Andreas Schnelzer

Showcase of Intraoperative 3D Imaging of the Sentinel Lymph Node in a Breast Cancer Patient using the New Freehand SPECT Technology

After the development of a hand-held intraoperative device for 3D real-time imaging of radioactively labeled sentinel lymph nodes in the human body, we present our first experience with the newest version of the free- hand single-photon emission computed tomography (SPECT) technology in the operating room. The freehand SPECT system combines a gamma probe and an optical infrared positioning system, and provides surgeons with 3D imaging including exact depth information of the radioactive target. This technology was used intraoperatively in a female breast cancer patient to localize the axillary sentinel lymph nodes. The data obtained with freehand SPECT correlate well with conventional lymphoscintigraphy and with data collected using a conventional hand-held probe. By offering fast real-time intraoperative imaging, the new freehand SPECT system might facilitate the detection and removal of the sentinel lymph node(s) in certain situations and can be used for documentation and quality assurance purposes.

Prevalence of deleterious germline variants in risk genes including BRCA1/2 in consecutive ovarian cancer patients (AGO-TR-1)

Background Identification of families at risk for ovarian cancer offers the opportunity to consider prophylactic surgery thus reducing ovarian cancer mortality. So far, identification of potentially affected families in Germany was solely performed via family history and numbers of affected family members with breast or ovarian cancer. However, neither the prevalence of deleterious variants in BRCA1/2 in ovarian cancer in Germany nor the reliability of family history as trigger for genetic counselling has ever been evaluated. Methods Prospective counseling and germline testing of consecutive patients with primary diagnosis or with platinum-sensitive relapse of an invasive epithelial ovarian cancer. Testing included 25 candidate and established risk genes. Among these 25 genes, 16 genes (ATM, BRCA1, BRCA2, CDH1, CHEK2, MLH1, MSH2, MSH6, NBN, PMS2, PTEN, PALB2, RAD51C, RAD51D, STK11, TP53) were defined as established cancer risk genes. A positive family history was defined as at least one relative with breast cancer or ovarian cancer or breast cancer in personal history. Results In total, we analyzed 523 patients: 281 patients with primary diagnosis of ovarian cancer and 242 patients with relapsed disease. Median age at primary diagnosis was 58 years (range 16–93) and 406 patients (77.6%) had a high-grade serous ovarian cancer. In total, 27.9% of the patients showed at least one deleterious variant in all 25 investigated genes and 26.4% in the defined 16 risk genes. Deleterious variants were most prevalent in the BRCA1 (15.5%), BRCA2 (5.5%), RAD51C (2.5%) and PALB2 (1.1%) genes. The prevalence of deleterious variants did not differ significantly between patients at primary diagnosis and relapse. The prevalence of deleterious variants in BRCA1/2 (and in all 16 risk genes) in patients <60 years was 30.2% (33.2%) versus 10.6% (18.9%) in patients ≥60 years. Family history was positive in 43% of all patients. Patients with a positive family history had a prevalence of deleterious variants of 31.6% (36.0%) versus 11.4% (17.6%) and histologic subtype of high grade serous ovarian cancer versus other showed a prevalence of deleterious variants of 23.2% (29.1%) and 10.2% (14.8%), respectively. Testing only for BRCA1/2 would miss in our series more than 5% of the patients with a deleterious variant in established risk genes. Conclusions 26.4% of all patients harbor at least one deleterious variant in established risk genes. The threshold of 10% mutation rate which is accepted for reimbursement by health care providers in Germany was observed in all subgroups analyzed and neither age at primary diagnosis nor histo-type or family history sufficiently enough could identify a subgroup not eligible for genetic counselling and testing. Genetic testing should therefore be offered to every patient with invasive epithelial ovarian cancer and limiting testing to BRCA1/2 seems to be not sufficient.

Changing the intraoperative nodal status of a breast cancer patient using freehand SPECT for sentinel lymph node biopsy.

Radio-guided sentinel lymph node biopsy in early-stage breast cancer is standard of care. Freehand SPECT is a system for intraoperative visualization of radioactivity in the body. It generates a 3-dimensional image of the radioactivity distribution complementing the acoustic information of the gamma probe by providing depth and radioactive uptake information. In the reported case, freehand SPECT was used in a breast cancer patient as a control method after conventional sentinel lymph node biopsy. Freehand SPECT identified an additional lymph node, changing the original stage from pN1(mic) (micrometastasis) to pN1a (nodal positive), resulting in an axillary lymph node dissection.

Endocrine Combination Therapy for Prostate and Metastatic Breast Cancer in a Male Patient

Background: Breast cancer in men is rare and requires therapy concepts including health considerations different from those in female patients. Case Report: We report on a 64-year-old male patient with metastatic breast cancer in the lung and cervical lymph nodes. Upon metastasis, initial adjuvant endocrine therapy with tamoxifen was changed to anastrozole. After 1 year of treatment, the patient was found to have rising prostatespecific antigen (PSA) levels, and diagnostic workup confirmed the diagnosis of early prostate cancer. Because of simultaneous progressive disease of metastatic breast cancer, chemotherapy with 6 cycles of docetaxel was administered resulting in a partial remission of both tumor types. The patient is currently treated with an endocrine combination therapy of fulvestrant, goserelin, and bicalutamide. He is in good clinical condition, and tumor markers for both tumor types are stable. Conclusion: Elevated PSA levels under therapy with aromatase inhibitors have been described in individual cases but always warrant a careful diagnostic workup to exclude prostate cancer as an important differential diagnosis. Genetic counseling has to be taken into consideration in the case of male breast cancer as well as in the case of coincidence of different tumor types, such as breast and prostate cancer, due to the possibility of e.g. BRCA mutations in these patients.

Introducing a novel highly prognostic grading scheme based on tumour budding and cell nest size for squamous cell carcinoma of the uterine cervix: Grading of cervical cancer

A novel histopathological grading system based on tumour budding and cell nest size has recently been shown to outperform conventional (WHO‐based) grading algorithms in several tumour entities such as lung, oral, and oesophageal squamous cell carcinoma (SCC) in terms of prognostic patient stratification. Here, we tested the prognostic value of this innovative grading approach in two completely independent cohorts of SCC of the uterine cervix. To improve morphology‐based grading, we investigated tumour budding activity and cell nest size as well as several other histomorphological factors (e.g., keratinization, nuclear size, mitotic activity) in a test cohort (n = 125) and an independent validation cohort (n = 122) of cervical SCC. All parameters were correlated with clinicopathological factors and patient outcome. Small cell nest size and high tumour budding activity were strongly associated with a dismal patient prognosis (p < 0.001 for overall survival [OS], disease‐specific survival, and disease‐free survival; test cohort) in both cohorts of cervical SCC. A novel grading algorithm combining these two parameters proved to be a highly effective, stage‐independent prognosticator in both cohorts (OS: p < 0.001, test cohort; p = 0.001, validation cohort). In the test cohort, multivariate statistical analysis of the novel grade revealed that the hazard ratio (HR) for OS was 2.3 for G2 and 5.1 for G3 tumours compared to G1 neoplasms (p = 0.010). In the validation cohort, HR for OS was 3.0 for G2 and 7.2 for G3 tumours (p = 0.012).

Abstract P1-01-22: Use of Freehand SPECT for 3D Navigated Radio-Guided Axillary Sentinel Lymph Node Biopsy and Quality Assurance in Breast Cancer Surgery

Background: The sentinel lymph node (SLN) concept in breast cancer is an integral standard of care. However, several practical issues have been raised preventing proper identification of the sentinel node in certain clinical scenarios. Moreover, the criteria for definition of sentinel node have recently been questioned, including the value of dynamic information or the value of preoperative lymphoscintigraphy. The problems behind some of these questions rely on the impracticability to incorporate the preoperative imaging information into the operative procedure of sentinel lymph node biopsy (SLNB). Methods: For the freehand SPECT (fhSPECT, SurgicEye Germany) acquisition a gamma probe system and an infrared optical tracking system were combined in one system including a data processing unit in order to acquire the readouts of the probe and the position synchronously, process the readings into a 3D image and display them for the user. To date, 20 patients with invasive breast cancer undergoing SLNB were recruited and scanned intraoperatively using fhSPECT before excision of SLNs. The localization of SLNs with fhSPECT was compared to the position of SLNs detected using gamma probe and blue dye. FhSPECT was further used to prove the excision of the SLN postoperatively. Preoperative planar scintigraphy was used as a reference. Results: Preoperatively, 38 SLNs were mapped with conventional scintigraphy. In the pre-excision scan (performed in 19 of 20 patients) fhSPECT managed to map all but 3 SLNs in the identical position as compared to node location at planar scintigrams (34/37). Only in 1 patient fhSPECT did not find any SLN in the pre-excision scan. Gamma probe failed to detect any SLNs in 2 patients and mapped in total 30 of 38 nodes. 28 SLNs were resected and confirmed to be radioactive ex-vivo. fhSPECT detected 11 SLNs in 11 patients after primary SLN excision. In 4 cases additionally detected nodes were resected and confirmed to be radioactive, while in 7 cases harvesting of the additionally detected node was discarded as higher uptake SLNs had been removed already. In the remaining 9 patients no residual radioactivity was found in the axilla. Pre-excision fhSPECT acquisitions took approx. 3.1min (SD, 1.1min) while post-excision scans took 3.2min (SD, 0.9min). The surgical procedure was extended by 12min (6min before incision and 6min after excision of SLNs). Discussion: Intraoperative 3D imaging with fhSPECT for lymphatic mapping in breast cancer patients is feasible. Identification of the SLN can be repeated at any time during surgery to guide proper and precise resection of the sentinel node(s). For quality assurance the system can digitally document that all SLNs have been successfully removed. The freehand SPECT provides also new options concerning the above stated controversies in the principal sentinel lymph node concept. Controlled studies using 3D intraoperative imaging could help to clarify many of the discussed issues, including the role of lymphatic uptake on selecting the nodes for surgical resection. Also, the option to transfer dynamic information from preoperative imaging into the OR or the possibility to skip preoperative imaging bears additional advantages over the standard procedure. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-22.

RFLP Molecular Analysis of the Urokinase-Type Plasminogen Activator Gene

Several cell biological studies have shown that the invasiveness of a variety of tumors depend on the regulated expression of proteolytic enzymes that degrade the surrounding extracellular matrix and dissociate cell-cell and/or cell-matrix attachments. One such enzyme, the serine protease urokinase-type plasminogen activator (uPA), converts enzymatically inactive plasminogen into the widely acting protease plasmin, which degrades several extracellular matrix components and also activates proenzyme forms of matrix metalloproteases. Thus, uPA is a central molecule in pericellular proteolysis (1-1). uPA (as well as other factors of the plasminogen activator system, the cell surface-associated uPA receptor [uPAR], and the plasminogen activator inhibitor type-1 [PAI-1]) is an important prognostic factor predicting relapse-free and/or survival in patients with a variety of solid malignant tumors including ovarian cancer; in all cases, high levels of uPA are associated with a poor prognosis (4-6).