P3-07-47: Validated Nomogram To Predict Sentinel Lymph Node Positivity in Breast Cancer Patients

Background: Sentinel lymph node(SLN) biopsy is commonly used to assess axillary lymph node status in breast cancer patients. Intraoperative (frozen section) evaluation of SLN may lead to immediate axillary dissection if the lymph node is found to be positive. In light of the recent outcomes of the Z00011 trial, the use of intraoperative evaluation for SLN should diminish since only select patients appear to benefit from axillary dissection. We have previously reported that tumor size and lymphovascular invasion (LVI) strongly predict SLN positivity in a cohort of 350 breast cancer patients [Modern Pathology (2011) 24, 30A]. From this test cohort, we developed a nomogram which could help identify patients more likely to have sentinel lymph node positivity. The aim of this study was to validate the efficacy of this nomogram by applying a new, non-overlapping cohort of breast cancer patients who had undergone sentinel lymph node sampling. Materials and Methods: 93 breast cancer patients aged 29–82 (mean:59) who underwent excision (54, 58%) or mastectomy (39, 42%) with a SLN biopsy were studied. Patients who had undergone neoadjuvant chemotherapy were excluded. Clinicopathologic parameters such as number of sentinel lymph nodes removed and/or positive, number of non-sentinel lymph nodes removed and/or positive, tumor size, histologic type/grade, presence of lymphovascular invasion, biomarker expression (ER,PR, HER-2/neu) and multifocality were recorded. Statistical analysis was performed to identify which variables correlated with SLN positivity in this validation cohort. In addition, the probability of SLN positivity for each case was determined by using the nomogram and this value was then compared to the patient's true SLN status. Results: When analyzed separately, tumor size (p=0.03) and LVI (p=0.01) were variables that were significantly associated with SLN positivity in both the test and validation cohorts. Employment of the nomogram demonstrated that 60% of patients who were predicted to have a positive SLN with at least 0.8 probability were truly positive by histologic and immunohistochemical examination. Moreover, 89% of patients who were predicted to have a negative SLN with at least 0.8 probability were truly negative by histologic and immunohistochemical examination. Conclusions: We conclude that the utility of this nomogram prior to surgery can help predict SLN positivity. This can serve as a complimentary adjunctive tool to better select patients who will likely need intraoperative evaluation of their sentinel lymph node due to their higher risk of sentinel node positivity and thus, benefit from the option of immediate axillary dissection at that time.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-47.

Cyclooxygenase-2 and Hypoxia-Inducible Factor-1alpha protein expression is related to inflammation, and up-regulated since the early steps of colorectal carcinogenesis

Chronic mucosal inflammation is considered a risk factor for colorectal cancer. Neutrophils are a major source of oxidants, whereas cyclooxygenase 2 (COX-2) and Hypoxia Inducible Factor-1alpha (HIF-1alpha) protein expression levels are increased in inflammatory and malignant lesions. The main purpose of the present study was to evaluate myeloperoxidase (MPO) positive cell infiltration, COX-2 and HIF-1alpha protein expression in colorectal carcinogenesis, especially in its early phases, using immunohistochemistry and immunofluorescence confocal microscopy techniques. MPO, COX-2 and HIF-1alpha proteins were expressed at higher rates in the normal colorectal mucosa of patients with inflammatory bowel diseases and colorectal tumours than in patients with normal colonoscopy. A gradual increase in COX-2 and HIF-1alpha protein expression was observed in dysplastic aberrant crypt foci, adenomas and carcinomas, showing a strong relation to dysplasia. In conclusion, the present study supports the hypothesis of a key role of inflammation in malignant transformation of colorectal mucosa. The evaluation of some early markers related to inflammation in the mucosa of the large bowel may serve as potential tool for prognosis and therapeutic strategies.

Myeloperoxidase-positive cell infiltration in colorectal carcinogenesis as indicator of colorectal cancer risk

Colorectal mucosa is targeted by toxic agents, which can initiate or promote colon cancer. The mechanism of damage might be a focal irritation with loss of normal epithelial cell barrier function. Genetic alterations in tumors may also affect host inflammatory response. The aim of this study was to define the extent of inflammation in colorectal mucosa, along colorectal carcinogenesis, and in microsatellite stable and unstable colorectal carcinomas. We collected 103 samples of normal colorectal mucosa from 65 patients (35 with colorectal cancer or adenoma, 8 with inflammatory bowel diseases, and 22 controls with normal colonoscopy). We also examined 24 aberrant crypt foci, 14 hyperplastic polyps, 16 adenomas, and 67 samples of colorectal carcinoma. Immunohistochemistry was used to count myeloperoxidase (MPO)-positive cells (neutrophils and monocytes) in x100 optical fields under a light microscope. Patients with colorectal tumors had a higher mean number of MPO-positive cells in normal mucosa than controls (mean +/- SD, 2.7 +/- 2.0 versus 1.4 +/- 1.4; P = 0.017). MPO-positive cell number was tightly linked to dysplasia in aberrant crypt foci and adenomas, and it was higher in carcinomas microsatellite unstable than those microsatellite stable (21.6 +/- 15.5 versus 11.9 +/- 8.0; P < 0.01). MPO immunohistochemistry is a simple and reliable technique for the quantification of inflammation in colorectal mucosa., and it may be a potential marker of colorectal cancer risk. Microsatellite instability seems to influence host immune responses to colorectal carcinoma. These observations strongly support a key role of inflammation in colorectal carcinogenesis.

Subcellular localization of beta-catenin and APC proteins in colorectal preneoplastic and neoplastic lesions

Adenomatous polyposis coli (APC) is a tumor suppressor gene whose main function is the destabilization of beta-catenin, a key effector of the Wnt signaling pathway. This gene is defective in familial adenomatous polyposis (FAP), a dominantly inherited disease, but inactivation of APC has been reported also in most sporadic colorectal tumors and it is considered an early event in colorectal tumorigenesis. The aim of the present study was to evaluate the intracellular ultrastructural distribution of beta-catenin and APC proteins in epithelial cells of normal colorectal mucosa, aberrant crypt foci (ACF, an early premalignant lesion) and cancer. We used the immunogold electron microscopic method to identify both proteins. Normal colonic epithelial cells showed a strong membranous expression of beta-catenin and lacked cytoplasmic and nuclear expression. Normal cells showed APC localization pattern characterized by diffuse nuclear expression and along the plasma membrane. In ACF and in carcinoma an absent or reduced membranous expression of beta-catenin was associated with an increased nuclear and cytoplasmatic expression. In aberrant crypt foci and carcinoma, APC was evident inside the nucleus and at the level of cell-cell junctions, but it was decreased in the cytoplasm. This method allowed the accurate localization of proteins of the Wnt signaling pathway in the early steps of colorectal carcinogenesis. The similar pattern of subcellular distribution of APC and beta-catenin in dysplastic ACF and colorectal cancer suggests that ACF are precursor lesions of sporadic and FAP-associated colorectal carcinoma.

[Adenocarcinoma of pancreas with situs viscerum inversus totalis]

A case of adenocarcinoma of the head of the pancreas in a patient with situs viscerum inversus totalis, an association described for the third time in literature, is reported. The possible coexistence of malformations of transposed organs and the specular anatomosurgical situation requires particular attention in the diagnosis and preoperative evaluation as well as a careful reorientation of the surgical perspective and a correct surgical conduct.

[Surgical treatment of hemorrhoidal disease using the circular stapler. Analysis of 60 operated cases]

BACKGROUND

The authors describe their experience of the treatment of hemorrhoidal disease using a circular stapler in order to evaluate the effectiveness of this technique.

METHODS

They describe the surgical technique used in a comparative study carried out at Modena Policlinic. A transversal mucohemorrhoidal transection is performed using a circular stapler above the anorectal joint, enabling radical surgery to be completed in a single stage with a rapid and mini-invasive technique. This technique associates the resection of hemorrhoidal nodules and prolapsed mucosa with fixing the residual mucosa to the anal canal and correcting the hypertension and hematic stasis in the venous spaces by breaking the terminal branches of the superior hemorrhoidal artery. Both male and female patients were enrolled in the study, aged over 18 years old, presenting second, third and fourth degree hemorrhoidal prolapse with indications for surgery. The analysis of the long-term follow-up for possible late complications in the 60 selected cases will be reported in a later work.

RESULTS

The technique is easy, rapid and causes moderate pain. The postoperative complications are negligible.

CONCLUSIONS

A hospital stay limited to a few hours, rapid physical recovery and the absence of out-patient treatment required by this surgical technique, which is comparable to an internal closed hemorrhoidectomy, all offer undoubted advantages, also of a psychological and social nature which amply justify the higher economic and management cost linked to the use of a surgical stapler.

Chemical composition and ecophysiological responses of Empetrum nigrum to aboveground element application

Empetrum nigrum L. (crowberry) is one of the plants surviving near the Cu-Ni smelters in Finland and Russia. According to field observations, the fine roots of E. nigrum are situated below 40 cm depth and the root biomass is reduced in the polluted sites. This could cause a reduced root uptake of macronutrients and trace elements in the field and, therefore, the possible element uptake by aboveground parts of E. nigrum was studied in a greenhouse. Six different treatment solutions containing various heavy metal and macronutrient concentrations were applied to the stems and leaves of E. nigrum and the chemical composition and ecophysiological parameters were measured. Heavy metal concentrations in the leaves and stem bark, and Cu concentrations in the stems, increased with increasing metal concentrations in the spraying solutions. The bark and leaves had higher heavy metal concentrations than the stems of comparable age classes. The macronutrient and Mn concentrations in E. nigrum did not change significantly with increasing element concentrations in the spraying solution. Neither the stem water potential nor the leaf chlorophyll concentrations showed any clear response to element applications. Therefore, the element uptake by aboveground parts of E. nigrum was not confirmed by this study. However, there was a tendency to a decrease in CO2 exchange rate and increase in foliar abscisic acid content in plants treated with the highest element concentrations.

Ecophysiological responses of Empetrum nigrum to heavy metal pollution

Chlorophyll, organic (citric and malic acids) and abscisic acid (ABA) contents and stem water potential were measured to indicate possible physiological effects of heavy metal deposition on Empetrum nigrum L. (crowberry). The leaves and stems of E. nigrum were collected at distances of 0.5 and 8 km from the Cu-Ni smelter at Harjavalta, south-west Finland. All the investigated parameters were clearly affected by heavy metal emissions. Chlorophyll contents in the leaves and organic acid contents in the leaves and stems were lower close to the emission source. Generally found increase in organic acid contents with increasing Ni concentrations was not found, which might be due to the lower production of organic acids measured by decreased photosynthesis near the smelter. In contrast, ABA contents in stems and leaves in general, were higher in plants growing 0.5 km from the pollution source. Close to the smelter the stem water potential of E. nigrum was less negative during the day but more negative during the night. These results suggest that smelter emissions have a negative effect on the ecophysiology of E. nigrum even though it is considered to be a tolerant species to heavy metals.

Copper resistance of Calluna vulgaris originating from the pollution gradient of a Cu-Ni smelter, in southwest Finland

The copper (Cu) resistance of 1-year-old seedlings of heather (Calluna vulgaris) was tested in a greenhouse experiment. The plant material originated from seeds collected from three peatland sites located 1.2 km to the NW, and 2.5 and 5.5 km to the NE of the Harjavalta Cu-nickel (Ni) smelter, SW Finland. The plants were watered with a nutrient solution containing five different levels of Cu (1, 10, 22, 46 and 100 mg l(-1)). Cu clearly decreased the length growth of shoots, shoot and root biomass of C. vulgaris. More than 50% of the seedlings exposed to the highest Cu treatment died. C. vulgaris accumulated high amounts of Cu, the living old roots containing a maximum of 2200 mg kg(-1) Cu and the living stems 1300 mg kg(-1) Cu. Discolouring leaves contained higher Cu concentrations than green leaves. The results indicate Cu accumulation in roots and root-to-shoot transport. Some differences were found between the responses of the three seed provenances, but none of the populations proved to be more resistant to Cu than the others in all the measured responses.

The tolerance of Empetrum nigrum to copper and nickel

The Cu and Ni tolerance of 3- to 5-year-old cuttings of crowberry (Empetrum nigrum) were tested in controlled conditions. Six levels of Cu (0.1-100 mg l(-1)), five levels of Ni (0-100 mg l(-1)) and nine levels of Cu+Ni were applied. The elongation of the shoots, new shoot and root dry weights indicated an adverse effect of increasing Cu and Ni concentrations. At low Cu levels the addition of Ni decreased the dry weights more than at high Cu levels. The results show that E. nigrum accumulated high concentrations of Cu and Ni mainly in old stem tissue, which contained a maximum of over 3000 mg kg(-1) Cu and 1000 mg kg(-1) Ni. The concentrations of Cu and Ni in E. nigrum were higher than those measured in plants growing in areas near to Cu-Ni smelters, but the accumulation pattern was similar. The survival of the cuttings was not affected suggesting that E. nigrum possesses an internal heavy metal tolerance.

[Studies carried out in the province of Nuoro on treatment modalities for oncologic pain during the terminal phase]

The purpose of this first level research is to analyze the organization of the treatment of oncological pain in one Italian province. For the data collection a questionnaire was submitted in the Intensive Care Unit to the responsibles and to the staff in the public hospital structures of the six USL of the Nuoro's province. Results prove that the motivation of the staff and their problem sensitivity, are inadequate to guarantee an effective answer to the patient's need. The main aspects are: legal aspect, concerning the district level interventions ache care formation aspect for registered nurses the necessity to adopt quality evaluation methods.

[Complications of gastroesophageal reflux: considerations on a non-selected case series]

According to the experience of the authors on a non-selected case report, pharmacologic progresses in the therapy of various aspects of peptic disease permit an ease management also of gastro-esophageal reflux disease. Moreover, endoscopy is the very modern pivot of conservative treatment of more severe complications as strictures are, through repetitive and progressive instrumental dilatations. The surgical treatment of the most severe and intractable eveniences must be chosen for only a low percentage number of patients, after a careful functional analysis of the single case. Very important is the endoscopic and histologic control of Barrett esophagus and severe dysplasia.

[Prevention of gastroesophageal reflux. Validity of hemifundoplication according to Cor-Casolo (experimental study)]

After a short preface about the main antireflux techniques employed in the treatment and prevention of gastro-oesophageal reflux, the problems involved in the iatrogenous gastro-oesophageal reflux are stated. As no unanimous opinion exists till now in literature about the importance and incidence of reflux after the operation of extramucous cardiomyotomy according to Heller, used in the treatment of achalasia, and after the Parietal Cell Vagotomy, employed in the treatment of duodenal ulcer, an experimental protocol was set up. An experimental research was performed on 16 dogs, subdivided into 3 groups: in the first group (6 dogs) extramucous cardiomyotomy according to Heller and antireflux procedure (antero-lateral hemifundoplication according to Dor-Casolo) were performed; in the second group (6 dogs) Parietal Cell Vagotomy + extramucous cardiomyotomy according to Heller + antero-lateral hemifundoplication according to Dor-Casolo were performed; in the third group (control) the only extramucous cardiomyotomy according to Heller was performed. In the research, articulated in two stages (1st time - operation; 2nd time - remote checking) the following was effected: pressure gauge test; pH-metric test; gastro-oesophageal scintigraphic test with Tc99m; histopathologic test. The experimental results obtained, elaborated by computer, demonstrated: that extramucous cardiomyotomy according to Heller causes serious oesophagitic phenomena, and therefore it should be joined to antireflux procedure; that Parietal Cell Vagotomy (P.C.V.) causes a significant decrease in the tone of L.E.S. (Lower Oesophageal Sphincter); that antero-lateral hemifundoplication according to Dor-Casolo (210 degrees) is effective in its antireflux action even after long time.

Therapeutic and prophylactic effects of cephalexin and bromhexine in respiratory tract complications of abdominal surgery

We report the results of a study carried out with cephalexin and bromhexine in a group of 100 patients at risk for bronchopulmonary complications following abdominal surgery. The treatment achieved very good activity and excellent tolerance. We consider this therapy very useful for prophylaxis and treatment of bronchopulmonary complications in patients who have undergone surgery.

[Intraoperative evaluation of the high pressure zone in anti-reflux plastic operations]

It has been done a manometric intraoperating study on 18 patients (7 acalasical megaoesophagi, 6 herniae of hiatus, 5 duodenal ulcers) who had undergone an operation of modified Dor's anti-reflux plastics. After Haller H.P.Z. pressure has gone down of 13 mmHg, and has gone up again of 5,5 mmHg after modified Dor; after plastics H.P.Z. average intraoperating pressure has been of 18 mmHg. The posterior plastics of hiatus and the reconstruction of His' angle for hernia of hiatus modify scarcely H.P.Z. pressure. During a superselective vagotomy we have recorded a modest reduction of H.P.Z. pressure, of which average intraoperating values after vagotomy and anti-reflux plastics have been of 16,5 mmHg. At a distance of 30 months from the operation it has been done a follow up on 70% of patients that had undergone an operation of anti-reflux plastics and also 18 patients that had had en intraoperating inspection. However it has been, a degradation of manometric values, the results have been satisfactory over 90% of cases. The authors insist on the utility of intraoperating manometry for a valuation of the completenes and the efficacy of the operation.