Sentinel node biopsy with intraoperative diagnosis in patients undergoing skin-sparing mastectomy and immediate breast reconstruction.

AIMS: False negative cases in the intraoperative assessment of sentinel node (SN) metastases in breast cancer prompt for a secondary axillary lymph node dissection (ALND). Such ALND is technically demanding and prone to complications in patients with immediate breast reconstruction (IBR) if there is a microvascular anastomosis or the thoracodorsal pedicle of a latissimus dorsi flap in the axilla. This study aims to evaluate the feasibility of the intraoperative diagnosis of sentinel node biopsy (SNB) in breast cancer patients undergoing IBR. METHODS: Sixty-two consecutive breast cancer patients undergoing SNB with the intraoperative diagnosis of SN metastases simultaneously with mastectomy and IBR between 2004 and 2006 were included in this study. Results of the SNB and especially the false negative cases in the intraoperative diagnosis were evaluated. RESULTS: Eleven patients had tumor positive SN. Nine of these cases were detected intraoperatively. The two false negative cases in the intraoperative diagnosis constituted of isolated tumor cells only. CONCLUSIONS: Our present study suggests that SNB with intraoperative diagnosis of SN metastases is feasible in patients undergoing IBR if the risk of nodal metastasis is low and the sensitivity of intraoperative SNB diagnosis is high.

Sentinel node biopsy is not sensible in breast cancer patients with large primary tumours.

AIMS: We aimed to evaluate the outcome of sentinel node biopsy (SNB) in breast cancer patients with large primary tumours. METHODS: Nine hundred and eighty-four patients with invasive breast cancer and SNB were studied. The histological tumour size was larger than 3 cm in 70 patients. The advantages of SNB like avoiding axillary clearance (AC) or more accurate staging by detecting micrometastases or parasternal sentinel node metastases were evaluated in relation to the tumour size. RESULTS: Axillary metastases were detected in 351/914 patients with a tumour size of 3 cm or smaller and in 50/70 patients with larger tumours (p<<0.0001). Micrometastases or isolated tumour cells only, were observed in 134/351 node positive patients with tumours not larger than 3 cm and in 10/50 cases with larger tumours (p=0.022). Parasternal sentinel node metastases were detected in 17/914 patients with a tumour size of 3 cm or smaller and 2/70 patients with larger tumours (p=ns). AC was omitted because of tumour negative sentinel node findings 168 of the 232 patients with stage T1 a-b tumours and 281 of those 489 with T1c tumours. Twenty of the 70 patients with tumours larger than 3 cm avoided AC. CONCLUSIONS: SNB is not sensible in breast cancer patients with tumours larger than 3 cm, because of the small proportion avoiding AC after SNB.

The prevalence of non-sentinel node metastases in breast cancer patients with sentinel node micrometastases.

AIMS: The aim of the study was to estimate the prevalence of and risk factors for non-sentinel node (NSN) involvement in breast cancer patients with sentinel node (SN) micrometastases. METHODS: Eighty-four patients with SN micrometastases were included. Both the SN and NSN were examined using serial sectioning and immunohistohemistry. Various indices were evaluated as possible risk factors for NSN involvement. RESULTS: NSN involvement was found in 22/84 patients. The median size of the NSN metastases was 1.25 mm (0.01-12 mm). The NSN metastases were larger than 2 mm in 8 patients and smaller than 0.2 mm in 6 patients. NSN involvement was observed in 14/35 patients with metastatic findings in all removed SN. Three of the 23 patients with 2 or 3 tumour negative SN had NSN metastases. None of the 12 patients with 4 or more uninvolved SN had NSN metastases. NSN involvement could not excluded by other patient, tumour or sentinel node related factors. CONCLUSIONS: Every fourth patient will have residual disease in the axilla, 10% even large metastases, if axillary clearance is omitted in patients with SN micrometastases. The risk of NSN involvement seems negligible in patients with a single SN micrometastasis and four or more healthy SN harvested.

Towards reasonable workload in diagnosis of sentinel lymph nodes: comparison of two frozen section methods.

AIMS: To compare two methods of histological assessment with intraoperative diagnosis of sentinel node metastases in breast cancer. METHODS AND RESULTS: A total of 204 consecutive breast cancer cases with lymphatic mapping, sentinel node biopsy and intraoperative diagnosis were included. The sentinel nodes in the first 102 cases (method A) were bisected and serially sectioned. In the other 102 cases (method B) the nodes were sliced thinly with a razor blade. All 1-1.5 mm thick slices were mounted on prechilled mounting medium on frozen section buttons. Cytological imprints were also made of the attached tissue slices. Postoperative diagnosis of sentinel lymph node metatases was taken as gold standard. Sentinel node metastases were found in 28 (27%) cases in group A and in 42 (40%) cases in group B (P = 0.05). The median size of the sentinel node metastases was 4.3 mm in group A and 3.3 mm in group B (P < 0.05). CONCLUSION: Method B finds more and smaller metastases and takes less time and effort in the laboratory. When using method A, many small metastases are not detected at all.

HER-2/neu oncogene expression in advanced breast cancer.

Tumor tissue from patients with advanced breast cancer was analyzed for HER-2/neu and p53 expression. The tissue samples from primary tumor and from axillary lymph nodes or distant metastases from 118 breast cancer patients were obtained. Sections from formalin-fixed, paraffin-embedded materials were immunostained for HER-2/neu and p53 oncoprotein expression. Staining results were correlated with survival times and disease-free survival times, flow cytometric synthesis phase fractions, and DNA ploidy. No correlation could be found between HER-2/neu and p53 or any other tested factor, but grade I primary cancers that were positive for HER-2/neu showed a tendency for better outcome. The HER-2/neu staining of the metastases was independent of the staining of the primary tumor. HER-2/neu can be used as a prognostic marker for advanced breast cancer, when the primary tumor is well differentiated.

Rat cytomegalovirus infection in kidney allograft recipients is associated with increased expression of intracellular adhesion molecule-1 vascular adhesion molecule-1, and their ligands leukocyte function antigen-1 and very late antigen-4 in the graft.

BACKGROUND: Cytomegalovirus (CMV) infection is suggested to be a risk factor for chronic rejection. We have recently shown that rat CMV (RCMV) increases the inflammatory response and accelerates chronic rejection in a model of rat kidney allograft. In this study, the early inflammatory response and time-related expression of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) and their ligands, leukocyte function antigen-1 (LFA-1) and very late antigen-4 (VLA-4), in the grafts were investigated in RCMV-infected rats and compared to noninfected rats developing chronic rejection. METHODS: Transplantations were performed in a rat strain combination of DA (RT1a)->BN (RT1n) receiving triple drug immunosuppression. One group of rats was infected with RCMV, and the other was left uninfected. The grafts were harvested at different time points after transplantation. The adhesion molecules, their ligands and activation markers, MHC class II antigens and interleukin-2-receptors (IL-2-R), were demonstrated by monoclonal antibodies and immunoperoxidase staining from frozen sections of the grafts. Graft histology was evaluated according to the Banff criteria. RESULTS: RCMV caused a significant, prolonged increase of VCAM-1 and ICAM-1 expression in the vascular endothelium compared to the noninfected grafts. Also, the number of cells expressing activation markers, LFA-1 and VLA-4 was significantly enhanced in these animals. Significantly enhanced histological changes of chronic rejection were seen in the RCMV-infected group. CONCLUSIONS: Prolonged, increased expression of ICAM-1 and VCAM-1, and increased numbers of inflammatory cells expressing their ligands in the CMV infected grafts, were associated with accelerated chronic allograft nephropathy.

Expression patterns of biologic markers in small breast cancers and preneoplastic breast lesions.

When does proliferating breast epithelium turn malignant? Single parameter analyses have not answered this question. We have tried to answer this through an analysis of immunohistochemical staining patterns in the following morphologically defined breast lesions: atypical ductal hyperplasia (ADH, 23 cases), papilloma (12 cases), ductal cancer in situ (DCIS, 28 cases), and mammographically detected small primary cancers (34 cases). The seven antibodies used were c-neu, bcl-2, p53, p21, CD44, MIB 1, and FAS. Staining patterns were compared within groups and between groups of lesions. Interesting differences in staining patterns were seen between invasive ductal cancer and invasive lobular cancer: invasive lobular cancer was less p53-positive and more CD44-positive than invasive ductal cancer. We found no common pattern in the different proliferating epithelia to show when they become malignant.

Flow cytometric DNA measurements in aspiration biopsies and surgical specimens of breast cancer.

OBJECTIVE: One of the prognostic factors in breast cancer is the proliferation activity of the tumor. This study sought knowledge of this activity before surgery to benefit the design and timing of therapy. STUDY DESIGN: Flow cytometric DNA analysis data from 52 diagnostic fine needle aspirates were compared with data from subsequent surgical specimens. RESULTS: The data showed that the coefficient of variation of the G1 peak was lower in the aspirates. Small, near-diploid peaks were detected more frequently in aspirate histograms than in surgical specimens. DNA analyses by flow cytometry from aspirates, which can be obtained prior to surgical treatment, were as reliable as those obtained from surgical specimens, provided that the cellular material was diagnostic of cancer. CONCLUSION: Our results suggest that flow cytometry DNA analysis from the first preoperative cytologic specimen from a breast tumor will permit faster planning and coordination of breast cancer care.

Cytomegalovirus infection-associated generalized immune activation in heart allograft recipients: a study of cellular events in peripheral blood and endomyocardial biopsy specimens.

An association between cytomegalovirus (CMV) infection, heart allograft rejection, and arteriosclerosis has been reported. To investigate the mechanisms of this association, the cellular immune response in peripheral blood and the inflammation in heart allografts during antigenemia were studied. CMV antigenemia occurred in 13 recipients. In recipients with severe CMV infection, a significantly weaker immune response was recorded in peripheral blood: fewer lymphoid blast cells (max. 2.4% +/- 0.4%) and large granular lymphocytes (LGL; max. 9.3% +/- 1.4%) were seen than in patients with mild or asymptomatic CMV infection (lymphoid blast cells max. 6.5% +/- 0.8% P < 0.01 and LGLs max. 20% +/- 2.3%, P < 0.05). Thus, a strong immune response with lymphoid activation was associated with clinically good outcome of CMV infection. In heart allograft histology, subendothelial inflammation of small intramyocardial vessels was a characteristic finding during CMV antigenemia compared to CMV-free recipients (at the peak P < 0.01). However, no difference in this mild and short-lived inflammatory response was observed between clinically mild or severe CMV infection. The CMV-linked generalized immune activation and inflammation of the vascular structures might contribute to the initiation of allograft vasculopathy and to the pathogenesis of chronic heart allograft rejection.

Cytomegalovirus infection and accelerated cardiac allograft vasculopathy in human cardiac allografts.

Cardiac allograft vasculopathy is a major limiting factor of the long-term survival of heart transplant patients. An association of cytomegalovirus infection and cardiac allograft vasculopathy has been described. We analyzed 104 endomyocardial biopsy specimens obtained from 53 heart transplant recipients and correlated the histologic findings with 115 angiograms obtained from the same patients during 4 postoperative years. The frequency of vascular changes in endomyocardial biopsy specimens was significantly higher than in angiograms during the first 3 posttransplantation years (P < 0.001, P < 0.005, P < 0.03, respectively). Also, in patients with angiographically documented cardiac allograft vasculopathy, significantly higher scores of capillary and arteriolar endothelial cell accumulation and arteriolar intimal thickness were recorded when compared with the recipients with normal angiograms (P < 0.02, P < 0.05, P < 0.005, respectively). Altogether, 29 of 53 recipients underwent cytomegalovirus infection during the first posttransplant year. Cytomegalovirus infection was associated with arteriolar endothelial cell accumulation and with increased intimal thickness of intramyocardial vessels of 1-year endomyocardial biopsy specimens when compared with cytomegalovirus-free recipients (P < 0.02 and P < 0.005, respectively). After the second year, the cytomegalovirus-associated endothelial cell response subsided, but the thickness of intima had increased when compared with cytomegalovirus-free patients (P < 0.05). Thereafter, the cytomegalovirus-associated histologic changes reached a plateau. In coronary angiography, the cardiac allograft vasculopathy changes were detected in a slower pace. Thus only after 2 posttransplantation years, cytomegalovirus-associated acceleration of cardiac allograft vasculopathy was observed, compared with cytomegalovirus-free patients (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitation of cytomegalovirus infection-associated histologic findings in endomyocardial biopsies of heart allografts.

To investigate whether histologic changes in heart allografts may be associated with cytomegalovirus infection, 46 heart transplant recipients were monitored for cytomegalovirus. Altogether, 762 endomyocardial biopsy specimens were analyzed. The histologic changes were semiquantitatively scored from mild to severe, and special attention was paid to inflammatory infiltrates and vascular changes. Cytomegalovirus infection occurred in 27 of 46 patients, shown by cytomegalovirus-antigenemia test. The endomyocardial biopsy findings were investigated in relation to cytomegalovirus-antigenemia. In the acute phase of cytomegalovirus infection during antigenemia, an inflammatory infiltrate, subendothelial lymphocytosis, was a characteristic finding in the endomyocardial biopsy specimens. An intense arteriolar endothelial cell proliferation and thickening of intima occurred. Long-term histologic findings with two years follow-up revealed a cytomegalovirus-associated enhanced vascular intimal thickening that narrowed the lumen of small intramyocardial arterioles. Acute rejection episodes were diagnosed in 15 of 27 patients with cytomegalovirus and in 9 of 19 patients free of cytomegalovirus. The inflammatory infiltrate of acute rejection was more peripheral to the vessels and did not obscure the findings characteristic to cytomegalovirus infection. The arteriolar endothelial proliferation and intimal thickening were significantly more prominent in cytomegalovirus infection than in biopsy specimens from patients with rejection only. In long-term follow-up, arteriolar endothelial proliferation declined, but the intimal thickness persisted and increased. The increase was significantly higher in patients with cytomegalovirus than in patients with rejection. In conclusion, an inflammatory response in vessel walls with alterations of small intramyocardial arterioles leading to narrowing of the vascular lumen of the graft was associated with cytomegalovirus infection in heart transplant patients.

Cytomegalovirus infection accelerates cardiac allograft vasculopathy: correlation between angiographic and endomyocardial biopsy findings in heart transplant patients.

In order to determine the impact of cytomegalovirus (CMV) infection on cardiac allograft vasculopathy (CAV), we quantitated angiograms and endomyocardial biopsy (EMB) specimens obtained from 53 heart transplant recipients. CMV infection was particularly associated with the development of discrete stenosis in major branch vessels (P < 0.03). Also, the number of diffusely affected vessel segments was significantly higher in CMV patients than in CMV-free recipients after the 2nd postoperative year (P < 0.05). The EMB histology correlated well with angiography. Significantly higher levels of arteriolar endothelial cell proliferation and intimal thickness were recorded in biopsies of CMV patients than in those of CMV-free recipients during the 1st postoperative year (P < 0.02 and P < 0.005, respectively). The CMV-associated vascular changes in EMB histology clearly preceded angiographically detectable CAV findings. Taken together, CMV infection accelerated heart allograft arteriosclerosis. The histological changes appeared prior to changes detected by coronary angiography. The CMV effect was particularly pronounced during the first 2 post-transplant years but leveled off thereafter. Thus, CMV-accelerated allograft arteriosclerosis may be linked in particular with early graft loss of CMV-infected heart transplant recipients.

A simple method for the preparation of paraffin-embedded cell blocks from fine needle aspirates, effusions and brushings.

A simple method for the preparation of paraffin-embedded cell blocks from cytologic specimens obtained by fine needle aspiration, by brushing or from effusions is described. The cells are fixed in suspension in 50% ethanol for one hour and pelleted by centrifugation in a 50-mL plastic tube. The fixative is removed, and the pellet is suspended in 3 mL of acetone for dehydration for ten minutes and thereafter repelleted. The acetone is then removed, and the cell pellet is dried at 60 degrees C for one hour. Melted paraffin is added onto the dry warmed cell mass and allowed to solidify at room temperature. A conical paraffin block with the cells in the top is obtained and can be handled as a routine tissue block.