Peadar S. Waters

Relationship between Circulating and Tissue microRNAs in a Murine Model of Breast Cancer

MiRNAs are key regulators of tumorigenesis that are aberrantly expressed in the circulation and tissue of patients with cancer. The aim of this study was to determine whether miRNA dysregulation in the circulation reflected similar changes in tumour tissue. Athymic nude mice (n = 20) received either a mammary fat pad (n = 8, MFP), or subcutaneous (n = 7, SC) injection of MDA-MB-231 cells. Controls received no tumour cells (n = 5). Tumour volume was monitored weekly and blood sampling performed at weeks 1, 3 and 6 following tumour induction (total n = 60). Animals were sacrificed at week 6 and tumour tissue (n = 15), lungs (n = 20) and enlarged lymph nodes (n = 3) harvested. MicroRNAs were extracted from all samples (n = 98) and relative expression quantified using RQ-PCR. MiR-221 expression was significantly increased in tumour compared to healthy tissue (p<0.001). MiR-10b expression was significantly higher in MFP compared to SC tumours (p<0.05), with the highest levels detected in diseased lymph nodes (p<0.05). MiR-10b was undetectable in the circulation, with no significant change in circulating miR-221 expression detected during disease progression. MiR-195 and miR-497 were significantly decreased in tumour tissue (p<0.05), and also in the circulation of animals 3 weeks following tumour induction (p<0.05). At both tissue and circulating level, a positive correlation was observed between miR-497 and miR-195 (r = 0.61, p<0.001; r = 0.41, p<0.01 respectively). This study highlights the distinct roles of miRNAs in circulation and tissue. It also implicates miRNAs in disease dissemination and progression, which may be important in systemic therapy and biomarker development.

Increasing Reporting of Adverse Events to Improve the Educational Value of the Morbidity and Mortality Conference

BACKGROUND The aim of this study was to investigate the impact of a validated complication proforma on surgical Morbidity and Mortality (M&M) conference reporting. STUDY DESIGN The ACS-NSQIP (American College of Surgeons-National Surgical Quality Improvement Program) 30-day complication proforma, when implemented, previously showed a 25% increase in morbidity and a 50% increase in mortality reporting. A pilot study introducing the paper-based proforma was undertaken, collecting prospective M&M data for 2,094 of 2,209 colorectal, upper gastrointestinal, breast, and vascular inpatients (94.7% compliance). A comparative analysis using the proforma vs traditional M&M data collection was used to compare accuracy of M&M data reporting. RESULTS There was a 73% increase in morbidities reported using the proforma as compared with M&M reporting (547 vs 316), and an increase of 10.81% (37 vs 41) in the reporting of mortalities. Of those patients with morbidities (n = 278), 70.24% (n = 203) had at least 1 surgical intervention. The median length of stay in patients with morbidities was 12 vs 3 days in those with no morbidities. CONCLUSIONS We demonstrated that prospective standardized incident recording provides significantly more accurate assessment of M&M data compared with current reporting methods. This increased accuracy should favorably affect surgical performance indicators and casemix funding.

Impact of Tumour Epithelial Subtype on Circulating microRNAs in Breast Cancer Patients

While a range of miRNAs have been shown to be dysregulated in the circulation of patients with breast cancer, little is known about the relationship between circulating levels and tumour characteristics. The aim of this study was to analyse alterations in circulating miRNA expression during tumour progression in a murine model of breast cancer, and to detemine the clinical relevance of identified miRNAs at both tissue and circulating level in patient samples. Athymic nude mice received a subcutaneous or mammary fat pad injection of MDA-MB-231 cells. Blood sampling was performed at weeks 1, 3 and 6 following tumour induction, and microRNA extracted. MicroRNA microArray analysis was performed comparing samples harvested at week 1 to those collected at week 6 from the same animals. Significantly altered miRNAs were validated across all murine samples by RQ-PCR (n = 45). Three miRNAs of interest were then quantified in the circulation(n = 166) and tissue (n = 100) of breast cancer patients and healthy control individuals. MicroArray-based analysis of murine blood samples revealed levels of 77 circulating microRNAs to be changed during disease progression, with 44 demonstrating changes >2-fold. Validation across all samples revealed miR-138 to be significantly elevated in the circulation of animals during disease development, with miR-191 and miR-106a levels significantly decreased. Analysis of patient tissue and blood samples revealed miR-138 to be significantly up-regulated in the circulation of patients with breast cancer, with no change observed in the tissue setting. While not significantly changed overall in breast cancer patients compared to controls, circulating miR-106a and miR-191 were significantly decreased in patients with basal breast cancer. In tissue, both miRNAs were significantly elevated in breast cancer compared to normal breast tissue. The data demonstrates an impact of tumour epithelial subtype on circulating levels of miRNAs, and highlights divergent miRNA profiles between tissue and blood samples from breast cancer patients.

The effects of normalizing hyperhomocysteinemia on clinical and operative outcomes in patients with critical limb ischemia.

Purpose To assess the outcome of patients with medically treated hyperhomocysteinemia (HHC) requiring intervention for critical limb ischemia (CLI). Methods A parallel observational study was conducted to compare the clinical and revascularization outcomes of CLI patients who received standardized treatment for HHC preoperatively (folic acid and vitamin B12) vs. contemporaneous patients with normal homocysteine levels. The threshold for HHC diagnosis was 13.0 μmol/L. From 2009 to 2011, 169 patients underwent revascularization procedures for CLI. Of these, all 66 patients (40 men; mean age 69.6±11.2 years) with HHC (mean 17.3 μmol/L, range 13.5–34.9) were treated to normalize the homocysteine level prior to lower limb revascularization. The remaining 103 patients (58 men; mean age 72.7±8.1 years) had normal homocysteine levels (8.2 μmol/L, range 5–12.3) before revascularization. The primary endpoint was symptomatic and hemodynamic improvement in the treated HHC group. The secondary endpoints were all-cause survival, binary restenosis, reintervention, amputation-free survival, and major adverse events. The treated HHC cohort was compared to an age/sex-matched historical group of patients with untreated HHC from 2002 to 2006 before HHC pretreatment became routine. All interventions (endovascular, hybrid, and open) were performed by the same surgeon, and the groups were evenly matched. Results Patients with HHC were treated for a mean 12.2 days, which significantly reduced their mean homocysteine level after 3 weeks to 10.1 μmol/L (range 6.2–14.4, p<0.05). After revascularization, immediate clinical improvement was similar between normal homocysteine and medically corrected HHC groups. There was no significant difference in time to binary restenosis (p=0.822). Secondary endpoints and all-cause mortality were similar. Multivariate logistic regression showed that untreated HHC was a significant factor for graft occlusion and limb loss (p<0.0001), but medically corrected HHC was no longer predictive of adverse operative outcome. Conclusion Patients with medically corrected HHC have similar outcomes compared to those with normal homocysteine levels. Thus, aggressively treating HHC with folic acid and vitamin B12 may help enhance the clinical outcome of CLI patients undergoing revascularization.

Symptomatic Breast Cancer Diagnosis and Multimodal Management in Women Aged 40 to 50 Years; Consequences of Current Mammographic Screening Programs

INTRODUCTION Consensus exists that screening mammography is appropriate for women aged 50 to 69 years. However, the effectiveness of such screening for women aged 40 to 50 years is still questioned. The aim of our study was to analyze breast cancer management in the 40- to 50-year age group. We also wished to determine the proportion of patients with a significant family history and whether this was associated with more advanced disease. PATIENTS AND METHODS All female patients with primary breast cancer diagnosed between 40 and 50 years of age were included over a 4-year period. The database of the National Breast Cancer Research Institute was interrogated, and a chart and radiology review carried out to obtain relevant details of clinical presentation, family history, radiological findings, and treatments undertaken. RESULTS Three hundred thirty-four patients were diagnosed in this cohort during the study period. Twenty-two percent of those diagnosed had a family history of breast cancer with 1.8% having a genetically confirmed predisposition to breast cancer. A significant proportion of patients presented with advanced disease, with 50% of patients having nodal involvement and 3% who presented with distant metastases. The overall rate of mastectomy was 47%, with minimal variation between the surgeons who performed the surgeries. More than half of the patients in our analysis underwent axillary clearance (51%). CONCLUSION Our results indicate that a large proportion of patients in the 40- to 50-year age group presented with advanced disease and required aggressive surgical and adjuvant treatment. The presence of a family history did not identify a subgroup with more advanced disease at presentation.

Enlarging neck masses in the elderly – Histological and surgical considerations

INTRODUCTION Anaplastic carcinoma of the thyroid is a rare but aggressive malignancy which can present with a rapidly enlarging neck mass or compressive sequelae of cough, dyspnoea, dysphagia and hoarseness. Treatment of such tumours is commonly palliative however they occasionally represent surgical challenges due to their rapid growth, diagnostic difficulty and locoregional spread. PRESENTATION OF CASE A 75 year-old retired veterinary surgeon was referred with a 2 month history of a painless, enlarging neck mass. The patient denied any secondary compressive symptoms or general symptoms of malignancy. On examination a large right-sided neck mass measuring 7cm×5cm was appreciated which was fixed, hard and irregular with associated adenopathy. DISCUSSION We discuss the diagnostic challenges posed by anaplastic carcinoma of the thyroid and the difficulties in selecting the appropriate intervention in this aggressive disease process. CONCLUSION Anaplastic carcinoma of the thyroid is encountered infrequently in clinical practice and can generate diagnostic and therapeutic challenges.

An unusual presentation of a calcified thyroid gland.

A multinodular goitre with cystic degeneration with haemorrhage and subsequent calcification is a common occurrence in long-standing multinodular goitres. But extensive enlargement and calcification causing obstructive symptoms including dysphagia and tracheal shift has not been commonly reported in the literature. Our patient, an 82-year-old man presented with long-standing dysphagia and tracheal shift. His case proved challenging with the retrosternal location of the calcified gland, needing a collar neck incision and a manubriotomy to assess the thyroid. There was a large calcified shell to the gland that made mobilising and removing the gland very difficult. Histology revealed a large multinodular goitre with a large calcified cyst representing previous cyst haemorrhage which underwent calcification. Symptoms resolved postsurgical intervention.

Colorectal intussusception secondary to primary rectal melanoma: A novel case report

Highlights • Intussusception in adults is a recognised, but rare, entity.• Large bowel intussusception in adults is often due to a malignant neoplasm.• Rectal melanoma is a rare condition.• This is a novel case of colorectal intussusception secondary to rectal melanoma.

Spontaneous aortic rupture due to human immunodeficiency virus-associated vasculitis: a lesson learnt.

We report a case of a 67-year-old male admitted to our services with a spontaneous contained rupture of the suprarenal abdominal aorta. Four months prior to his presentation to the vascular services, this gentleman was diagnosed with HIV and was subsequently reviewed by the infectious disease physicians. His CD4 count at that time was 128 (7.4%) and it was noted that he had had a reactivation of Herpes zoster suggestive of immunosuppression. It was thus decided to start him on highly active antiretroviral therapy (HAART) commencing with Combivir (lamivudine and zidovudine) and efavirenz. On routine screening, he was negative for both Hepatitis B and C; however, his venereal disease research laboratory serology test was positive, a diagnosis of latent syphilis was made and a course of benzylpenicillin was commenced. Four months post-HIV diagnosis, he presented as an emergency admission with right upper and lower limb weakness, slurred speech and right facial droop. In the first week of that admission, he developed sudden severe lower back pain and worsening of his lower limb weakness. An MRI scan was performed demonstrating an infiltrating mass at the level of the juxtarenal aorta and thought initially to be consistent with an infiltrating Kaposi’s sarcoma. A CT angiogram was obtained and this confirmed the mass to be a suprarenal aortic haematoma with the aortic rupture site located immediately below the origin of the superior mesenteric artery and involving the aorta at the level of the right renal artery (Figure 1). He underwent an endovascular repair using a right renal chimney graft to extend the landing zone for an aortic exclusion graft. The aortic main body graft comprised a Talent (Medtronic, Santa Rosa, CA, USA) aortic extension graft (AXF3030W28AX: 30mm 28mm). The right renal artery ‘chimney graft’ was a Viabahn (Gore Medical, Flagstaff, AZ, USA) endoprosthesis (PAH080502: 8mm 50mm 120mm) deployed via the left brachial artery. The patient recovered well in the immediate post-operative period and was recommenced on antiretroviral therapy on the first post-operative day. Follow-up CT scan demonstrated that the aortic stent was in a good position with complete patency of the right renal artery stent (Figure 2). Two months later, he represented with pallor, diaphoresis and hypotension. CT angiogram confirmed aortic rupture below the previous stent. He underwent endovascular intervention, involving placement of two Powerlink (Endologix, Irvine, CA, USA) infrarenal aortic extension endografts (25-25-55L: 25mm 25mm 55mm and 34-34-80L: 34 34 80mm) overlapping with the previous stent. He recovered well from this procedure and his post-operative duplex scan on third post-operative day did not show any endoleak. On day 5 postoperatively, however, he had a further hypotensive episode and following discussion with the patient and his partner the decision was made that he would not be for further intervention. He passed away two days later.

Bilateral saccular inguinal hernias in an elderly woman presenting with advanced ovarian cancer

We present a case of an elderly woman presenting with bilateral groin hernias, one reducible and the other irreducible. CT of the abdomen and pelvis demonstrated an irreducible left inguinal hernia containing an incarcerated loop of transverse colon together with saccular metastatic tumour spread. Disseminated omental disease and ascitic fluid were noted throughout the peritoneal cavity secondary to ovarian carcinoma. As a consequence of extensive malignant disease and advanced age, the patient was treated conservatively and subsequently died a number of weeks later. To the best of our knowledge, this is only the second case of bilateral inguinal hernias presenting in a woman with a background of disseminated ovarian malignancy. This case highlights the importance of pre-reduction imaging in atypical complex cases.