Kevin P. Bethke

Comparison of Sentinel Lymph Node Biopsy Alone and Completion Axillary Lymph Node Dissection for Node-Positive Breast Cancer

PURPOSE For women with breast cancer, the role of completion axillary lymph node dissection (ALND) after identification of nodal metastases by sentinel lymph node biopsy (SLNB) has been questioned. Our objectives were to assess national nodal evaluation practice patterns and to examine differences in recurrence and survival for SLNB alone versus SLNB with completion ALND. PATIENTS AND METHODS From the National Cancer Data Base (1998 to 2005), women with clinically node-negative breast cancer who underwent SLNB and who had nodal metastases were identified. Practice patterns and outcomes were examined for patients who underwent SLNB alone versus SLNB with completion ALND (median follow-up, 63 months). RESULTS Of 97,314 patients, 20.8% underwent SLNB alone, and 79.2% underwent SLNB with completion ALND. In 2004 to 2005, patients were significantly more likely to undergo SLNB alone if they were older, had smaller tumors, or were treated at non-National Cancer Institute-designated cancer centers. In patients with macroscopic nodal metastases (n = 20,075 during 1998 to 2000), there was a nonsignificant trend toward better outcomes for completion ALND (v SLNB alone) after analysis was adjusted for differences between the two groups: axillary recurrence (hazard ratio [HR], 0.58; 95% CI, 0.32 to 1.06) and overall survival (HR, 0.89; 95% CI, 0.76 to 1.04). In patients with microscopic nodal metastases (n = 2,203 during 1998 to 2000), there were no significant differences in axillary recurrence or survival for patients who underwent SLNB alone versus completion ALND. CONCLUSION Compared with SLNB alone, completion ALND does not appear to improve outcomes for breast cancer patients with microscopic nodal metastases; however, there was a nonsignificant trend toward better outcomes with completion ALND for those with macroscopic disease.

Learning sentinel node biopsy: Results of a prospective randomized trial of two techniques

BACKGROUND Evidence indicates that sentinel node (SN) biopsy can accurately predict axillary nodal status. Debate exists as to the optimal method of SN identification. METHODS Patients with clinical T1 or T2 tumors and negative axillae were randomized to SN localization with blue dye (B) alone (n = 50) or blue dye plus radioactivity (B+R) (n = 42). Patients undergoing needle localization (n = 47) were assigned to blue dye. RESULTS The SN was identified in 110 patients (79%) and contained metastases in 28. The SN predicted the axillary nodal status in 96% of cases. The SN identification rate did not differ between B (88%) or B+R (86%) but was significantly lower in patients requiring localization (64%). The time to SN identification also did not differ between B and B+R. The number of cases done by an individual surgeon was a significant predictor of SN identification. A stepwise logistic regression analysis of factors influencing the success of SN identification identified tumor location, needle localization, number of operations, and body mass index as significant predictors. CONCLUSIONS Our study does not identify any advantage for the use of the more expensive and complex method of SN identification using B+R compared with B alone, even for surgeons learning the techniques.

Autologous Options for Postmastectomy Breast Reconstruction: A Comparison of Outcomes Based on the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND The postmastectomy patient faces a plethora of choices when opting for autologous breast reconstruction; however, multi-institutional data comparing the available techniques are lacking. The National Surgical Quality Improvement Program (NSQIP) database provides a robust patient cohort for comparing outcomes and determining independent predictors of complications for each autologous method. STUDY DESIGN The NSQIP database was retrospectively reviewed from 2006 to 2010, identifying 3,296 autologous breast reconstruction patients. Univariate analyses compared complication and reoperation rates. Multivariable logistic regression analyses of 4 cohorts (free flaps, pedicled transverse rectus abdominis myocutaeous (TRAM) flaps, latissimus, and all flaps in aggregate) determined complication rates and independent risk factors for complications and specific outcomes of interest (surgical site infection [SSI], flap failure, reoperation) in all flap types. RESULTS American Society of Anesthesiologists (ASA) classification ≥ 3, body mass index > 30 kg/m(2), recent surgery, delayed reconstruction, and prolonged operative times are significant predictors of increased complications in autologous reconstructions. Rates of complications, flap failure, and reoperation were highest in the free tissue transfer group (p < 0.001). Latissimus flaps showed significantly lower rates of complications than other autologous methods (p < 0.001). Pedicled TRAM patients had the highest incidences of venous thromboembolic disease and SSI. CONCLUSIONS This large-scale, multicenter evaluation of outcomes in autologous breast reconstruction found that free flaps have the highest captured 30-day complication and reoperation rates of any autologous reconstructive method; complications in latissimus flaps were surprisingly few. Pedicled TRAM and latissimus flaps remain the most commonly used autologous reconstructive methods. In addition to providing statistically robust outcomes data, this study contributes significantly to patient education and preoperative planning discussions.

A Randomized Phase II Presurgical Trial of Transdermal 4-Hydroxytamoxifen Gel versus Oral Tamoxifen in Women with Ductal Carcinoma In Situ of the Breast

Purpose: Local transdermal therapy to the breast may achieve effective target-organ drug delivery, while diminishing systemic effects. We conducted a randomized, double-blind, placebo-controlled phase II trial comparing transdermal 4-hydroxytamoxifen gel (4-OHT) to oral tamoxifen (oral-T) in women with ductal carcinoma in situ (DCIS). Methods: Twenty-seven pre- and postmenopausal women were randomized to 4-OHT (4 mg/day) or oral-T (20 mg/day) for 6 to 10 weeks before surgery. Plasma, nipple aspirate fluid, and breast adipose tissue concentrations of tamoxifen and its major metabolites were determined by liquid chromatography/tandem mass spectrometry. The primary endpoint was Ki67 labeling in DCIS lesions, measured by immunohistochemistry. In plasma, insulin-like growth factor-1 (IGFI), sex hormone–binding globulin (SHBG), and coagulation protein concentrations were determined. Results: Posttherapy Ki67 decreased by 3.4% in the 4-OHT and 5.1% in the oral-T group (P ≤ 0.03 in both, between-group P = 0. 99). Mean plasma 4-OHT was 0.2 and 1.1 ng/mL in 4-OHT and oral groups, respectively (P = 0.0003), whereas mean breast adipose tissue concentrations of 4-OHT were 5.8 ng/g in the 4-OHT group and 5.4 ng/g in the oral group (P = 0.88). There were significant increases in plasma SHBG, factor VIII, and von Willebrand factor and a significant decrease in plasma IGFI with oral-T, but not with 4-OHT. The incidence of hot flashes was similar in both groups. Conclusions: The antiproliferative effect of 4-OHT gel applied to breast skin was similar to that of oral-T, but effects on endocrine and coagulation parameters were reduced. These findings support the further evaluation of local transdermal therapy for DCIS and breast cancer prevention. Clin Cancer Res; 20(14); 3672–82. ©2014 AACR.

Successful Long-Term Cryopreservation and Transplantation of Human Fetal Pancreas

To obtain sufficient quantities of human fetal pancreatic tissue (HFP) for transplantation, long-term storage of the tissue must be achieved. The functional viability of HFP after cryopreservation by stepwise addition of dimethyl sulfoxide was determined. Human fetal pancreas explants (1–2 mm3; gestational age 16–21 wk) were prepared and slowly cooled (0.25°C/min) to −40°C before placement in liquid nitrogen. After rapid thaw (37°C) and overnight culture, insulin release in response to high glucose and theophylline challenge determined in vitro functional viability. No difference was found between the responses of fresh and cryopreserved tissue (fresh 29.2 ± 3.0 ng/mg tissue, cryopreserved 29.9 ± 3.3 ng/mg tissue; P > .1). Diabetic BALB/c nu/nu mice transplanted with cryopreserved HFP returned to normoglycemia in 11 ± 2 wk (range 8–15 wk). Oral glucose tolerance tests indicated in vivo serum glucose control equivalent to or better than that of nondiabetic control mice (peak serum glucose of nondiabetic mice 164 ± 66 mg/dl, of cryopreserved grafted mice 180 ± 67 mg/dl; P > .8). In vitro insulin release of cryopreserved grafted tissue demonstrated that the tissue had differentiated and matured and was now capable of responding to high-glucose challenge (39.3 ± 11.5 ng insulin released/mg tissue). The results described herein are the first demonstration that cryopreserved HFP maintains the in vivo capacity to differentiate and mature and the capacity to reverse diabetes in an animal system.

Expansion and tumour specific cytokine secretion of bryostatin-activated T-cells from cryopreserved axillary lymph nodes of breast cancer patients

Current adoptive immunotherapy strategies in cancer patients require large numbers of activated T-cells and are limited by the availability of autologous tumour. We describe a novel method of T-cell activation that produced relatively rapid, high-fold expansion of stored, frozen lymphocytes obtained from the lymph nodes of 20 breast cancer patients during axillary dissection but does not require autologous tumour. In vitro exposure of thawed cells to bryostatin-1 (B), a non-tumour promoting protein kinase C activator and ionomycin (I), a calcium ionophore, at day 0 followed by culture in low dose interleukin-2 (IL-2 20 units ml-1) and restimulation again on day 10 results in 269-28,206 fold (geometric mean = 2254) expansion in cell numbers counted 17 days after initial stimulation. Analysis of cell surface markers revealed that B/I expanded human cells were predominantly T-cells (83-97%) and consisted of a mixture of CD8+ (46-74%) and CD4+ (4-30%) cells. B/I expanded cells did not lyse autologous tumour cells when tested in a 4-h 51Cr release assay, but murine studies reported previously have demonstrated specific and curative in vivo efficacy in MCA-105 tumour-bearing mice despite an inability to lyse autologous tumour in vitro. B/I expanded T-cells from five of six patients secreted the cytokines tumour necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) in response to co-culture with autologous tumour cells but not with irrelevant tumour. These results are analogous to findings in a murine model, in which non-cytolytic B/I expanded T-cells mediated specific, curative anti-tumour effects in vivo, and lay the groundwork for a clinical trial of this novel strategy for the adoptive immunotherapy of breast cancer patients.

Bryostatin 1-activated T cells can traffic and mediate tumor regression

Adoptive immunotherapy in humans may be limited by the lack of autologous tumor cells to activate and expand tumor-specific T cells. Pharmacologic manipulation of protein kinase C (PKC) and intracellular calcium may substitute for tumor antigen and stimulate T cells for adoptive immunotherapy. In the present study, we evaluated the ability of the PKC activator Bryostatin 1 (B) plus the calcium ionophore ionomycin (I) to activate lymphocytes obtained from popliteal lymph nodes (DLN) draining an MCA-105 footpad tumor. The adoptive transfer of B/I-stimulated DLN cells eradicated MCA-105 pulmonary metastases. These lymphocytes do not require concomitant IL-2 administration to mediate regression of lung metastases. Three days after intrasplenic injection of tumor cells and splenectomy, mice were given iv injections of B/I-stimulated DLN cells. Adoptive immunotherapy with these cells induced regression of established liver metastases. In an intradermal tumor model, the adoptive transfer of B/I-stimulated MCA-105 DLN cells cured mice of MCA-105 intradermal (id) tumors, but did not induce regression of MCA-206 tumors. Mice cured of MCA-105 id tumors were protected against MCA-105, but not MCA-203, tumor challenge in the footpad 7 weeks after adoptive immunotherapy.

Acellular dermis-assisted breast reconstruction with the use of crescentric tissue expansion: A functional cosmetic analysis of 40 consecutive patients

BACKGROUND Crescentric tissue expanders have the potential to improve postoperative aesthetic results via selective lower pole expansion; however, limited data are available on their efficacy. OBJECTIVES The authors assess postoperative functional and cosmetic outcomes of acellular dermis-assisted breast reconstruction with crescentric tissue expansion. METHODS This study is a single-institution, retrospective review of 40 consecutive patients who underwent acellular dermis-assisted breast reconstruction with crescentric tissue expansion. Demographic data, operative details, and procedural outcomes were recorded and assessed. Cosmetic outcomes were assessed using the Breast Evaluation Questionnaire. RESULTS Fifty-eight breasts representing 36 bilateral and 22 unilateral reconstructions were analyzed. Of these, 45 (78%) underwent tissue expander (TE) to implant exchange. The mean interval between stage 1 and stage 2 was 92 +/- 20 days, with a total follow-up time of 141 +/- 16 days. The average intraoperative expander fill volume was 213.5 mL, with an average final fill of 285 mL (range, 180-740 mL). The average number of expansions was 1.6. Overall, there were five complications (8.6%). Eighty-three percent of patients participated in the breast evaluation questionnaire. Answers to each question were reported using a qualitative five-point scale that ranged from 1 (very dissatisfied) to 5 (very satisfied). For the bilateral reconstructions, the average score in all contexts was 4.5 +/- 0.3, 4.33 +/- 0.5, and 4.36 +/- 0.33 for size, shape, and firmness, respectively. For unilateral reconstructions, the average scores were 4.0 +/- 0.58, 3.93 +/- 0.38, and 4.13 +/- 0.21, respectively. CONCLUSIONS Crescentric expander-based reconstruction with acellular dermis assistance is well tolerated, especially in smaller breasted women. Functional and cosmetic outcomes were acceptable and comparable to previous reports of traditional expander-based reconstructions.

Lipid metabolism genes in contralateral unaffected breast and estrogen receptor status of breast cancer

Risk biomarkers that are specific to estrogen receptor (ER) subtypes of breast cancer would aid the development and implementation of distinct prevention strategies. The contralateral unaffected breast of women with unilateral breast cancer (cases) is a good model for defining subtype-specific risk because women with ER-negative (ER−) index primaries are at high risk for subsequent ER-negative primary cancers. We conducted random fine needle aspiration of the unaffected breasts of cases. Samples from 30 subjects [15 ER-positive (ER+) and 15 ER− cases matched for age, race and menopausal status] were used for Illumina expression array analysis. Findings were confirmed using quantitative real-time PCR (qRT-PCR) in the same samples. A validation set consisting of 36 subjects (12 ER+, 12 ER− and 12 standard-risk healthy controls) was used to compare gene expression across groups. ER− case samples displayed significantly higher expression of 18 genes/transcripts, 8 of which were associated with lipid metabolism on gene ontology analysis (GO: 0006629). This pattern was confirmed by qRT-PCR in the same samples, and in the 24 cases of the validation set. When compared to the healthy controls in the validation set, significant overexpression of 4 genes (DHRS2, HMGCS2, HPGD and ACSL3) was observed in ER− cases, with significantly lower expression of UGT2B11 and APOD in ER+ cases, and decreased expression of UGT2B7 in both subtypes. These data suggest that differential expression of lipid metabolism genes may be involved in the risk for subtypes of breast cancer, and are potential biomarkers of ER-specific breast cancer risk. Cancer Prev Res; 6(4); 321–30. ©2013 AACR.

Two surgeons, one patient: The impact of surgeon–surgeon familiarity on patient outcomes following mastectomy with immediate reconstruction

BACKGROUND Mastectomy with immediate reconstruction requires the coordination and expertise of two distinct surgeons. This often results in several different combinations of mastectomy and reconstructive surgeons, but with an unknown impact on patient outcomes. We evaluate the effect of different surgical teams on complication rates following mastectomy and immediate reconstruction. METHODS Retrospective review of consecutive patients that underwent mastectomy with immediate prosthetic reconstruction from 4/1998 to 10/2008 at one institution was performed. Patients of the three highest-volume mastectomy and reconstructive surgeons were stratified by their individual combination of surgeons, resulting in nine different surgical teams. Complications were categorized by end-outcome. Appropriate statistics, including multiple linear regression, were performed. RESULTS Clinical characteristics were similar among patients (n = 511 patients, 699 breasts) with the same mastectomy surgeon but different reconstructive surgeon. Mean follow-up was 38.4 ± 25.7 months. For each mastectomy surgeon, the choice of reconstructive surgeon did not affect complication rates. Furthermore, the combined complication rates of the three highest-volume teams (n = 384 breasts) were similar to the remaining lower-volume teams (n = 315 breasts). Patient factors, but not the individual surgeon or surgical team, were independent risk factors for complications. DISCUSSION Our study suggests that among high-volume surgeons, complication rates following mastectomy with immediate reconstruction are not affected by the surgeon-surgeon familiarity. The individual surgeons expertise, and patient risk factors, may have a greater impact on outcomes than the teams experience with each other. These results validate the efficacy and safety of the surgeon distribution model currently used by many breast surgery practices.