Edward Clifford

uPAR and HER-2 gene status in individual breast cancer cells from blood and tissues

Overexpression of urokinase plasminogen activator system or HER-2 (erbB-2) in breast cancer is associated with a poor prognosis. HER-2 overexpression is caused by HER-2 gene amplification. The anti-HER-2 antibody trastuzumab significantly improves clinical outcome for HER2-positive breast cancer. Drugs that target the uPA system are in early clinical trials. The aims of this study were to determine whether urokinase plasminogen activator receptor (uPAR) gene amplification occurs and whether analysis of individual tumor cells (TCs) in the blood or tissue can add information to conventional pathological analysis that could help in diagnosis and treatment. Analysis of individual TCs indicates that uPAR amplification occurs in a significant portion of primary breast cancers and also circulating tumor cells (CTCs) from patients with advanced disease. There was complete concordance between touch preps (TPs) and conventional pathological examination of HER-2 and uPAR gene status in primary tumors. There was also excellent concordance of HER-2 gene status between primary tumors and CTCs provided that acquisition of HER-2 gene amplification in CTCs was taken into account. Unexpectedly, gene amplification of HER-2 and uPAR occurred most frequently in the same TC and patient, suggesting a biological bias and potential advantage for coamplification. Expression of HER-2 and uPAR in primary tumors predicted gene status in 100 and 92% of patients, respectively.

Sentinel lymph node biopsy, an alternative to elective axillary dissection for breast cancer

BACKGROUND Axillary metastases remain an important prognostic indicator in breast cancer. Axillary lymphadenectomy (ALND) carries significant morbidity and is unnecessary in most patients with early breast cancer; thus, sentinel lymph node (SLN) biopsy has been advocated for axillary staging. We studied the SLN identification rate and its accuracy in predicting axillary metastases. METHODS One hundred nineteen women with breast carcinoma underwent SLN and ALND. Lymphoscintigraphy was performed using Technetium99 sulfur colloid supplemented by Isosulfan blue dye. Hematoxylin/eosin-stained lymph node sections were examined by light microscopy. RESULTS The SLN identification rate was 81%. One SLN was negative (1%) in a patient with axillary disease. SLN histology correctly predicted the absence of axillary disease in 98.6%. Sensitivity, specificity, and positive and negative predictive values were 96%, 100%, 100%, and 99%, respectively. CONCLUSIONS Sentinel lymph node biopsy accurately predicts total axillary status and is valuable in the surgical staging of breast cancer.

Improved lymphatic mapping technique for breast cancer.

Abstract: Breast sentinel lymph node biopsy is becoming more common. However, the best injection technique is not well established. Currently the gold standard is peritumoral injection. However, for upper outer quadrant tumors there is considerable axillary “shine through” which makes the identification of the radioactive sentinel lymph node difficult. We undertook a study to compare an injection in Sappeys subareolar plexus to the gold standard of peritumoral injection. Between December 1997 and March 1998, 85 patients with breast cancer were enrolled in the study. All patients were injected with 2 cc of normal saline containing 1.0 mCi of unfiltered technetium sulfur colloid in Sappeys subareolar plexus in the clock position of the breast cancer. In the operating room the patients underwent a peritumoral injection of 5 cc of 1% isosulfan blue. All blue and radioactive lymph nodes were identified and removed. The majority of the tumors were in the upper outer quadrant and were diagnosed by core biopsy. Only half of the patients had palpable tumors and approximately 25% had previous upper outer quadrant biopsy incisions. Peritumoral blue dye injection yielded an identification rate of 94%, with 99% of these being blue and radioactive. Three patients had radioactive lymph nodes with no blue lymph nodes identified. One of these patients had a micrometastasis. Injection in Sappeys subareolar plexus in the clock position of the tumor drained to the same sentinel lymph node as peritumoral injection. This injection technique solved the two major problems confronting the wide adoption of sentinel lymph node biopsy for breast cancer staging. First, it eliminates axillary “shine through” which will allow nonspecialist surgeons to more easily identify the radioactive axillary sentinel lymph node. Second, it allows for easier isotope injection by the technician or nuclear medicine physician, by eliminating the need for three‐dimensional localization. This new technique should allow the majority of breast cancer patients who are treated by nonspecialist surgeons to be offered this less morbid, more accurate procedure.

Detection of carcinoma cells in the blood of breast cancer patients.

BACKGROUND Breast cancers shed cancer cells into the blood soon after they become invasive. We developed an assay for removing these circulating cancer cells. In this study, we wanted to determine the percentage of early stage and metastatic patients with circulating breast cancer cells. METHODS Twenty milliliters of blood were drawn from patients with breast cancer. Epithelial cells were removed by immunomagnetic selection and analyzed by flow cytometry, cytomorphology, and immunocystochemistry. RESULTS Early stage patients averaged 16 epithelial cells per 20 cc blood whereas metastatic patients averaged 122 tumor cells. Cytomorphology and immunostains confirmed that these were cancer cells. Control blood samples had 1.7 squamous epithelial cells per 20 cc blood. CONCLUSION This assay can identify and characterize circulating breast cancer cells. Metastatic patients had more circulating cells than early stage patients. This assay could screen high-risk patients, determine the need for and monitor response to adjuvant therapy, and detect early recurrence of breast cancer.

Scintimammography in the diagnosis of breast cancer

BACKGROUND Mammography has a positive predictive value in the detection of breast cancer of 15% to 25%. Ten percent of patients with breast cancer present with normal mammograms; however, the false negative rate is increased in younger patients. The purpose of this study was to evaluate the effectiveness of Tc-99m Sestamibi imaging in the diagnosis of breast disease. METHODS Images were collected on 147 women. Patients were evaluated with a combination of physical examination, sonography, and mammography. Each patient received 20 millicuries of Tc-99m Sestamibi intravenously. Anterior and lateral images were obtained, the latter with the patient prone and the breast in the dependent position. RESULTS One hundred seven patients showed no enhancement (negative scan). Seven of these patients were found at biopsy to have carcinoma. Five had ductal carcinoma in-situ (DCIS) with no associated mass, 1 had an incidental 3 mm focus of invasive ductal carcinoma (IDC), and 1 had a 5-cm cystic lesion with IDC. Forty-one patients showed focal enhancement on their scans (positive scan). Thirty-six were found to have either invasive or in-situ cancer. Four of the 5 patients with benign findings had sclerosing adenosis. The positive and negative predictive values for scintimammography in this group of patients were 88% and 93%, respectively. The sensitivity and specificity were 84% and 95%, respectively. CONCLUSIONS We conclude that scintimammography is a highly specific test that deserves study as a modality to further refine the indications for breast surgery.

Intraoperative cytologic diagnosis of breast sentinel lymph nodes in the routine, nonacademic setting: A highly specific test with limited sensitivity

Abstract:  Intraoperative determination of metastatic breast carcinoma in sentinel lymph nodes (SLNs) by cytologic methods has been proposed as highly specific and sensitive. Much of these data are derived from academic institutes with highly trained personnel and without axillary dissection occurring as a direct result of the intraoperative interpretation. This prospective study was undertaken to assess the sensitivity and specificity of cytology in the routine, private‐practice, intraoperative setting. A total of 207 SLNs from 96 breast carcinoma patients were evaluated by intraoperative cytologic preparations by general surgical pathologists; positive results led to axillary lymphadenectomy. Ten nodes were positive by intraoperative cytology (IC). Permanent section analysis confirmed the presence of carcinoma in the IC‐positive cases and documented carcinoma in 19 of the IC‐negative cases. IC sensitivity and specificity were 34% and 100%, respectively. False‐negative IC interpretations occurred in nodes with occult micrometastases (12 of 19 nodes) and lobular carcinoma (6 of 19 nodes). Only one of eight grossly positive sentinel nodes resulted in a false‐negative IC. While near‐perfect specificity and high sensitivity can be achieved with grossly positive sentinel nodes by IC, sensitivity is quite low in cases with micrometastatic and lobular carcinoma. 

Results of in-situ saphenous vein bypass to the foot

To determine the efficacy of extending vascular reconstruction to the pedal vessels, the records of 115 in-situ saphenous vein bypasses to the infragenicular vessels were examined. Ninety-four percent were performed for limb-threatening ischemia and 6 percent for claudication. Ninety-one bypasses were to tibial vessels in the calf (Group 1), whereas severe disease of the tibial vessels in the calf necessitated bypass to arteries at the ankle and beyond in 24 (Group 2). Life-table analysis was used to calculate limb salvage, graft patency, and functional status for Group 1 and Group 2 36 months postoperatively; there were no statistical differences between groups with regard to these variables (p = 0.38). Diabetes had no impact on the success of reconstruction, and preoperative noninvasive testing was not predictive of graft failure in either group. Significantly, limb salvage closely paralleled graft patency and functional status, illustrating the severe disease in all patients. Patients with severe tibial-peroneal atherosclerosis may benefit from bypass grafting to the pedal arteries with a success rate equal to those done to more proximal sites.