Identification of reference genes for RT-qPCR in ovine mammary tissue during late pregnancy and lactation and in response to maternal nutritional programming.

The mammary gland is a complex tissue consisting of multiple cell types which, over the lifetime of an animal, go through repeated cycles of development associated with pregnancy, lactation and involution. The mammary gland is also known to be sensitive to maternal programming by environmental stimuli such as nutrition. The molecular basis of these adaptations is of significant interest, but requires robust methods to measure gene expression. Reverse-transcription quantitative PCR (RT-qPCR) is commonly used to measure gene expression, and is currently the method of choice for validating genome-wide expression studies. RT-qPCR requires the selection of reference genes that are stably expressed over physiological states and treatments. In this study we identify suitable reference genes to normalize RT-qPCR data for the ovine mammary gland in two physiological states; late pregnancy and lactation. Biopsies were collected from offspring of ewes that had been subjected to different nutritional paradigms during pregnancy to examine effects of maternal programming on the mammary gland of the offspring. We evaluated eight candidate reference genes and found that two reference genes (PRPF3 and CUL1) are required for normalising RT-qPCR data from pooled RNA samples, but five reference genes are required for analyzing gene expression in individual animals (SENP2, EIF6, MRPL39, ATP1A1, CUL1). Using these stable reference genes, we showed that TET1, a key regulator of DNA methylation, is responsive to maternal programming and physiological state. The identification of these novel reference genes will be of utility to future studies of gene expression in the ovine mammary gland.

Opportunities and challenges of next-generation DNA sequencing for breast units.

BACKGROUND: The aim of this review is to introduce the topic of next-generation DNA sequencing, a new technology that is being introduced into clinical practice, and to explain the potential impact for breast cancer surgeons and the wider breast cancer multidisciplinary team. METHODS: The PubMed database was used to identify relevant studies relating to breast cancer genetics. This evidence was then used to provide context and background information to demonstrate how next-generation sequencing (NGS) might change breast cancer practice. RESULTS: With NGS, breast cancer clinicians will know whether their patients carry high-risk mutations in genes, such as BRCA1 or BRCA2, before the start of treatment. This could alter treatment decisions; for instance, more women might opt for mastectomy instead of breast-conserving surgery, or for bilateral rather than unilateral surgery. CONCLUSION: The introduction of NGS will have a significant impact on breast cancer services in the near future. Speed of testing will improve in regions of the world where NGS is adopted in place of conventional sequencing, and, as costs decrease, genetic testing will also become accessible and realistic in less well funded health economies. This will create opportunities to improve patient treatment and challenges for the breast cancer multidisciplinary team.

The effects of birth rank (single or twin) and dam age on the lifetime productive performance of female dual purpose sheep (Ovis aries) offspring in New Zealand.

Greater rates of genetic gain can be achieved by selecting animals born to younger parents. However, little is known about the lifetime performance of dual purpose ewes (Ovis aries) that are born to primiparous ewe lambs (8 to 9 months old at breeding). This experiment investigated the effect of being born from either a ewe lamb or mixed age dam as either a single or twin on the lifetime performance of ewe progeny. Lifetime performance was measured in terms of the life time live weights of the ewes, the weight and number of lambs born and weaned, the efficiency of production (kilograms of lamb weaned / predicted pasture intake (kgDM) of the ewes), and ewe survival. The study followed the lifetime production of 17 single and 41 twin female lambs born to mature ewes (M1 and M2, respectively), and 28 single and 29 twin lambs born to ewe lambs (L1 and L2, respectively). Over their lifetime L2 ewes were lighter (P<0.05) but had similar body condition scores to the other three ewe groups. There was no difference in average progeny weaning weight or total progeny litter weaning weights between groups. The M1 ewes had the greatest longevity (P<0.05) of the four groups. Even though L2 ewes were lighter than the other three groups, this was insufficient to increase their lifetime efficiency of production (kg lamb weaned/predicted pasture consumption), relative to the other groups. These results suggest farmers could select replacements born to ewe lambs without sacrificing animal production.

Mixing gilts in early pregnancy does not affect embryo survival.

There is general acceptance that mixing sows during the first 3 weeks of gestation is detrimental to embryo development and survival. However, there is a paucity of data describing the influence of group housing and remixing during the first 14 days of gestation on pregnancy outcomes. Using 96 purebred maternal (Large White)/terminal (Duroc) line gilts, the current study determined the effects of regrouping, and the timing of regrouping, during the pre-implantation period on embryo mortality. The study was conducted in 2 blocks, with 12 gilts allocated to each of 4 treatments in each block. At 175 days of age, the combination of PG600 and 20 min of daily physical boar contact was used to stimulate puberty, with boar contact resuming 12 days after first detection of oestrus and gilts receiving two artificial inseminations (AIs), 24 h apart, at their second oestrus. After their first AI gilts were allocated to one of four treatment groups (n=12 gilts/treatment). Gilts in one treatment group were housed individually in stalls (STALL). The remaining gilts continued to be housed in their pre-AI groups and were either not remixed (NOMIX), or remixed to form new groups on day 3/4 (RMIXD3/4) or day 8/9 (RMIXD8/9) of gestation (day 0=day of first detection of second oestrus and first insemination). Group-housed gilts were housed in groups of 6, with a space allowance of 2.4 m2/gilt. All gilts were fed once a day (2.2 kg/gilt). Reproductive tracts were collected on day 26.6+/-0.13 of gestation, and the number of corpora lutea (CL) and viable embryos counted. Pregnancy rate was similar across all treatments, averaging 94.5% across the four treatment groups. The number of embryos present on day 26 of gestation was unaffected by housing treatments (P>0.05); gilts in the STALL, NOMIX, RMIXD3/4 and RMIXD8/9 groups possessed 13.2+/-0.67, 12.9+/-0.66, 14.1+/-0.46 and 13.8+/-0.57 embryos, respectively. Similarly, embryo survival rates were 0.91+/-0.04, 0.85+/-0.04, 0.91+/-0.02 and 0.87+/-0.05 for the STALL, NOMIX, RMIXD3.4 and RMIXD8/9 groups, respectively (P>0.05). In conclusion, the current data indicate that individually housing gilts immediately after their first AI does not improve embryo survival. There also appear to be no adverse effects on embryo development or survival when group-housed, mated gilts are remixed during the first 10 days of gestation.

Effect of dam weight and pregnancy nutrition on average lactation performance of ewe offspring over 5 years.

The foetal mammary gland is sensitive to maternal weight and nutrition during gestation, which could affect offspring milk production. It has previously been shown that ewes born to dams offered maintenance nutrition during pregnancy (day 21 to 140 of gestation) produced greater milk, lactose and CP yields in their first lactation when compared with ewes born to dams offered ad libitum nutrition. In addition, ewes born to heavier dams produced greater milk and lactose yields when compared with ewes born to lighter dams. The objective of this study was to analyse and compare the 5-year lactation performance of the previously mentioned ewes, born to heavy or light dams that were offered maintenance or ad libitum pregnancy nutrition. Ewes were milked once per week, for the first 6 weeks of their lactation, for 5 years. Using milk yield and composition data, accumulated yields were calculated over a 42-day period for each year for milk, milk fat, CP, true protein, casein and lactose using a Legendre orthogonal polynomial model. Over the 5-year period, ewes born to heavy dams produced greater average milk (P=0.04), lactose (P=0.01) and CP (P=0.04) yields than offspring born to light dams. In contrast, over the 5-year period dam nutrition during pregnancy did not affect average (P>0.05) offspring milk yields or composition, but did increase milk and lactose accumulated yield (P=0.03 and 0.01, respectively) in the first lactation. These results indicate that maternal gestational nutrition appears to only affect the first lactational performance of ewe offspring. Neither dam nutrition nor size affected grand-offspring live weight gain to, or live weight at weaning (P>0.05). Combined these data indicate that under the conditions of the present study, manipulating dam weight or nutrition in pregnancy can have some effects of offspring lactational performance, however, these effects are not large enough to alter grand-offspring growth to weaning. Therefore, such manipulations are not a viable management tool for farmers to influence lamb growth to weaning.

Dietary ractopamine supplementation during the first lactation affects milk composition, piglet growth and sow reproductive performance.

Excessive mobilization of body reserves during lactation delays the return to reproductive function in weaned primiparous sows. This study tested the hypothesis that supplementing the lactation diets of first-parity sows with ractopamine hydrochloride would reduce maternal weight loss and improve subsequent reproductive performance. Gestating gilts were allocated to one of two treatment groups (n=30 sows/treatment), with one group fed a standard lactation diet (2.5g/Mcal LYS: DE) throughout lactation (CTRL), whereas the treatment group received the standard lactation diet supplemented with 10mg/kg ractopamine hydrochloride (RAC) from d 1 to 13 of lactation and 20mg/kg RAC from d 14 of lactation until artificial insemination (AI). Weaning occurred on d 21 of lactation, with AI occurring at the first post-weaning estrus. Compared to CTRL, RAC supplementation decreased (P<0.05) liveweight loss between d 13 and 20 of lactation (4.3±0.90 versus 1.3±0.96kg), and tended to increase (P=0.06) the number of second litter piglets born alive (9.5±0.52 versus 8.1±0.74). Treatment (RAC versus CTRL) reduced milk protein levels on d 13 and 20 of lactation (P<0.05), and piglet weight gain between d 13 and 20 of lactation (260±0.01 versus 310±0.01g/day, P<0.01). In conclusion, it is evident that dietary RAC altered milk composition and stimulated conservation of maternal body reserves during the third week of lactation, resulting in a beneficial effect on subsequent reproductive performance.

Effect of oral polyamine supplementation pre-weaning on piglet growth and intestinal characteristics.

A high proportion of piglets fail to adapt to the changing composition of their diet at weaning, resulting in weight loss and increased susceptibility to pathogens. Polyamines are present in sow milk and promote neonatal maturation of the gut. We hypothesised that oral spermine and spermidine supplementation before weaning would increase piglet growth and promote gastrointestinal development at weaning. In Experiment One, one pair of liveweight (LW)-matched piglets per litter from first and third lactation sows received 2 ml of a 0 (Control) or 463 nmol/ml spermine solution at 14, 16, 18, 20 and 22 days of age (n=6 piglets/treatment per parity). Villus height and crypt depth in the duodenum and jejunum were measured at weaning (day 23 postpartum). In Experiment Two, piglets suckling 18 first and 18 third lactation sows were used. Within each litter, piglets received 2 ml of either water (Control), 463 nmol/ml spermine solution or 2013 nmol/ml spermidine solution at 14, 16, 18, 22 and 24 days of age (n=54 piglets/treatment per sow parity). Piglets were weighed individually at 14, 18, 24 (weaning) and 61 days of age. In Experiment One, oral spermine supplementation resulted in a 41% increase in villus height, a 21% decrease in crypt depth and 79% decrease in the villus height : crypt depth ratio compared with control piglets (P<0.01). In Experiment Two, spermine and spermidine-supplemented piglets suckling first lactation sows grew faster (P<0.05) between days 14 and 18 postpartum than control piglets: 0.230±0.011 and 0.227±0.012 v. 0.183±0.012 kg/day, respectively. Spermine supplementation tended (P<0.1) to increase piglet LW gain from weaning to day 37 post-weaning compared with control piglets (0.373±0.009 v. 0.341±0.010 kg/day). In conclusion, spermine supplementation increased villus height at weaning, and appears to have the potential to improve the pre- and post-weaning growth of conventionally weaned piglets.

Gestation-related gene expression and protein localization in endometrial tissue of Suffolk and Cheviot ewes at gestation Day 19, after transfer of Suffolk or Cheviot embryos.

The objective of this study was to investigate the gene expression of progesterone and estrogen receptor α (PR, ERα), insulin-like growth factor (IGF) 1, IGF-2, their receptor (IGFR1), IGF-binding proteins (BP) 1 to 6, insulin receptor, adiponectin receptors (AdipoR1/2), cyclooxygenase 2 (PTGS2), mucin 1 and to localize PR, ERα, IGF-1, IGFR1, PTGS2, and proliferating cellular nuclear antigen (PCNA) in the endometrium of pregnant (Day 19) Suffolk and Cheviot ewes carrying Suffolk and Cheviot embryos transferred within and reciprocally between breeds. Gene expression was determined by real-time quantitative polymerase chain reaction (RT-qPCR), and antigen determination was measured by immunohistochemistry in the luminal epithelium (LE), superficial and deep glands (SG, DG, respectively) and superficial and deep stroma. Gene expression of PR, IGF-1, IGFBP2, and IGFBP5 was higher in Suffolk than that in Cheviot ewes (P < 0.05). Greater abundance of IGF-2 and IGBP3 expression was found in Cheviot ewes carrying Cheviot embryos than Cheviot ewes carrying Suffolk embryos (P < 0.05). No staining for PR and ERα was observed in the LE, very scarce staining in SG and DG, whereas positive staining was observed in both superficial and deep stroma. No differences were found for PR staining, but Cheviot ewes had higher ERα staining intensity than Suffolk ewes (P < 0.05). Positive staining for IGF-1 was observed in all cell types except DG, and staining of IGFR1 was observed in all cell types. No differences among groups in staining were found for IGF-1 or IGFR1 in any cell type. Positive staining of PTGS2 was observed in LE and SG in all groups. An interaction between ewe and embryo breed affected PTGS2 staining (P < 0.05), whereby Cheviot ewes carrying Suffolk embryos had a lower PTGS2 staining than Suffolk ewes carrying Suffolk embryos. Positive staining of PCNA was found in LE and SG. Suffolk ewes carrying Suffolk embryos showed lower PCNA immunostaining than Cheviot ewes carrying Suffolk embryos (P < 0.05), whereas no differences were observed in ewes carrying Cheviot embryos. This study showed that gestation-related protein expression in the endometrium of Suffolk and Cheviot ewes is affected by both ewe and embryo breed at Day 19 of pregnancy.

Maternal insulin sensitivity in midpregnancy does not determine birth weight after embryo transfer between large and small breed sheep.

Embryo transfer of large sheep breed embryos (Suffolk) into small breed ewes (Cheviot) constrains birth size, but the maternal factors influencing fetal growth restriction are unknown. We hypothesized that reciprocal embryo transfer crosses between breeds of divergent size would affect pregnancy-related development of maternal insulin resistance in midgestation, thereby influencing fetal growth. Following superovulation, embryos were surgically collected 6 d postmating and transferred to recipients on the same day. Between- and within-breed transfers were performed. Between 60 and 70 d of pregnancy overnight-fasted ewes underwent hyperinsulinemic-euglycemic clamps for assessment of insulin sensitivity. Maternal insulin sensitivity did not vary with transferred lamb breed. Overall, Cheviot ewes tended to have higher fasting glucose (P = 0.068), fasting insulin (P = 0.052), and steady-state glucose (P = 0.065) concentrations than Suffolk ewes at the stage of pregnancy studied. As expected, transferred between-breed Suffolk lambs were born lighter (P = 0.014), and transferred between-breed Cheviot lambs tended to be heavier at birth (P = 0.056) than respective lambs transferred within breed. Midgestation insulin sensitivity does not appear to be a major factor constraining growth of large breed sheep fetus transferred into smaller breed or a factor in releasing constraint in growth of a small breed fetus within a larger breed ewe. However, as embryo size is already different between transferred groups by 19 d, factors other than maternal gestational insulin resistance may determine fetal growth in this embryo transfer paradigm.

Is physical function a more appropriate measure than volume excess in the assessment of breast cancer-related lymphoedema (BCRL)?

The aim of this study was to objectively measure impairment of arm function in women with breast cancer-related lymphoedema (BCRL), and investigate possible associations between this, arm volume excess, and psychological morbidity as measured by the Medical Outcomes Study 36-item short form (SF-36) questionnaire. A total of 48 patients were recruited. Manual dexterity was significantly impaired in the affected arm, independent of dominant or non-dominant arm involvement, but was not associated with arm volume excess. Psychological morbidity was significantly impaired in the domains of 'physical function' and 'bodily pain' when compared with population controls. Degree of impairment in the 'physical function' domain correlated with the absolute level of objectively tested manual dexterity. Impairment of manual dexterity appears to have a greater impact than arm volume excess on the overall psychological morbidity associated with BCRL, suggesting that greater emphasis should be placed upon arm function in the assessment, treatment targeting, and monitoring of patients with this condition.

Radioguided occult lesion localisation (ROLL) and sentinel node biopsy for impalpable invasive breast cancer.

AIM: The aim of this study was to simplify the technique of ROLL and sentinel node biopsy without compromising tumour excision and sentinel node biopsy. METHODS: Twenty patients with impalpable primary invasive breast carcinoma underwent an injection of 99mTc-nanocolloid mixed with radiographic contrast medium Iohexol into the centre of the lesion under ultrasound or stereotactic guidance pre-operatively. No guidewire localisation was performed. Under general anaesthesia, a periareolar intradermal/subcutaneous injection of patent blue-V dye was performed. The sentinel node was identified by blue-stained lymphatics and node and a hot spot on the gamma probe. Surgical excision of the primary tumour was then carried out using the gamma probe. RESULTS: In eight of 20 cases an immediate re-excision was carried out and on histological assessment, all 20 patients were clear of invasive disease at the margins. In two patients, in situ disease was present at the margins and a further re-excision was therefore performed. The sentinel node was identified in all cases. In all, five of 20 patients were node positive on routine HE staining. In a further two patients, tumour cells were identified by immunohistochemistry with CAM5.2 antibody. Completion axillary clearance in six patients confirmed that the sentinel node was the only positive node. CONCLUSIONS: This modification of the previously described ROLL technique is feasible and safe and does not compromise tumour excision or sentinel node detection.

Variation in lymphatic function may predispose to development of breast cancer-related lymphoedema.

AIMS: Breast cancer-related lymphoedema (BCRL) remains a common complication of breast cancer treatment. Many features of this condition remain poorly understood, such as why only approximately 25% of women are affected after similar treatment, and the phenomenon of 'sparing', in which regions of an otherwise swollen arm, most commonly the hand, remain unaffected. This study uses dual-isotope lymphoscintigraphy, involving measurement of rate of clearance of radiolabelled protein from a subcutaneous depot and subsequent appearance in blood, to quantify alterations in lymphatic function in women with BCRL, and to further investigate differences between those in whom the hand is involved with swelling and those in whom it is spared. METHODS: Participants received a depot injection of human immunoglobulin G in the dorsum of both hands, labeled with technetium-99m on one side and indium-111 on the other. Rates of clearance from the depot and appearance in venous blood were measured at regular intervals over a 3 h period. RESULTS: A total of 18 women with a history of BCRL were studied. Significant reductions in both depot clearance and venous appearance were observed in the affected arm compared with the unaffected contralateral control. On sub-group analysis, significant differences were also observed between swollen and spared hand groups, both for the affected and unaffected contralateral arm. DISCUSSION: This study, as well as confirming impaired lymphatic function in arms affected by BCRL, also shows underlying variation in lymphatic function in the unaffected contralateral arm, between those with and without hand sparing. This raises the possibility that the risk of developing BCRL may be, in part, pre-determined.

Lactation Biology Symposium: maternal nutrition during early and mid-to-late pregnancy: Comparative effects on milk production of twin-born ewe progeny during their first lactation.

Studies using sheep models indicate that the fetal mammary gland is sensitive to maternal nutrition during gestation; however, results have been inconsistent and do not identify critical feeding periods. This study aimed to clarify previous findings by partitioning the period of maternal nutritional manipulation into 2 stages: early and mid-to-late pregnancy. Sixty-six twin-born, twin-bearing ewes, born to dams that were fed either submaintenance, maintenance, or ad libitum during early pregnancy (d 21 to 50 of pregnancy; SmP21-50, MP21-50, or AdP21-50, respectively) and then either maintenance or ad libitum during mid-to-late pregnancy (d 50 to 140 of pregnancy; MP50-140 or AdP50-140, respectively) were milked once a week, starting from d 7 ± 1 postpartum, for 7 subsequent weeks to enable estimation of daily milk yield and composition. Their lambs were weighed weekly. Ewes born to dams fed MP21-50 tended to have greater accumulated milk (P = 0.10), fat (P = 0.07), and NE (P = 0.06) yields over 50 d compared with ewes born to dams fed SmP21-50 and AdP21-50. In contrast, ewes born to dams fed AdP50-140 tended to have greater accumulated milk (P = 0.10) and lactose (P = 0.09) yields compared with ewes born to dams fed MP50-140. Grandoffspring birth weights were unaffected by granddam nutrition during pregnancy. Ewes born to dams fed AdP21-50 weaned lighter lambs (P = 0.05) than ewes born to dams fed AmP21-50 and tended to wean lighter lambs (P = 0.07) than ewes born to dams fed MP21-50 whereas there were no differences between the weaning weights of lambs (P = 0.43) from ewes born to dams fed AdP50-140 and MP50-140. Maintenance nutrition of dams during early pregnancy appears to be associated with an improved lactation performance of ewe offspring. Higher levels of nutrition during mid-to-late pregnancy also appears to improve the first-lactation performance of ewe offspring. Interestingly, although grandoffspring birth weights were unaffected, weaning weight appears to be influenced by granddam early pregnancy nutrition in a manner discordant with the lactational performance of their dam. Results from this study indicate that dam nutrition during early pregnancy can influence the lactational performance of ewe offspring and the BW at weaning of their grandoffspring, which may ultimately affect farmer profits. This highlights the importance of nutritional management of breeding ewes during this period.

The effects of PG600 and boar exposure on oestrus detection and potential litter size following mating at either the induced (pubertal) or second oestrus.

Within gilt pools, incidences of delayed puberty attainment, failure to exhibit regular oestrous cycles and low first litter size are often high. Boar exposure is an effective method of accelerating puberty; however, the timing of gilt response can vary greatly. Although, PG600 (400 IU of PMSG and 200 IU of hCG; Intervet) can induce a rapid and synchronous ovulatory response, thus providing an alternative to boar contact, the quality of the response is often variable. This study compared the effect of PG600, either alone (NBC) or in conjunction with boar exposure (BC), on puberty attainment and maintenance of oestrous cyclicity. The effects of first mating these gilts at the hormonally induced (pubertal) or second oestrus on ovulation rate and early embryo survival were also studied. Eighty Large White cross terminal (Duroc) line gilts were used in this study. The study was conducted in two blocks, with 10 gilts allocated to each of the four treatments in each block. Gilts were artificially inseminated at the allocated oestrus, with the reproductive tracts collected at 26.5+/-0.29 days after first mating (mean+/-S.E.M.), and the number of corpora lutea and viable embryos recorded. Mean days-to-puberty was significantly reduced (P<0.05) when gilts received both PG600 and boar exposure as opposed to PG600 alone (5.7+/-0.15 versus 6.9+/-0.37 days; P<0.01). The proportion of gilts exhibiting an ovulatory response to PG600 was similar for the BC and NBC treatment groups (0.88 and 0.84); however, the proportion of gilts exhibiting visible signs of oestrus in response to PG600 was significantly higher for the BC compared to the NBC treatment groups (0.81 versus 0.49; P<0.05). Boar contact resulted in a numerical, but not significant, increase in the proportion of gilts exhibited a second oestrus (1.00 versus 0.76). There was no significant effect of boar contact on ovulation rate, embryo number or survival. Although ovulation rate was unaffected by oestrus at mating, embryo number was significantly increased (P<0.05) following mating at the second compared to the first oestrus (11.2+/-0.96 versus 7.8+/-1.17). In conclusion, the current data indicate that the timing of puberty attainment and oestrus detection are significantly improved when PG600 treated gilts receive full boar contact. Further, it is evident that mating gilts at their second as opposed to the hormonally induced oestrus significantly increases embryo number at day 26 post-mating.

Lymphatic transfer studies with immunoglobulin scintigraphy after axillary surgery.

AIMS: The study objective was to investigate the effects of axillary lymph node clearance surgery on the function and morphology of the lymphatic system of the upper limb in women with breast cancer. METHODS: Nineteen women were studied before and 3 months after surgery. Fifteen were studied again 12 months after surgery. On each occasion, scintigraphy following intradermal hand webspace injection of Tc-99m-human polyclonal immunoglobulin was performed to include the affected upper limb and torso. RESULTS: There was considerable functional variability in response to surgery. Seven patients subsequently developed breast cancer-related lymphedema (BCRL). Neither lymph re-routing (defined as a change in lymph vessel morphology or definition) nor linear velocity of protein transit up the arm was associated with the development of BCRL. Blood pool activity, judged from visual inspection of the cardiac blood pool on the whole body images, was earlier and more marked 3 and 12 months after surgery than before. The count rate (per 100 pixels/MBq injected activity), measured in a cardiac region of interest, was significantly higher after surgery than before, was higher in patients who developed BCRL and, in the patient population as a whole, correlated positively with arm swelling. CONCLUSION: The consequences of axillary lymph node clearance were variable, unexpected and largely persistent. An increased rate of access of intradermally injected protein into the blood pool is significantly associated with BCRL.

Axillary vein abnormalities contribute to development of lymphoedema after surgery for breast cancer.

BACKGROUND: The aetiology of breast cancer-related lymphoedema (BCRL) is poorly understood and multifactorial. Previous work has suggested that acquired abnormalities of the axillary vein may contribute to arm swelling. This prospective study evaluated venous changes in patients with a new diagnosis of breast cancer who had surgery that included axillary lymph node clearance. METHODS: Patients underwent arm volume measurement and Doppler ultrasonographic assessment of the axillary vein before, and at 3 and 12 months after surgery. RESULTS: A complete data set was available for 70 patients. BCRL was observed in 16 per cent at 3 months and 11 per cent at 12 months. Significant alterations to venous flow patterns were observed in those with BCRL. Vein wall movement was significantly reduced after surgery for the group as a whole, but did not correlate with arm swelling. Venous stenosis with impaired flow was also observed in the absence of BCRL. CONCLUSION: Axillary clearance can cause altered flow within the axillary vein, which is associated with an increased risk of developing lymphoedema.

Lymphoedema following surgery for breast cancer.

BACKGROUND: Lymphoedema is a common complication of breast cancer treatment, affecting approximately a quarter of patients. Those affected can have an uncomfortable, unsightly and sometimes functionally impaired limb prone to episodes of superficial infection. The aetiology, pathophysiology and management of these patients is poorly understood. METHODS: This is a systematic review of all published literature on lymphoedema following treatment for breast cancer, using the Medline and Cinahl databases with cross-referencing of major articles on the subject up to the end of 1999. RESULTS AND CONCLUSION: The aetiology and pathophysiology of lymphoedema in patients with breast cancer appear to be multifactorial and are still not fully understood. Although conservative treatment techniques can be very successful in controlling symptoms, they do not afford a cure. The place of surgical and pharmacological therapy remains unclear. Improved understanding of the pathophysiology may assist in reducing the incidence of this condition, or help to identify those at greatest risk, in whom early initiation of conservative treatment measures may prove effective.

Variations in treatment and survival in breast cancer.

To achieve optimum quality of care for women with breast cancer in the UK, uniformity of care in accordance with consensus guidelines is needed. This review highlights variations in provision of care for women with breast cancer, with particular emphasis on care received in the UK, examines differences in survival, and discusses the factors that may underlie these differences. Strong variation in treatment was identified, which appeared to affect survival significantly. These findings reinforce the need for women with breast cancer to be treated by dedicated specialists working within a multidisciplinary team to provide a high standard of care.

Tissue-to-blood transport of radiolabelled immunoglobulin injected into the web spaces of the hands of normal subjects and patients with breast cancer-related lymphoedema.

AIM: The ability to return interstitial protein to central blood is key to the defence against oedema. The aim of this study was to quantify this ability by measuring the rate at which radiolabelled human immunoglobulin (HIgG) accumulated in blood following injection into the subcutis of the hand in normal volunteers and in patients with breast cancer-related lymphoedema (BCRL). METHODS: A total of 37 control subjects (healthy normal volunteers or breast cancer patients prior to treatment) and 18 women with BCRL were studied with dual-isotope lymphoscintigraphy. Each received bilateral subcutaneous depot injection in the dorsal web space of HIgG labelled with Tc-99m on one side and In-111 on the other. Activities remaining at the depot and accumulating in blood were measured at regular intervals for 3 h. Clearance from the depot was exponential and expressed as the rate constant k(depot) (min(-1)). Accumulation in blood was essentially linear and, using an estimate of blood volume based on height and weight, was expressed as the linear constant b(blood) (% administered activity x min(-1)). The time axis intercept of this linear fit was recorded as an index of the minimum time to arrival of radioprotein in blood. The efficiency with which radioprotein that has left the depot (extra-depot activity) is transported into blood [tissue-to-blood (T-B) transport] was quantified (1) as the quotient b(blood)/k(depot), and (2) as a function of time after injection by comparing the total amount of radioprotein in blood at any time with the total amount of radioprotein that was no longer in the depot at the same time. RESULTS: Tc-99m-HIgG and In-111-HIgG behaved similarly and are interchangeable. At all times between 60 and 180 min in controls, about 50% of protein that had left the depot was present in blood. T-B transport was reduced to about 20% in BCRL arms in which the hand was involved in swelling (p < 0.001 versus controls), but remained unchanged in patients in whom the hand was spared. The minimum time to arrival of radioprotein in blood was not reduced in BCRL; on the contrary, there appeared to be a small proportion of injected activity that arrived rapidly in blood in BCRL patients but not in controls. CONCLUSION: We conclude that T-B transport is only impaired in BCRL when radioprotein is injected into swollen tissue. Significant quantities of radioprotein may escape from the arm via local access to blood. Individual variation in this capacity may explain the regional sparing observed in BCRL.