Balloon dilatation of benign rectal anastomotic strictures -- a review

BACKGROUND

The occurrence of anastomotic stricture at the level of the rectum gives rise to three broad therapeutic options, namely major pelvic and abdominal revisional surgery, faecal diversion (stoma), or local revision by transanal approaches (including endoscopic and fluoroscopic). This article updates the current evidence and focuses on the results of the balloon dilatation technique.

METHODS

A Medline search was carried out using the search terms (dilatation OR dilatation) AND (stricture OR strictures OR stenosis OR stenotic) AND (rectum OR rectal). In an effort to lessen publication bias, articles included at least 10 patients who were consecutively referred for treatment.

RESULTS/CONCLUSION

This review would suggest that probably relatively short strictures have been chosen for balloon dilatation and that the results have had a very low major morbidity (0.45%) and mortality (0%) rate.

P5-13-15: Proteomic Identification of Predictive Biomarkers of Resistance to Neoadjuvant Chemotherapy in Luminal Breast Cancer: A Possible Role for 14–3-3 and BID?

Background: Chemotherapy resistance is a major obstacle in effective neoadjuvant treatment for oestrogen receptor (ER)-positive breast cancer. The ability to predict tumour response would allow chemotherapy administration to be directed towards only those patients who would benefit, thus maximising treatment efficiency. We aimed to identify protein biomarkers associated with chemotherapy resistance, using proteomic analysis of fresh ER-positive breast cancer samples, and then to perform pilot clinical validation experiments. Materials and Methods: Chemotherapy resistant and chemotherapy sensitive tumour samples were collected from breast cancer patients who received standard anthracycline-based neoadjuvant therapy consisting of epirubicin with cyclophosphamide followed by docetaxel. Comparative proteomics experiments were performed using invasive ductal carcinomas which demonstrated ER-positivity (luminal subtype). Protein expression was compared between chemotherapy resistant and chemotherapy sensitive tumour samples using 2-dimensional gel electrophoresis (2-DE) with MALDI-TOF/TOF mass spectrometry (MS). In addition the Panorama XPRESS Profiler725 antibody microarray, containing 725 antibodies from a wide variety of cell signalling and apoptosis pathways, was employed in the discovery phase. Differentially expressed proteins (DEPs) were submitted to Ingenuity Pathway Analysis (IPA) to identify any canonical pathway links. A pilot series of archival breast cancer samples, from patients treated with neoadjuvant anthracycline-based chemotherapy, was used for preliminary clinical validation of putative predictive biomarkers.

Results: Five datasets were generated by antibody microarray analysis, revealing 41 targets. Of these, 7 DEPs were identified in at least 2 datasets and these included 14–3-3, BID and Bcl-xL. The top canonical pathway matched in IPA was “ERK5 signaling”, which involved 6 DEPs, including 14–3-3. The “PI3/AKT” pathway also involved 6 DEPs, including 14–3-3 and Bcl-xL. Three datasets were generated using 2-DE with MALDI-TOF/TOF MS, containing over 300 DEPs. These included several isoforms of 14–3-3. Differential expression of 14–3-3, BID and Bcl-xL was confirmed by immunoblotting in samples used for the discovery phase. A pilot clinical validation using immunohistochemical analysis of archival breast cancers revealed 14–3-3 tau and tBID to be significantly associated with chemotherapy resistance.

Discussion: We have successfully utilised clinical tumour samples for the discovery of putative biomarkers of chemotherapy resistance using two complementary proteomic platforms. We propose a potential role for 14–3-3 tau and BID as predictive biomarkers of chemotherapy resistance in ER-positive tumours and further validation in a larger sample series is now required.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-15.

Minimally invasive excision of gynaecomastia--a novel and effective surgical technique

INTRODUCTION

More aesthetically acceptable treatment options have been sought to minimise the morbidity associated with open surgery for gynaecomastia. This study investigated the use of a vacuum-assisted biopsy device (VABD) and liposuction to provide minimally invasive approach.

PATIENTS AND METHODS

Patients diagnosed with idiopathic benign gynaecomastia referred to the Breast Care Unit of Castle Hill Hospital between June 2002 and April 2007 and requesting surgical intervention underwent VABD excision and liposuction. All patients underwent thorough investigations to exclude any underlying cause for their gynaecomastia. The procedure was carried out by a single consultant surgeon with special interest in breast surgery. An 8-G mammotome probe was advanced through a 4-mm incision positioned in the corresponding anterior axillary line to excise the glandular disc. Liposuction was performed through the same incision. Incision wounds were closed with Steristrips. A pressure dressing was applied over wound by corset and an inflatable device.

RESULTS

Thirty-six male patients with grade I and II gynaecomastia were recruited (22 bilateral, 14 unilateral). Average age was 33.3 years (range, 16-88 years). All underwent mammotome excision and liposuction. There were no conversions to an open procedure. The average procedure time was 50.3 min (range, 30-80 min). One intra-operative complication was recorded. The minimum follow-up time was 2 months. Thirty-four patients reported excellent satisfaction, two patients had residual gynaecomastia and needed a re-do procedure. Three patients developed small haematomas that resolved spontaneously.

CONCLUSION

This novel, minimally invasive, surgical approach for gynaecomastia gives excellent results with minimal morbidity.

Oestrogen and progesterone receptor status of individual foci in multifocal invasive ductal breast cancer

Widespread acceptance of breast conserving surgery for early breast cancer has led to renewed interest in multifocality, which is seen in 13-63% of breast cancers. According to current guidelines, oestrogen/progesterone receptor status is assessed on the sample obtained at initial core biopsy or the main tumour focus in multifocal breast cancer (more than one distinct tumour focus in a quadrant). We assessed receptor status of individual foci in multifocal breast cancer. Mastectomy specimens for 18 cases of multifocal breast cancer were identified. Immunohistochemical staining for oestrogen and progesterone receptors was performed on all tumour foci. On histological examination 11 patients demonstrated two independent tumour foci, three demonstrated three foci and four demonstrated four foci. Minor differences in oestrogen receptor score were seen between foci (attributed to the subjective nature of the scoring system), which did not affect the overall positive/negative classification. Sixteen patients (88%) were oestrogen receptor-positive. Progesterone receptor staining showed more variability between foci in two patients but, since the tumours were oestrogen receptor-positive this would not have affected clinical decision-making. No major differences in oestrogen receptor status between multiple tumour foci in the same quadrant were found in this pilot study.

Magnetic resonance imaging accuracy in assessing tumour down-staging following chemoradiation in rectal cancer

OBJECTIVE

Magnetic resonance imaging (MRI) is increasingly accepted as the radiological modality of choice staging rectal cancer but is subject to error. Neoadjuvant therapy is increasingly used in rectal cancer and MRI is used to stage response and occasionally plan surgery. We aim to assess the staging accuracy of MRI following chemoradiotherapy in rectal cancer.

METHOD

Retrospective analysis of 86 patients with MRI stage pre- and postlong-course chemoradiotherapy and comparison with pathological assessment.

RESULTS

Fourty-nine patients (34 men, 15 women) with median age 68 years (60-74) were analysed. The median time from completion of CRT to MRI was 32 days (16-37). Chemoradiotherapy led to significant down-staging (P < 0.001). MRI-staging accuracy was 43% (21/49) with over- and under-staging in 43% (21/49) and 14% (7/49) respectively. T-stage accuracy was 45% (22/49) with over-staging in 33% (16/49) and under-staging in 22% (11/49). MRI stage correlated poorly with pathological assessment for International Union Against Cancer (kappa = 0.255) and T stages (kappa = 0.112). MRI nodal assessment was 71% (35/49) accurate, with 82% (9/11) sensitivity, 68% (26/38) specificity and positive predictive value (PPV) of 43% (9/21) and negative predictive value of 93% (26/28). There was a significant difference in node positivity between MRI and pathological staging (P = 0.005, Fisher's exact). Complete radiological response was observed in 4% (2/49). Complete pathological response was observed in 10% (5/49), which were staged 0(1), I(1), II(2) and III(1) postchemoradiotherapy by MRI.

CONCLUSION

MRI staging following chemoradiation is poor. Over-staging occurs three times more commonly than under-staging. Over-staging is due to poor PPV of nodal assessment.

Antibody microarray analysis identifies biomarkers associated with radioresistant breast cancer cell lines

Abstract #5072

Background: Resistance to radiotherapy may be a significant factor in the development of local recurrence following surgical resection and radiotherapy. In addition, if patients with radioresistant breast cancers can be identified, harmful side effects from exposure to unnecessary ionizing radiation could be prevented. We aimed to develop a novel in vitro model of radioresistance using breast cancer cell lines and to subsequently identify molecular biomarkers which may be associated with the radioresistant phenotype. Antibody microarrays offer a complementary approach for proteomic analysis in conjunction with standard screening methods such as two dimensional gel electrophoresis/ mass spectrometry and other quantitative proteomic techniques. We previously utilised the Panorama Cell Signalling Antibody Microarray Kit (Sigma-Aldrich) consisting of 224 antibodies (Smith et al Mol Cancer Ther 5:2115-20, 2006). In this study we utilised a novel high density 725 antibody microarray to screen for proteins associated with radioresistance.&#x2028; Material and Methods: We established novel breast cancer cell sublines which were significantly resistant to radiotherapy when compared with the parental cells (T47D; MCF-7). The radioresistant sublines were created by irradiating cells in fractionated doses of 2Gy up to a total dose of 40Gy. Sufficient time was allowed for the cells to recover between subsequent irradiations. A dose response curve was assessed at the end of treatment to demonstrate a statistically significant increase in radioresistance for the novel cell subline when compared with parental cells. The radioresistant/parental cell pairs were analysed using the Panorama Antibody Microarray XPRESS Profiler725 Kit (Sigma-Aldrich). The microarray comprised 725 different antibodies on nitrocellulose coated microscope slides. The antibodies were selected from a wide variety of pathways, including apoptotic and cell signalling pathways.&#x2028; Results: Utilising a Cy3/Cy5 labelling strategy the antibody microarray approach yielded a number of a total of 28 targets for further study. Of these, three proteins were identified independently from both of the radioresistant cell lines. These were GFI1 (Growth Factor Independence-1), DR4 (Death Receptor 4) and Importin a1. Immunoblotting and other proteomic approaches have confirmed the identities and differential expression of some candidate protein targets.&#x2028; Conclusion: High density antibody microarrays potentially offer a powerful new proteomic technique to allow the global analysis of many proteins simultaneously. This analysis has produced both complementary and confirmatory data in our proteomic screening for putative biomarkers associated with radiotherapy resistance. We successfully identified a number of protein targets which may be associated with a radioresistant phenotype. Further confirmatory and validation studies are ongoing.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5072.

Accuracy of DCE – MRI in predicting response in patients treated with taxane based neoadjuvant chemotherapy

Abstract #5120

Background: Neoadjuvant chemotherapy for locally advanced breast cancer is an established treatment option. Several studies have shown DCE-MRI scanning to be the most accurate investigation to assess response to EC chemotherapy. Recent trials have shown that addition of Taxanes increases the overall response rate and the rate of breast conserving surgery. Taxanes act by inhibiting angiogenesis in the tumour and this could potentially affect the quality of the post treatment scan images as DCE-MR scan and cause inappropriate decisions regarding the required surgery.&#x2028; Aim: To compare the accuracy of DCE-MR scan in identifying residual disease in patients treated with FEC (Fluoro uracil, Epirubicin, Cyclophosphamide) vs EC (Epirubicin, Cyclophosphamide) followed by Taxane.&#x2028; Methods: Patients treated with primary chemotherapy who subsequently underwent breast conserving surgery were identified from a prospectively maintained database. Clinical details including chemotherapy regimes, pre and post chemotherapy MRI data, number of surgical procedures and histological parameters of the excised specimen were obtained.&#x2028; Results: A total of 121 patients treated with primary chemotherapy were identified. Of these, 76 were treated with FEC or EC based chemotherapy and 45 were treated with EC+Taxane. DCE-MRI was significantly less accurate (p&lt;0.05) when predicting the size of residual disease in the Taxane group.&#x2028; &#x2028; Conclusion: DCE MR scan is not as accurate for quantifying size of residual disease in patients treated with taxane when compared with patients treated with traditional FEC/EC based primary chemotherapy. This should be considered when planning surgery after neoadjuvant therapy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5120.

Recurrence rates after DCE-MRI image guided planning for breast-conserving surgery following neoadjuvant chemotherapy for locally advanced breast cancer patients

BACKGROUND

Neoadjuvant therapy results in a significant increase in breast-conserving surgery. However, traditional imaging methods are unable to accurately predict the extent of viable residual disease leading to uncertainty in surgical planning and some previous studies have shown a disproportionately high incidence of locoregional recurrence. Dynamic contrast enhanced-MRI (DCE-MRI) has been shown to provide a potentially more accurate prediction of residual disease.

RESULTS

Patients undergoing neoadjuvant chemotherapy for breast cancer in our unit are staged with the DCE-MRI of the breast performed at 1.5 T before, during and after treatment and the final result was used to plan surgery. Two hundred and four patients with breast cancer were treated with neoadjuvant chemotherapy between 1996 and April 2005. Eighteen of these patients had distant metastases at the time of initial diagnosis and so were excluded from the present study. Following neoadjuvant chemotherapy, 186 patients underwent surgical treatment. Of these, 68 patients had breast-conserving surgery. At a median follow up of 30 months (range: 5.6-72 months) 21 patients in this group developed subsequent recurrence (21/68 - 30%) of whom 9 (9/68 - 13%) had locoregional recurrence, 7 had local recurrence (7/68 - 10%), and 17 (17/68 - 25%) had distant recurrence. Logistic regression analysis revealed only vascular invasion (p=0.006) of the tumour to be significantly associated with overall recurrence. None of the pathological factors (ER, PR status, vascular invasion, lymph node metastases, pathological complete response to neoadjuvant chemotherapy) showed a significant association with locoregional recurrence.

CONCLUSION

Breast-conserving surgery with DCE-MRI planning after neoadjuvant chemotherapy provides an acceptable level of local recurrence without the need for mastectomy.

Direct polymerase chain reaction amplification of formalin-fixed, paraffin-wax-embedded tissue after automated sequential laser microdissection and pressure catapulting

A robust method to facilitate rapid laser microdissection and pressure catapulting (LMPC) coupled with direct polymerase chain reaction (dPCR) to eliminate the need for extraction of DNA before a PCR-based assay is described. This sequential LMPC-dPCR method is rapid and decreases the number of processing steps, reducing the chance of tissue loss and contamination.

Spontaneous growth hormone release in term infants: changes during the first four days of life

Healthy term infants have higher umbilical cord GH levels compared to older infants and children. In the sheep, GH concentrations rapidly fall within an hour of birth; the physiology of GH release after parturition in the human term infant is less well known. The purpose of this study was to investigate spontaneous 12-h GH release in male and female term infants of varying postnatal ages. We studied 14 infants (7 males and 7 females). Subjects were divided into those studied earlier following delivery (28.2 +/- 3.4 h of age, mean +/- SE) and into those studied at a later time (74.8 +/- 3.5 h, P < 0.0005). The age at study was defined as the age (hours) when blood sampling began. There were eight infants studied at an early age (four males and four females) and six studied at a later age (three males and three females). Subjects were comparable with respect to gestational age, birth weight, and length; all were biochemically euthyroid. One infant was large for gestational age although his head circumference was in the normal range. Blood (0.1 mL) was taken every 30 min over a 12-h period from an indwelling umbilical catheter; no stress occurred during the blood withdrawal. GH was determined by a double-antibody RIA using 0.01 mL plasma. GH pulse detection was undertaken using Cluster, a computerized pulse detection algorithm. Total insulin-like growth factor I (IGF-I) was measured following separation of the IGFs from the serum binding proteins. Spontaneous pulsatile GH release was observed in all infants studied. No differences in GH characteristics were found between male and female subgroups in the early or late study groups. In subsequent analysis, the data for the males and females are combined. The GH pulse frequency per 12 h was greater in the earlier studied group, 5.1 +/- 0.9 (mean +/- SE) vs. 2.5 +/- 0.7 in the later group (P < 0.05). The maximal pulse amplitude was 47.1 +/- 7.9 micrograms/L in the early and 27.1 +/- 4.1 in the later studied group (P < 0.06). The incremental pulse amplitude was 26.4 +/- 3.4 micrograms/L in the early and 12.8 +/- 2.7 in the later group (P = 0.01). The pulse width was greater in the later studied group (202.8 +/- 71.1 min vs. 84.1 +/- 21.6, P < 0.06).(ABSTRACT TRUNCATED AT 400 WORDS)