Carole Mathelin

Ki-67: level of evidence and methodological considerations for its role in the clinical management of breast cancer: analytical and critical review

Clinicians can use biomarkers to guide therapeutic decisions in estrogen receptor positive (ER+) breast cancer. One such biomarker is cellular proliferation as evaluated by Ki-67. This biomarker has been extensively studied and is easily assayed by histopathologists but it is not currently accepted as a standard. This review focuses on its prognostic and predictive value, and on methodological considerations for its measurement and the cut-points used for treatment decision. Data describing study design, patients’ characteristics, methods used and results were extracted from papers published between January 1990 and July 2010. In addition, the studies were assessed using the REMARK tool. Ki-67 is an independent prognostic factor for disease-free survival (HR 1.05–1.72) in multivariate analyses studies using samples from randomized clinical trials with secondary central analysis of the biomarker. The level of evidence (LOE) was judged to be I-B with the recently revised definition of Simon. However, standardization of the techniques and scoring methods are needed for the integration of this biomarker in everyday practice. Ki-67 was not found to be predictive for long-term follow-up after chemotherapy. Nevertheless, high KI-67 was found to be associated with immediate pathological complete response in the neoadjuvant setting, with an LOE of II-B. The REMARK score improved over time (with a range of 6–13/20 vs. 10–18/20, before and after 2005, respectively). KI-67 could be considered as a prognostic biomarker for therapeutic decision. It is assessed with a simple assay that could be standardized. However, international guidelines are needed for routine clinical use.

STARD3 or STARD3NL and VAP form a novel molecular tether between late endosomes and the ER

Summary Inter-organelle membrane contacts sites (MCSs) are specific subcellular regions favoring the exchange of metabolites and information. We investigated the potential role of the late-endosomal membrane-anchored proteins StAR related lipid transfer domain-3 (STARD3) and STARD3 N-terminal like (STARD3NL) in the formation of MCSs involving late-endosomes (LEs). We demonstrate that both STARD3 and STARD3NL create MCSs between LEs and the endoplasmic reticulum (ER). STARD3 and STARD3NL use a conserved two phenylalanines in an acidic tract (FFAT)-motif to interact with ER-anchored VAP proteins. Together, they form an LE–ER tethering complex allowing heterologous membrane apposition. This LE–ER tethering complex affects organelle dynamics by altering the formation of endosomal tubules. An in situ proximity ligation assay between STARD3, STARD3NL and VAP proteins identified endogenous LE–ER MCS. Thus, we report here the identification of proteins involved in inter-organellar interaction.

Laparoscopic sacrocolpopexy for female genital organ prolapse: establishment of a learning curve

OBJECTIVE The widespread diffusion of laparoscopic sacrocolpopexy in the management of female genital organ prolapse is hampered by its presumed length and technical difficulties. The aim of our study was to analyse the learning curve of a senior urogynecologic surgeon who was initiated into this technique. STUDY DESIGN The first 48 laparoscopic sacrocolpopexies performed by the same surgeon were analysed retrospectively for pre-operative, operative and post-operative data. At the time of the study, patients were asked about their degree of satisfaction by an anonymous questionnaire. To discover a turning point, the duration of each procedure was reported and the study population was divided into 8 equal groups of 6 interventions each, classed chronologically. Statistical analysis was carried out by Mauchlys sphericity test and then by Student-Newman-Keuls test. Other descriptive statistics were computed with the use of standard methods for means, medians and proportions. RESULTS The mean operative time was of 236.9 min. The learning curve showed a linear decrease in the duration of surgery with a turning point after 18-24 procedures (p<0.001). It was marked by 2 (4.1%) minor operative complications (2 cystostomies) and 2 immediate post-operative ones: one port-site hernia and one case of urinary retention. At 1 month, 1 patient (2.2%) presented an erosion of the posterior mesh. The mean follow-up was of 15.8 months. During this period, 2 patients (4.1%) presented with a recurrence of prolapse and 6 (12.5%) with de novo stress urinary incontinence. Forty-five patients (93.7%) answered an anonymous questionnaire regarding satisfaction: 40/45 (88.8%) were totally satisfied, 4 (8.8%) moderately and 1 (2.2%) not satisfied. CONCLUSIONS The learning curve of laparoscopic sacrocolpopexy shows a steady decrease in the duration of surgery. A turning point is observed after 18-24 procedures. During the learning curve there is no increased morbidity. Anatomical and functional results at short and medium terms are similar to those reported in the literature.

Precise localization of sentinel lymph nodes and estimation of their depth using a prototype intraoperative mini gamma-camera in patients with breast cancer.

The aim of this study was to evaluate the ability of a prototype intraoperative mini γ-camera, the CarolIReS, with a 50 × 50 mm field of view, to precisely localize sentinel lymph nodes (SLNs) and to determine their depth in a series of patients with infiltrative breast cancer requiring SLN excision. Methods: With the use of phantoms, the broadness of the signal of an acquired projection was shown to linearly depend on its distance from the collimator. A preclinical ex vivo study of 25 excised SLNs demonstrated that SLN size did not influence depth estimation. The minimum activity threshold for successful use of the proposed method was determined. After a preoperative radioisotope injection and lymphoscintigraphy, the SLN was localized in a series of 11 patients using both the mini γ-camera and a γ-probe. During surgery, a ruler was used to measure the depth of all SLNs before their excision. Results: Using the measured linear dependence of image broadness, we found that the expected SLN anatomic depth was compatible with its measured depth during surgery. Conclusion: This study showed that the mini γ-camera efficiently estimated the location of SLNs in 3 dimensions.

Towards an inline reconstruction architecture for micro-CT systems

Recent developments in micro-CT have revolutionized the ability to examine in vivo living experimental animal models such as mouse with a spatial resolution less than 50 microm. The main requirements of in vivo imaging for biological researchers are a good spatial resolution, a low dose induced to the animal during the full examination and a reduced acquisition and reconstruction time for screening purposes. We introduce inline acquisition and reconstruction architecture to obtain in real time the 3D attenuation map of the animal fulfilling the three previous requirements. The micro-CT system is based on commercially available x-ray detector and micro-focus x-ray source. The reconstruction architecture is based on a cluster of PCs where a dedicated communication scheme combining serial and parallel treatments is implemented. In order to obtain high performance transmission rate between the detector and the reconstruction architecture, a dedicated data acquisition system is also developed. With the proposed solution, the time required to filter and backproject a projection of 2048 x 2048 pixels inside a volume of 140 mega voxels using the Feldkamp algorithm is similar to 500 ms, the time needed to acquire the same projection.

Infiltrative Breast Cancer during Pregnancy and Conservative Surgery

Mastectomy is considered as the standard therapy for gestational breast cancer. Since radiation therapy is harmful for the fetus, conservative surgery is rarely used during pregnancy. Among 16 patients with gestational breast cancer, 10 and 6 were treated with conservative surgery and mastectomy, respectively. No local recurrences occurred with a median follow-up time of 87 months. Among the 10 patients treated with conservative surgery, 3 chose therapeutic abortion and 7 opted to continue their pregnancy. Concerning these 7 fetuses, there were no congenital anomalies, nor growth restriction. All children were normal physically and neurologically. We concluded that conservative breast surgery may be an alternative to mastectomy in the treatment of gestational breast cancer and is safe for the fetus.

Optimization of sentinel lymph node biopsy in breast cancer using an operative gamma camera

BackgroundSentinel lymph node (SLN) procedure is now a widely accepted method of LN staging in selected invasive breast cancers (unifocal, size ≤ 2 cm, clinically N0, without previous treatment). Complete axillary clearance is no longer needed if the SLN is negative. However, the oncological safety of this procedure remains to be addressed in randomized clinical trials. One main pitfall is the failure to visualize SLN, resulting in incorrect tumor staging, leading to suboptimal treatment or axillary recurrence. Operative gamma cameras have therefore been developed to optimize the SLN visualization and the quality control of surgery.Case presentationA 44-year-old female patient with a 14-mm infiltrative ductal carcinoma underwent the SLN procedure. An operative gamma camera was used during and after the surgery. The conventional lymphoscintigraphy showed only one SLN, which was also detected by the operative gamma camera, then removed and measured (9.6 kBq). It was analyzed by frozen sections, showing no cancer cells. During this analysis, the exploration of the axillary area with the operative gamma camera enabled the identification of a second SLN with low activity (0.5 kBq) that conventional lymphoscintigraphy, surgical probe and blue staining had failed to visualize. Histological examination revealed a macrometastasis. Axillary clearance was then performed, followed by a postoperative image proving that no SLN remained. Therefore, the use of the operative gamma camera prevented an under-estimation of staging which would have resulted in a suboptimal treatment for this patient.ConclusionThis case report illustrates that an efficient operative gamma camera may be able to decrease the risk of false negative rate of the SLN procedure, and could be an additional tool to control the quality of the surgery.Trial RegistrationClinicalTrials.gov Identifier: NCT00357487

Improvement in intramammary sentinel lymph node removal using a novel prototype hand held probe during breast conservative surgery.

SummaryIntramammary sentinel lymph node excision during breast conservative surgery was performed, in this case report, using a prototype intraoperative gamma probe. In contrast to the four axillary sentinel lymph nodes that were subnormal, the excised intramammary sentinel lymph node was massively invaded by cancer cells. Therefore this finding had profound implication for the staging of the tumor and for treatment selection. This case report illustrates that an efficient intraoperative gamma probe is useful to locate and remove intramammary sentinel lymph node in breast cancer patients treated with breast conservation.

First report of granulomatous mastitis associated with Sjögren’s syndrome

Granulomatous mastitis is a rare and often considered as idiopathic disease. However, clinical examination and thorough diagnostic investigations have to be carried out in order to identify cases that are secondary to infections or systemic diseases since these forms may be cured with appropriate etiologic treatment. To the best of our knowledge, this report is the first to describe the association of granulomatous mastitis with Sjögren’s syndrome. We discuss the clinical, pathological and therapeutic implications of this association.

Matrix metalloproteinase 11/stromelysin-3 exerts both activator and repressor functions during the hematogenous metastatic process in mice

MMP11 expression is a poor prognosis factor in human carcinomas. Although it has been shown to favor primary tumor development, its role in metastatic processes remains unclear. We studied the hematogenous metastatic activity of C26 mouse colon cancer cells injected into the tail vain of wild‐type or MMP11‐deficient mice during 2 months. Using X‐ray computed tomography to image metastasis development in recipient living mice, lung metastases were found to occur earlier and to grow faster in wild‐type mice. Histological analyses of the lung, liver, kidney, adrenal gland, mammary gland, ovary and salivary gland, performed at the end of experiment, also showed lower numbers of metastases in wild‐type mice, regardless of organ. Lung metastases showed similar Factor VIII‐positive vascular networks regardless of the mouse MMP11 status. However, those found in MMP11‐deficient mice also exhibited vessel‐like structures that did not express Factor VIII, Lyve‐1 and vimentin, and were not stained with PAS. Consequently, they did not correspond to vascular or lymphatic vessels or to vascular mimicry channels. Collectively, these results revealed significant spatio‐temporal variability that is dependent on host MMP11 status. Furthermore, they point‐out the paradoxical role of MMP11 in favoring the onset and growth of lung metastases but limiting lung foci number, and inhibiting the cancer cell dissemination to other organs. These data highlight the complexity of the metastatic process in which the same factor can play activator or repressor functions depending on the metastatic step.