The association of breast surgery ASPIRE: breast pain pathway rapid evaluation project - study protocol.

Background: Breast pain accounts for 20-40% of new referrals to breast units in the UK and these patients have a very low risk of breast cancer. Patients have previously been assessed in resource-intensive, cancer-exclusion, one stop clinics, which are now failing to meet government targets due to excessive demand. UK Breast units are increasingly piloting Breast Pain-only Pathways (BPP) to assess these patients, and there is no consensus for the optimal pathway. The aim of this prospective multicentre study is to assess the safety and patient satisfaction of different BPPs to inform future BPP design and implementation. Methods: All UK breast units will be invited to join the ASPIRE study between January 2023 and December 2023. Units with a BPP are invited to submit their pathway for evaluation; and those without a BPP who see patients with breast pain-only in a one stop clinics setting are also invited to join the study to evaluate the traditional pathway model concurrently. Patient satisfaction assessments will be collected after their initial consultation and patient outcomes, including subsequent cancer diagnosis, will be followed up at 12 months to determine if they have cancer diagnosis after discharge to assess pathway safety.

Lung ultrasound as a tool for monitoring the interstitial changes in recently hospitalised patients with COVID-19 pneumonia - The COVIDLUS study.

Background Long-term respiratory effects can occur after COVID-19 pneumonia (CP). The COVID Lung Ultrasound Study (COVIDLUS) aimed to investigate the utility of serial lung ultrasound (LUS) to track functional and physiological recovery after hospitalisation in patients with CP. Methods Between April 2021 and April 2022, 21 patients were recruited at discharge (D0). LUS was performed on D0, day 41 (D41) and day 83 (D83). CT Thorax was performed on D83. Lymphocyte count, Ferritin, Lactate Dehydrogenase, Troponin, CRP, and D-dimers were measured at D0, D41 and D83. 6 minute walking test (6MWT) was performed on D83 and quality of life questionnaires and spirometry completed on D41 and D83. Results 19 subjects completed the study (10 males [52%]; mean age: 52 years [range:37-74]). 1 patient died. LUS scores were significantly higher at D0, compared to D41 and D83 (Mean score:10.9 [D0]/2.8 [D41]/1.5 [D83]; p < 0.0001). LUS scores correlated poorly with CT at D83 (Pearson r2 = 0.28). Mean lymphocyte counts were lower at D0 but increased at D41 and D83. Mean serum Ferritin was significantly lower at D41 and D83, as compared to D0. The mean 6MWT distance was 385 m (130-540 m). Quality of life measures did not differ at D41 and D83. Lung function increased between D41 and D83 with mean increase in FEV1 and FVC of 160 ml and 190 ml respectively. Conclusion LUS can monitor the early recovery of lung interstitial changes from CP. The utility of LUS to predict development of subsequent lung fibrosis post-COVID deserves further study.

Enhanced axillary assessment using intradermally injected microbubbles and contrast-enhanced ultrasound (CEUS) before neoadjuvant systemic therapy (NACT) identifies axillary disease missed by conventional B-mode ultrasound that may be clinically relevant.

PURPOSE: The purpose of this study is to measure pre-treatment diagnostic yield of malignant lymph nodes (LN) using contrast-enhanced ultrasound (CEUS) in addition to B-mode axillary ultrasound and compare clinicopathological features, response to NACT and long-term outcomes of patients with malignant LN detected with B-mode ultrasound versus CEUS. METHODS: Between August 2009 and October 2016, NACT patients were identified from a prospective database. Follow-up data were collected until May 2019. RESULTS: 288 consecutive NACT patients were identified; 77 were excluded, 110 had malignant LN identified by B-mode ultrasound (Group A) and 101 patients with negative B-mode axillary ultrasound had CEUS with biopsy of sentinel lymph nodes (SLN). In two cases CEUS failed. Malignant SLN were identified in 35/99 (35%) of B-mode ultrasound-negative cases (Group B). Patients in Group A were similar to those in Group B in age, mean diagnostic tumour size, grade and oestrogen receptor status. More Group A patients had a ductal phenotype. In the breast, 34 (31%) Group A patients and 8 (23%) Group B patients achieved a pathological complete response (PCR). In the axilla, 41 (37%) and 13 (37%) Groups A and B patients, respectively, had LN PCR. The systemic relapse rate was not statistically different (5% and 16% for Groups A and B, respectively). CONCLUSIONS: Enhanced assessment with CEUS before NACT identifies patients with axillary metastases missed by conventional B-mode ultrasound. Without CEUS, 22 (63%) of cases in Group B (negative B-mode ultrasound) may have been erroneously classed as progressive disease by surgical SLN excision after NACT.

Does Contrast Enhanced Ultrasound (CEUS) of Normal/Benign Axillary Lymph Nodes in Patients with Breast Cancer Identify Significant Axillary Nodal Burden?

PURPOSE: Contrast enhanced ultrasound (CEUS) of the axilla allows preoperative identification and biopsy of the sentinel lymph node. Our aims were to evaluate the accuracy of the CEUS procedure for identifying axillary lymph node metastases preoperatively and compare the volume of axillary metastases in patients with malignant versus benign CEUS guided core biopsy at end of primary surgical treatment. METHODS: Retrospective analysis of prospectively collected data on patients with breast cancer with normal axillary ultrasound or benign axillary FNAC undergoing preoperatively CEUS guided sentinel lymph node biopsy between 2013 and 2018. RESULTS: SLN was successfully identified by CEUS in 186 (90.7%) of patients with definitive diagnosis obtained in 163 (87.6%). Overall sensitivity was 55.77%, but significantly higher for high volume disease (77.78%) than for low volume disease (32.00%, odds ratio = 7.44, 95% CI = 2.16 to 25.62, p = .001) Specificity was 100%. NPV was 82.84% overall, 86.72% for low volume disease and 94.87 % for high volume disease. 72.4% of patients with initial malignant CEUS guided SLN core biopsy had two or more macrometastases at end of surgical treatment compared to 4.47% of patients with initial benign CEUS guided core biopsy. CONCLUSION: When disease was present, CEUS guided sentinel lymph node core biopsy identify nodal metastases in 55.77% of patients with normal axillary grey scale ultrasound. This study suggests that the likelihood of extensive axillary disease at end of surgical treatment is low with an initial benign CEUS guided SLN core biopsy.

Rivaroxaban compared to no treatment in ER-negative stage I-III early breast cancer patients (the TIP Trial): study protocol for a phase II preoperative window-of-opportunity study design randomised controlled trial.

BACKGROUND: Breast cancer patients are at a four-fold increased risk of developing a venous thromboembolism (VTE), a major cause of death in this group. Conversely, coagulation factors promote tumour growth and metastasis. This has been evidenced in preclinical models, with an inhibitory effect of anticoagulants on cancer growth through proliferative, angiogenic, apoptotic, cancer stem cell and metastatic processes. The extrinsic clotting pathway is also more upregulated in patients in the relatively poorer prognosis oestrogen receptor (ER)-negative breast cancer subgroup, with increased tumour stromal expression of the coagulation factors Tissue Factor and thrombin. Rivaroxaban (Xarelto®, Bayer AG, Leverkusen, Germany) is a direct oral anticoagulant (DOAC). It is a Factor Xa inhibitor that is routinely prescribed for the prevention of stroke in non-valvular atrial fibrillation and for both VTE prophylaxis and treatment. This trial will assess the anti-proliferative and other anti-cancer progression mechanisms of Rivaroxaban in ER-negative early breast cancer patients. METHODS: This UK-based preoperative window-of-opportunity phase II randomised control trial will randomise 88 treatment-naïve early breast cancer patients to receive 20 mg OD Rivaroxaban treatment for 11 to 17 days or no treatment. Treatment will be stopped 24 h (range 18-36 h) prior to surgery or repeat core biopsy. All patients will be followed up for 2 weeks following surgery or repeat core biopsy. The primary endpoint is change in tumour Ki67. Secondary outcome measures include tumour markers of apoptosis and angiogenesis, extrinsic clotting pathway activation and systemic markers of metastasis, tumour load and coagulation. DISCUSSION: Laboratory evidence supports an anti-cancer role for anticoagulants; however, this has failed to translate into survival benefit when trialled in patients with metastatic disease or poor prognosis cancers, such as lung cancer. Subgroup analysis supported a potential survival benefit in better prognosis advanced disease patients. This is the first study to investigate the anti-cancer effects of anticoagulants in early breast cancer. TRIAL REGISTRATION: UK National Research Ethics Service (NRES) approval 15/NW/0406, MHRA Clinical Trials Authorisation 48380/0003/001-0001. The sponsor is Manchester University NHS Foundation Trust, and the trial is co-ordinated by Cancer Research UK Liverpool Cancer Trials Unit (LCTU). EudraCT 2014-004909-33 , registered 27 July 2015. ISRCTN14785273 .

3D Super-Resolution US Imaging of Rabbit Lymph Node Vasculature in Vivo by Using Microbubbles.

Background Variations in lymph node (LN) microcirculation can be indicative of metastasis. The identification and quantification of metastatic LNs remains essential for prognosis and treatment planning, but a reliable noninvasive imaging technique is lacking. Three-dimensional super-resolution (SR) US has shown potential to noninvasively visualize microvascular networks in vivo. Purpose To study the feasibility of three-dimensional SR US imaging of rabbit LN microvascular structure and blood flow by using microbubbles. Materials and Methods In vivo studies were carried out to image popliteal LNs of two healthy male New Zealand white rabbits aged 6-8 weeks. Three-dimensional, high-frame-rate, contrast material-enhanced US was achieved by mechanically scanning with a linear imaging probe. Individual microbubbles were identified, localized, and tracked to form three-dimensional SR images and super-resolved velocity maps. Acoustic subaperture processing was used to improve image contrast and to generate enhanced power Doppler and color Doppler images. Vessel size and blood flow velocity distributions were evaluated and assessed by using Student paired t test. Results SR images revealed microvessels in the rabbit LN, with branches clearly resolved when separated by 30 µm, which is less than half of the acoustic wavelength and not resolvable by using power or color Doppler. The apparent size distribution of most vessels in the SR images was below 80 µm and agrees with micro-CT data, whereas most of those detected with Doppler techniques were larger than 80 µm in the images. The blood flow velocity distribution indicated that most of the blood flow in rabbit popliteal LN was at velocities lower than 5 mm/sec. Conclusion Three-dimensional super-resolution US imaging using microbubbles allows noninvasive nonionizing visualization and quantification of lymph node microvascular structures and blood flow dynamics with resolution below the wave diffraction limit. This technology has potential for studying the physiologic functions of the lymph system and for clinical detection of lymph node metastasis. Published under a CC BY 4.0 license. Online supplemental material is available for this article.

Enhanced pre-operative axillary staging using intradermal microbubbles and contrast-enhanced ultrasound to detect and biopsy sentinel lymph nodes in breast cancer: a potential replacement for axillary surgery.

OBJECTIVE: To compare the experience of four UK Centres in the use of intradermal microbubbles and contrast enhanced ultrasound (CEUS) to pre-operatively identify and biopsy sentinel lymph nodes (SLN) in patients with breast cancer. METHODS: In all centres, breast cancer patients had a microbubble/CEUS SLN core biopsy prior to axillary surgery and patients in Centres 1 and 2 had a normal greyscale axillary ultrasound. Data were collected between 2010 and 2016; 1361 from Centre 1 (prospective, sequential), 376 from Centre 2 (retrospective, sequential), 121 from Centre 3 (retrospective, selected) and 48 from Centre 4 (prospective, selected). RESULTS: SLN were successfully core biopsied in 80% (Centre 1), 79.6% (Centre 2), 77.5% (Centre 3) and 88% (Centre 4). The sensitivities to identify all SLN metastases were 46.9% [95% confidence intervals (CI) (39.4-55.1)], 52.5% [95% CI (39.1-65.7)], 46.4% [95% CI (27.5-66.1)] and 45.5% [95% CI (16.7-76.6)], respectively. The specificities were 99.7% [95% CI (I98.9-100)], 98.1% [95% CI (94.5-99.6)], 100% [95% CI (93.2-100%)] and 96.3% [95% CI (81-99.9)], respectively.The negative predictive values were 87.0% [95% CI (84.3-89.3)], 84.5% [95% CI (78.4-89.5)], 86.9% [95% CI (82.4-90.3)] and 86.2% [95% CI (78.4-91.5)], respectively. At Centres 1 and 2, 12/730 (1.6%) and 7/181 (4%), respectively, of patients with a benign microbubble/CEUS SLN core biopsy had two or more lymph node (LN) macrometastases found at the end of primary surgical treatment. CONCLUSION: The identification and biopsy of SLN using CEUS is a reproducible technique. Advances in knowledge: In the era of axillary conservation, microbubble/CEUS SLN core biopsy has the potential to succeed surgical staging of the axilla.

Axillary Nodal Staging with Contrast-Enhanced Ultrasound.

PURPOSE OF REVIEW: Axillary staging in the context of breast cancer is a contentious topic due to the varied practices across UK, Europe, and America. The ACOSOG Z0011 trial has questioned the role of axillary ultrasound in women with breast cancer. Published data has shown that women with ultrasound-positive lymph nodes have a worse prognosis than those with ultrasound-negative lymph nodes. Axillary ultrasound is limited as the sentinel lymph node (SLN) cannot be identified using B-mode ultrasound; however, with the advent of contrast-enhanced ultrasound (CEUS), this has now changed. RECENT FINDINGS: The published literature has shown that the sentinel lymph node can be identified using CEUS. The rates are equivalent to blue dye alone but currently inferior to the dual technique of sentinel lymph node biopsy. There are several different contrast agents that can be used and the agents that remain in the sentinel lymph node for longer can identify areas of poor enhancement, allowing for targeted biopsy. SUMMARY: CEUS has the potential to revolutionize the way we manage the axilla in the future and may even replace surgical staging.

Contrast-Enhanced Ultrasound Biopsy of Sentinel Lymph Nodes in Patients with Breast Cancer: Implications for Axillary Metastases and Conservation.

BACKGROUND: In breast cancer patients, sentinel lymph nodes (SLN) can be identified in the breast clinic using contrast-enhanced ultrasound (CEUS). This study aimed to characterize and compare the extent of axillary metastases in patients with either a benign or malignant SLN core biopsy at the end of surgical treatment. METHODS: Between 2009 and 2014, prospective data were collected on consecutive patients who underwent targeted core biopsy of SLN identified using CEUS in the breast clinic. Patients with abnormal lymph nodes (LN) detected on grey-scale ultrasound were not included. Patients whose initial SLN core biopsy was benign were compared with those who had a malignant SLN core biopsy. RESULTS: 555 patients with invasive breast cancer had SLN successfully identified and core biopsied. 487 had a benign SLN core biopsy and 427 (88 %) did not have metastases found in surgically excised SLN. Only 2 % of patients with an initial benign SLN core biopsy were found to have 2 or more LN macrometastases. 68 patients had a malignant SLN core biopsy and 52 % had 2 or more LN macrometastases. The total volume of LN metastases was higher in the group of patients who had an initial malignant SLN core biopsy (P < 0.001). CONCLUSIONS: Patients with a normal grey-scale ultrasound and benign SLN core biopsy are unlikely to have extensive axillary disease and may be ideally suited for axillary conservation. The decision to omit axillary LN dissection for patients with a malignant SLN core biopsy must be carefully considered because many will have undetected high-volume metastases.

Predictive factors for invasive cancer in surgical specimens following an initial diagnosis of ductal carcinoma in situ after stereotactic vacuum-assisted breast biopsy in microcalcification-only lesions.

PURPOSE: The aim of this study was to determine the incidence of invasive breast carcinoma in patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) by stereotactic vacuum-assisted biopsy (SVAB) performed for microcalcification-only lesions, and to identify the predictive factors of invasion. METHODS: From 2000 to 2010, the records of 353 DCIS patients presenting with microcalcification-only lesions who underwent SVAB were retrospectively reviewed. The mammographic size of microcalcification cluster, presence of microinvasion within the cores, the total number of calcium specks, and the number of calcium specks within the retrieved core biopsy specimen were recorded. Patients were grouped as those with or without invasion in the final pathologic report, and variables were compared between the two groups. RESULTS: The median age was 58 years (range, 34-88 years). At histopathologic examination of the surgical specimen, 63 of 353 patients (17.8%) were found to have an invasive component, although SVAB cores had only shown DCIS preoperatively. The rate of underestimation was significantly higher in patients with microcalcification covering an area of 40 mm or more, in the presence of microinvasion at biopsy, and in cases where less than 40% of the calcium specks were removed from the lesion. CONCLUSION: Invasion might be underestimated in DCIS cases diagnosed with SVAB performed for microcalcification-only lesions, especially when the mammographic size of calcification is equal to or more than 40 mm or if microinvasion is found within the biopsy specimen and less than 40% of the calcifications are removed. At least 40% of microcalcification specks should be removed from the lesion to decrease the rate of underestimation with SVAB.

Preoperative sentinel node identification with ultrasound using microbubbles in patients with breast cancer.

OBJECTIVE: Sentinel lymph node (SLN) biopsy is the standard procedure for axillary staging in early breast cancer. Lymphatic imaging after peritumoral microbubble injection has been described in animal models. The aim of this study was to identify and localize SLNs preoperatively by contrast-enhanced sonography after intradermal injection of microbubbles in patients with breast cancer. SUBJECTS AND METHODS: Eighty consecutive consenting patients with primary breast cancer were recruited. Patients received a periareolar intradermal injection of microbubble contrast agent. Breast lymphatics were visualized by sonography and followed to the axilla to identify SLNs. A guidewire was deployed to localize the SLN. The next day, patients underwent standard tumor excision and SLN biopsy. RESULTS: In 71 (89%) of the 80 patients, SLNs were identified and guidewires were inserted. In these patients, operative findings using conventional radioisotope and blue dye techniques confirmed that the wired nodes were SLNs. Fourteen patients were found to have metastases in SLNs. In these patients, the SLNs were identified correctly and were localized with guidewires before surgery. CONCLUSION: SLNs may be identified and localized before surgery using contrast-enhanced sonography after injection of microbubbles.

Dynamic visualization of lymphatic channels and sentinel lymph nodes using intradermal microbubbles and contrast-enhanced ultrasound in a swine model and patients with breast cancer.

OBJECTIVE: Sentinel lymph node (SLN) identification using intradermal micro-bubbles and contrast-enhanced ultrasound (CEUS) has been recently reported in swine models and patients with breast cancer. The objective of this study was to investigate the dynamics of intradermally administered microbubbles as they travel to draining SLNs in pigs. We also performed a detailed study of the passage of microbubbles through breast lymphatic channels in a small group of patients with breast cancer. METHODS: Nine anesthetized healthy pigs were used for the study, and 5 female patients with primary breast cancer were recruited. Pigs received intradermal injections of a microbubble contrast agent in several territories to access lymphatic drainage to regional lymph nodes. Patients had periareolar intradermal injection of the microbubble contrast agent. Ultrasound examination was performed in the real-time contrast pulse sequencing mode with a commercial scanner. RESULTS: Sentinel lymph nodes were identified rapidly (<1 minute) and consistently in pigs. Intradermal microbubble injection and CEUS were found to have perfect concordance with the Evans blue dye method in locating swine SLNs. In all 5 patients with breast cancer, the microbubble contrast agent entered breast lymphatic channels and traveled to draining ipsilateral axillary SLNs within 3 minutes. CONCLUSIONS: Intradermally injected microbubbles traverse readily though lymphatic channels in pigs and human breast tissue. The ability to rapidly identify SLNs in the diagnostic period would enable targeted biopsy and may facilitate preoperative axillary staging in patients with early breast cancer.

Plasmacytoid dendritic cells (PDC) are the major DC subset innately producing cytokines in human lymph nodes.

Plasmacytoid dendritic cells (PDC) constitute a distinct subset of DC found in human peripheral lymph nodes (LN), but little is known about their function. Cell suspensions were prepared from tumor draining LN (n=20) and control LN (n=11) of women undergoing surgical resection for primary breast cancer and elective surgery for benign conditions, respectively. Using four-color flow cytometry, human leukocyte antigen-DR+ DC subsets were identified phenotypically. The proportions and numbers of cells innately producing interleukin (IL)-4, IL-10, IL-12, and interferon-gamma (IFN-gamma) were also measured from intracellular accumulation of cytokine after blocking with monensin. All flow cytometry data were collected without compensation and were compensated off-line using the Winlist algorithm (Verity software). This package also provided the subtraction program to calculate percentage positive cells and intensity of staining. PDC (CD11c-, CD123+) expressed more cytokines than did myeloid DC (CD11c+) or CD1a+ putative "migratory" DC (P<0.001). LN PDC from patients with a good prognosis (px; n=11) demonstrated a relative increase in IL-12 and IFN-gamma expression (median IL-10:IL-12 ratio=0.78 and median IL-4:IFN-gamma ratio=0.7), and PDC from LN draining poor px cancer (n=9) showed a relative increase in IL-10 and IL-4 expression (median IL-10:IL-12 ratio=1.31 and median IL-4:IFN-gamma ratio=2.6). The difference in IL-4:IFN-gamma expression between good and poor px cancer groups was significant (P<0.05). Thus, PDC innately producing cytokines were identified in cell suspensions from human LN, and the character of PDC cytokine secretion may differ between two breast cancer prognostic groups. We speculate that a shift towards PDC IL-10 and IL-4 expression could promote tumor tolerance in LN draining poor px breast cancer.