Intraoperative spectroscopic evaluation of sentinel lymph nodes in breast cancer surgery.

BACKGROUND AND OBJECTIVES: Sentinel lymph node (SLN) biopsy is a standard procedure for patients with breast cancer and normal axilla on imaging. Positive SLNs on histological examination can lead to a subsequent surgery for axillary lymph node clearance (ALNC). Here we report a non-destructive technique based on autofluorescence (AF) imaging and Raman spectroscopy for intra-operative assessment of SLNs excised in breast cancer surgery. METHODS: A microscope integrating AF imaging and Raman spectroscopy modules was built to allow scanning of lymph node biopsy samples. During AF-Raman measurements, AF imaging determined optimal sampling locations for Raman spectroscopy measurements. After optimisation of the AF image analysis and training of classification models based on data from 85 samples, the AF-Raman technique was tested on an independent set of 81 lymph nodes comprising 58 fixed and 23 fresh specimens. The sensitivity and specificity of AF-Raman were calculated using post-operative histology as a standard of reference. RESULTS: The independent test set contained 66 negative lymph nodes and 15 positive lymph nodes according to the reference standard, collected from 78 patients. For this set of specimens, the area under the receiver operating characteristic (ROC) curve for the AF-Raman technique was 0.93 [0.83-0.98]. AF-Raman was then operated in a regime that maximised detection specificity, producing a 94% detection accuracy: 80% sensitivity and 97% specificity. The main confounders for SLN metastasis were areas rich in histiocytes clusters, for which only few Raman spectra had been included in the training dataset. DISCUSSION: This preliminary study indicates that with further development and extension of the training dataset by inclusion of additional Raman spectra of histiocytes clusters and capsule, the AF-Raman may become a promising technique for intra-operative assessment of SLNs. Intra-operative detection of positive biopsies could avoid second surgery for axillary clearance.

Correction: The clinical significance of oestrogen receptor expression in breast ductal carcinoma in situ.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The clinical significance of oestrogen receptor expression in breast ductal carcinoma in situ.

BACKGROUND: Oestrogen receptor (ER) in invasive breast cancer (BC) predicts response to endocrine therapy (ET) and provides prognostic value. In this study, we investigated the value of ER expression in ductal carcinoma in situ (DCIS) in terms of outcome and the impact on ET decision. METHODS: In total, 643 pure DCIS, diagnosed at Nottingham University Hospitals, were assessed for ER. Clinicopathological data were correlated against ER status, together with assessment of recurrence rate. RESULTS: ER positivity was observed in 74% (475/643) of cases. ER positivity was associated with clinicopathological variables of good prognosis; however, outcome analysis revealed that ER status was not associated with local recurrence. In the intermediate- and high-grade ER-positive DCIS, 58% (11/19) and 63% (15/24) of the recurrences were invasive, respectively, comprising 7% and 6% of all ER-positive DCIS, respectively. Invasive recurrence in low-grade DCIS was infrequent (2%), and none of these patients died of BC. The ER status of the recurrent invasive tumours matched the primary DCIS ER status (94% in ipsilateral and 90% of contralateral recurrence). CONCLUSION: The strong correlation between DCIS and invasive recurrence ER status and the clinical impact of ET justify discussion of the use of ET in ER-positive DCIS treated by breast-conserving surgery. The excellent outcome of low-grade DCIS, which was almost always ER-positive, does not, in the opinion of authors, justify the use of risk-reducing ET. Therefore, the decision on ET for DCIS should be personalised and consider grade, ER status and other characteristics.

Surgical management of ductal carcinoma in situ of the breast: A large retrospective study from a single institution.

BACKGROUND: Management of breast ductal carcinoma in situ (DCIS) has various approaches with distinct institutional specific practice. Here, we review DCIS management in a single institution with emphasize on re-operation rates and outcome. METHODS: Breast ductal carcinoma in situ cases diagnosed at the Nottingham Breast Institute between 1987 and 2017 were identified (n = 1249). Clinicopathological data were collected. Cases were histologically reviewed, and different factors associated with primary operation selection, re-excision, presence of residual tumor in the re-excision specimens, use of radiotherapy and ipsilateral recurrences were analyzed. RESULTS: 34% of DCIS patients were initially treated by mastectomy and were more frequently symptomatic, of high nuclear tumor grade, size >40 mm, and associated with comedo necrosis and Paget's disease of the nipple. Further surgery was due to involved or narrow surgical margins. Residual tumor tissue was detected in 53% of the re-excision specimens. Re-excision rates of patients treated with breast-conserving surgery (BCS) were reduced from approximately 70% to 23%, and the final mastectomy rates decreased from 60% to 20%. Changes in surgical practice with acceptance of smaller excision margins and more frequent use of local radiotherapy have led to a significant decrease not only in the re-excision rate but also in the final mastectomy rate together with non-significant reduction in 5- and 10-year local recurrence rates. CONCLUSION: Although BCS is increasingly the preferred primary surgical option for DCIS management, a proportion of low-risk DCIS patients continue to undergo re-excision surgery or completion mastectomy. Despite acceptance of smaller margins, recurrence rate is decreasing.

Prolyl-4-hydroxylase Α subunit 2 (P4HA2) expression is a predictor of poor outcome in breast ductal carcinoma in situ (DCIS).

BACKGROUND: Extracellular matrix (ECM) plays a crucial role in tumour behaviour. Prolyl-4-hydroxlase-A2 (P4HA2) is a key enzyme in ECM remodelling. This study aims to evaluate the prognostic significance of P4HA2 in breast ductal carcinoma in situ (DCIS). METHODS: P4HA2 expression was assessed immunohistochemically in malignant cells and surrounding stroma of a large DCIS cohort comprising 481 pure DCIS and 196 mixed DCIS and invasive carcinomas. Outcome analysis was evaluated using local recurrence free interval (LRFI). RESULTS: High P4HA2 expression was detected in malignant cells of half of pure DCIS whereas its expression in stroma was seen in 25% of cases. Higher P4HA2 expression was observed in mixed DCIS cases compared to pure DCIS both in tumour cells and in stroma. High P4HA2 was associated with features of high risk DCIS including younger age, higher grade, comedo necrosis, triple negative and HER2-positive phenotypes. Interaction between P4HA2 and radiotherapy was also observed regarding the outcome. High P4HA2 expression was an independent prognostic factor in predicting shorter LRFI. CONCLUSION: P4HA2 plays a role in DCIS progression and can potentially be used to predict DCIS outcome. Incorporation of P4HA2 with other clinicopathological parameters could refine DCIS risk stratification that can potentially guide management decisions.

Prognostic significance of tumor-infiltrating lymphocytes in ductal carcinoma in situ of the breast.

Tumor-infiltrating lymphocytes (TILs) provide prognostic value in invasive breast cancer and guidelines for their assessment have been published. This study aims to evaluate: (a) methods of TILs assessment, and (b) their prognostic significance in breast ductal carcinoma in situ (DCIS). Hematoxylin and eosin sections from two clinically annotated DCIS cohorts; a training set (n = 150 pure DCIS) and a validation set (n = 666 comprising 534 pure DCIS and 132 cases wherein DCIS and invasive breast carcinoma were co-existent) were assessed. Seven different scoring methods were applied to the training set to identify the most optimal reproducible method associated with strongest prognostic value. Among different methods, TILs touching ducts' basement membrane or away from it by one lymphocyte cell thickness provided the strongest significant association with outcome and highest concordance rate [inter-cluster correlation coefficient = 0.95]. Assessment of periductal TILs at increasing distances from DCIS (0.2 , 0.5 , and 1 mm) as well as percent of stromal TILs were practically challenging and showed lower concordance rates than touching TILs. TILs hotspots and lymphoid follicles did not show prognostic significance. Within the pure DCIS validation set, dense TILs were associated with younger age, symptomatic presentation, larger size, higher nuclear grade, comedo necrosis and estrogen receptor negativity as well as shorter recurrence-free interval (p = 0.002). In multivariate survival analysis, dense TILs were independent predictor of shorter recurrence-free interval (p = 0.002) in patients treated with breast conservation. DCIS associated with invasive carcinoma showed denser TILs than pure DCIS (p = 9.0 × 10-13). Dense TILs is an independent prognostic variable in DCIS. Touching TILs provides a reproducible method for their assessment that can potentially be used to guide management.

Lower extremity arterial revascularization using conditioned small-diameter great saphenous vein.

OBJECTIVE: This study was conducted to determine whether it was feasible to increase the diameter of smaller great saphenous veins (GSVs) in preparation for possible bypass and whether such a conditioned conduit could be used with reasonable patency. METHODS: Twenty-five patients (26 cases: 24 peripheral arterial occlusive disease, 2 popliteal aneurysms) with GSV diameters between 2 and 3 mm underwent in situ GSV valvulotomy and were observed for 3 months. After GSV dilation to >3 mm for below-knee revascularization and >3.5 mm for above-knee revascularization, arterial bypass surgery was performed with the valvulotomized GSV. RESULTS: Adequate GSV diameter was reached in 20 cases (77%). Arterial bypass surgery using valvulotomized GSV was performed an average 131 days (range, 64-373 days) after valvulotomy in 16 patients (61.5%). No deaths, amputations, or aneurysms occurred 2 years after surgery. At 1 and 2 years, primary patency was 81% ± 9.8% and 69% ± 11.8%, respectively, and secondary patency was 87% ± 8.3% and 75% ± 11%, respectively. CONCLUSIONS: Valvulotomy can be used to expand small-diameter GSV for lower extremity arterial bypass.

Left gastric artery aneurysm rupture: a rare cause of retroperitoneal bleeding: a case report.

INTRODUCTION: Visceral artery aneurysms are very rare. Patients usually present as emergency secondary to the sudden rupture of the aneurysm or as an incidental finding on ultrasound, MRI or abdominal computed tomography. Among these, splenic artery aneurysms are the most common ones accounting for 60% of all splanchnic aneurysms and gastric and gastroepiploic aneurysms account for only about 4%. CASE PRESENTATION: We present a 61-year-old Caucasian male previously fit and well, presenting with sudden onset epigastric pain due to retroperitoneal haemorrhage secondary to ruptured left gastric artery aneurysm. Apart from a tender epigastrium, there were no other obvious signs elicited on abdominal examination. He had persistent tachycardia and haemoglobin drop from 10 g/dl to 6.7 g/dl. He underwent a contrast computed tomography which identified the ruptured left gastric artery. The aneurysm was controlled successfully with coil embolisation of the left gastric artery. At three-month follow-up, there was no evidence of the aneurysm. CONCLUSION: Clinical presentations that do not correlate with examination finding should prompt immediate extensive investigation. The aid of contrast computed tomography and minimally invasive radiological interventional is the key to a fruitful outcome for this very rare entity.

Obesity-associated changes in molecular biology of primary breast cancer.

Obesity is associated with an increased risk of developing breast cancer (BC) and worse prognosis in BC patients, yet its impact on BC biology remains understudied in humans. This study investigates how the biology of untreated primary BC differs according to patients' body mass index (BMI) using data from >2,000 patients. We identify several genomic alterations that are differentially prevalent in overweight or obese patients compared to lean patients. We report evidence supporting an ageing accelerating effect of obesity at the genetic level. We show that BMI-associated differences in bulk transcriptomic profile are subtle, while single cell profiling allows detection of more pronounced changes in different cell compartments. These analyses further reveal an elevated and unresolved inflammation of the BC tumor microenvironment associated with obesity, with distinct characteristics contingent on the estrogen receptor status. Collectively, our analyses imply that obesity is associated with an inflammaging-like phenotype. We conclude that patient adiposity may play a significant role in the heterogeneity of BC and should be considered for BC treatment tailoring.

Combined total internal reflection AF spectral-imaging and Raman spectroscopy for fast assessment of surgical margins during breast cancer surgery.

The standard treatment for breast cancer is surgical removal mainly through breast-conserving surgery (BCS). We developed a new technique based on auto-fluorescence (AF) spectral imaging and Raman spectroscopy for fast intraoperative assessment of excision margins in BCS. A new wide-field AF imaging unit based on total internal reflection (TIR) was combined with a Raman spectroscopy microscope equipped with a 785 nm laser. The wavelength of the AF excitation was optimized to 365 nm in order to maximize the discrimination of adipose tissue. This approach allows for the non-adipose regions of tissue, which are at a higher risk of containing a tumor, to be targeted more efficiently by the Raman spectroscopy measurements. The integrated TIR-AF-Raman was tested on small tissue samples as well as fresh wide local excisions, delivering the analysis of the entire cruciate surface of BCS specimens (5.1 × 7.6 cm2) in less than 45 minutes and also providing information regarding the location of the tumor in the specimen. Full automation of the instrument and selection of a faster translation stage would allow for the measurement of BCS specimens within an intraoperative time scale (20 minutes). This study demonstrates that the TIR-AF Raman microscope represents a feasible step towards the development of a technique for intraoperative assessment of large WLE within intraoperative timescales.

The role of combined assessment in preoperative axillary staging.

BACKGROUND: Axillary lymph node status is the most significant single prognostic factor in breast cancer, and preoperative axillary staging is essential in determining lymph node status. Axillary ultrasound scan (AUS) is the gold standard modality in preoperative staging. However, triple assessment-including clinical examination and radiological assessment with fine needle aspiration (FNA) with or without core biopsy-ensures high sensitivity. METHODS: Our study included 219 women diagnosed with invasive breast cancer between 2009 and 2010. All patients underwent a preoperative staging AUS that was graded from normal (U1) to malignant (U5). All patients with ultrasound scans graded U3 (indeterminate) and above underwent FNA that was graded from C1 (inadequate for diagnosis) to C5 (malignant). Patients diagnosed preoperatively with metastatic lymph nodes were offered axillary lymph node clearance. The rest of the patients were offered sentinel lymph node biopsy. RESULTS: The 219 women were diagnosed with 228 invasive breast cancers. The mean age was 60 years (range 29-90 years). The final histology report showed metastatic axillary lymph nodes in 49 (21.5%) cases. Of these 49 cases, 22 were diagnosed preoperatively with metastatic axillary lymph node and were elected for axillary lymph node clearance, and 27 were elected for sentinel lymph node biopsy that revealed metastatic lymph nodes. AUS showed abnormal (U3/U4/U5) axillary lymph nodes in 30 of 49 (61.2%) cancer cases with an overall accuracy of 91.6%. CONCLUSION: Combined triple assessment increases the sensitivity, negative predictive value, and overall accuracy of preoperative staging of the axilla.

Breast metastasis from a melanoma.

Benign and primary malignant breast tumors are quite common, but secondary tumors in the breast from metastatic malignancies are rare. Nevertheless, metastasis to the breast must be considered in any patient with a known primary malignant tumor history who presents with a breast lump. We report a case of a premenopausal woman diagnosed with a metastatic melanoma in her breast.

Breast cancer mimicking fibroadenomas in postmenopausal women.

INTRODUCTION: Fibroadenomas (FADs) are benign breast lesions usually seen in late teens less so common in postmenopausal women. This is a case series of postmenopausal patients, where breast cancer looked like fibroadenoma on imaging. The aim of this study was to identify the important role of tissue diagnosis in FAD like lesions on imaging and highlight the deceiving imaging findings. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients at our Breast unit who were treated for breast cancer under one surgeon in the period of Feb 2009 to Jan 2010. Patients underwent triple assessment as per protocol of the breast screening unit. All had fine needle aspiration and core biopsy of the lesions. Appropriate surgery was offered and the size, grade and lymph node status were evaluated and Nottingham Prognostic Index (NPI) used to predict survival. RESULTS: 5 patients were identified with breast cancers that had initial radiological diagnosis of fibroadenoma. All patient lesions were screen detected on NHS screening programme. One patient out of five was discharged after triple assessment and represented with a lump 18 months later. The Median age was 56 years (range 50-66 years). The mammogram showed these to be benign-looking lesions and ultrasound scans suggested fibroadenomas as reported by specialist breast radiologist. Seven lesions were identified in 5 patients. One patient had 3 lesions. Lesions size ranged between 8 mm and 25 mm on mammogram (median 14 mm) and 8-20 mm on ultrasound (range 8-20). Fine needle aspiration cytology was C5 in the two lesions, C4 in 2 and C3 in 1 lesion. Two patients had unifocal grade 3 tumours. One patient had multifocal cancer (3 cancers - in unilateral breast) all were grade 3 cancers with lymph node involvement. One patient had grade 2 cancer and 1 was found to have adenoid cystic adenocarcinoma and therefore the grade and NPI were not assessed. NPI was good in 1, moderate in 2 and poor in 1 patient. CONCLUSION: Our case series suggested that one should have a high index of suspicion for FAD in the postmenopausal ladies and triple assessment should include thorough tissue sampling in the form of FNA and core biopsy.