Combination of verteporfin-photodynamic therapy with 5-aza-2'-deoxycytidine enhances the anti-tumour immune response in triple negative breast cancer.

Introduction: Triple negative breast cancer (TNBC) is a subtype of breast cancer characterised by its high tumourigenic, invasive, and immunosuppressive nature. Photodynamic therapy (PDT) is a focal therapy that uses light to activate a photosensitizing agent and induce a cytotoxic effect. 5-aza-2'-deoxycytidine (5-ADC) is a clinically approved immunomodulatory chemotherapy agent. The mechanism of the combination therapy using PDT and 5-ADC in evoking an anti-tumour response is not fully understood. Methods: The present study examined whether a single dose of 5-ADC enhances the cytotoxic and anti-tumour immune effect of low dose PDT with verteporfin as the photosensitiser in a TNBC orthotopic syngeneic murine model, using the triple negative murine mammary tumour cell line 4T1. Histopathology analysis, digital pathology and immunohistochemistry of treated tumours and distant sites were assessed. Flow cytometry of splenic and breast tissue was used to identify T cell populations. Bioinformatics were used to identify tumour immune microenvironments related to TNBC patients. Results: Functional experiments showed that PDT was most effective when used in combination with 5-ADC to optimize its efficacy. 5-ADC/PDT combination therapy elicited a synergistic effect in vitro and was significantly more cytotoxic than monotherapies on 4T1 tumour cells. For tumour therapy, all types of treatments demonstrated histopathologically defined margins of necrosis, increased T cell expression in the spleen with absence of metastases or distant tissue destruction. Flow cytometry and digital pathology results showed significant increases in CD8 expressing cells with all treatments, whereas only the 5-ADC/PDT combination therapy showed increase in CD4 expression. Bioinformatics analysis of in silico publicly available TNBC data identified BCL3 and BCL2 as well as the following anti-tumour immune response biomarkers as significantly altered in TNBC compared to other breast cancer subtypes: GZMA, PRF1, CXCL1, CCL2, CCL4, and CCL5. Interestingly, molecular biomarker assays showed increase in anti-tumour response genes after treatment. The results showed concomitant increase in BCL3, with decrease in BCL2 expression in TNBC treatment. In addition, the treatments showed decrease in PRF1, CCL2, CCL4, and CCL5 genes with 5-ADC and 5-ADC/PDT treatment in both spleen and breast tissue, with the latter showing the most decrease. Discussion: To our knowledge, this is the first study that shows which of the innate and adaptive immune biomarkers are activated during PDT related treatment of the TNBC 4T1 mouse models. The results also indicate that some of the immune response biomarkers can be used to monitor the effectiveness of PDT treatment in TNBC murine model warranting further investigation in human subjects.

Population pharmacokinetic modelling of indium-based quantum dot nanoparticles: preclinical in vivo studies.

There is considerable interest in biomedical applications of quantum dot (QD) nanoparticles, in particular their use as imaging agents for diagnostic applications. In order to investigate the in vivo biodistribution and the potential toxicity of quantum dots (QDs), it is crucial to develop pharmacokinetic (PK) models as basis for prediction of QDs exposure profiles over time. Here, we investigated the in vivo biodistribution of novel indium-based QDs in mice for up to three months after intravenous administration and subsequently developed a translational population PK model to scale findings to humans. This evaluation was complemented by a comprehensive overview of the in vivo toxicology of QDs in rats. The QDs were primarily taken up by the liver and spleen and were excreted via hepatobiliary and urinary pathways. A non-linear mixed effects modelling approach was used to describe blood and organ disposition characteristics of QDs using a multi-compartment PK model. The observed blood and tissue exposure to QDs was characterised with an acceptable level of accuracy at short and long-term. Of note is the fast distribution of QDs from blood into liver and spleen in the first 24 h post-injection (half-life of 28 min) followed by a long elimination profile (half-life range: 47-90 days). This is the first study to assess the PK properties of QDs using a population pharmacokinetic approach to analyse in vivo preclinical data. No organ damage was observed following systemic administration of QDs at doses as high as 48 mg/kg at 24 h, 1 week and 5 weeks post-injection. In conjunction with the data arising from the toxicology experiments, PK parameter estimates provide insight into the potential PK properties of QDs in humans, which ultimately allow prediction of their disposition and enable optimisation of the design of first-in-human QDs studies.

Elastic scattering spectroscopy for early detection of breast cancer: partially supervised Bayesian image classification of scanned sentinel lymph nodes.

Sentinel lymph node biopsy is a standard diagnosis procedure to determine whether breast cancer has spread to the lymph glands in the armpit (the axillary nodes). The metastatic status of the sentinel node (the first node in the axillary chain that drains the affected breast) is the determining factor in surgery between conservative lumpectomy and more radical mastectomy including axillary node excision. The traditional assessment of the node requires sample preparation and pathologist interpretation. An automated elastic scattering spectroscopy (ESS) scanning device was constructed to take measurements from the entire cut surface of the excised sentinel node and to produce ESS images for cancer diagnosis. Here, we report on a partially supervised image classification scheme employing a Bayesian multivariate, finite mixture model with a Markov random field (MRF) spatial prior. A reduced dimensional space was applied to represent the scanning data of the node by a statistical image, in which normal, metastatic, and nonnodal-tissue pixels are identified. Our results show that our model enables rapid imaging of lymph nodes. It can be used to recognize nonnodal areas automatically at the same time as diagnosing sentinel node metastases with sensitivity and specificity of 85% and 94%, respectively. ESS images can help surgeons by providing a reliable and rapid intraoperative determination of sentinel nodal metastases in breast cancer.

Low-cost surface reconstruction for aesthetic results assessment and prediction in breast cancer surgery.

The high incidence and low mortality of breast cancer surgery has led to an increasing emphasis on the cosmetic outcome of surgical treatment. Advances in aesthetic evaluation, as well as surgical planning and outcome prediction, have been investigated by using geometrically precise 3D modelling of the breast surface prior to surgery and after the procedure. However, existing solutions are based on expensive site specific setups and remain weakly validated. In this paper, we explore the possibility of using low-cost RGBD cameras as an affordable and mobile system for breast surface reconstruction. The methodology relies on sensor calibration, uncertainty-driven point filtering, dense reconstruction and subsequent multi-view joint optimization to diffuse residual pose errors. Results from a phantom study, with ground truth obtained through commercially available scanners, indicate that the approach is promising with RMS errors in order of 2 mm. A clinical study shows the practical applicability of our method and compares favourably to high-end scanning solutions.

Intraoperative radiotherapy for breast cancer.

Intra-operative radiotherapy (IORT) as a treatment for breast cancer is a relatively new technique that is designed to be a replacement for whole breast external beam radiotherapy (EBRT) in selected women suitable for breast-conserving therapy. This article reviews twelve reasons for the use of the technique, with a particular emphasis on targeted intra-operative radiotherapy (TARGIT) which uses X-rays generated from a portable device within the operating theatre immediately after the breast tumour (and surrounding margin of healthy tissue) has been removed. The delivery of a single fraction of radiotherapy directly to the tumour bed at the time of surgery, with the capability of adding EBRT at a later date if required (risk-adaptive technique) is discussed in light of recent results from a large multinational randomised controlled trial comparing TARGIT with EBRT. The technique avoids irradiation of normal tissues such as skin, heart, lungs, ribs and spine, and has been shown to improve cosmetic outcome when compared with EBRT. Beneficial aspects to both institutional and societal economics are discussed, together with evidence demonstrating excellent patient satisfaction and quality of life. There is a discussion of the published evidence regarding the use of IORT twice in the same breast (for new primary cancers) and in patients who would never be considered for EBRT because of their special circumstances (such as the frail, the elderly, or those with collagen vascular disease). Finally, there is a discussion of the role of the TARGIT Academy in developing and sustaining high standards in the use of the technique.

Objective assessment of cosmetic outcome after targeted intraoperative radiotherapy in breast cancer: results from a randomised controlled trial.

The international randomised targeted intraoperative radiotherapy (TARGIT) trial has demonstrated evidence of non-inferiority between the novel technique of TARGIT (intra-operative radiotherapy with Intrabeam(®)) and conventional external beam radiotherapy (EBRT) in women with early breast cancer in terms of the primary outcome measure of risk of local relapse within the treated breast. Cosmesis is an increasingly important outcome of breast conserving treatment with both surgery and radiotherapy contributing to this. It was unknown if the single high dose of TARGIT may lead to damaging fibrosis and thus impair cosmesis further, so we objectively evaluated the aesthetic outcome of patients within the TARGIT randomised controlled trial. We have used an objective assessment tool for evaluation of cosmetic outcome. Frontal digital photographs were taken at baseline (before TARGIT or EBRT) and yearly thereafter for up to 5 years. The photographs were analysed by BCCT.core, a validated software which produces a composite score based on symmetry, colour and scar. 342 patients were assessed, median age at baseline 64 years (IQR 59-68). The scores were dichotomised into Excellent and Good (EG), and Fair and Poor (FP). There were statistically significant increases in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group at year 1 (OR 2.07, 95 % CI 1.12-3.85, p = 0.021) and year 2 (OR 2.11, 95 % CI 1.0-4.45, p = 0.05). Following a totally objective assessment in a randomised setting, the aesthetic outcome of patients demonstrates that those treated with TARGIT have a superior cosmetic result to those patients who received conventional external beam radiotherapy.

Religious/spiritual coping resources and their relationship with adjustment in patients newly diagnosed with breast cancer in the UK.

BACKGROUND: Religious/spiritual resources may serve multiple functions in adjustment to cancer. However, there is very little evidence of the importance of religious/spiritual variables outside the USA. This paper reports the cross-sectional data of a longitudinal study examining the beneficial and harmful effects of religious/spiritual coping resources on adjustment in the first year after a breast cancer diagnosis. METHOD: One hundred and fifty-five patients newly diagnosed with breast cancer were assessed after surgery. Several aspects of religiousness/spirituality in relation to anxiety and depression were examined: religiosity/spirituality, strength of faith, belief in God, private and public practices, spiritual involvement, perceived spiritual support and positive and negative religious coping strategies. Non-religious coping, social support and optimism were also assessed. RESULTS: 'Feeling punished and abandoned by God' significantly explained 5% of the variance in increased levels of anxiety but was partially mediated by denial coping. It was also partially mediated by acceptance coping, lowering levels of anxiety. Feeling punished and abandoned by God was a significant independent predictor of depressed mood, explaining 4% of the variance. CONCLUSION: Using religious/spiritual resources in the coping process during the early stages of breast cancer may play an important role in the adjustment process in patients with breast cancer. Patients may benefit from having their spiritual needs addressed as experiencing some form of religious/spiritual struggle may serve as a barrier to illness adjustment. Implications for research and clinical practices are discussed.

In vivo dosimetry for single-fraction targeted intraoperative radiotherapy (TARGIT) for breast cancer.

PURPOSE: In vivo dosimetry provides an independent check of delivered dose and gives confidence in the introduction or consistency of radiotherapy techniques. Single-fraction intraoperative radiotherapy of the breast can be performed with the Intrabeam compact, mobile 50 kV x-ray source (Carl Zeiss Surgical, Oberkochen, Germany). Thermoluminescent dosimeters (TLDs) can be used to estimate skin doses during these treatments. METHODS AND MATERIALS: Measurements of skin doses were taken using TLDs for 72 patients over 3 years of clinical treatments. Phantom studies were also undertaken to assess the uncertainties resulting from changes in beam quality and backscatter conditions in vivo. RESULTS: The mean measured skin dose was 2.9 ± 1.6 Gy, with 11% of readings higher than the prescription dose of 6 Gy, but none of these patients showed increased complications. Uncertainties due to beam hardening and backscatter reduction were small compared with overall accuracy. CONCLUSIONS: TLDs are a useful and effective method to measure in vivo skin doses in intraoperative radiotherapy and are recommended for the initial validation or any modification to the delivery of this technique. They are also an effective tool to show consistent and safe delivery on a more frequent basis or to determine doses to other critical structures as required.

Intraoperative radiotherapy in the treatment of breast cancer: a review of the evidence.

The surgical treatment of early breast cancer has evolved from the removal of the entire breast and surrounding tissues (mastectomy) to the removal of the tumour together with a margin of healthy tissue (lumpectomy). Adjuvant radiotherapy, however, is still mainly given to the whole breast. Furthermore, external beam radiotherapy is often given several months after initial surgery and requires the patient to attend the radiotherapy centre daily for several weeks. A single fraction of radiotherapy given during surgery directly to the tumour bed (intraoperative radiotherapy) avoids these problems. The rationale and level-1 evidence for the safety and efficacy of the technique are reviewed.

Targeted intraoperative radiotherapy for breast cancer in patients in whom external beam radiation is not possible.

PURPOSE: External beam radiation therapy (EBRT) following wide local excision of the primary tumor is the standard treatment in early breast cancer. In some circumstances this procedure is not possible or is contraindicated or difficult. The purpose of this study was to determine the safety and efficacy of targeted intraoperative radiotherapy (TARGIT) when EBRT is not feasible. METHODS AND MATERIALS: We report our experience with TARGIT in three centers (Australia, Germany, and the United Kingdom) between 1999 and 2008. Patients at these centers received a single radiation dose of 20 Gy to the breast tissue in contact with the applicator (or 6 Gy at 1-cm distance), as they could not be given EBRT and were keen to avoid mastectomy. RESULTS: Eighty patients were treated with TARGIT. Reasons for using TARGIT were 21 patients had previously received EBRT, and 31 patients had clinical reasons such as systemic lupus erythematosus, motor neuron disease, Parkinson's disease, ankylosing spondylitis, morbid obesity, and cardiovascular or severe respiratory disease. Three of these patients received percutaneous radiotherapy without surgery; 28 patients were included for compelling personal reasons, usually on compassionate grounds. After a median follow-up of 38 months, only two local recurrences were observed, an annual local recurrence rate of 0.75% (95% confidence interval, 0.09%-2.70%). CONCLUSIONS: While we await the results of the randomized trial (over 2,000 patients have already been recruited), TARGIT is an acceptable option but only in highly selected cases that cannot be recruited in the trial and in whom EBRT is not feasible/possible.

Scanning elastic scattering spectroscopy detects metastatic breast cancer in sentinel lymph nodes.

A novel method for rapidly detecting metastatic breast cancer within excised sentinel lymph node(s) of the axilla is presented. Elastic scattering spectroscopy (ESS) is a point-contact technique that collects broadband optical spectra sensitive to absorption and scattering within the tissue. A statistical discrimination algorithm was generated from a training set of nearly 3000 clinical spectra and used to test clinical spectra collected from an independent set of nodes. Freshly excised nodes were bivalved and mounted under a fiber-optic plate. Stepper motors raster-scanned a fiber-optic probe over the plate to interrogate the node's cut surface, creating a 20x20 grid of spectra. These spectra were analyzed to create a map of cancer risk across the node surface. Rules were developed to convert these maps to a prediction for the presence of cancer in the node. Using these analyses, a leave-one-out cross-validation to optimize discrimination parameters on 128 scanned nodes gave a sensitivity of 69% for detection of clinically relevant metastases (71% for macrometastases) and a specificity of 96%, comparable to literature results for touch imprint cytology, a standard technique for intraoperative diagnosis. ESS has the advantage of not requiring a pathologist to review the tissue sample.

Patients' view on intraoperative diagnosis of sentinel nodes in breast cancer: is it an automatic choice?

UNLABELLED: Intraoperative detection of sentinel node metastases in breast cancer enables immediate axillary lymph node dissection. This approach, however, introduces uncertainty for patients as to the extent of surgery. Waking to find a surgical drain implies more extensive surgery and worse prognosis disease. False negative diagnoses may cause disappointment. AIM: To evaluate patients' views and preferences on intraoperative diagnosis of sentinel nodes in breast cancer. METHODS: Questionnaire based survey of 100 patients who had previously undergone sentinel node biopsy with intraoperative diagnosis using touch imprint cytology (TIC). Patients were encouraged to add free text comments. RESULTS: Sixty-four patients responded to the questionnaire. Patients rated the information provided and their understanding of the procedure highly. Fifty-nine percent of respondents overestimated the sensitivity of TIC. Ninety-five percent of patients would choose to undergo intraoperative diagnosis in future if required. Five percent of patients would choose not to undergo intraoperative diagnosis, citing the resultant uncertainty, disappointment on waking and needing time to come in terms with the diagnosis of metastases as reasons. CONCLUSION: Given the choice, most patients would choose intraoperative diagnosis, though a minority would explicitly not, due to the adverse psychological effect thereof. Despite a good understanding of the procedure, the majority of patients overestimate the sensitivity of intraoperative diagnosis of sentinel nodes, which may heighten disappointment when a false negative diagnosis occurs. Intraoperative diagnosis should not be the automatic choice and patients should be actively involved in this decision making process.

Allergy to technetium-labelled nanocolloidal albumin for sentinel node identification.

Optimal sentinel node identification requires using the combination technique with blue dye and radiocolloid. Allergic reactions to the common blue dyes in use are well recognised. In this report, we present a patient with breast carcinoma who developed a type I hypersensitivity reaction to intradermal injection of technetium-99m labelled nanocolloidal albumin. While reactions to colloids are rare, and in this case minor, operators using this radiopharmaceutical should be prepared for a potential severe anaphylactic reaction.

Detection of the sentinel lymph node in breast cancer.

INTRODUCTION: Axillary lymph node status for lymphatic staging in breast cancer is the best prognostic indicator and guides systemic treatment. Sentinel lymph node (SLN) biopsy is a novel, minimally invasive technique for lymphatic staging proven to improve quality of life. The accurate detection of the SLN is paramount for the success of the procedure. METHODS: Relevant literature was reviewed with regards to the different dyes and techniques used for the detection of SLN in breast cancer. RESULTS: Highest identification rates and lowest false negative rates are achieved by using the combined blue dye and radiocolloid technique with pre-operative imaging using a gamma camera. There is a well-recognized learning curve to successfully perform SLN biopsy. CONCLUSIONS: The concept of SLN has been well validated and is the standard of care in early breast cancer. A multidisciplinary approach and structured training is the key to the successful introduction of the technique.

Monitoring recovery after laser surgery of the breast with optical tomography: a case study.

Results are presented of a study to monitor the changes in the optical properties of breast tissue over a 12-month period after interstitial laser photocoagulation treatment of a fibroadenoma. The study involved generating cross-sectional images of the breast with a multichannel time-resolved imaging system and a nonlinear image reconstruction algorithm. Images of the internal absorbing and scattering properties revealed the expected initial inflammatory response, followed by the development of low-scattering cysts consistent with corresponding ultrasound examinations. Although results indicate that purely qualitative images can potentially provide clinically valuable data, means of enhancing diagnostic information by overcoming present limitations of the approach are discussed.

New approaches in breast cancer management: sentinel node biopsy and intraoperative radiotherapy.

Breast cancer is presenting earlier, and treatment is becoming less invasive. We review two recent changes in the approach to management. Sentinel lymph node biopsy is a minimally invasive technique to identify the first draining lymph node in direct communication with the primary tumor; it enables "selective lymphadenectomy." Axillary lymph node dissection is reserved as a therapeutic procedure only for proven node positive patients. The concept has been validated, the techniques have been optimized, and randomized controlled trials have confirmed lower morbidity without compromising regional control compared with conventional treatment. The procedure is considered by many as the standard of care for staging the axilla in early breast cancer, although several unanswered questions remain. Adequate training and experience in the technique are vital to ensure high sentinel node identification and low false negative rates. Intraoperative radiotherapy is an attractive concept that enables delivery of single fraction radiotherapy in the operating room immediately after resection of the primary tumor. It is convenient for patients and appears effective in pilot studies. Partial breast irradiation to the index quadrant has been practiced for many years in the form o brachytherapy. Trials are under way comparing intraoperative radiotherapy with conventional external bea irradiation. Intra-operative radiotherapy should not be used outside of clinical trials until the results of the current randomized trials are known.

The emerging role and implications of sentinel node biopsy in breast carcinoma.

The surgical management of breast cancer has become less invasive in recent years. Accurate lymphatic staging remains crucial for determining adjuvant treatment and prognosis. Sentinel node biopsy enables highly accurate lymphatic staging with minimal morbidity. In this article we give a historical overview, outline the technique, give succinct guidelines for practice based on current evidence, examine recently published work as well as highlight the most important trials in progress. The advent of sentinel node biopsy for the routine treatment of breast carcinoma will have significant implications on the whole team involved in beast cancer care. Training for the entire team needs to be addressed, and preparations made as patients are likely to soon demand this procedure as part of the routine management of their breast carcinoma.

Clinical role of sentinel-lymph-node biopsy in breast cancer.

The introduction of sentinel-lymph-node biopsy has brought new impetus to the early staging of cancer in general, and breast cancer in particular. This technique has rekindled the discussion on the present role and routine practice of axillary-lymph-node dissection in early breast cancer, the methods available for the histopathological assessment of lymph nodes, and the current thoughts about best surgical practice in the management of breast cancer. Sentinel-lymph-node biopsy has spread so rapidly that surgeons, pathologists, and patients are no longer willing or able to ignore the possible consequences of its implementation. A vast amount of data (over 1150 publications in the peer-reviewed literature on this subject to date) attests to the explosive interest in the past 5 years. In this article we review our own experience and discuss recommendations for clinical practice.