Nomogram including the total tumoral load in the sentinel nodes assessed by one-step nucleic acid amplification as a new factor for predicting nonsentinel lymph node metastasis in breast cancer patients.

Several models have been developed to predict non-sentinel nodes (NSLN) metastasis in patients with a positive sentinel node (SLN) that incorporates a standard pathology examination of the SLN. It has been reported that total tumoral load (TTL) in the SLNs assessed by one-step nucleic acid amplification (OSNA) is a predictive factor for additional NSLN metastasis in the axillary lymph node dissection (ALND). The objective was to develop a nomogram that predicts patient´s risk of additional NSLN metastasis incorporating TTL in the SLNs assessed by OSNA. Six hundred and ninety-seven consecutive patients with positive SLN evaluation by OSNA and a completion ALND were recruited. Pathologic features of the primary tumor and SLN metastases, including TTL were collected. Multivariate logistic regression identified factors predictive of non-SLN metastasis. A nomogram was developed with these variables and validated in an external cohort. On multivariate logistic regression analysis, tumor size, number of affected SLN, Her2 overexpression, lymphovascular invasion, and TTL were each associated with the likelihood of additional NSLN metastasis (p < 0.05). The overall predictive accuracy of the nomogram, as measured by the AUC was 0.7552 (95 %CI 0.7159-0.7945). When applied to the external cohort the nomogram was accurate with an AUC = 0.678 (95 %CI 0.621-0.736). This novel nomogram that incorporates TTL assessed by OSNA performs well and may help clinicians to make decisions about ALND for individual patients. Moreover, the standardization of pathologic assessment by OSNA may help to achieve interinstitutional reproducibility among nomograms.

Diagnosis of the sentinel lymph node in breast cancer: a reproducible molecular method: a multicentric Spanish study.

AIMS: Standardization of the sentinel node (SN) as a diagnostic tool has not yet been achieved, because the protocol for histopathological study is highly variable between centres. We compared the results of a new method with conventional histological tests and evaluated its feasibility for intra-operative evaluation, and propose it as a method to standardize the sentinel node evaluation procedure. METHODS AND RESULTS: Trial 1 included 181 cases; in parallel, 2-mm-thick sections of the SN were processed alternately for histological analysis and for the one-step nucleic acid amplification (OSNA) procedure. A final concordance of 99.45% was observed in the first trial of our study. For trial 2, the timing of every procedural step was recorded in an electronic database in order to discern the time spent for each step, the total SN evaluation time and to identify areas of improvement. In the second trial, after a learning period and feedback on data recorded, we spent a mean of 31 min for the entire SN evaluation procedure. CONCLUSION: Our multi-centric trial using the OSNA assay for sentinel node evaluation in breast cancer demonstrates that this is a highly sensitive, specific and reproducible technique that allows for standardization of the SN diagnostic procedure, a necessary, and until now unresolved, issue.

Tumour molecular subtyping according to hormone receptors and HER2 status defines different pathological complete response to neoadjuvant chemotherapy in patients with locally advanced breast cancer.

PURPOSE: To study the role of breast cancer molecular subtypes according to hormone receptors and HER2 status as a predictive factor for pathological complete response (pCR) to neoadjuvant chemotherapy. PATIENTS AND METHODS: Eligible patients received one of the two chemotherapy schedules every two weeks with prophylactic growth factor support; schedule A: epirubicin 90 mg/m2-cyclophosphamide 600 mg/m2 d1 for 3 cycles followed by a second sequence with paclitaxel (P) 150 mg/ m2-gemcitabine (G) 2500 mg/m2 d1+/-trastuzumab (T) 2 mg/kg/week according to HER2 status (n=73); schedule B: adriamycin (40 mg/m2) d1 plus P (150 mg/m2)-G (2000 mg/m2) d2 for 6 cycles (n=54). Subsequently, patients underwent surgery, radiotherapy and/or adjuvant hormonal therapy according to standard practice. RESULTS: A total of 127 patients were evaluated. Forty-three patients (33.9%) achieved a pCR (50% in patients with HER2+tumours treated with T). Patients treated with che - motherapy alone (n=107, 18 HER2+) had a pCR of 32% (p=0.068). The pCR rate for patients with triple negative (HR and HER2-) cancers was 58.3%, 39.5% for HER2+ and 5.4% for ER/PR+ and HER2- (p<0.001). No differences in disease-free survival (DFS) were noted as a function of pCR, HER2 and HR status or treatment received (+/-T). However, statistical differences in DFS were observed as a function of whether patients had + or - axillar lymph nodes. Patients with + lymph node disease did worse (3 years DFS of 53.7% vs. 81.5%, p=0.025). Breast-conserving surgery was performed in 77 patients (60.6%). CONCLUSION: Tumour molecular subtyping defines different pCR to neoadjuvant chemotherapy (NC) but has no impact over DFS in patients with LABC. Although no significant correlation between HER2 status and trastuzumab therapy with pCR was found, probably due to the small number of patients, a favourable trend was observed in the group of HER2+ tumours treated with T.

Redox status in the sentinel lymph node of women with breast cancer.

BACKGROUND: Lymphatic metastasis is regulated in multiple steps including the transit of tumor cells via the lymphatic vessels and the successful seeding in draining lymph nodes. Thus, several molecular signals and cellular changes must be involved in this complex process to facilitate tumor cell entry, colonization, and survival in the lymph node. To our knowledge, the present work explores, for the first time in the literature, the redox status (oxidative stress parameters and enzymatic and non-enzymatic antioxidant defense systems) in the sentinel lymph node (SLN) of women with breast cancer. PATIENTS AND METHODS: SLNs from 75 women with breast cancer were identified using the one-step nucleic acid amplification (OSNA) method as negative (n = 43), with micrometastases (n = 13), or with macrometastases (n = 19). It will allow us to gain knowledge about the pro-oxidant/antioxidant mechanisms involved in the processes of distant metastases in breast cancer and also to assess whether these parameters may be alternative techniques for staging. RESULTS: We found different levels of lipid peroxidation in SLNs with micrometastases (increased) and macrometastases (decreased), a decrease in carbonyl group content in SLNs with macrometastases only, and an increase in total antioxidant capacity (TAC) in SNLs with micrometastases and macrometastases. A decrease in the levels of reduced glutathione (GSH) also appears in the SLNs with macrometastases only. Finally, we show increased levels of superoxide dismutase (SOD) and catalase (CAT) activity in SLNs with micrometastases and macrometastases, and decreased levels of glutathione peroxidase (GPx) activity in SNLs with macrometastases but not with micrometastases. CONCLUSIONS: Redox status of lymph node microenvironment participates in the progression of metastatic breast cancer.

Insulin-regulated aminopeptidase/placental leucil Aminopeptidase (IRAP/P-lAP) and angiotensin IV-forming activities are modified in serum of rats with breast cancer induced by N-methyl-nitrosourea.

BACKGROUND: In previous reports, changes in oxytocinase activity in human breast cancer tissue and in the serum of N-methyl-nitrosourea (NMU)-induced rat mammary tumors were described. Insulin-regulated aminopeptidase (IRAP) has been identified with oxytocinase and has also been referred to as placental leucine aminopeptidase (P-LAP). MATERIALS AND METHODS: The IRAP/P-LAP activity in rat serum was assayed to analyze the putative role that IRAP/P-LAP may play in regulating mammary gland carcinogenesis induced by NMU. Furthermore, as it has been recently described that IRAP/P-LAP is the angiotensin IV (Ang IV) receptor AT4, the activities of Ang IV-forming aminopeptidase N (APN) and aminopeptidase B (APB) were also assayed. RESULTS: Changes in serum IRAP/P-LAP and Ang IV-forming APB activities were found in rats with mammary tumors induced by NMU. Both activities were greatly increased, although the Ang IV-forming APN activity was not modified. CONCLUSION: These changes in aminopeptidase activities may reflect the local functional status of their substrates, which can be selectively activated or inhibited in the affected tissue as a result of specific conditions brought about by the tumor. Thus, these enzymatic activities may be involved in the promotion and progression of breast cancer through oxytocin (OT), vasopressin (AVP) and/or renin-angiotensin system (RAS) misregulation.

Serum enkephalin-degrading aminopeptidase activity in N-methyl nitrosourea-induced rat breast cancer.

BACKGROUND: Breast cancer is the most frequent spontaneous malignancy diagnosed in women in the western world, although no specific etiological agent(s) or the mechanism responsible for the initiation of the disease has been identified as yet. Enkephalins (Leu5-enkephalin and Met5-enkephalin) (ENK) act in the breast in different ways such as modulating esteroid receptors and proteases secretion. ENK are hydrolyzed by specific enzymes, leading to their inactivation, such as the enkephalin-degrading tyrosyl aminopeptidase (EDA). Breast tumours induced in rats by administration of N-methyl-nitrosourea (NMU) constitute a useful tool for dissecting the multistep process of carcinogenesis, which involves initiation, promotion and progression. The aim of the present work was to analyse EDA activity (E.C: 3.4.11.-) in serum of rats with mammary tumours induced by NMU, to evaluate the potential value of this activity as a biological marker of the carcinogenesis process, and the putative role of ENK in the promotion and progression of the disease. MATERIALS AND METHODS: Tumours were induced by intraperitoneal injection of three doses of NMU at 50, 80 and 110 days after birth. Serum EDA was measured fluorimetrically using tyrosyl-beta-naphthylamide as substrate. RESULTS: The increase found in EDA activity suggests the existence of decreased serum circulating levels of ENK in rat with mammary tumours induced by NMU. CONCLUSION: Although the exact role of ENK in breast cancer initiation, promotion and/or progression remains unknown, our results suggest that changes in EDA activity might play an important role in the origin and evolution of breast cancer.

Circulating oxidative stress parameters in pre- and post-menopausal healthy women and in women suffering from breast cancer treated or not with neoadjuvant chemotherapy.

We evaluate here the redox status in pre- and post-menopausal healthy women and in women with breast cancer in order to understand the consequences of the hormonal alterations of menopause for the oxidative stress status, its modifications with breast cancer and the influence of neoadjuvant chemotherapy (NC). To that, serum oxidative stress parameters (total antioxidant capacity, lipid peroxidation and protein oxidation), non-enzyme antioxidant defenses (total glutathione, uric acid and bilirubin) and enzyme antioxidant defenses (superoxide dismutase, catalase and glutathione peroxidase activities) were measured in healthy women and in women with breast cancer divided according to their menopausal status and that received or not NC. Circulating estradiol, progesterone, FSH and LH were also analyzed. We found that menopause itself modifies the redox status of healthy women, being most of these differences also reflected in women with breast cancer. However, several changes occur as a consequence of the disease. Furthermore, NC increases oxidative damage, decreases antioxidant defenses and eliminates the differences found in menopause. We conclude that the normal redox balance is disrupted by breast cancer but is also affected by the hormonal status promoted by menopause. In fact, NC nullifies the differences found between pre- and postmenopausal women in several antioxidant defense systems.

Neoadjuvant chemotherapy modifies serum angiotensinase activities in women with breast cancer.

PURPOSE: The aim of this study was to investigate the putative changes in serum angiotensinase activities (aminopeptidase N, APN; aminopeptidase B, APB; aminopeptidase A, APA; aspartyl aminopeptidase, ASAP) involved in the renin-angiotensin system (RAS) in women with breast cancer treated or not with a neoadjuvant therapy of paclitaxel and anthracycline and in healthy women volunteers. METHODS: We fluorometrically analysed serum APN, APB, APA and ASAP activities using their corresponding aminoacyl-ß-naphthylamides as substrates in women with breast cancer treated with a neoadjuvant therapy of paclitaxel and anthracycline. RESULTS: When compared with healthy controls, women with breast cancer not treated with neoadjuvant chemotherapy, showed a decrease in angiotensinase activity, which support the putative increase of angiotensin II (Ang II) levels, indicating that the tumour process would favour the development of the disease. Also, an increase in APN and APB activities was observed, which support a role for angiotensin IV (Ang IV). In women treated with a neoadjuvant therapy, we described an increase in ASAP and APA activities, supporting the idea that this treatment increases Ang II catabolism. The resulting decrease in Ang II level could lead to an inhibition of the tumour growth. CONCLUSION: Present results show changes in serum angiotensinase activities in women with breast cancer and in women with breast cancer treated with a neoadjuvant therapy of paclitaxel and anthracycline. Therefore, considerable attention should be focused on the development of RAS blockade therapy as a new strategy for breast cancer treatment.

Putative relationship between hormonal status and serum pyrrolidone carboxypeptidase activity in pre- and post- menopausal women with breast cancer.

In breast cancer, hormonal changes are rather constant in post-menopausal women since they tend to vary only over long time spans. However, in pre-menopausal women, the development of breast cancer is associated with hormonal physiological variations. The aim of the present work was to analyse the changes in circulating levels of gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in pre- and post-menopausal women that were healthy or with breast cancer, and their connection to serum pyrrolidone carboxypeptidase (Pcp) activity. We observed significant changes in the hormonal profile in post-menopausal women with breast cancer compared to the control group. In pre-menopausal women, we found significant changes in circulating GnRH levels with respect to the healthy group. Our present results support the existence of neuroendocrine misregulation that could be involved in tumour progression, with Pcp being a potentially new pharmacological target in breast cancer treatments.

Renin angiotensin system-regulating aminopeptidase activities in serum of pre- and postmenopausal women with breast cancer.

Angiotensin peptides regulate vascular tone and natriohydric balance through the renin angiotensin system (RAS) and are related with the angiogenesis which plays an important role in the metastatic pathway. Estrogen influences the aminopeptidases (APs) involved in the metabolism of bioactive peptides of RAS through several pathways. We analyze RAS-regulating AP activities in serum of pre- and postmenopausal women with breast cancer to evaluate the putative value of these activities as biological markers of the development of breast cancer. We observed an increase in aminopeptidase N (APN) and aminopeptidase B (APB) activities in women with breast cancer; however, a decrease in aspartyl-aminopeptidase (AspAP) activity in premenopausal women. These results suggest a slow metabolism of angiotensin II (Ang II) to angiotensin III (Ang III) in premenopausal women and a rapid metabolism of Ang III to angiotensin IV (Ang IV) in pre- and postmenopausal women with breast cancer. An imbalance in the signals activated by Ang II may produce abnormal vascular growth with different response between pre- and postmenopausal women depending on the hormonal profile and the development of the disease.

Consenso sobre la biopsia selectiva del ganglio centinela en el cáncer de mama. Revisión 2013 de la Sociedad Española de Senología y Patología Mamaria / Consensus on sentinel lymph node biopsy in breast cancer. Review of the Spanish Society of Senology and Breast Pathology 2013

La biopsia selectiva del ganglio centinela es una técnica diagnóstica aceptada como el procedimiento de elección para la estadificación axilar del cáncer de mama. En este documento, correspondiente a la última Reunión de Consenso celebrada en Valencia y organizada por la Sociedad Española de Senología y Patología Mamaria, se actualizan los consensos previos y se reflejan las conclusiones acerca de las últimas propuestas en el manejo del ganglio centinela en el cáncer de mama (AU)

Sentinel lymph node biopsy is currently a widely accepted diagnostic technique and is the procedure of choice for axillary staging of breast cancer. In this article, following the latest Consensus Meeting held in Valencia organized by the Spanish Society of Senology and Breast Pathology, previous consensus are updated. Also discussed are conclusions related to the latest trends in the management of the sentinel node in breast cancer (AU)

Diseño del instrumento de ayuda para la toma de decisiones: “alternativas de tratamiento para el cáncer de mama: ¿qué opción prefiero? / Design a decision-making aid: “alternative treatment for breast cancer: What option do you prefer?

Objetivo: Diseñar un Instrumento de Ayuda para la Toma de Decisiones (IATD) en el Proceso Asistencial Integrado ‘Cáncer de mama’ del Sistema Sanitario Público de Andalucía (SSPA) para el abordaje terapéutico de esta enfermedad en estadio inicial. Método: El diseño del IATD se realizó en cuatro fases: 1) Explorar la receptividad de las usuarias y los profesionales del SSPA sobre la incorporación de IATD en el proceso “Cáncer de mama”. 2). Seleccionar un IATD entre las experiencias internacionales.; 3) Adaptar transculturalmente del IATD seleccionado al entorno del SSPA. 4) Validar el IATD en el SSPA. Resultado: El IATD “Alternativas de tratamiento para el cáncer de mama: ¿Qué opción prefiero?” diseñado para el SSPA incluye contenidos innovadores frente a otras experiencias revisadas. Los resultados de la validación del IATD han mostrado que su diseño es atractivo para la paciente, su extensión y lenguaje idóneos, y la información clínica que contiene es de calidad. El Instrumento resuelve sus dudas (95%) y resume la información esencial para tomar la decisión (90%). El IATD ofrece información relevante que prepara a la paciente para la toma de decisiones (ausencia de conflicto decisional: 85,31), facilita la labor en consulta y la comunicación médico-paciente. Conclusiones: Pacientes y profesionales coinciden en recomendar la utilización del IATD y fomentar la participación en la toma de decisiones aunque reconocen que el factor tiempo es el principal obstáculo para incorporar su uso en el SSPA. (AU)

Purpose: To design a Decision-making Aid within the ‘Breast cancer’ healthcare process modelling of the Andalusian Public Health System (SSPA) for the therapeutic approach of early-stage disease. Methods: The Decision Aid design was conducted in four phases: 1) Explore the receptiveness of users and professionals in the mainstream of the SSPA Decision Aid “Breast Cancer” process. 2) Select a Decision Aid from international experiences. 3) Transcultural adaptation of above selected Decision Aid. 4) Decision Aid Validation in the SSPA. Results: The Decision Aid “Alternative treatment for breast cancer: What option do I prefer?” designed for the SSPA includes innovative contents compared to other reviewed experiences. The results of the validation of Decision Aid have shown that the design is attractive for the patient, ideal size and suitable language, and that the clinical information it contains is of quality. The Decision Aid an- swers your questions (95%) and summarizes the essential information to make the decision (90%). The Decision Aid offers relevant information that help the patient in the decision making process (lack of decisional conflict: 85.31), facilitates the work in the practice and doctor-patient communication. Results: The Decision Aid “Alternative treatment for breast cancer: What option do I prefer?” designed for the SSPA includes innovative contents compared to other reviewed experiences. The results of the validation of Decision Aid have shown that the design is attractive for the patient, ideal size and suitable language, and that the clinical information it contains is of quality. The Decision Aid an- swers your questions (95%) and summarizes the essential information to make the decision (90%). The Decision Aid offers relevant information that help the patient in the decision making process (lack of decisional conflict: 85.31), facilitates the work in the practice and doctor-patient communication. Conclusion: Patients and professionals agree to recommend the use of Decision Aid and to encourage participation in decision making while recognizing that the time factor is the main obstacle to incorporate its use in the SSPA (AU)