Brian Hogan

Surgery induced immunosuppression

Surgery and anaesthesia result in a variety of metabolic and endocrine responses, which result in a generalised state of immunosuppression in the immediate post-operative period. Surgery induced immunosuppression has been implicated in the development of post-operative septic complications and tumour metastasis formation. In addition the effectiveness of many treatments in the adjuvant setting is dependent on a functioning immune system. By understanding the mechanisms contributing to surgery-induced immunosuppression, surgeons may undertake strategies to minimise its effect and reduce potential short-term and long-term consequences to patients.

Circulating microRNA profiles reflect the presence of breast tumours but not the profiles of microRNAs within the tumours.

BackgroundExtra-cellular microRNAs have been identified within blood and their profiles reflect various pathologies; therefore they have potential as disease biomarkers. Our aim was to investigate how circulating microRNA profiles change during cancer treatment. Our hypothesis was that tumour-related profiles are lost after tumour resection and therefore that comparison of profiles before and after surgery would allow identification of biomarker microRNAs. We aimed to examine whether these microRNAs were directly derived from tumours, and whether longitudinal expression monitoring could provide recurrence diagnoses.MethodsPlasma was obtained from ten breast cancer patients before and at two time-points after resection. Tumour tissue was also obtained. Quantitative PCR were used to determine levels of 367 miRNAs. Relative expressions were determined after normalisation to miR-16, as is typical in the field, or to the mean microRNA level.Results210 microRNAs were detected in at least one plasma sample. Using miR-16 normalisation, we found few consistent changes in circulating microRNAs after resection, and statistical analyses indicated that this normalisation was not justifiable. However, using data normalised to mean microRNA expression we found a significant bias for levels of individual circulating microRNAs to be reduced after resection. Potential biomarker microRNAs were identified, including let-7b, let-7g and miR-18b, with higher levels associated with tumours. These microRNAs were over-represented within the more highly expressed microRNAs in matched tumours, suggesting that circulating populations are tumour-derived in part. Longitudinal monitoring did not allow early recurrence detection.ConclusionsWe concluded that specific circulating microRNAs may act as breast cancer biomarkers but methodological issues are critical.

Intramammary lymph node metastasis predicts poorer survival in breast cancer patients

Involvement of an intramammary lymph node with metastatic breast cancer is an uncommon clinical or radiological presentation. Previously reported series of patients are small in number and the clinical advice is unclear. We identified 100 patients on our pathology database with intramammary lymph nodes in association with a primary breast cancer. Ten were identified pre-operatively on breast imaging and 90 were first discovered on pathological assessment of excised breast tissue. Twenty one contained metastasis. Factors that predicted for intramammary node metastasis were increasing age (p=0.017), lymphovascular invasion (p=0.002) and grade of tumour (p=0.012). The presence of metastasis within the intramammary lymph node was associated with a poorer disease free survival (p=0.007) and reduced overall survival (p=0.035). Sixty seven percent of patients with intramammary node metastasis had further axillary metastases. One patient had an intramammary node metastasis but uninvolved axillary sentinel node. She presented 19 months later with an axillary nodal recurrence. The presence of intramammary lymph node metastasis is associated with poorer outcome in breast cancer patients. Pre-operative detection of intramammary lymph node metastasis is helpful to guide breast and axillary surgeries. Intramammary lymph node metastasis predicts strongly for axillary metastatic disease and axillary node clearance is recommended.

Circulating tumour cells in breast cancer: Prognostic indicators, metastatic intermediates, or irrelevant bystanders? (Review).

Circulating tumour cells (CTCs) have been of considerable interest for many years. The rarity of these cells presents the main challenge associated with their analysis. Current detection methods use antibody and nucleic acid techniques and are sensitive for CTC detection but limited in their utility by the occurrence of false-positive results. Despite this, there are a number of clinical studies which show that the presence of CTCs is an important prognostic indicator, particularly in the metastatic setting. Current efforts to phenotype CTCs may provide a valuable insight into the metastatic process and may also allow the development of specific CTC-targeted treatment strategies in the future.

Perioperative reductions in circulating lymphocyte levels predict wound complications after excisional breast cancer surgery.

OBJECTIVE Postoperative wound complications after excisional surgery for primary breast cancer can result in patients requiring additional treatments and delay adjuvant therapy and are associated with worse prognoses.We investigated factors that might predispose patients to wound complications. BACKGROUND A number of patient characteristics have been associated with wound complications, but there is currently no quantitative measure of the risk of their occurrence. Our hypothesis was that wound complications are related, in part, to the immune status of patients. METHODS We recruited patients undergoing surgery for primary breast cancer and determined their circulating levels of various immune cells shortly before and after surgery as a measure of immune status. RESULTS One hundred seventeen patients were recruited; 16 (13.7%) developed wound complications. The following patient and tumor characteristics were associated with higher wound complication rates: diabetes (P = 0.02); larger tumors (T2/3 vs T1; P = 0.02); metastatic axillary nodes (P = 0.006). With respect to immune status, no significant differences in preoperative levels of circulating immune cells were detected between patients who developed wound complications and those who did not. However, patients who developed complications showed greater reductions in lymphocyte levels 4 hours postoperatively than those who did not (P <0.001). Multivariate analyses demonstrated that falls in lymphocyte levels of greater than 20% or 50% 4 hours postoperatively acted as a significant and independent predictor of wound complications (P < 0.005 and P < 0.0001,respectively). CONCLUSIONS Perioperative changes in lymphocyte levels could provide a practical predictive marker for wound complications on which selective antibiotic prophylaxis could be based.

The expression of activating natural killer cell receptors in patients with primary breast cancer.

Abstract #5047 Background: The effect of primary breast tumours and their subsequent treatment on immune system function is still poorly understood and may have critical implications with regard to disease recurrence and success of treatment with the new generation of biologicals. In line with our interest in the expression and role of natural killer (NK) cell activating receptors, we measured the expression of NK cell surface receptors NKp30, NKp46 and NKG2D in patients with primary breast cancer. NKp30 and NKp46 are members of the natural cytotoxic receptors (NCRs) and are expressed on the majority of NK cells of healthy individuals. NKG2D is a member of the C type lectin superfamily. These receptors activate NK cells upon stimulation and are involved in NK cell tumour recognition and triggering although their ligands on tumour cells remain elusive.
 Methods: Our experimental procedure involved obtaining serial blood samples prior to and post surgery (4 hours-6 months) in patients with primary breast cancer. This allowed us to study basal levels of NK cell receptors as well as to investigate the effect of surgery and post surgery treatment on receptor expression. NK receptor analysis was performed on whole blood by three colour flow cytometry using antibodies against CD3, CD56 and the NK receptors with samples analysed on a FACSCalibur flow cytometer (BD).The data was analysed using CELLQuest.
 Results and Discussion: NK cells were defined as CD3-, CD56+ lymphocytes and their frequency, as measured by the three colour staining protocol, was broadly in agreement with the levels found using four colour antibody staining and Trucount tubes (BD). The majority of patients expressed NKp30, NKp46 and NKG2D at levels consistent with that seen in age and sex matched control samples obtained from healthy individuals. However, in a number of patients (10/30), the levels of NKp30 and NKp46 expression were low at all timepoints tested. The levels of NKp30 were generally lower than NKp46 and were unrelated to surgery. NKG2D expression was less affected with the levels similar to that found in controls individuals. The significance of these findings with respect to NK cell target recognition is unclear as an array of activating and inhibitory receptors are involved in NK cell activation and target recognition. This staining approach has also allowed us to assess the relative frequency of CD56dim and CD56bright NK cells. In healthy individuals the majority of NK cells are CD56dim whilst around 5% are CD56bright. These are considered to represent a functionally distinct population. In a number of patients in this study, the expression of CD56 on NK cells was relatively low with the consequential decrease in the frequency of CD56bright cells. We are prospectively following the importance of these NK cell differences with respect to patient health, and disease free and overall survival. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5047.

Peri-Operative Suppression of Immune-Regulatory Blood Cells Predicts Wound Complications in Breast Cancer Patients.

IntroductionWe have previously demonstrated an association between post-operative wound complications and systemic breast cancer recurrence (p Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4132.

The use of ultrasound in pre-operative assessment of the axilla in breast cancer.

Abstract #1019 Introduction Sentinel lymph node biopsy is now standard practice in axillary staging in breast cancer. It is associated with less morbidity than an axillary node clearance. A drawback of sentinel node biopsy is the need for a second surgical procedure if the sentinel node shows metastases. Clinical examination of the axilla has been the standard pre-operative assessment but this has been shown to be unreliable. More recently ultrasound has been used to identify axillary metastases pre-operatively. The aim of our study is to assess the role of pre-operative ultrasound and fine needle aspirate cytology in refining the selection of patients for whom sentinel node biopsy is appropriate.
 Methods Three hundred patients with primary operable invasive breast cancer had axillary ultrasound preoperatively. If the ultrasound was normal the patient was offered a sentinel node procedure. If it identified equivocal nodes a fine needle cytology was performed. If the cytology was benign a sentinel node biopsy was performed. If the cytology was malignant then an axillary node clearance was performed. In cases where pathological nodes were identified on imaging, cytology was performed to confirm malignancy. An axillary node clearance was then performed.
 Results. Eighty three percent of our patients (n=249) had a normal axillary ultrasound pre-operatively. Of these 74.5% had a benign sentinel node biopsy. Sixty two percent of patients with equivocal nodes on pre-operative imaging had metastases on final histology (n=19). Of these 63% (n=12) were correctly identified pre-operatively with fine needle aspirate cytology of the equivocal node and had an axillary node clearance performed form the outset. Ultrasound identified pathological nodes in 7% of our patients (n=20). Malignancy was confirmed on cytology and an axillary node clearance was performed.
 Using ultrasound and fine needle aspirate cytology to assess the axilla pre-operatively sentinel node biopsy was performed in 265 patients (88%). Of these, 74.8% had a benign final histology. Thirty two patients had a pre-operative diagnosis of nodal metastases and had an axillary node clearance. All 32 had lymph node metastases on final histology. Factors that predicted for a malignant sentinel node were lymphovascular invasion (p Conclusion Eighty eight percent of our patients had a sentinel lymph node biopsy to stage the axilla. Pre-operative ultrasound combined with cytology correctly determined the status of the node in 78% of cases. Our rate of second axillary operations was reduced by 32%. Importantly all patients diagnosed with node metastases pre-operatively and advised to have an axillary node clearance did have metastases on final histology. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1019.

Pathological and Patient Factors Affecting the Accuracy of Ultrasound Combined with Fine Needle Aspiration Cytology in Pre-Operative Staging of the Axilla in Breast Cancer.

Introduction:Ultrasound combined with fine needle aspiration cytology is effective in pre-operative staging of the axilla in breast cancer. Accurate pre-operative diagnosis of lymph node metastases allows for a one stage axillary operation and may also influence decisions regarding neo-adjuvant chemotherapy and breast reconstruction. The aim of this study is to identify pathological and patient factors that influence the accuracy of ultrasound and FNAC in determining the status of the axilla pre-operatively.Methods:Three hundred patients with primary operable invasive breast cancer had an axillary ultrasound pre-operatively. If the ultrasound was normal the patient was offered a sentinel node biopsy. If it identified equivocal or pathological nodes a fine needle aspirate cytology was performed. If the cytology was malignant then an axillary node clearance was performed.Results:Ultrasound combined with FNAC correctly determined the status of the axilla pre-operatively in 78% of cases. Sensitivity for the detection of metastases was 32% with 100% specificity. Factors affecting the accuracy of ultrasound and FNAC were the pathological size of tumour (p Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5020.

Predicting Axillary Lymph Node Status Using Preoperative Ultrasound-Guided Fine Needle Aspiration Cytology of Radiologically Equivocal and Abnormal Nodes.:

Introduction:The superiority of ultrasound (US) over clinical examination in the assessment of axillary nodes in patients with breast carcinoma is well recognised. Fine needle aspiration cytology (FNAC) is a quick and minimally invasive procedure to determine the status of axillary lymph nodes pre-operatively. Sentinel lymph node biopsy (SLNB) is now widely accepted as the primary axillary staging procedure in the management of early breast cancer. A negative SLNB obviates the need for more extensive axillary surgery, thereby reducing the morbidity associated with axillary node clearance (ANC) in patients with node negative breast cancer. Patients with a SLNB positive for metastasis usually require further axillary treatment, which may include completion ANC and/or radiotherapy. Improving the accuracy of pre-operative staging is desirable in reducing the number of completion ANC procedures necessitated following positive SLNB. The aim of this study is to assess the accuracy of pre-operative US-guided FNAC of radiologically equivocal or abnormal axillary lymph nodes.Method:Patients with a diagnosis of invasive breast carcinoma underwent axillary US. Those with radiologically equivocal or abnormal nodes had US-guided FNAC. Patients with a metastatic FNAC had ANC, whereas those with insufficient (i.e. no lymphocytes seen on cytology), benign or equivocal FNAC had SLNB.Results:The positive predictive value of suspicious or malignant cytology from a radiologically equivocal or abnormal node is 97%. The negative predictive value is 70%. US-guided FNAC used in the context has 83% sensitivity and 94% specificity.Of the five patients with radiologically equivocal or abnormal nodes and an inadequate cytology (no lymphocytes seen), four had a metastatic sentinel node biopsy.One patient had a malignant FNAC prior to neoadjuvant chemotherapy (NACT) and had benign histology on subsequent ANC. If this patient is excluded from analysis, the positive predictive value rises to 100%.Conclusion:US-guided FNAC of radiologically equivocal or abnormal axillary lymph nodes accurately predicts node positivity and can be used to avoid an unnecessary SLNB procedure.Inadequate FNAC from an equivocal or abnormal node is not sufficient evidence to recommend SLNB rather than ANC as the initial surgical axillary procedure. Patients with such findings should have a repeat US-guided FNAC before choosing to proceed with SLNB. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1031.