC, n=34). Methylation Index (MI) for each biomarker was calculated based on methylated and unmethylated copy numbers measured by Absolute Quantitative Assessment Of Methylated Alleles (AQAMA). Trends in MI by developmental stage were analysed. Results: Methylation levels increased significantly during the progressive stages of breast cancer development; P-values are 0.0012, 0.0003, 0.012, <0.0001 and <0.0001 for MINT17, MINT31, RARβ2, RASSF1A and combined biomarkers, respectively. In both DCIS and IDC, hypermethylation was associated with unfavourable characteristics. Conclusion: DNA hypermethylation of selected biomarkers occurs early in breast cancer development, and may present a predictor of malignant potential.
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Affiliation(s)
- A Q van Hoesel
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, CA 90404, USA
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Huynh KT, Takei Y, Kuo C, Scolyer RA, Murali R, Chong K, Takeshima L, Sim MS, Morton DL, Turner RR, Thompson JF, Hoon DSB. Aberrant hypermethylation in primary tumours and sentinel lymph node metastases in paediatric patients with cutaneous melanoma. Br J Dermatol 2012; 166:1319-26. [PMID: 22293026 DOI: 10.1111/j.1365-2133.2012.10867.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Debate on how to manage paediatric patients with cutaneous melanoma continues, particularly in those with sentinel lymph node (SLN) metastases who are at higher risk of poor outcomes. Management is often based on adult algorithms, although differences in clinical outcomes between paediatric and adult patients suggest that melanoma in paediatric patients differs biologically. Yet, there are no molecular prognostic studies identifying these differences. OBJECTIVES We investigated the epigenetic (methylation) regulation of several tumour-related genes (TRGs) known to be significant in adult melanoma progression in histopathology(+) SLN metastases (n = 17) and primary tumours (n = 20) of paediatric patients with melanoma to determine their clinical relevance. METHODS Paediatric patients (n = 37; ≤ 21 years at diagnosis) with American Joint Committee on Cancer stage I-III cutaneous melanoma were analysed. Gene promoter methylation of the TRGs RASSF1A, RARβ2, WIF1 and APC was evaluated. RESULTS Hypermethylation of RASSF1A, RARβ2, WIF1 and APC was found in 29% (5/17), 25% (4/16), 25% (4/16) and 19% (3/16) of histopathology(+) SLNs, respectively. When matched to adult cutaneous melanomas by Breslow thickness and ulceration, hypermethylation of all four TRGs in SLN(+) paediatric patients with melanoma was equivalent to or less than in adults. With a median follow-up of 55 months, SLN(+) paediatric patients with melanoma with hypermethylation of > 1 TRG vs. ≤ 1 TRG had worse disease-free (P = 0·02) and overall survival (P = 0·02). CONCLUSIONS Differences in the methylation status of these TRGs in SLN(+) paediatric and adult patients with melanoma may account for why SLN(+) paediatric patients have different clinical outcomes. SLN biopsy should continue to be performed; within SLN(+) paediatric patients with melanoma, hypermethylation of TRGs can be used to identify a subpopulation at highest risk for poor outcomes who warrant vigilant clinical follow-up.
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Affiliation(s)
- K T Huynh
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, CA 90404, USA
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11
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van Hoesel AQ, van de Velde CJH, Kuppen PJK, Liefers GJ, Putter H, Sato Y, Elashoff DA, Turner RR, Shamonki JM, de Kruijf EM, van Nes JGH, Giuliano AE, Hoon DSB. Hypomethylation of LINE-1 in primary tumor has poor prognosis in young breast cancer patients: a retrospective cohort study. Breast Cancer Res Treat 2012; 134:1103-14. [PMID: 22476853 DOI: 10.1007/s10549-012-2038-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 03/15/2012] [Indexed: 10/28/2022]
Abstract
Long interspersed element 1 (LINE-1), a non-coding genomic repeat sequence, methylation status can influence tumor progression. In this study, the clinical significance of LINE-1 methylation status was assessed in primary breast cancer in young versus old breast cancer patients. LINE-1 methylation index (MI) was assessed by absolute quantitative assessment of methylated alleles (AQAMA) PCR assay. Initially, LINE-1 MI was assessed in a preliminary study of 235 tissues representing different stages of ductal breast cancer development. Next, an independent cohort of 379 primary ductal breast cancer patients (median follow-up 18.9 years) was studied. LINE-1 hypomethylation was shown to occur in DCIS and invasive breast cancer. In primary breast cancer it was associated with pathological tumor stage (p = 0.026), lymph node metastasis (p = 0.022), and higher age at diagnosis (>55, p < 0.001). In multivariate analysis, LINE-1 hypomethylation was associated with decreased OS (HR 2.19, 95 % CI 1.17-4.09, log-rank p = 0.014), DFS (HR 2.05, 95 % CI 1.14-3.67, log-rank p = 0.016) and increased DR (HR 2.83, 95 % CI 1.53-5.21, log-rank p = 0.001) in younger (≤55 years), but not older patients (>55 years). LINE-1 analysis of primary breast cancer demonstrated cancer-related age-dependent hypomethylation. In patients ≤55 years, LINE-1 hypomethylation portends a high-risk of DR.
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Affiliation(s)
- Anneke Q van Hoesel
- Department of Molecular Oncology, John Wayne Cancer Institute (JWCI) at St. John's Health Center, 2200 Santa Monica Blvd., Santa Monica, CA 90404, USA
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12
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Yoshimura T, Nagahara M, Kuo C, Turner RR, Soon-Shiong P, Hoon DSB. Lymphovascular invasion of colorectal cancer is correlated to SPARC expression in the tumor stromal microenvironment. Epigenetics 2011; 6:1001-11. [PMID: 21725199 DOI: 10.4161/epi.6.8.16063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
As an integral component of the microenvironment in colorectal cancer (CRC), stromal cells can influence tumor progression. Found in the extracellular matrix of CRC, secreted protein acidic and rich in cysteine (SPARC) is expressed in stromal and CRC cells. While SPARC's influence on CRC is not clear, we hypothesized that epigenetically regulated SPARC expression in the microenvironment stromal cells of CRC can affect primary CRC progression and is influenced by lymphovascular invasion (LVI). Quantitative immunohistochemistry (IHC) analysis of paraffin-embedded (n=72) from 37 LVI-positive and 35 LVI-negative primary CRCs was performed. MassARRAY sequencing was performed to assess the methylation status of the promoter region in 22 LVI-positive and 20 LVI-negative CRC and to identify specific CpG island(s) regulating SPARC expression. SPARC in CRC cells was not correlated with LVI, whereas SPARC in the microenvironment stromal cells was inversely related to LVI (P < 0.0001). There was a direct relationship between LVI and 6 specific CpG site methylation in the SPARC promoter region of stromal cells (P = 0.017) but not in CRC cells. Stromal SPARC expression inversely correlated with VEGF-A expression in CRC (P = 0.003) and positively correlated with HSP27 expression (P = 0.009). The results suggested that the epigenetic regulation of SPARC expression in tumor cells versus stromal cells of CRC is significantly different. Stromal cell SPARC expression is epigenetically influenced by LVI of CRC tumors, and may play a significant role in primary CRC progression.
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Affiliation(s)
- Tetsunori Yoshimura
- Department of Molecular Oncology, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, CA USA
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13
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Abstract
Background Methylation levels of genomic repeats such as long interspersed nucleotide elements (LINE-1) are representative of global methylation status and play an important role in maintenance of genomic stability. The objective of the study was to assess LINE-1 methylation status in colorectal cancer (CRC) in relation to adenomatous and malignant progression, tissue heterogeneity, and TNM-stage. Methodology/Principal Findings DNA was collected by laser-capture microdissection (LCM) from normal, adenoma, and cancer tissue from 25 patients with TisN0M0 and from 92 primary CRC patients of various TNM-stages. The paraffin-embedded tissue sections were treated by in-situ DNA sodium bisulfite modification (SBM). LINE-1 hypomethylation index (LHI) was measured by absolute quantitative analysis of methylated alleles (AQAMA) realtime PCR; a greater index indicated enhanced hypomethylation. LHI in normal, cancer mesenchymal, adenoma, and CRC tissue was 0.38 (SD 0.07), 0.37 (SD 0.09), 0.49 (SD 0.10) and 0.53 (SD 0.08), respectively. LHI was significantly greater in adenoma tissue compared to its contiguous normal epithelium (P = 0.0003) and cancer mesenchymal tissue (P<0.0001). LHI did not differ significantly between adenoma and early cancer tissue of Tis stage (P = 0.20). LHI elevated with higher T-stage (P<0.04), was significantly greater in node-positive than node-negative CRC patients (P = 0.03), and was significantly greater in stage IV than all other disease stages (P<0.05). Conclusion/Significance By using in-situ SBM and LCM cell selection we demonstrated early onset of LINE-1 demethylation during adenomatous change of colorectal epithelial cells and demonstrated that LINE-1 demethylation progression is linear in relation to TNM-stage progression.
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Affiliation(s)
- Eiji Sunami
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, California, United States of America
| | - Michiel de Maat
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, California, United States of America
| | - Anna Vu
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, California, United States of America
| | - Roderick R. Turner
- Department of Surgical Pathology, Saint John's Health Center, Santa Monica, California, United States of America
| | - Dave S. B. Hoon
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, California, United States of America
- * E-mail:
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Nguyen T, Kuo C, Nicholl MB, Sim MS, Turner RR, Morton DL, Hoon DSB. Downregulation of microRNA-29c is associated with hypermethylation of tumor-related genes and disease outcome in cutaneous melanoma. Epigenetics 2011; 6:388-94. [PMID: 21081840 PMCID: PMC3063331 DOI: 10.4161/epi.6.3.14056] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 10/30/2010] [Indexed: 12/16/2022] Open
Abstract
Hypermethylation of the promoter region of tumor-related genes (TRGs) has been shown to silence gene expression during melanoma progression, whereas microRNA-29(miR-29) has been found to downregulate DNA methyltransferases DNMT3A and DNMT3B which were shown as essential to the methylation of TRGs. We hypothesized that the expression level of miR-29 is associated to TRG methylation status and may have prognostic utility in melanoma. AJCC stage I-IV cutaneous melanoma paraffin-embedded archival tissue (PEAT) specimens (n=149) were assessed. Expression of miR-29 isoforms a, b, and c were analyzed by reverse-transcription quantitative real-time polymerase chain reaction(RT-qPCR). Expression of DNMT3A and DNMT3B was assessed by immunohistochemistry(IHC) on defined clinically annotated tissue microarrays (TMA) of AJCC stage III melanoma lymph node metastases. Promoter region CpG island methylation status of RASSF1A, TFPI-2, RAR-β, SOCS, GATA4 and genomic repeat sequence MINT17 and MINT31 were previously evaluated in melanoma tissues. Only miR-29c isoform expression was correlated to advancing AJCC stages in melanoma. miR-29c expression was significantly downregulated in AJCC stage IV melanoma tumors compared to primary melanomas. Hypermethylation status of TRGs and non-coding MINT loci in different stages of melanoma showed an inverse association with miR-29c expression. Overall, an increase in miR-29c expression inversely correlated to both DNMT3A and DNMT3B protein expression in melanomas. Expression of DNMT3B and miR-29c were significantly (p=0.004 and p=0.002, respectively) associated with overall survival(OS) in AJCC stage III melanoma patients by multivariate analysis. The studies demonstrated that both miR-29c and DNMT3B have significant roles in melanoma progression, and may be useful epigenetic biomarkers for disease outcome.
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Affiliation(s)
- Tung Nguyen
- Department of Molecular Oncology, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, CA, USA
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15
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de Maat MFG, Narita N, Benard A, Yoshimura T, Kuo C, Tollenaar RAEM, de Miranda NFCC, Turner RR, van de Velde CJH, Morreau H, Hoon DSB. Development of sporadic microsatellite instability in colorectal tumors involves hypermethylation at methylated-in-tumor loci in adenoma. Am J Pathol 2010; 177:2347-56. [PMID: 20952593 DOI: 10.2353/ajpath.2010.091103] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Microsatellite instability (MSI) and genomic hypermethylation of methylated-in-tumor (MINT) loci are both strong prognostic indicators in a subgroup of patients with sporadic colorectal cancer (CRC). The present study was designed to determine whether the methylation of MINT loci during the progression of adenoma to CRC is related to MSI in CRC cases. Methylation index (MI) was measured by absolute quantitative assessment of methylated alleles at seven MINT loci in primary CRC with contiguous adenomatous and normal tissues of 79 patients. Results were then validated in primary CRC tissues from an independent group of 54 patients. Increased MI of both MINT loci 1 and 31 was significantly associated with MSI in CRC and was specific for adenoma. Total MI and the number of methylated loci were threefold (P=0.02) and fivefold (P=0.004) higher, respectively, in adenomas associated with microsatellite-stable CRC versus microsatellite-unstable CRC. MINT MI was found to be correlated with mismatch repair protein expression, MSI, BRAF (V600E) mutation status, mut-L homologue 1 methylation status, and disease-specific survival in the second independent validation group of patients. MI of specific MINT loci may be prognostic indicators of colorectal adenomas that will develop into sporadic microsatellite-unstable CRCs. Increased MINT locus methylation appears to precede MSI and may have utility in defining clinical pathology in the absence of features of malignant invasive tumors.
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Affiliation(s)
- Michiel F G de Maat
- Department of Molecular Oncology, John Wayne Cancer Institute, 2200 Santa Monica Blvd, Santa Monica, CA 90404, USA
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Abstract
Atmospheric deposition during the growing season contributes one-third or more of the estimated total flux of lead, zinc, and cadium from the forest canopy to soils beneath an oak stand in the Tennessee Valley but less than 10 percent of the flux of manganese. The ratio of the wet to dry deposition flux to the vegetation during this period ranges from 0.1 for manganese to 0.8 for lead to approximately 3 to 4 for cadmium and zinc. Interactions between metal particles deposited on dry leaf surfaces and subsequent acid precipitation can result in metal concentrations on leaves that are considerably higher than those in rain alone.
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Cunningham DK, Yao KA, Turner RR, Singer FR, Van Herle AR, Giuliano AE. Sentinel Lymph Node Biopsy for Papillary Thyroid Cancer: 12 Years of Experience at a Single Institution. Ann Surg Oncol 2010; 17:2970-5. [DOI: 10.1245/s10434-010-1141-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Indexed: 11/18/2022]
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Affiliation(s)
| | - Nora M. Hansen
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA
| | - Baiba J. Grube
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA
| | - Xing Ye
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA
| | - Roderick R. Turner
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA
| | - R.J. Brenner
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA
| | - Myung-Shin Sim
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA
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Wasif N, Faries MB, Saha S, Turner RR, Wiese D, McCarter MD, Shen P, Stojadinovic A, Bilchik AJ. Predictors of occult nodal metastasis in colon cancer: results from a prospective multicenter trial. Surgery 2010; 147:352-7. [PMID: 20116081 DOI: 10.1016/j.surg.2009.10.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 10/02/2009] [Indexed: 01/02/2023]
Abstract
BACKGROUND The relationship between primary colon cancer and occult nodal metastases (OMs) detected by cytokeratin immunohistochemistry (CK-IHC) is unknown. We sought to investigate the correlation of clinicopathologic features of colon cancer with OMs and to identify predictors of OM. METHODS Patients with colon cancer from 5 tertiary referral cancer centers enrolled in a prospective trial of staging had standard pathologic analysis performed on all resected lymph nodes (using hematoxylin and eosin staining [H&E]). Nodes negative on H&E underwent CK-IHC to detect OMs, which were defined as micrometastases (N1mic) or isolated tumor cells (N0i+). Patients who were negative on both H&E and CK-IHC were defined as node negative (NN), and those positive on H&E were node positive (NP). The relationships between tumor characteristics and OMs were analyzed using the Kruskal-Wallis and the Fisher exact test. RESULTS OMs were identified in 23.4% (25/107) of patients. No significant differences were found in demographics, tumor location, tumor size, and number of nodes examined between groups. Compared with the NN group, patients with OMs had more tumors that were T3/T4 (72% vs 57%; P < .001), had tumors of higher grade (28% vs 12%; P = .022), and had tumors with lymphovascular invasion (16% vs 3%; P < .001). CONCLUSION Adverse primary pathologic colon cancer characteristics correlate with OMs. In patients with negative nodes on H&E and stage T3/T4 colon cancer, lymphovascular invasion, or high tumor grade, consideration should be given to performing CK-IHC. The detection of OMs in this subset may influence decisions regarding adjuvant chemotherapy and risk stratification.
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Affiliation(s)
- Nabil Wasif
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA, USA
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20
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Goto Y, Arigami T, Murali R, Scolyer RA, Tanemura A, Takata M, Turner RR, Nguyen L, Nguyen T, Morton DL, Ferone S, Hoon DSB. High molecular weight-melanoma-associated antigen as a biomarker of desmoplastic melanoma. Pigment Cell Melanoma Res 2009; 23:137-40. [PMID: 19968820 DOI: 10.1111/j.1755-148x.2009.00660.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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21
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Hansen NM, Grube B, Ye X, Turner RR, Brenner RJ, Sim MS, Giuliano AE. Impact of micrometastases in the sentinel node of patients with invasive breast cancer. J Clin Oncol 2009; 27:4679-84. [PMID: 19720928 DOI: 10.1200/jco.2008.19.0686] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Lymph node metastases are the most significant prognostic indicator for patients with breast cancer. Sentinel node biopsy (SNB) has led to an increase in the detection of micrometastases in the sentinel node (SN). This prospective study was designed to determine the survival impact of micrometastases in SNs of patients with invasive breast cancer. This study is based on the new sixth edition of the American Joint Committee on Cancer (AJCC) staging criteria. PATIENTS AND METHODS Between January 1, 1992 and April 30, 1999, 790 patients entered this prospective study at the John Wayne Cancer Institute. The SN was examined first by hematoxylin and eosin (HE), and if the SN was negative with HE, then immunohistochemical staining was performed. The patients were then divided into four groups based on AJCC nodal staging: pN0(i-), no evidence of tumor (n = 486); pN0(i+), tumor deposit < or = 0.2 mm (n = 84); pN1mi, tumor deposit more than 0.2 mm but < or = 2 mm (n = 54), and pN1, tumor deposit more than 2 mm (n = 166). Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The log-rank test was used to determine differences in DFS and OS of patients from different groups. RESULTS At a median follow-up of 72.5 months, the size of SN metastases was a significant predictor of DFS and OS. CONCLUSION Patients with micrometastatic tumor deposits, pN0(i+) or pN1mi, do not seem to have a worse 8-year DFS or OS compared with SN-negative patients. As expected, there was a significant decrease in 8-year DFS and OS in patients with pN1 disease in the SN.
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Affiliation(s)
- Nora M Hansen
- John Wayne Cancer Institute, Santa Monica, CA 90404, USA
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22
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Koyanagi K, Bilchik AJ, Saha S, Turner RR, Wiese D, McCarter M, Shen P, Deacon L, Elashoff D, Hoon DSB. Prognostic relevance of occult nodal micrometastases and circulating tumor cells in colorectal cancer in a prospective multicenter trial. Clin Cancer Res 2008; 14:7391-6. [PMID: 19010855 PMCID: PMC2586882 DOI: 10.1158/1078-0432.ccr-08-0290] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Nodal micrometastasis and circulating tumor cells detected by multimarker quantitative real-time reverse transcription-PCR (qRT-PCR) may have prognostic importance in patients with colorectal cancer. EXPERIMENTAL DESIGN Paraffin-embedded sentinel lymph nodes from 67 patients and blood from 34 of these patients were evaluated in a prospective multicenter trial of sentinel lymph node mapping in colorectal cancer. Sentinel lymph nodes were examined by H&E staining and cytokeratin immunohistochemistry. Sentinel lymph nodes and blood were examined by a four-marker qRT-PCR assay (c-MET, melanoma antigen gene-A3 family, beta1-->4-N-acetylgalactosaminyltransferase, and cytokeratin-20); qRT-PCR results were correlated with disease stage and outcome. RESULTS In H&E-negative sentinel lymph node patients that recurred, cytokeratin immunohistochemistry and qRT-PCR detected metastasis in 30% and 60% of patients, respectively. Disease-free survival differed significantly by multimarker qRT-PCR upstaged sentinel lymph node (P = 0.014). qRT-PCR analysis of blood for circulating tumor cells correlated with overall survival (P = 0.040). CONCLUSION Molecular assessment for micrometastasis in sentinel lymph node and blood specimens may help identify patients at high risk for recurrent colorectal cancer, who could benefit from adjuvant therapy.
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Affiliation(s)
- Kazuo Koyanagi
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, California 90404, USA
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Wright BE, Scheri RP, Ye X, Faries MB, Turner RR, Essner R, Morton DL. Importance of sentinel lymph node biopsy in patients with thin melanoma. ACTA ACUST UNITED AC 2008; 143:892-9; discussion 899-900. [PMID: 18794428 DOI: 10.1001/archsurg.143.9.892] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
HYPOTHESIS The status of the sentinel node (SN) confers important prognostic information for patients with thin melanoma. DESIGN, SETTING, AND PATIENTS We queried our melanoma database to identify patients undergoing sentinel lymph node biopsy for thin (< or =1.00-mm) cutaneous melanoma at a tertiary care cancer institute. Slides of tumor-positive SNs were reviewed by a melanoma pathologist to confirm nodal status and intranodal tumor burden, defined as isolated tumor cells, micrometastasis, or macrometastasis (< or =0.20, 0.21-2.00, or >2.00 mm, respectively). Nodal status was correlated with patient age and primary tumor depth (< or = 0.25, 0.26-0.50, 0.51-0.75, or 0.76-1.00 mm). Survival was determined by log-rank test. MAIN OUTCOME MEASURES Disease-free and melanoma-specific survival. RESULTS Of 1592 patients who underwent sentinel lymph node biopsy from 1991 to 2004, 631 (40%) had thin melanomas; 31 of the 631 patients (5%) had a tumor-positive SN. At a median follow-up of 57 months for the 631 patients, the mean (SD) 10-year rate of disease-free survival was 96% (1%) vs 54% (10%) for patients with tumor-negative vs tumor-positive SNs, respectively (P < .001); the mean (SD) 10-year rate of melanoma-specific survival was 98% (1%) vs 83% (8%), respectively (P < .001). Tumor-positive SNs were more common in patients aged 50 years and younger (P = .04). The SN status maintained importance on multivariate analysis for both disease-free survival (P < .001) and melanoma-specific survival (P < .001). CONCLUSIONS The status of the SN is significantly linked to survival in patients with thin melanoma. Therefore, sentinel lymph node biopsy should be considered to obtain complete prognostic information.
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Affiliation(s)
- Byron E Wright
- Department of Surgical Oncology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA
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Goto Y, Ferrone S, Arigami T, Kitago M, Tanemura A, Sunami E, Nguyen SL, Turner RR, Morton DL, Hoon DSB. Human high molecular weight-melanoma-associated antigen: utility for detection of metastatic melanoma in sentinel lymph nodes. Clin Cancer Res 2008; 14:3401-7. [PMID: 18519770 DOI: 10.1158/1078-0432.ccr-07-1842] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Detection of micrometastasis in melanoma-draining lymph nodes is important for staging and prognosis. Immunohistochemical staining (IHC) using S-100p-HMB-45-, and MART-1-specific antibodies is used for detecting metastases in sentinel lymph nodes (SLN). However, improvement in IHC is needed for melanoma micrometastasis detection. EXPERIMENTAL DESIGN Paraffin-embedded archival tissue (PEAT) specimens were obtained from 42 non-SLN macrometastases, 42 SLN metastases, and 16 tumor-negative SLNs of 100 melanoma patients who underwent SLN biopsy. PEAT specimens were assessed by IHC with high molecular weight-melanoma-associated antigen (HMW-MAA)-specific monoclonal antibodies (mAb) and with S-100p-, HMB-45-, and MART-1-specific antibodies. Quantitative real-time reverse-transcriptase PCR assay was used for HMW-MAA and MART-1 mRNA detection. RESULTS Expression frequency and immunostaining intensity were higher for HMW-MAA than MART-1 in nodal macrometastases (P < 0.0001 and P < 0.0001, respectively) and micrometastases (P < 0.0001 and P = 0.004, respectively). All 52 (100%) macrometastases were positive with HMW-MAA-specific mAbs, whereas 43 (83%) were positive with MART-1-specific mAbs. In a comparison analysis, 23 of 23 (100%) micrometastases were HMW-MAA-positive, whereas 21 (91%) and 18 (78%) specimens were S-100p- and HMB-45-positive, respectively. Quantitative real-time reverse-transcriptase PCR analysis of 48 nodal metastases showed HMW-MAA mRNA detection in SLNs with metastases. CONCLUSIONS HMW-MAA is more sensitive and specific than MART-1, S-100p, and HMB-45 for IHC-based detection of SLN micrometastases. SLN PEAT-based detection specificity of melanoma micrometastases can be improved by IHC with HMW-MAA-specific mAbs.
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Affiliation(s)
- Yasufumi Goto
- Department of Molecular Oncology, John Wayne Cancer Institute, 2200 Santa Monica Boulevard, Santa Monica, CA 90404, USA
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de Maat MF, van de Velde CJ, van der Werff MP, Putter H, Umetani N, Klein-Kranenbarg EM, Turner RR, van Krieken JHJ, Bilchik A, Tollenaar RA, Hoon DS. Quantitative Analysis of Methylation of Genomic Loci in Early-Stage Rectal Cancer Predicts Distant Recurrence. J Clin Oncol 2008; 26:2327-35. [DOI: 10.1200/jco.2007.14.0723] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose There are no accurate prognostic biomarkers specific for rectal cancer. Epigenetic aberrations, in the form of DNA methylation, accumulate early during rectal tumor formation. In a preliminary study, we investigated absolute quantitative methylation changes associated with tumor progression of rectal tissue at multiple genomic methylated-in-tumor (MINT) loci sequences. We then explored in a different clinical patient group whether these epigenetic changes could be correlated with clinical outcome. Patients and Methods Absolute quantitative assessment of methylated alleles was used to assay methylation changes at MINT 1, 2, 3, 12, 17, 25, and 31 in sets of normal, adenomatous, and malignant tissues from 46 patients with rectal cancer. Methylation levels of these biomarkers were then assessed in operative specimens of 251 patients who underwent total mesorectal excision (TME) without neoadjuvant radiotherapy in a multicenter clinical trial. Results Methylation at MINT 2, 3, and 31 increased 11-fold (P = .005), 15-fold (P < .001), and two-fold (P = .02), respectively, during adenomatous transformation in normal rectal epithelium. Unsupervised grouping analyses of quantitative MINT methylation data of TME trial patients demonstrated two prognostic subclasses. In multivariate analysis of node-negative patients, this subclassification was the only predictor for distant recurrence (hazard ratio [HR], 4.17; 95% CI, 1.72 to 10.10; P = .002), cancer-specific survival (HR, 3.74; 95% CI, 1.4 to 9.43; P = .003), and overall survival (HR, 2.68; 95% CI, 1.41 to 5.11; P = .005). Conclusion Methylation levels of specific MINT loci can be used as prognostic variables in patients with American Joint Committee on Cancer stage I and II rectal cancer. Quantitative epigenetic classification of rectal cancer merits evaluation as a stratification factor for adjuvant treatment in early disease.
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Affiliation(s)
- Michiel F.G. de Maat
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Cornelis J.H. van de Velde
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Martijn P.J. van der Werff
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Hein Putter
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Naoyuki Umetani
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Elma Meershoek Klein-Kranenbarg
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Roderick R. Turner
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - J. Han J.M. van Krieken
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Anton Bilchik
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Rob A.E.M. Tollenaar
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Dave S.B. Hoon
- From the Department of Molecular Oncology, John Wayne Cancer Institute; Department of Surgical Pathology, Saint John's Health Center, Santa Monica, CA; Department of Surgery, Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; and Department of Pathology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
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Turner RR, Weaver DL, Cserni G, Lester SC, Hirsch K, Elashoff DA, Fitzgibbons PL, Viale G, Mazzarol G, Ibarra JA, Schnitt SJ, Giuliano AE. Nodal Stage Classification for Breast Carcinoma: Improving Interobserver Reproducibility Through Standardized Histologic Criteria and Image-Based Training. J Clin Oncol 2008; 26:258-63. [DOI: 10.1200/jco.2007.13.0179] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Reliable pathologic stage classification of axillary lymph nodes is an important determinant of prognosis and therapeutic decision making for patients with invasive breast cancer. Pathologists' distinction between micrometastasis (pN1mi) and isolated tumor cells [ITC; pN0(i+)] is variable using the American Joint Committee on Cancer (AJCC) Staging Manual (Sixth Edition). We sought to determine whether a set of clearly defined histologic criteria could lead to reproducible nodal classification by pathologists. Patients and Methods Digital images of sentinel lymph node biopsies from 56 patients with small-volume nodal metastases were examined by six experienced breast pathologists (MDs), first as a pre-test, and again as a post-test after studying a training program that outlined and illustrated the classification criteria. Results Post-test results, after study of the training program, were significantly improved. Compared with the reference MD, agreement improved from 76.2% (pre-test κ = 0.575; standard deviation [SD], 0.25) to 97.3% (post-test κ = 0.947; SD, 0.049). Multirater analysis of agreement among the six MDs improved from 71.5% (pre-test κ = 0.487; ASE, 0.039) to 95.7% (post-test κ = 0.915; ASE, 0.037). Agreement on lobular carcinoma metastasis classification improved from 55% (23 of 42; pre-test) to 100% (42 of 42; post-test) (P < .001), and agreement on ITC classification in nodal parenchyma improved from 67.6% (69 of 102; pre-test) to 98.0% (100 of 102; post-test; P < .001). Conclusion Application of current definitions for classification of small-volume nodal metastases are inconsistent, leading to variable classification of ITC and micrometastases. Reproducibility of pathologic nodal stage classification is achievable through study of a training set to clarify the AJCC criteria.
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Affiliation(s)
- Roderick R. Turner
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Donald L. Weaver
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Gabor Cserni
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Susan C. Lester
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Karen Hirsch
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - David A. Elashoff
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Patrick L. Fitzgibbons
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Giuseppe Viale
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Giovanni Mazzarol
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Julio A. Ibarra
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Stuart J. Schnitt
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
| | - Armando E. Giuliano
- From the John Wayne Cancer Institute at Saint John's Health Center, Santa Monica; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles; St Jude Medical Center, Fullerton; Orange Coast Memorial Medical Center, Fountain Valley, CA; University of Vermont College of Medicine, Burlington, VT; Bacs-Kiskun County Teaching Hospital, Kecskemet, Hungary; Brigham and Women's Hospital; Beth Israel Deaconess Medical Center, Boston, MA; and European Institute of Oncology and University
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Rosen LS, Bilchik AJ, Beart RW, Benson AB, Chang KJ, Compton CC, Grothey A, Haller DG, Ko CY, Lynch PM, Nelson H, Stamos MJ, Turner RR, Willett CG. New approaches to assessing and treating early-stage colon and rectal cancer: summary statement from 2007 Santa Monica Conference. Clin Cancer Res 2008; 13:6853s-6s. [PMID: 18006789 DOI: 10.1158/1078-0432.ccr-07-1629] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 2007 Santa Monica Conference on Assessing and Treating Early-Stage Colon and Rectal Cancer, a multidisciplinary meeting of leaders in surgery, medical and radiation oncology, and pathology, was convened on January 12 to 13, 2007. The purpose of the meeting was to assess current data and issues in the field and to develop recommendations for advancing patient care and clinical research. Topics included pathologic assessment and staging, transanal versus laparoscopic versus open resection, adjuvant therapy, genetic testing and counseling, cooperative group strategies, and the use of biological therapies and novel agents. A review of the key issues discussed, as well as conclusions and recommendations considered significant to the field, is summarized below and presented at greater length in the individual manuscripts and accompanying discussion that comprise the full conference proceedings. Although the management of early-stage colon and rectal cancers remains a challenge for all of us, the development and use of new technologies and methods of assessment and treatment over the past several decades is yielding encouraging results. A variety of opportunities to further improve outcomes were addressed in this forum, including recommendations that specific protocols be adopted regarding surgical and pathologic dissection and reporting, particularly for stage II disease; the corollary need to increase active multidisciplinary collaboration; and the development of comprehensive consensus guidelines and recommendations to standardize care in early-stage colorectal cancer.
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Affiliation(s)
- Lee S Rosen
- Premiere Oncology, Santa Monica, CA 90404, USA.
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Bilchik AJ, Hoon DSB, Saha S, Turner RR, Wiese D, DiNome M, Koyanagi K, McCarter M, Shen P, Iddings D, Chen SL, Gonzalez M, Elashoff D, Morton DL. Prognostic impact of micrometastases in colon cancer: interim results of a prospective multicenter trial. Ann Surg 2007; 246:568-75; discussion 575-7. [PMID: 17893493 DOI: 10.1097/sla.0b013e318155a9c7] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The 25% rate of recurrence after complete resection of stage II colon cancer (CC) suggests the presence of occult nodal metastases not identified by hematoxylin and eosin staining (H&E). Interim data from our ongoing prospective multicenter trial of sentinel node (SN) biopsy indicate a 29.6% rate of micrometastases (MM) identified by immunohistochemical staining (IHC) of H&E-negative SNs in CC. We hypothesized that these MM have prognostic importance. METHODS Between March 2001 and August 2006, 152 patients with resectable colorectal cancer were enrolled in the trial. IHC and quantitative RT-PCR (qRT) assay were performed on H&E-negative SNs. Results were correlated with disease-free survival. RESULTS The sensitivity of lymphatic mapping was significantly better in CC (75%) than rectal cancer (36%), P<0.05. Of 92 node-negative CC patients 7 (8%) were upstaged to N1 and 18 (22%) had IHC MM. Four patients negative by H&E and IHC were positive by qRT. At a mean follow-up of 25 months, 15 patients had died from noncancer-related causes, 12 had developed recurrence, 5 had died of CC (2 with macrometastases, 3 with MM), and 7 were alive with disease. The 12 recurrences included 4 patients with SN macrometastases and 6 with SN MM (2 by IHC, 4 by qRT). One of the 2 SN-negative recurrences had other positive lymph nodes by H&E. All patients with CC recurrences had a positive SN by either H&E/IHC or qRT. No CC patient with a negative SN by H&E and qRT has recurred (P=0.002). CONCLUSION This is the first prospective evaluation of the prognostic impact of MM in colorectal cancer. These results indicate that the detection of MM may be clinically relevant in CC and may improve the selection of patients for adjuvant systemic chemotherapy. Patients with CC who are node negative by cumulative detection methods (H&E/IHC and qRT) are likely to be cured by surgery alone.
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Affiliation(s)
- Anton J Bilchik
- Department of Gastrointestinal Oncology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA 90404, and Michigan State University McLaren Regional Medical Center, Flint, MI, USA.
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Scheri RP, Essner R, Turner RR, Ye X, Morton DL. Isolated tumor cells in the sentinel node affect long-term prognosis of patients with melanoma. Ann Surg Oncol 2007; 14:2861-6. [PMID: 17882497 DOI: 10.1245/s10434-007-9472-y] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 05/06/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND The clinical significance of isolated tumor cells (ITCs) in the melanoma-draining sentinel nodes (SNs) is unclear. METHODS Records of patients who underwent SN biopsy (SNB) for stage I/II melanoma at our institute between 1991 and 2003 were reviewed to identify patients whose SNs were tumor-free or contained only ITC (<or=0.2 mm). Tumor-positive SNs were reevaluated by the study pathologist to confirm the diagnosis and microstage the SN. Characteristics of the primary melanoma, tumor status of regional lymph nodes, and other prognostic variables were recorded. Melanoma-specific survival (MSS) rates were compared by the log-rank test. RESULTS Of 1,382 patients who underwent SNB, 1,168 (85%) had tumor-free SNs; among the 214 remaining patients with tumor-positive SNs, 57 had metastases limited to ITC. Completion lymphadenectomy (CLND) was performed in 52 of 57 patients: six (12%) had metastases in nonsentinel nodes (NSNs). At a median follow-up of 57 months, 5-year and 10-year MSS was significantly higher (P = .02) for the 1168 patients with tumor-negative SNs (94 +/- 1% and 87 +/- 2%, respectively) than the 57 patients with ITC-positive SNs (89 +/- 4% and 80 +/- 7%, respectively). Multivariate analysis identified ITC (P = .002), Breslow's thickness (P < .0001), ulceration (P < .0001), and primary site (P = .04) as significant for MSS. CONCLUSION Patients with ITC in SNs have a significantly higher risk of melanoma-specific death than those with tumor-negative SNs. The 12% incidence of nonsentinel node metastasis is similar to rates reported for patients with more extensive SN involvement. Patients with ITC should be considered for CLND.
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Affiliation(s)
- Randall P Scheri
- Department of Surgical Oncology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA, USA.
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de Maat MFG, Umetani N, Sunami E, Turner RR, Hoon DSB. Assessment of methylation events during colorectal tumor progression by absolute quantitative analysis of methylated alleles. Mol Cancer Res 2007; 5:461-71. [PMID: 17510312 DOI: 10.1158/1541-7786.mcr-06-0358] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To date, the epigenetic events involved in the progression of colorectal cancer are not well described. To study, in detail, methylation during colorectal cancer development in high-risk adenomas, we developed an assay combining in situ (on-slide) sodium bisulfite modification (SBM) of paraffin-embedded archival tissue sections with absolute quantitative assessment of methylated alleles (AQAMA). We tested the performance of the assay to detect methylation level differences between paired pre-malignant and malignant colorectal cancer stages. AQAMA assays were used to measure methylation levels at MINT (methylated in tumor) loci MINT1, MINT2, MINT12, and MINT31. Assay performance was verified on cell line DNA and standard cDNA. On-slide SBM, allowing DNA methylation assessment of 1 to 2 mm(2) of paraffin-embedded archival tissue, was employed. Methylation levels of adenomatous and cancerous components within a single tissue section in 72 colorectal cancer patients were analyzed. AQAMA was verified as accurately assessing CpG island methylation status in cell lines. The correlation between expected and measured cDNA methylation levels was high for all four MINT AQAMA assays (R >or= 0.966, P<0.001). Methylation levels at the four loci increased in 11% and decreased in 36% of specimens comparing paired adenoma and cancer tissues (P<0.0001 by Kolmogorov-Smirnov test). Single-PCR AQAMA provided accurate methylation level measurement. Variable MINT locus methylation level changes occur during malignant progression of colorectal adenoma. Combining AQAMA with on-slide SBM provides a sensitive assay that allows detailed histology-oriented analysis of DNA methylation levels and may give new, accurate insights into understanding development of epigenetic aberrancies in colorectal cancer progression.
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Affiliation(s)
- Michiel F G de Maat
- Department of Molecular Oncology, John Wayne Cancer Institute, 2200 Santa Monica Boulevard, Santa Monica, CA 90404, USA
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Moore KH, Sweeney KJ, Wilson ME, Goldberg JI, Buchanan CL, Tan LK, Liberman L, Turner RR, Lagios MD, Cody Iii HS, Giuliano AE, Silverstein MJ, Van Zee KJ. Outcomes for Women With Ductal Carcinoma-in-Situ and a Positive Sentinel Node: A Multi-Institutional Audit. Ann Surg Oncol 2007; 14:2911-7. [PMID: 17597346 DOI: 10.1245/s10434-007-9414-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Accepted: 03/21/2007] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Katrina H Moore
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, MRI 1026, New York, NY 10021, USA
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Nakagawa T, Huang SK, Martinez SR, Tran AN, Elashoff D, Ye X, Turner RR, Giuliano AE, Hoon DSB. Proteomic Profiling of Primary Breast Cancer Predicts Axillary Lymph Node Metastasis. Cancer Res 2006; 66:11825-30. [PMID: 17178879 DOI: 10.1158/0008-5472.can-06-2337] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To determine if protein expression in primary breast cancers can predict axillary lymph node (ALN) metastasis, we assessed differences in protein expression between primary breast cancers with and without ALN metastasis using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS). Laser capture microdissection was performed on invasive breast cancer frozen sections from 65 patients undergoing resection with sentinel lymph node (SLN) or level I and II ALN dissection. Isolated proteins from these tumors were applied to immobilized metal affinity capture (IMAC-3) ProteinChip arrays and analyzed by SELDI-TOF-MS to generate unique protein profiles. Correlations between unique protein peaks and histologically confirmed ALN status and other known clinicopathologic factors were examined using ANOVA and multivariate logistic regression. Two metal-binding polypeptides at 4,871 and 8,596 Da were identified as significant risk factors for nodal metastasis (P = 0.034 and 0.015, respectively) in a multivariate analysis. Lymphovascular invasion (LVI) was the only clinicopathologic factor predictive of ALN metastasis (P = 0.0038). In a logistic regression model combining the 4,871 and 8,596 Da peaks with LVI, the area under the receiver operating characteristic curve was 0.87. Compared with patients with negative ALN, those with > or =2 positive ALN or non-SLN metastases were significantly more likely to have an increased peak at 4,871 Da (P = 0.016 and 0.0083, respectively). ProteinChip array analysis identified differential protein peaks in primary breast cancers that predict the presence and number of ALN metastases and non-SLN status.
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Affiliation(s)
- Taku Nakagawa
- Department of Molecular Oncology, Division of Biostatistics, and Joyce Eisenberg Keefer Breast Center, John Wayne Cancer Institute, Santa Monica, CA 90404, USA
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Kim J, Giuliano AE, Turner RR, Gaffney RE, Umetani N, Kitago M, Elashoff D, Hoon DSB. Lymphatic mapping establishes the role of BRAF gene mutation in papillary thyroid carcinoma. Ann Surg 2006; 244:799-804. [PMID: 17060774 PMCID: PMC1856588 DOI: 10.1097/01.sla.0000224751.80858.13] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To define the role of BRAF gene mutation in the progression of papillary thyroid carcinoma. SUMMARY BACKGROUND DATA BRAF gene mutation is frequently detected in papillary thyroid carcinoma. Its role in pathogenesis or progression is under investigation. METHODS Patients who underwent thyroidectomy and sentinel lymph node biopsy for papillary thyroid cancer were accrued. BRAF mutation was assessed in primary tumors and matched sentinel lymph nodes by a quantitative real-time PCR assay. RESULTS Tissue specimens from 103 consecutive patients were evaluated. BRAF mutation of the primary tumor was detected in 34 (33%) patients. In 26 of 34 (76%) patients with BRAF mutation, concomitant lymph node metastasis was detected. On the contrary, in 69 patients with BRAF mutation-negative primary tumors, only 12 (17%) patients had lymph node metastasis (chi, P < 0.0001). BRAF mutation was detected in 20 of 26 (77%) lymph node metastases matched to BRAF mutation-positive primary tumors; it was not detected in lymph node metastases matched to BRAF mutation-negative primary tumors. Univariate analysis identified age, stage, tumor size, and BRAF mutation as prognostic factors for lymph node metastasis. In multivariate analysis, only BRAF mutation remained a significant prognostic factor for lymph node metastasis (odds ratio = 10.8, 95% confidence interval, 3.5-34.0, P < 0.0001). CONCLUSIONS BRAF mutation may be a key genetic factor for the metastatic progression of papillary thyroid carcinoma. The study demonstrates that this gene mutation is a significant risk factor for locoregional lymph node metastasis and has potential utility as a surrogate marker.
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Affiliation(s)
- Joseph Kim
- Department of Molecular Oncology, John Wayne Cancer Institute at Saint Johns Hospital, Santa Monica, CA 90404, USA
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Kim J, Mori T, Chen SL, Amersi FF, Martinez SR, Kuo C, Turner RR, Ye X, Bilchik AJ, Morton DL, Hoon DSB. Chemokine receptor CXCR4 expression in patients with melanoma and colorectal cancer liver metastases and the association with disease outcome. Ann Surg 2006; 244:113-20. [PMID: 16794396 PMCID: PMC1570598 DOI: 10.1097/01.sla.0000217690.65909.9c] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To determine the role of chemokine receptor (CR) expression in patients with melanoma and colorectal cancer (CRC) liver metastases. SUMMARY BACKGROUND DATA Murine and in vitro models have identified CR as potential factors in organ-specific metastasis of multiple cancers. Chemokines via their respective receptors have been shown to promote cell migration to distant organs. METHODS Patients who underwent hepatic surgery for melanoma or CRC liver metastases were assessed. Screening cDNA microarrays of melanoma/CRC cell lines and tumor specimens were analyzed to identify CR. Microarray data were validated by quantitative real-time RT-PCR (qRT) in paraffin-embedded liver metastases. Migration assays and immunohistochemistry were performed to verify CR function and confirm CR expression, respectively. RESULTS Microarray analysis identified CXCR4 as the most common CR expressed by both cancers. qRT demonstrated CXCR4 expression in 24 of 27 (89%) melanoma and 28 of 29 (97%) CRC liver metastases. In vitro treatment of melanoma or CRC cells with CXCL12, the ligand for CXCR4, significantly increased cell migration (P < 0.001). Low versus high CXCR4 expression in CRC liver metastases correlated with a significant difference in overall survival (median 27 months vs. 10 months, respectively; P = 0.036). In melanoma, low versus high CXCR4 expression in liver metastases demonstrated no difference in overall survival (median 11 months vs. 8 months, respectively; P = not significant). CONCLUSIONS CXCR4 is expressed and functional on melanoma and CRC cells. The ligand for CXCR4 is highly expressed in liver and may specifically attract melanoma and CRC CXCR4 (+) cells. Quantitative analysis of CXCR4 gene expression in patients with liver metastases has prognostic significance for disease outcome.
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Affiliation(s)
- Joseph Kim
- Department of Molecular Oncology, Gastrointestinal Cancer Section, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, CA 90404, USA
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Bilchik AJ, DiNome M, Saha S, Turner RR, Wiese D, McCarter M, Hoon DSB, Morton DL. Prospective multicenter trial of staging adequacy in colon cancer: preliminary results. ACTA ACUST UNITED AC 2006; 141:527-33; discussion 533-4. [PMID: 16785352 DOI: 10.1001/archsurg.141.6.527] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
HYPOTHESIS Lymph node evaluation is an important prognostic factor in colorectal cancer (CRC). A 25% recurrence rate in patients with node-negative CRC suggests that current staging practices are inadequate. Focused analysis of the sentinel node (SN) by multiple sectioning and immunohistochemistry improves staging accuracy. DESIGN Prospective phase 2 multicenter trial. SETTING Tertiary referral cancer centers. PATIENTS Between March 2001 and June 2005, 132 patients were enrolled with clinical stage I and II CRC in a prospective multicenter trial (R01-CA90484). INTERVENTION During a standard oncologic resection, lymphatic mapping was performed and the SN identified either by the surgeon or the pathologist. Hematoxylin-eosin staining was performed on all lymph nodes and immunohistochemistry, on lymph nodes negative by hematoxylin-eosin staining. MAIN OUTCOME MEASURES Micrometastases greater than 0.2 mm but less than 2 mm and isolated tumor cells less than 0.2 mm were defined according to the sixth edition of the American Joint Committee on Cancer Cancer Staging Manual. RESULTS The 63 men and 69 women had a median age of 74 years. Sixty-eight patients (52%) underwent a right hemicolectomy; 3 (2.3%), a transverse colectomy; 9 (7%), a left colectomy; 15 (11%), a sigmoid colectomy; 34 (26%), a low anterior resection; 1 (1%), an abdominal perineal resection; and 2 (2%), a total colectomy. Of the 111 evaluable primary tumors, 19 (17%) were T1 lesions; 17 (15%), T2; 72 (65%), T3; and 3 (2.7%), T4 tumors. Thirty-three patients (30%) were classified as stage I; 46 (41%), stage II, and 32 (29%), stage III. The SN was identified by the surgeon in 127 patients (96%) and by the pathologist in 5 patients (4%). The median number of SNs and total lymph nodes examined were 3 and 14.5, respectively. The sensitivity of lymphatic mapping and SN analysis was 88.2% and the false-negative rate, 7.4% (6/81). Of the 6 false-negative results, 4 were attributed to lymphatic channels obliterated by tumor. Upstaging occurred in 28 patients (23.6%). CONCLUSIONS In a multicenter trial, ultrastaging of colon cancer is feasible and accurate. In stage II CRC, 24% of patients had nodal carcinoma cells not detected by conventional staging methods. Surgical technique (adequate lymph node retrieval) and focused pathological analysis may improve staging accuracy and the selection of patients for chemotherapy. The unnecessary toxicity and expense of chemotherapy may be avoided in those patients who are truly node negative.
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Affiliation(s)
- Anton J Bilchik
- John Wayne Cancer Institute and Saint Johns Health Center, Santa Monica, CA 90404, USA.
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Affiliation(s)
- Hiroya Takeuchi
- Department of Molecular Oncology, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, California 90404, USA
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Calhoun KE, Hansen NM, Turner RR, Giuliano AE. Nonsentinel node metastases in breast cancer patients with isolated tumor cells in the sentinel node: implications for completion axillary node dissection. Am J Surg 2005; 190:588-91. [PMID: 16164927 DOI: 10.1016/j.amjsurg.2005.06.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2005] [Revised: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Controversy exists regarding axillary dissection (ALND) for sentinel node (SLN) metastases detected as isolated tumor cells (ITC). We hypothesized that the number of positive non-SLNs is low and ALND is unnecessary for most patients with ITC. METHODS From 1995 to 1999, 634 breast cancer patients underwent SLND. SLNs were examined using immunohistochemistry if hematoxylin and eosin was negative. ALND was recommended for ITC-positive SLNs. RESULTS Seventy-eight patients (12.3%) with ITC-positive SLNs were offered ALND. Sixty-one consented, whereas 17 refused. Fifty-eight (95.1%) had negative non-SLNs. Three (4.9%) had non-SLN metastases. One patient (1.6%) had macrometastatic disease, whereas 2 (3.3%) had micrometastases. No ITC-only-positive SLN patient experienced axillary recurrence. CONCLUSIONS When ALND was performed for ITC, 1.6% of non-SLNs harbored macrometastases and 3.3% had micrometastases. When ALND was not performed, axillary recurrence was not seen. The low risk of non-SLN disease in this study fails to support the routine use of ALND for ITC-positive SLNs.
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Affiliation(s)
- Kristine E Calhoun
- The Joyce Eisenberg Keefer Breast Center, John Wayne Cancer Institute at Saint John's Health Center, 2200 Santa Monica Boulevard, Santa Monica, CA 90404, USA
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Lyman GH, Giuliano AE, Somerfield MR, Benson AB, Bodurka DC, Burstein HJ, Cochran AJ, Cody HS, Edge SB, Galper S, Hayman JA, Kim TY, Perkins CL, Podoloff DA, Sivasubramaniam VH, Turner RR, Wahl R, Weaver DL, Wolff AC, Winer EP. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005; 23:7703-20. [PMID: 16157938 DOI: 10.1200/jco.2005.08.001] [Citation(s) in RCA: 1247] [Impact Index Per Article: 65.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To develop a guideline for the use of sentinel node biopsy (SNB) in early stage breast cancer. METHODS An American Society of Clinical Oncology (ASCO) Expert Panel conducted a systematic review of the literature available through February 2004 on the use of SNB in early-stage breast cancer. The panel developed a guideline for clinicians and patients regarding the appropriate use of a sentinel lymph node identification and sampling procedure from hereon referred to as SNB. The guideline was reviewed by selected experts in the field and the ASCO Health Services Committee and was approved by the ASCO Board of Directors. RESULTS The literature review identified one published prospective randomized controlled trial in which SNB was compared with axillary lymph node dissection (ALND), four limited meta-analyses, and 69 published single-institution and multicenter trials in which the test performance of SNB was evaluated with respect to the results of ALND (completion axillary dissection). There are currently no data on the effect of SLN biopsy on long-term survival of patients with breast cancer. However, a review of the available evidence demonstrates that, when performed by experienced clinicians, SNB appears to be a safe and acceptably accurate method for identifying early-stage breast cancer without involvement of the axillary lymph nodes. CONCLUSION SNB is an appropriate initial alternative to routine staging ALND for patients with early-stage breast cancer with clinically negative axillary nodes. Completion ALND remains standard treatment for patients with axillary metastases identified on SNB. Appropriately identified patients with negative results of SNB, when done under the direction of an experienced surgeon, need not have completion ALND. Isolated cancer cells detected by pathologic examination of the SLN with use of specialized techniques are currently of unknown clinical significance. Although such specialized techniques are often used, they are not a required part of SLN evaluation for breast cancer at this time. Data suggest that SNB is associated with less morbidity than ALND, but the comparative effects of these two approaches on tumor recurrence or patient survival are unknown.
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Affiliation(s)
- Gary H Lyman
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Zogakis TG, Essner R, Wang HJ, Turner RR, Takasumi YT, Gaffney RL, Lee JH, Morton DL. Melanoma Recurrence Patterns After Negative Sentinel Lymphadenectomy. ACTA ACUST UNITED AC 2005; 140:865-71; discussion 871-2. [PMID: 16172295 DOI: 10.1001/archsurg.140.9.865] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS A tumor-negative sentinel node (SN) does not eliminate the chance of melanoma recurrence. Patterns of metastasis can be identified and characterized in patients with tumor-negative SNs. DESIGN Retrospective review. SETTING Melanoma referral center. PATIENTS Patients who underwent lymphatic mapping and sentinel lymphadenectomy between 1995 and 2002 and whose SNs were negative for metastasis by hematoxylin-eosin and immunohistochemistry staining were included in the study. The SN specimens from patients with recurrent disease were reexamined for missed metastasis. MAIN OUTCOME MEASURES Differences in survival related to sites of recurrence and the rate of false-negative histopathologic SN diagnosis were determined. RESULTS At a median follow-up of 36.7 months, 69 (8.9%) of 773 patients with tumor-negative SNs had recurrent disease. Three-year survival after first recurrence was 17.1% in the 37 patients with distant recurrence, 48.7% in the 19 patients with local or in-transit recurrence, and 63.5% in the 13 patients with regional basin recurrence; the difference in survival between patients with local or regional and distant recurrences was statistically significant (P<.001). Histopathologic reexamination of SNs from the 69 patients identified 9 patients with false-negative SNs; 2 of these had same-basin recurrences. CONCLUSIONS The SN is a valuable prognostic indicator because only 8.9% of patients with tumor-negative SNs will develop recurrence. The low incidence (1.7%) of regional basin recurrence in patients with negative SNs supports the accuracy of our current method of lymphatic mapping and sentinel lymphadenectomy to identify occult regional nodal basin metastasis.
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Affiliation(s)
- Theresa G Zogakis
- Roy E. Coats Research Laboratories, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, CA 90404, USA
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Kim J, Takeuchi H, Lam ST, Turner RR, Wang HJ, Kuo C, Foshag L, Bilchik AJ, Hoon DSB. Chemokine receptor CXCR4 expression in colorectal cancer patients increases the risk for recurrence and for poor survival. J Clin Oncol 2005; 23:2744-53. [PMID: 15837989 DOI: 10.1200/jco.2005.07.078] [Citation(s) in RCA: 289] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Liver metastasis is the predominant cause of colorectal cancer (CRC) related mortality. Chemokines, soluble factors that orchestrate hematopoetic cell movement, have been implicated in directing cancer metastasis, although their clinical relevance in CRC has not been defined. Our hypothesis was that the chemokine receptor CXCR4 expressed by CRC is a prognostic factor for poor disease outcome. METHODS CRC cell lines (n = 6) and tumor specimens (n = 139) from patients with different American Joint Committee on Cancer (AJCC) stages of CRC were assessed. Microarray screening of select specimens and cell lines identified CXCR4 as a prominent chemokine receptor. CXCR4 expression in tumor and benign specimens was assessed by quantitative real-time reverse transcription polymerase chain reaction and correlated with disease recurrence and overall survival. RESULTS High CXCR4 expression in tumor specimens (n = 57) from AJCC stage I/II patients was associated with increased risk for local recurrence and/or distant metastasis (risk ratio, 1.35; 95% CI, 1.09 to 1.68; P = .0065). High CXCR4 expression in primary tumor specimens (n = 35) from AJCC stage IV patients correlated with worse overall median survival (9 months v 23 months; RR, 2.53; 95% CI, 1.19 to 5.40; P = .016). CXCR4 expression was significantly higher in liver metastases (n = 39) compared with primary CRC tumors (n = 100; P < .0001). CONCLUSION CXCR4, a well-characterized chemokine receptor for T-cells, is differentially expressed in CRC. CXCR4 gene expression in primary CRC demonstrated significant associations with recurrence, survival, and liver metastasis. The CXCR4-CXCL12 signaling mechanism may be clinically relevant for patients with CRC and represents a potential novel target for disease-directed therapy.
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Affiliation(s)
- Joseph Kim
- Department of Molecular Oncology, John Wayne Cancer Institute, 2200 Santa Monica Blvd., Santa Monica, CA 90404, USA
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Takeuchi H, Morton DL, Kuo C, Turner RR, Elashoff D, Elashoff R, Taback B, Fujimoto A, Hoon DSB. Prognostic significance of molecular upstaging of paraffin-embedded sentinel lymph nodes in melanoma patients. J Clin Oncol 2004; 22:2671-80. [PMID: 15226334 PMCID: PMC2856457 DOI: 10.1200/jco.2004.12.009] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Detection of micrometastases in sentinel lymph nodes (SLNs) is important for accurate staging and prognosis in melanoma patients. However, a significant number of patients with histopathology-negative SLNs subsequently develop recurrent disease. We hypothesized that a quantitative realtime reverse transcriptase polymerase chain reaction (qRT) assay using multiple specific mRNA markers could detect occult metastasis in paraffin-embedded (PE) SLNs to upstage and predict disease outcome. PATIENTS AND METHODS qRT was performed on retrospectively collected PE SLNs from 215 clinically node-negative patients who underwent lymphatic mapping and sentinel lymphadenectomy for melanoma and were followed up for at least 8 years. PE SLNs (n = 308) from these patients were sectioned and assessed by qRT for mRNA of four melanoma-associated genes: MART-1 (antigen recognized by T cells-1), MAGE-A3 (melanoma antigen gene-A3 family), GalNAc-T (beta1-->4-N-acetylgalactosaminyl-transferase), and Pax3 (paired-box homeotic gene transcription factor 3). RESULTS Fifty-three (25%) patients had histopathology-positive SLNs by hemotoxylin and eosin and/or immunohistochemistry. Of the 162 patients with histopathology-negative SLNs, 48 (30%) had nodes that expressed at least one of the four qRT markers, and these 48 patients also had a significantly increased risk of disease recurrence by a Cox proportional hazards model analysis (P <.0001; risk ratio, 7.48; 95% CI, 3.70 to 15.15). The presence of > or = one marker in histopathology-negative SLNs was also a significant independent prognostic factor by multivariate analysis for overall survival (P =.0002; risk ratio, 11.42; 95% CI, 3.17 to 41.1). CONCLUSION Molecular upstaging of PE histopathology-negative SLNs by multiple-marker qRT assay is a significant independent prognostic factor for long-term disease recurrence and overall survival of patients with early-stage melanoma.
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Affiliation(s)
- Hiroya Takeuchi
- Department of Molecular Oncology, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, CA 90404, USA
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Taback B, Bilchik AJ, Saha S, Nakayama T, Wiese DA, Turner RR, Kuo CT, Hoon DSB. Peptide nucleic acid clamp PCR: a novel K-ras mutation detection assay for colorectal cancer micrometastases in lymph nodes. Int J Cancer 2004; 111:409-14. [PMID: 15221969 DOI: 10.1002/ijc.20268] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Inaccurate staging of colorectal cancer (CRC) has been attributed to the failure to detect lymph node metastases by conventional pathology. We have previously reported the use of lymphatic mapping to accurately identify those lymph nodes most likely to harbor micrometastatic disease and permit focused pathologic examination. Mutation of K-ras allele at codons 12 or 13 occurs frequently in early stages of CRC development. The purpose of our study was to assess sentinel lymph nodes (SLN) for occult CRC micrometastases using a unique peptide nucleic acid (PNA) clamp PCR assay specific for K-ras mutations. Seventy-two paraffin-embedded primary CRC and paired SLN were evaluated by PNA clamp PCR for K-ras mutations. Thirty primary tumors (42%) were positive for K-ras mutations, and in 5 of these cases the SLN were positive for metastases by Hematoxylin and Eosin staining. PNA clamp PCR identified occult metastases in an additional 6 patients, upstaging 24% of K-ras positive primary CRCs (p = 0.014). No K-ras mutations were detected among the 20 noncancer lymph nodes assessed. This study demonstrates the utility, specificity and sensitivity of PNA clamp PCR assay in identifying occult micrometastases in the SLN of CRC patients by single-base mutation analysis.
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Affiliation(s)
- Bret Taback
- Department of Molecular Oncology, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, CA 90404, USA
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Morton DL, Hoon DSB, Cochran AJ, Turner RR, Essner R, Takeuchi H, Wanek LA, Glass E, Foshag LJ, Hsueh EC, Bilchik AJ, Elashoff D, Elashoff R. Lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: therapeutic utility and implications of nodal microanatomy and molecular staging for improving the accuracy of detection of nodal micrometastases. Ann Surg 2003; 238:538-49; discussion 549-50. [PMID: 14530725 PMCID: PMC1360112 DOI: 10.1097/01.sla.0000086543.45557.cb] [Citation(s) in RCA: 223] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Lymphatic mapping and sentinel lymphadenectomy (LM/SL) have been applied to virtually all solid neoplasms since our original description of LM/SL for melanoma. Our objectives were to determine the diagnostic and therapeutic utility of LM/SL, investigate carbon dye for mapping the microanatomy of lymphatic flow within the sentinel node (SN), and determine the prognostic accuracy of molecular assessment of the SN. METHODS Since 1985, 1599 patients with AJCC Stage I/II melanoma have been treated by LM/SL at our institution and 4590 have been treated by wide excision (WE) without nodal staging. We examined the incidence of clinical nodal recurrence after WE alone, the incidence of subclinical nodal metastases found by LM/SL, and the incidence of nodal recurrence in basins with histopathology-negative SNs. RESULTS In 1514 LM/SL patients with a primary of known Breslow thickness, the incidence of metastasis in nodes claimed to be sentinel was 7.3%, 19.7%, 33.2%, and 39.7% for primary lesions =1.0, 1.01-2.0, 2.01-4.0, and >4.0 mm, respectively. In 3652 WE-only patients, the corresponding rates of nodal recurrence were 12.0%, 32.0%, 34.4%, and 30.1%. Thus, LM/SL detected only 60% of expected nodal metastases from primary melanomas <2.01 mm. Forty of 1599 (3.1%) patients developed recurrence in basins with immunohistochemistry (IH)-negative SNs. To determine whether nonrandom intranodal distribution of tumor cells could explain missed SN metastases, we coinjected carbon particles and blue dye during LM/SL in 166 patients: 25 (16%) patients had nodal metastases, all of which were found only in nodal subsectors containing carbon particles. When paraffin-embedded SNs from a subset of 162 IH-negative patients were re-examined by quantitative multimarker reverse-transcriptase polymerase chain reaction (qRT) assay, 49 (30%) gave positive signals. These patients had a significantly higher risk of disease recurrence and death than did patients whose IH and qRT results were negative (p < 0.0001). Comparison of 287 prognostically matched pairs of patients who underwent immediate (after LM/SL) versus delayed (after observation) dissection of nodal metastases revealed 5-, 10-, and 15-year survival rates of 73%, 69%, and 69% versus 51%, 37%, and 32%, respectively (P < or = 0.001). CONCLUSIONS SN assessment based on intranodal compartmentalization of lymphatic flow (carbon dye mapping) should increase the accuracy of IH and, in combination with multimarker qRT assessment, will allow confident identification of most patients for whom surgery alone is curative. Our data suggest a significant therapeutic benefit for immediate dissection based on identification of a tumor-involved SN.
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Affiliation(s)
- Donald L Morton
- Roy E Coats Research Laboratories of the John Wayne Cancer Insstitute at Saint John's Health Center, Santa Monica, CA 90404, USA.
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Turner RR, Nora DT, Trocha SD, Bilchik AJ. Colorectal carcinoma nodal staging. Frequency and nature of cytokeratin-positive cells in sentinel and nonsentinel lymph nodes. Arch Pathol Lab Med 2003; 127:673-9. [PMID: 12741889 DOI: 10.5858/2003-127-673-ccns] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Nodal staging accuracy is important for prognosis and selection of patients for chemotherapy. Sentinel lymph node (SLN) mapping improves staging accuracy in breast cancer and melanoma and is being investigated for colorectal carcinoma. OBJECTIVE To assess pathologic aspects of SLN staging for colon cancer. DESIGN Sentinel lymph nodes were identified with a dual surgeon-pathologist technique in 51 colorectal carcinomas and 12 adenomas. The frequency of cytokeratin (CK)-positive cells in mesenteric lymph nodes, both SLN and non-SLN, was determined along with their immunohistochemical characteristics. RESULTS The median number of SLNs was 3; the median number of total nodes was 14. The CK-positive cell clusters were detected in the SLNs of 10 (29%) of 34 SLN-negative patients. Adjusted per patient, SLNs were significantly more likely to contain CK-positive cells than non-SLNs (P <.001). Cell clusters, cytologic atypia, and/or coexpression of tumor and epithelial markers p53 and E-cadherin were supportive of carcinoma cells. Single CK-positive cells only, however, could not be definitively characterized as isolated tumor cells; these cells generally lacked malignant cytologic features and coexpression of tumor and epithelial markers and in 2 cases represented mesothelial cells with calretinin immunoreactivity. Colorectal adenomas were associated with a rare SLN CK-positive cell in 1 (8%) of 12 cases. CONCLUSIONS Sentinel lymph node staging with CK-immunohistochemical analysis for colorectal carcinomas is highly sensitive for detection of nodal tumor cells. Cohesive cell clusters can be reliably reported as isolated tumor cells. Single CK-positive cells should be interpreted with caution, because they may occasionally represent benign epithelial or mesothelial cells.
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Affiliation(s)
- Roderick R Turner
- Department of Pathology, Saint John's Health Center, Santa Monica, Calif, USA.
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Bilchik AJ, Nora DT, Sobin LH, Turner RR, Trocha S, Krasne D, Morton DL. Effect of lymphatic mapping on the new tumor-node-metastasis classification for colorectal cancer. J Clin Oncol 2003; 21:668-72. [PMID: 12586804 DOI: 10.1200/jco.2003.04.037] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Sensitive detection methods and accurate reporting are necessary to determine the prognostic significance of micrometastases (MM) and isolated tumor cells (ITCs) in lymph nodes that drain colorectal cancers (CRCs). This study examined the role of lymphatic mapping (LM) in the application of the new tumor-node-metastasis (TNM) classification for MM and ITC. PATIENTS AND METHODS All patients at the John Wayne Cancer Institute underwent LM immediately before standard resection of primary CRC between 1996 and 2001. Sentinel nodes (SNs) were identified using blue dye and/or radiotracer and were examined by hematoxylin-eosin (H&E) staining, cytokeratin immunohistochemistry, and multilevel sectioning. The comparison group comprised 370 patients whose primary CRCs were resected without LM during the same period at the same institution. RESULTS LM was successfully performed in 115 of 120 (96%) patients and correctly predicted the tumor status of the nodal basin in 110 of 115 (96%) patients. Thirty-seven patients (32%) were lymph node-positive by H&E, ITC and MM were found in 23 patients (29.4%) whose lymph nodes were negative by H&E. Tumor deposits were found in the SN only in 29 patients (50%). Nodal involvement was identified for 14.3%, 30%, 74.6%, and 83.3% of T1, T2, T3, and T4 tumors, respectively, in the study group, and for 6.8%, 8.5%, 49.3%, and 41.8% of T1, T2, T3, and T4 tumors, respectively, in the comparison group. The study group had a higher percentage of nodal metastases (53% v 36%; P <.01) and a higher incidence of MM and ITC (29.4% v 1.9%; P <.0001). The mean number of lymph nodes found in the study group (14) was also significantly more than the number found in the comparison group (10; P <.00001). CONCLUSION Conventional examination of lymph nodes for CRC is inadequate for the detection of MM and ITC as described in the new TNM classification. Thus, LM and focused SN analysis should be considered to fully stage CRC.
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Affiliation(s)
- Anton J Bilchik
- Division of Surgical Oncology, John Wayne Cancer Institute at Saint John's Health Center, 2200 Santa Monica Boulevard, Santa Monica, CA 90404, USA.
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Wood TF, Nora DT, Morton DL, Turner RR, Rangel D, Hutchinson W, Bilchik AJ. One hundred consecutive cases of sentinel lymph node mapping in early colorectal carcinoma: detection of missed micrometastases. J Gastrointest Surg 2002; 6:322-9; discussion 229-30. [PMID: 12022982 DOI: 10.1016/s1091-255x(02)00013-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Almost one third of patients with "node-negative" colorectal carcinoma (CRC) develop systemic disease. This implies that these patients have occult disease that is inadequately treated by surgery alone. We have coupled sentinel lymph node mapping and a focused pathologic examination to detect occult nodal micrometastases in CRC. Since 1996, sentinel lymph node mapping has been performed in 100 consecutive patients undergoing colectomy for CRC. Peritumoral injection of 0.5 to 1.0 ml of isosulfan blue dye was performed to demonstrate the sentinel node(s). All lymph nodes in the resection specimen were examined by routine hematoxylin and eosin staining. In addition, a focused examination of multiple sections of the sentinel nodes was performed using both hematoxylin and eosin and cytokeratin immunohistochemical analysis (CK-IHC). Overall, lymphatic mapping successfully demonstrated one to four sentinel lymph nodes in 97 (97%) of 100 patients. These sentinel nodes accurately reflected the status of the nodal basin in 92 (95%) of 97 patients. All five of the false negative cases occurred in T3/T4 tumors, and three of the five occurred during the first 30 cases in the experience. Unexpected lymphatic drainage was encountered in eight patients (8%) and altered the operative approach. Twenty-six patients were node positive by routine hematoxylin and eosin staining. Of the remaining 74 patients with hematoxylin and eosin-negative nodes, an additional 18 patients (24%) were upstaged by identification of occult nodal micrometastases that were missed on routine hematoxylin and eosin staining but detected on multiple sections (n = 5) or by CK-IHC (n = 13). The sentinel lymph nodes were the only positive nodes in 19 cases. Sentinel lymph node mapping may be performed in CRC with a high degree of success and accuracy. A focused pathologic examination of the sentinel node detects micrometastatic disease that is missed by conventional techniques in a significant proportion of patients with early CRC. Further studies are necessary to elucidate the clinical relevance of these micrometastases.
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Affiliation(s)
- Thomas F Wood
- John Wayne Cancer Institute, Santa Monica, CA 90404, USA
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Turner RR. Histopathologic assessment of the sentinel lymph node in breast cancer. Ann Surg Oncol 2001; 8:56S-59S. [PMID: 11599901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Thorough pathologic examination of the sentinel lymph node (SLN) improves the accuracy of breast cancer staging and reduces the rate of false-negative results. Intraoperative examination of the SLN with cytological or frozen section techniques remains problematic. Diagnostic difficulties encountered on hematoxylin and eosin paraffin sections in general are easily resolved with cytokeratin immunohistochemistry, but the finding of minute metastases may lead to diagnostic and therapeutic dilemmas. Pathologic characteristics of the primary tumor and SLN metastasis determine the risk of non-SLN metastasis in the same lymphatic basin.
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Affiliation(s)
- R R Turner
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA.
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Abstract
BACKGROUND False-negative results from lymphatic mapping and sentinel lymphadenectomy (LM/SL) are associated with technical failures in nuclear medicine and surgery or with erroneous histologic evaluation. Any method that can confirm sentinel lymph node (SN) identity might decrease the false-negative rate. Carbon dye has been used as an adjunct to assist lymphadenectomy for some tumors, and the authors hypothesized that it could be used for the histologic verification of SNs removed during LM/SL. The current study assessed the clinical utility of carbon dye as a histopathologic adjunct for the identification of SNs in patients with melanoma and correlated the presence of carbon particles with the histopathologic status of the SNs. METHODS LM/SL was performed using carbon dye (India ink) combined with isosulfan blue dye and sulfur colloid. Blue-stained and/or radioactive lymph nodes (two times background) were defined as SNs. Lymph nodes were evaluated for the presence of carbon particles and melanoma cells. If an SN lacked carbon dye in the initial histologic sections, four additional levels were obtained with S-100 protein and HMB-45 immunohistochemistry. Completion lymph node dissection (CLND) was performed if any SN contained melanoma cells. RESULTS One hundred patients underwent successful LM/SL in 120 lymph node regions. Carbon particles were identified in 199 SNs from 111 lymph node regions of 96 patients. Sixteen patients had tumor-positive SNs, all of which contained carbon particles. The anatomic location of the carbon particles within these tumor-positive SNs was found to be correlated with the location of tumor cells in the SNs. The presence of carbon particles appeared to be correlated with blue-black staining (P = 0.0001) and with tumor foci (P = 0.028). All 35 non-SNs that were removed during LM/SL were tumor-negative, and only 2 contained carbon particles. Of the 272 non-SNs removed during CLND, 5 contained metastases; 3 of these 5 were the only non-SNs that had carbon particles. The use of carbon particles during LM/SL was found to be safe and nontoxic. CONCLUSIONS Carbon dye used in LM/SL for melanoma permits the histologic confirmation of SNs. Carbon particles facilitate histologic evaluation by directing the pathologist to the SNs most likely to contain tumor. The location of carbon particles within SNs may assist the pathologist in the detection of metastases, thereby decreasing the histopathologic false-negative rate of LM/SL and subsequently reducing the same-basin recurrence rate.
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Affiliation(s)
- P I Haigh
- Roy E. Coats Research Laboratories, Division of Surgical Oncology, John Wayne Cancer Institute at Saint John's Health Center, 2200 Santa Monica Blvd., Santa Monica, CA 90404, USA
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Abstract
The recently introduced technique of sentinel lymph node dissection (SLND) may replace complete axillary lymph node dissection for axillary staging of early breast cancer. Successful SLND is predicated on meticulous delineation of the lymphatic pathway and sentinel node(s). Currently employed lymphatic mapping materials include vital blue dyes and radioactive tracers. Techniques of intraoperative lymphatic mapping and SLND using dye, tracer, or both have high success rates in the hands of experienced investigators, but their routine and widespread use awaits resolution of questions about the timing, dose, and type of radioactive tracer; the optimal lymphatic mapping technique; indications and contraindications for SLND; and certification of qualified surgeons, pathologists, and nuclear medicine physicians.
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Affiliation(s)
- E C Hsueh
- Joyce Eisenberg-Keefer Breast Center and the Division of Surgical Oncology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA 90404, USA.
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