Hyperthermia-mediated drug delivery induces biological effects at the tumor and molecular levels that improve cisplatin efficacy in triple negative breast cancer.

Triple negative breast cancer is an aggressive disease that accounts for at least 15% of breast cancer diagnoses, and a disproportionately high percentage of breast cancer related morbidity. Intensive research efforts are focused on the development of more efficacious treatments for this disease, for which therapeutic options remain limited. The high incidence of mutations in key DNA repair pathways in triple negative breast cancer results in increased sensitivity to DNA damaging agents, such as platinum-based chemotherapies. Hyperthermia has been successfully used in breast cancer treatment to sensitize tumors to radiation therapy and chemotherapy. It has also been used as a mechanism to trigger drug release from thermosensitive liposomes. In this study, mild hyperthermia is used to trigger release of cisplatin from thermosensitive liposomes in the vasculature of human triple negative breast cancer tumors implanted orthotopically in mice. This heat-triggered liposomal formulation of cisplatin resulted in significantly delayed tumor growth and improved overall survival compared to treatment with either non-thermosensitive liposomes containing cisplatin or free cisplatin, as was observed in two independent tumor models (i.e. MDA-MB-231 and MDA-MB-436). The in vitro sensitivity of the cell lines to cisplatin and hyperthermia alone and in combination was characterized extensively using enzymatic assays, clonogenic assays, and spheroid growth assays. Evaluation of correlations between the in vitro and in vivo results served to identify the in vitro approach that is most predictive of the effects of hyperthermia in vivo. Relative expression of several heat shock proteins and the DNA damage repair protein BRCA1 were assayed at baseline and in response to hyperthermia both in vitro and in vivo. Interestingly, delivery of cisplatin in thermosensitive liposomes in combination with hyperthermia resulted in the most significant tumor growth delay, relative to free cisplatin, in the less cisplatin-sensitive cell line (i.e. MDA-MB-231). This work demonstrates that thermosensitive cisplatin liposomes used in combination with hyperthermia offer a novel method for effective treatment of triple negative breast cancer.

MultIethNic Study of BrEast ARterial Calcium Gradation and CardioVAscular Disease: cohort recruitment and baseline characteristics.

PURPOSE: MultIethNic Study of BrEast ARterial Calcium Gradation and CardioVAscular Disease (MINERVA) was designed to answer the question of whether a novel continuous breast arterial calcification (BAC) mass score improves cardiovascular risk stratification among asymptomatic postmenopausal women. This article describes recruitment and baseline characteristics. METHODS: MINERVA is a multiethnic longitudinal cohort study. The phenotype data include BAC mass by densitometry applied to digital mammograms, sociodemographic factors, self-reported medical history, medications, parental history, reproductive history, smoking, alcohol consumption, physical activity, anthropometry, ankle-brachial index, blood pressure, laboratory panel, breast volumes, cognitive function, bioelectrical impedance, habitual diet, dietary supplements, sleep, psychosocial factors, and sun exposure. RESULTS: A total of 5145 women aged 60 to 79 years with available digital, uncompressed mammograms were recruited from the membership of Kaiser Permanente of Northern California between October 24, 2012 and February 13, 2015 and completed a baseline clinic visit or an abbreviated phone questionnaire. Of those, 4153 underwent phlebotomy and have blood biomarkers. Overall prevalence of BAC was 26%, and it varied by age and race. The mean (SD) BAC mass was 12 (23) mg and the range 0-342 mg. CONCLUSIONS: MINERVA is the first cohort with a continuous measure of BAC. The cohort is large, ethnically diverse, and deeply phenotyped in terms of socioeconomic, behavioral, and clinical factors, and blood biomarkers.

Use of indocyanine green fluorescent angiography in a hyperbaric patient with soft tissue radiation necrosis: a case report.

INTRODUCTION: Indocyanine green fluorescent angiography (ICFA), commonly used to assess vascularity in patients with non-healing lower extremity wounds, is emerging as a useful adjunct for hyperbaric oxygen (HBO2)therapy patients. We describe the use of ICFA to measure vascularity and help tailor an appropriate HBO2 regimen in a patient with breast soft tissue radiation necrosis (STRN). CASE REPORT: 67-year-old female with a history of right breast cancer treated two years previously with lumpectomy and radiation therapy (6200 cGy), developed open wounds in the right breast. A diagnosis of STRN was established; the patient completed 20 HBO2 treatments, followed by surgical closure of the right breast wounds. Intraoperative ICFA demonstrated a focal area of hypovascularity at the medial margin of the incision. Due to a concern of suboptimal vascularity, the patient returned for additional HBO2 treatments. ICFA was performed after eight postoperative HBO2 treatments, and showed improved vascularity in the previously identified area of concern. DISCUSSION: Studies of patients previously irradiated for head and neck cancer suggest that HBO2-induced vascularity is apparent after approximately eight HBO2 treatments and peaks around 20 treatments. The results from this case indicate that the doses of HBO2 needed for adequate neovascularization in patients with STRN may be variable. CONCLUSION: The use of ICFA may provide additional insight regarding HBO2-induced angiogenesis. Additional studies are required to establish the correct number of HBO2 treatments required for angiogenesis in previously irradiated patients with STRN, and to explore the role of ICFA in patients treated with HBO2.

Design, synthesis, and biological evaluation of water-soluble amino acid prodrug conjugates derived from combretastatin, dihydronaphthalene, and benzosuberene-based parent vascular disrupting agents.

Targeting tumor vasculature represents an intriguing therapeutic strategy in the treatment of cancer. In an effort to discover new vascular disrupting agents with improved water solubility and potentially greater bioavailability, various amino acid prodrug conjugates (AAPCs) of potent amino combretastatin, amino dihydronaphthalene, and amino benzosuberene analogs were synthesized along with their corresponding water-soluble hydrochloride salts. These compounds were evaluated for their ability to inhibit tubulin polymerization and for their cytotoxicity against selected human cancer cell lines. The amino-based parent anticancer agents 7, 8, 32 (also referred to as KGP05) and 33 (also referred to as KGP156) demonstrated potent cytotoxicity (GI50=0.11-40nM) across all evaluated cell lines, and they were strong inhibitors of tubulin polymerization (IC50=0.62-1.5µM). The various prodrug conjugates and their corresponding salts were investigated for cleavage by the enzyme leucine aminopeptidase (LAP). Four of the glycine water-soluble AAPCs (16, 18, 44 and 45) showed quantitative cleavage by LAP, resulting in the release of the highly cytotoxic parent drug, whereas partial cleavage (<10-90%) was observed for other prodrugs (15, 17, 24, 38 and 39). Eight of the nineteen AAPCs (13-16, 42-45) showed significant cytotoxicity against selected human cancer cell lines. The previously reported CA1-diamine analog and its corresponding hydrochloride salt (8 and 10, respectively) caused extensive disruption (at a concentration of 1.0µM) of human umbilical vein endothelial cells growing in a two-dimensional tubular network on matrigel. In addition, compound 10 exhibited pronounced reduction in bioluminescence (greater than 95% compared to saline control) in a tumor bearing (MDA-MB-231-luc) SCID mouse model 2h post treatment (80mg/kg), with similar results observed upon treatment (15mg/kg) with the glycine amino-dihydronaphthalene AAPC (compound 44). Collectively, these results support the further pre-clinical development of the most active members of this structurally diverse collection of water-soluble prodrugs as promising anticancer agents functioning through a mechanism involving vascular disruption.

Regression of vascular calcification in a patient treated with cinacalcet: a case report.

The purpose of this case report is to describe the regression of vascular calcifications (VC) in a patient with secondary hyperparathyroidism (SHPT) after having added cinacalcet to her treatment. We present the clinical case of a 48-year-old woman with chronic renal failure secondary to tubulointerstitial disease. She was being treated with long-term haemodialysis (HD) and underwent two kidney transplants with transplantectomies. The patient presented with severe SHPT caused by parathyroid gland hypertrophy. The radiology test showed signs of VC in the radial and interdigital arteries, and VC in a linear arrangement were observed in both breasts on the mammography. Cinacalcet was added to her treatment with vitamin D derivatives and phosphate-binding agents, which resulted in a good control of mineral metabolism. The radiology test showed that the calcification in the interdigital artery had disappeared and that the bone appeared to be more structured. The mammography also showed regression of the VC. To conclude, cinacalcet may have potential for regression of VC in patients with SHPT.

Breast arterial calcification is a predictive factor of cardiovascular disease in Brazilian postmenopausal women.

OBJECTIVE: The objectives of this study were to evaluate the association between cardiovascular disease (CVD) and breast arterial calcification (BAC), as well as the prevalence rates of these conditions in Brazilian postmenopausal women. METHODS: A cross-sectional study was performed in 307 women over 40 years of age who were receiving care at the gynecology clinic of the Center for Women's Integrated Healthcare (CAISM), ABC School of Medicine. All these women had been amenorrheic for at least 12 months and had undergone mammography in the preceding 12 months. Cardiovascular disease and its subtypes were evaluated, as well as its association with BAC. Means and standard deviations, absolute frequencies and percentages were calculated, and univariate analysis and multiple logistic regression were performed. RESULTS: The mean age of the patients was 55.2 +/- 6.8 years; age at menopause was 48.5 +/- 4 years. Time since menopause was 80.2 +/- 75.4 months; 96.1% of the patients were non-smokers and 46.3% were using hormone therapy. Of the patients, 33.6% had systemic arterial hypertension, 4.9% had diabetes mellitus and 5.2% had hypercholesterolemia. The mean body mass index was 27.3 +/- 4.3 kg/m(2). CVD was found in 6.8% and BAC in 8.5% of the women. Significantly more women with BAC had CVD compared to the women who did not have this condition (23.1% vs. 5.3%, p = 0.0006). BAC was associated with an odds ratio of 8.13 (95% confidence interval 2.68-24.64) for predicting CVD. CONCLUSIONS: In postmenopausal women, breast arterial calcification may represent a higher likelihood of cardiovascular disease.

Skin-reducing mastectomy.

BACKGROUND: The authors propose a combined flap technique to reconstruct large and medium-sized ptotic breasts in a single-stage operation by use of anatomical permanent implants. METHODS: The authors enrolled 28 patients fulfilling criteria for skin-sparing mastectomy and presenting with ptotic breasts whose areola-to-inframammary fold distance was more than 8 cm. All reconstructions were performed as a single-stage procedure. After preoperative planning, a large area in the lower half of the breast was deepithelialized according to the conventional Wise pattern. Mastectomy was then carried out. To perform reconstructions, the inferomedial fibers of the pectoralis major muscle were dissected and sutured to the superior border of the inferior dermal flap. An anatomical implant was then inserted into the pouch, which was closed laterally with the previously harvested serratus anterior fascia. Skin flaps were finally closed down to the inframammary fold. RESULTS: The authors performed 30 procedures on 28 patients. The medium size anatomical implants was 433 cc. Twelve women achieved symmetrization in a single stage ending in a symmetric inverted-T scar. The overall complication rate was 20 percent, with four cases (13 percent) complicated by severe, extensive necrosis of the skin flaps requiring implant removal. CONCLUSIONS: Breast cancer treatment must nowadays optimize cosmetic results. This can be accomplished in selected cases by means of a single-stage operation that the authors call "skin-reducing mastectomy." The final scars imitate those of cosmetic surgery. Careful patient selection and improvement in the learning curve may reduce the complication rate.

[Clinical research on relationship between angiogensis and TCM syndrome type of cyclomastopathy].

OBJECTIVE: To study the relationship between angiogensis and TCM Syndrome type of cyclomastopathy (CMP) to investigate the objective standardization of TCM Syndrome diagnosis of the disease. METHODS: One hundred and forty patients with CMP were divided into three groups according to TCM syndrome typing. The pathological type, grade and expressions of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and microvascular density (MVD) in mammary biopsy were observed. RESULTS: The expressions of VEGF, bFGF and MVD was different in CMP patients of different TCM types and pathological grades (P < 0.05). The proportion of atypical proliferation, the count of MVD and the expression of VEGF and bFGF were higher in patients of phlegm and stasis type than those in Gan stagnation caused Qistagnation type and Chong and Ren meridians disorder type. CONCLUSION: TCM Syndrome type of CMP patients is related with vascular activity and grade of angiogensis. The pathological characteristics of mammary tissue and expression of VEGF, bFGF and MVD can be regarded as the objective indexes of TCM typing and clinical efficacy evaluation for CMP.

Dynamic MRI of breast hardness following radiation treatment.

PURPOSE: To evaluate functional microvascular characteristics of breast induration several years after radiation treatment using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) techniques. MATERIALS AND METHODS: Fifteen women with moderate or marked breast induration after surgery and radiotherapy for breast cancer (2-15 years) were examined. Images of the irradiated breast (boost and nonboost sites) on short tau inversion recovery (STIR) and DCE-MRI sequences were subjectively evaluated for edema and the presence of enhancement and compared to the contralateral normal breast. Quantitative enhancement parameters-percent enhancing pixels, transfer constant (K(trans)), rate constant (k(ep)), leakage space (v(e)), and maximum contrast medium accumulation (MCMA)-were also compared. RESULTS: No tumor recurrence was seen. Fat necrosis was seen in 2/15 cases. Increased parenchymal edema at the electron boost site was seen in 12/14 patients. Greater enhancement in the irradiated breast was seen in 11/14 evaluable patients. Kinetic parameter estimates including K(trans) were similar except for percent enhancing pixels, which was greater in the irradiated breast at both boost and nonboost sites (P = 0.03 and 0.04, respectively). v(e) and MCMA estimates were greater in breasts with marked induration compared to moderate grades (P = 0.002 and 0.01, respectively). CONCLUSION: Parenchymal edema may be an important contributor to palpable induration several years after breast radiotherapy. Increased fluid content may be related to increased numbers of perfused microvessels and/or impaired lymphatic drainage.

Mitochondrial uptake of sestamibi distinguishes between normal, inflammatory breast changes, pre-cancers, and infiltrating breast cancer.

The evaluation of breast tissue using nuclear imaging is dependent upon the delivery and uptake of the isotope by breast tissue. This is dependent upon blood flow to the breast and functioning mitochondria. This 2-part study investigated (1) differences in uptake of sestamibi when blood flow is enhanced (breast enhanced scintigraphy test [BEST]), and (2) differences in isotope uptake in normal (Nl) breast tissue, inflammatory changes in breast tissue (ICB), and breast cancer (CA). In the first part of the study, 10 women were compared using both Miraluma and BEST imaging; in the second part, 195 people were studied using BEST imaging only. The results were compared with histopathologic specimens. Little difference was noted between Miraluma and BEST imaging in the first part. Women with ICB showed a statistically significant (P <.05) increase in isotope uptake using BEST imaging. This difference was even more significant (P <.005) in women with CA. During the second part of the study, BEST imaging demonstrated an exponential increase in tracer uptake. When maximal count activity was compared, there was a statistically significant (P <.001) difference between Nl and ICB, between ICB and atypia (A), and between A and CA. BEST imaging demonstrated significant increases in isotope delivery when compared with Miraluma imaging. These differences allowed differentiation of breast tissue, including the detection of early changes in breast tissue.

An infiltration technique for reduction mammaplasty: results in 192 consecutive breasts.

The use of local anaesthetic infiltration with adrenaline is now considered safe in reduction mammaplasty. However, the technique of infiltration by those who support its use is often unclear. Any technique must take account of the neurovascular anatomy of the breast if it is to be effective. We propose the use of a large volume of dilute local anaesthetic (20 ml of 1% lignocaine and 1 mg of adrenaline made up to 400 ml with 0.9% saline) which is placed judiciously in the retroglandular space 15 minutes prior to surgery. The results in 96 consecutive patients (192 breasts) who had an inferior pedicle technique were analysed. The breast complication rate was 9.36% and the patient complication rate 19.79%. Postoperative blood loss ranged from 0 to 305 ml with a mean of 56.03 ml and a median of 50 ml. The described method could be considered a variation of the tumescent technique used in liposuction. The results is an almost bloodless dissection with minimal postoperative blood loss. It should be possible to dispense with the use of drains in most cases.

Preoperative injection using a diluted anesthetic/adrenaline solution significantly reduces blood loss in reduction mammaplasty.

Breast reductions are very common operations in the plastic surgical practice. The cosmetic results are generally satisfactory but are often accompanied with large volumes of blood lost. In this study, the reduction of blood loss together with other positive and negative effects of a preoperatively diluted anesthetic/adrenaline solution was tested. A group of 41 female patients treated with the infiltration solution was compared with a group of 29 female patients treated without the solution. No statistical differences were found in age at operation, weight, length, Quetelet index, amount of tissue resected, preoperative hemoglobin and hematocrit, postoperative drainage, duration of operation, and the viability of the skin flaps (p > 0.05). Blood loss was significantly less in the adrenaline-treated group measured in several ways (p < 0.0001). There were more adrenaline-treated patients with less hospitalization time compared with the nontreated group (p = 0.0858). In conclusion, diluted anesthetic/adrenaline solution significantly reduces blood loss in reduction mammaplasty without any adverse effects.

[The value of the "vascular invasion" factor for prognosis of breast cancer]. / Die Wertigkeit des Faktors "Gefässinvasion" für die Prognose des Mammakarzinoms.

The histological sections of 106 patients, who underwent a primary breast cancer operation in the years 1986 and 1987, were inspected for the presence of tumour vascular invasion. With immunohistochemical methods, tumour vessels were tomographed and the paraffin sections were stained with an antibody, which is sensitive to factor VIII-antigen. A tumour embolus was considered present, if a malignant cell was established within a positively stained lumen. The question of possible influence on the pathogenesis of breast cancer was examined in case of vascular invasion in the histological preparation. In 46 of the 106 patients (43.4%), tumour emboli were found. After an average observation period of 59 months, no tumour progression was seen in 60 patients, 46 patients developed a recurrence of the tumour at the check-up date. The presence of vascular invasion correlates with undifferentiated tumour grading. The probability of relapse- free survival after 5 years was 83.9% within the group without vascular invasion, compared with 47.9% (p = 0.0001) within the group with established vascular invasion. In the multivariate analysis of the factors lymphonodular status, grading and vascular invasion, it was found, that the presence of tumour vascular invasion with a relative risk of 3.68 (95% CI 1.93-7.03) was the strongest statistically significant prognostic factor for relapse-free survival (p = 0.0001).

Doppler measurement of breast vascularity in women under pharmacologic treatment of benign breast disease.

Breast vascularization was measured with an 8-MHz continuous wave Doppler pencil probe. Flow values were low in asymptomatic women and high in patients with severe pain or dysplastic changes. Mild treatment with a plant extract produced only a small decrease in breast vascularization. Treatment with norethisterone acetate showed a dose-dependent decrease in blood flow. A good response was seen with a dosage of 5 mg/d, and a dramatic decrease was seen when 10 mg/d was taken. These results showed a good correlation with the patients' symptoms.

The relevance of tumour and surrounding normal tissue vascular density in clinical hyperthermia of locally advanced breast carcinoma.

It follows from the present work that the vascularization of the normal tissue present in the treatment volume limits the temperatures achieved during heat treatment of invasive ductal breast carcinoma. The temperatures can often be increased by giving fractionated heat treatment because heat treatment may reduce the cooling capacity of the normal tissue vasculature. Significant damage to supplying vessels occurs at the heat doses necessary to cause necrosis in the tumour and surrounding normal tissue, indicating that secondary cell death is an important mechanism for cell inactivation following hyperthermic treatment of breast carcinoma.

Effect of electrical nerve stimulation on healing of ischaemic skin flaps.

Blood circulation was measured by laser doppler flowmetry in fasciocutaneous flaps of 24 patients who underwent reconstructive surgery for mammary carcinoma. 19 of the 24 patients had clinical signs of deficient circulation in the flaps. 14 patients were treated with electrical nerve stimulation (ENS) and 10 with placebo-ENS. Varying degrees of necrosis developed in 8 of the 10 patients who received placebo stimulation but in none of those treated with ENS. In the 5 patients with good capillary refilling and no signs of stasis or oedema before treatment, only minor increases in blood flow occurred after ENS.

The follow up study of intra-arterial infusion chemotherapy with local vein blocking as a surgical neo-adjuvant treatment for locally advanced breast cancer.

Preoperative intra-arterial infusion neo-adjuvant chemotherapy, in combination with local vein blocking, was administered to thirty-one patients with locally advanced stage III breast cancer. The anti-cancer drugs and dosages used were 500 mg of 5-Fluorouracil (5FU), which was infused daily for 7-14 days, and 20 mg of Adriamycin (ADM), which was administered as a bolus dose twice into the subclavian and internal mammary arteries. The response rate of this method on the primary tumor was 48.4 per cent, and, histologically it was found to be as high as 90.3 per cent. The response rate of the clinical effects on the regional lymph nodes was 50.0 per cent, however, histologically, it was found to be lower than that of the primary tumor. In the long-term follow-up study the 5-year survival rate was 72.2 per cent. Thus, this method seems to be effective as a combined modality in cases of locally advanced stage III breast cancer.

Selenium, estradiol 17 beta, nitrites, and human breast cancer.

Breast cancer is the most common cancer in women in the United States. Although there is a large body of studies dealing with selenium, estrogens and nitrites in relation to cancer, most of them are correlated singly and the dynamics of carcinogenesis are overly simplified. The epidemiologic and etiologic effects of selenium, estrogens and nitrites in human breast cancer are traced in their important dimensions. A hypothesis for the interaction of these factors, especially in relation to the erythrocyte is presented within a multi-stage focus of carcinogenesis. A biochemical process for breast cell carcinogenesis in general is postulated and the erythrocyte interaction with breast cancer is diagramed. An enzyme "X" is postulated (estradiase) as a facilitator in vivo of the necessary biochemical conversion of estradiol 17 to a carcinogen.

Late development of hematoma around a breast implant, necessitating removal.

We present a patient who bled into the pocket around a breast implant 2 1/2 years after an augmentation mammaplasty. She had received inflatible silicone prostheses, each containing 40 mg of triamcinolone acetonide. Our belief is that this large dosage of corticosteroid was responsible for the late erosion of the medium-sized artery, which caused the hemorrhage. Exploration and evacuation of the hematoma was followed by an uneventful postoperative course.

Pathologic findings from the National Surgical Adjuvant Breast Project (protocol no. 4). I. Observations concerning the multicentricity of mammary cancer.

Microscopic foci of multicentric cancer were detected in 121 of 904 breasts surgically removed for a clinically overt, invasive cancer. This incidence of 13.4% is regarded as a conservative estimate since examples of such lesions occurring in the same quadrant as the dominant mass, except in those instances in which the latter was present within the tail of the breast or beneath the nipple, were excluded from the analysis. Further, this data was obtained from only one randomly selected block of the quadrants, and in 41% of the cases only one or two were available for study. Multiple multicentric cancers were found in the same breast in two and three quadrants in 11.6% and 5.8% of the cases respectively. In 9.3% of the cases the multicentric cancers were designated as noninvasive (lobular in situ and/or intraductal) and in 4.1% invasive. An attempt to correlate the occurrence of multicentric cancers with a large number of pathologic and some clinical features disclosed a statistically significant association between multicentricity and grossly nonencapsulated dominant cancers with maximum diameters greater than 5 cm, the presence of a moderate or marked intraductal component and noninvasive cancer in its vicinity, and tumor involvement of the nipple. In addition, it was noted that there was a greater likelihood that the primary tumor was of the lobular invasive type and that the overlying skin was involved when the multicentric cancer was invasive rather than noninvasive. Lymphatic tumor emboli were observed in quadrants in 18 or 2.0% of the cases. Although the number of examples is small, nevertheless positive associations were noted with the occurrence of primary tumors that were in the left breast or beneath the nipple and were not grossly circumscribed, but exhibited a nuclear grade of 1, intralymphatic and blood vessel invasion, calcium, and involvement of the overlying skin as well as nipple. In addition, patients with such intralymphatic extension were more likely to have clinically detectable lymph nodes of which four or more contained metastases. The relationship of these findings to the rationale of such procedures as segmental resection in the surgical treatment of breast cancer is discussed.