Sybren L. Meijer

Sentinel Lymph Node Biopsy in Breast Cancer: Guidelines and Pitfalls of Lymphoscintigraphy and Gamma Probe Detection

BACKGROUND Sentinel node (SN) biopsy appears to offer an alternative to routine axillary lymph node dissection (ALND) for staging patients with breast cancer. Various techniques have been studied for identifying the SN, using vital blue dye or radioactive colloid, and initial reports are promising. The inherent limitations and pitfalls must be clearly understood before SN biopsy can be implemented in dinical practice. STUDY DESIGN In a prospective trial, the feasibility of using lymphoscintigraphy and gamma probe detection for performing SN biopsy was studied. In 130 consecutive patients with T1-T2, N0 breast cancer, preoperative lymphoscintigraphy was performed with technetium 99m-colloidal albumin. During ALND, the radioactive axillary SNs were localized by the gamma probe. Histopathologic examination of the harvested SNs was compared with the status of the axillary lymph nodes. RESULTS Axillary focal accumulations were clearly identified on lymphoscintigraphy in 116 patients (89%). The failure rate was significantly higher in patients who had a previous excision biopsy (36%) than in those with a palpable tumor in situ (4%). Using the gamma probe, radiolabeled axillary SNs were successfully biopsied in 122 patients (94%). Because 18 of these patients did not undergo formal lymphadenectomy, the predictive accuracy of SN biopsy was analyzed in 104 patients. Radioactive nodes revealed metastases in 44 of 104 patients (42%); in 26 of them (59%), these were the only involved axillary nodes. The SN was negative in 60 patients (58%); in one patient the ALND was found to contain metastatic disease (1.7% false negatives). Biopsy of the SN was 98% accurate in predicting the absence of nodal metastases. CONCLUSIONS There are certain guidelines for performing SN biopsy by lymphoscintigraphy and gamma probe detection. Success depends primarily on an adequate functional capacity of the SN, necessary for sufficient nodal uptake to ensure accurate identification. Lymphoscintigraphy defines the pattern of lymph flow and may prevent failure or false-negative biopsies. Biopsy of the SN is a highly accurate, minimally invasive method of staging patients with breast cancer and can substantially reduce the morbidity and costs of surgical treatment by avoiding unnecessary ALND in the majority of patients.

Radiofrequency Ablation vs Endoscopic Surveillance for Patients With Barrett Esophagus and Low-Grade Dysplasia: A Randomized Clinical Trial

IMPORTANCE Barrett esophagus containing low-grade dysplasia is associated with an increased risk of developing esophageal adenocarcinoma, a cancer with a rapidly increasing incidence in the western world. OBJECTIVE To investigate whether endoscopic radiofrequency ablation could decrease the rate of neoplastic progression. DESIGN, SETTING, AND PARTICIPANTS Multicenter randomized clinical trial that enrolled 136 patients with a confirmed diagnosis of Barrett esophagus containing low-grade dysplasia at 9 European sites between June 2007 and June 2011. Patient follow-up ended May 2013. INTERVENTIONS Eligible patients were randomly assigned in a 1:1 ratio to either endoscopic treatment with radiofrequency ablation (ablation) or endoscopic surveillance (control). Ablation was performed with the balloon device for circumferential ablation of the esophagus or the focal device for targeted ablation, with a maximum of 5 sessions allowed. MAIN OUTCOMES AND MEASURES The primary outcome was neoplastic progression to high-grade dysplasia or adenocarcinoma during a 3-year follow-up since randomization. Secondary outcomes were complete eradication of dysplasia and intestinal metaplasia and adverse events. RESULTS Sixty-eight patients were randomized to receive ablation and 68 to receive control. Ablation reduced the risk of progression to high-grade dysplasia or adenocarcinoma by 25.0% (1.5% for ablation vs 26.5% for control; 95% CI, 14.1%-35.9%; P < .001) and the risk of progression to adenocarcinoma by 7.4% (1.5% for ablation vs 8.8% for control; 95% CI, 0%-14.7%; P = .03). Among patients in the ablation group, complete eradication occurred in 92.6% for dysplasia and 88.2% for intestinal metaplasia compared with 27.9% for dysplasia and 0.0% for intestinal metaplasia among patients in the control group (P < .001). Treatment-related adverse events occurred in 19.1% of patients receiving ablation (P < .001). The most common adverse event was stricture, occurring in 8 patients receiving ablation (11.8%), all resolved by endoscopic dilation (median, 1 session). The data and safety monitoring board recommended early termination of the trial due to superiority of ablation for the primary outcome and the potential for patient safety issues if the trial continued. CONCLUSIONS AND RELEVANCE In this randomized trial of patients with Barrett esophagus and a confirmed diagnosis of low-grade dysplasia, radiofrequency ablation resulted in a reduced risk of neoplastic progression over 3 years of follow-up. TRIAL REGISTRATION trialregister.nl Identifier: NTR1198.

Barrett's oesophagus patients with low-grade dysplasia can be accurately risk-stratified after histological review by an expert pathology panel

Objective Reported malignant progression rates for low-grade dysplasia (LGD) in Barretts oesophagus (BO) vary widely. Expert histological review of LGD is advised, but limited data are available on its clinical value. This retrospective cohort study aimed to determine the value of an expert pathology panel organised in the Dutch Barretts Advisory Committee (BAC) by investigating the incidence rates of high-grade dysplasia (HGD) and oesophageal adenocarcinoma (OAC) after expert histological review of LGD. Design We included all BO cases referred to the BAC for histological review of LGD diagnosed between 2000 and 2011. The diagnosis of the expert panel was related to the histological outcome during endoscopic follow-up. Primary endpoint was development of HGD or OAC. Results 293 LGD patients (76% men; mean 63 years±11.9) were included. Following histological review, 73% was downstaged to non-dysplastic BO (NDBO) or indefinite for dysplasia (IND). In 27% the initial LGD diagnosis was confirmed. Endoscopic follow-up was performed in 264 patients (90%) with a median follow-up of 39 months (IQR 16–72). For confirmed LGD, the risk of HGD/OAC was 9.1% per patient-year. Patients downstaged to NDBO or IND had a malignant progression risk of 0.6% and 0.9% per patient-year, respectively. Conclusions Confirmed LGD in BO has a markedly increased risk of malignant progression. However, the vast majority of patients with community LGD will be downstaged after expert review and have a low progression risk. Therefore, all BO patients with LGD should undergo expert histological review of the diagnosis for adequate risk stratification.

HEPATIC RESECTIONS FOR COLORECTAL METASTASES IN THE NETHERLANDS - A MULTIINSTITUTIONAL 10-YEAR STUDY

Background and Methods. The records of 118 patients who had hepatic resections for colorectal liver metastases were analyzed retrospectively.

Outcome of thoracoscopic pulmonary metastasectomy evaluated by confirmatory thoracotomy.

BACKGROUND The aim of this study was to determine the feasibility, accuracy, and outcome of thoracoscopic resection of peripherally located pulmonary metastases. METHODS The 28 patients had three or fewer solitary metastases, located in the periphery of the lung, with a diameter 3 cm or less on computed tomography scan. A thoracoscopic resection was performed to remove all identified lesions evaluated by confirmatory thoracotomy. RESULTS A thoracoscopic resection was technically impossible in 10 patients. In 1 patient a confirmatory thoracotomy was not performed because the lesion was diagnosed as carcinoid. Among the 17 patients who underwent confirmatory thoracotomy, 12 patients had a complete thoracoscopic resection and 5 patients had residual disease. The success rate appeared to be higher (p = 0.01) in patients with one lesion (11 of 12 patients), than in patients with more than one lesion (1 of 5 patients) found by preoperative computed tomography scan. CONCLUSIONS Thoracoscopic resection can be considered a viable treatment option for patients who present with a solitary pulmonary metastasis with a diameter of 3 cm or less, when the lesion is located in the periphery of the lung.

The combination of autofluorescence endoscopy and molecular biomarkers is a novel diagnostic tool for dysplasia in Barrett's oesophagus

Objective Endoscopic surveillance for Barretts oesophagus (BO) is limited by sampling error and the subjectivity of diagnosing dysplasia. We aimed to compare a biomarker panel on minimal biopsies directed by autofluorescence imaging (AFI) with the standard surveillance protocol to derive an objective tool for dysplasia assessment. Design We performed a cross-sectional prospective study in three tertiary referral centres. Patients with BO underwent high-resolution endoscopy followed by AFI-targeted biopsies. 157 patients completed the biopsy protocol. Aneuploidy/tetraploidy; 9p and 17p loss of heterozygosity; RUNX3, HPP1 and p16 methylation; p53 and cyclin A immunohistochemistry were assessed. Bootstrap resampling was used to select the best diagnostic biomarker panel for high-grade dysplasia (HGD) and early cancer (EC). This panel was validated in an independent cohort of 46 patients. Results Aneuploidy, p53 immunohistochemistry and cyclin A had the strongest association with dysplasia in the per-biopsy analysis and, as a panel, had an area under the receiver operating characteristic curve of 0.97 (95% CI 0.95 to 0.99) for diagnosing HGD/EC. The diagnostic accuracy for HGD/EC of the three-biomarker panel from AFI+ areas was superior to AFI− areas (p<0.001). Compared with the standard protocol, this panel had equal sensitivity for HGD/EC, with a 4.5-fold reduction in the number of biopsies. In an independent cohort of patients, the panel had a sensitivity and specificity for HGD/EC of 100% and 85%, respectively. Conclusions A three-biomarker panel on a small number of AFI-targeted biopsies provides an accurate and objective diagnosis of dysplasia in BO. The clinical implications have to be studied further.

Determining sensitivity and specificity of HER2 testing in breast cancer using a tissue micro-array approach

IntroductionOverexpression of the human epidermal growth factor receptor 2 (HER2) as a result of HER2 gene amplification is associated with a relatively poor prognosis in breast cancer and is predictive of HER2-targeting therapy response. False-positive rates of up to 20% for HER2 testing have been described. HER2-testing laboratories are therefore encouraged to participate in external quality control schemes in order to improve HER2-testing standardization.MethodsThis study investigated the feasibility of retesting large numbers of invasive breast cancers for HER2 status on tissue micro-array (TMA) as part of a quality control scheme. For this assessment different HER2 testing methods were used including HER2 detecting antibodies SP3, 4B5, Herceptest and mono color silver in situ hybridization (SISH) and dual color SISH. Final HER2 status for each tumor on the TMA was compared to the local testing result for the same tumor. Discordances between these two results were investigated further by staining whole tumor sections.ResultsFor this study, 1,210 invasive breast carcinomas of patients treated in six hospitals between 2006 and 2008 were evaluated. Results from the three immunohistochemistry (IHC) and two in situ hybridization (ISH) assays performed on the TMAs were compared. The final HER2 status on TMA was determined with SP3, 4B5 and mono color SISH. Concordance between local HER2 test results and TMA retesting was 98.0%. Discordant results between local and TMA retesting were found in 20 tumors (2.0%). False positive HER2 IHC results were identified in 13 (1.3%) tumors; false negative IHC results in seven (0.7%) tumors.ConclusionsRetesting large volumes of HER2 classified breast carcinomas was found to be feasible and can be reliably performed by staining TMAs with SP3, 4B5 and mono color SISH in combination with full-sized slides for discordant cases. The frequency of false-positive results was lower than previously reported in the literature. This method is now offered to other HER2-testing laboratories.

Detection of buried Barrett's glands after radiofrequency ablation with volumetric laser endomicroscopy.

BACKGROUND AND AIMS The prevalence and clinical relevance of buried Barretts glands (BB) after radiofrequency ablation (RFA) in Barretts esophagus (BE) are debated. Recent optical coherence tomography studies demonstrated a high prevalence of BBs. Direct histological correlation, however, has been lacking. Volumetric laser endomicroscopy (VLE) is a second-generation optical coherence tomography system capable of scanning a large surface of the esophageal wall layers with low-power microscopy resolution. The aim was to evaluate whether post-RFA subsquamous glandular structures (SGSs), detected with VLE, actually correspond to BBs by pursuing direct histological correlation with VLE images. METHODS In vivo VLE was performed to detect SGSs in patients with endoscopic regression of BE post-RFA. A second in vivo VLE scan was performed to confirm correct delineation of the SGSs. After endoscopic resection, the specimens were imaged ex vivo with VLE. Extensive histological sectioning of SGS areas was performed, and all histology slides were evaluated by an expert BE pathologist. RESULTS Seventeen patients underwent successful in vivo VLE (histological diagnosis before endoscopic treatment: early adenocarcinoma in 8 patients and high-grade dysplasia in 9). In 4 of 17 patients, no SGSs were identified during VLE, and a random resection was performed. In the remaining 13 patients (76%), VLE detected SGS areas, which were all confirmed on a second in vivo VLE scan and subsequently resected. Most SGSs identified by VLE corresponded to normal histological structures (eg, dilated glands and blood vessels). However, 1 area containing BBs was found on histology. No specific VLE features to distinguish between BBs and normal SGSs were identified. CONCLUSIONS VLE is able to detect subsquamous esophageal structures. One area showed BBs beneath endoscopically normal-appearing neosquamous epithelium; however, most post-RFA SGSs identified by VLE correspond to normal histological structures. ( CLINICAL TRIAL REGISTRATION NUMBER NTR4056.).

Effects of Autofluorescence Imaging on Detection and Treatment of Early Neoplasia in Patients With Barrett's Esophagus

BACKGROUND & AIMS Studies have reported that autofluorescence imaging (AFI) increases targeted detection of high-grade intraepithelial neoplasia (HGIN) and intramucosal cancer (IMC) in patients with Barretts esophagus (BE). We analyzed data from trials to assess the clinical relevance of AFI-detected lesions. METHODS We collected information on 371 patients with BE, along with endoscopy and histology findings, from databases of 5 prospective studies of AFI (mean age, 65 years; 305 male). We compared these data with outcomes of treatment and follow-up. Study end points included the diagnostic value of AFI (proportion of surveillance patients with HGIN or IMC detected only by AFI-targeted biopsies) and value of AFI in selection of therapy (the proportion of patients for which detection of an HGIN or IMC lesion by AFI changed the treatment strategy based on white-light endoscopy or random biopsy analysis). RESULTS Of study participants, 211 were referred for surveillance and 160 were referred for early stage neoplasia; HGIN or IMC were diagnosed in 147 patients. In 211 patients undergoing surveillance, 39 had HGIN or IMC (23 detected by white-light endoscopy, 11 detected by random biopsies, 5 detected by AFI). So, the diagnostic value of AFI was 5 (2%) of 211. In 24 patients, HGIN or IMC was diagnosed using only AFI. In 33 patients, AFI detected additional HGINs or IMCs next to lesions detected by primary white-light endoscopy. Lesions detected by AFI were treated in 57 patients: 26 patients underwent radiofrequency ablation and showed full remission of neoplasia, whereas 31 underwent endoscopic resection and 6 were found to have IMC. The value of AFI in selection of therapy was 6 (2%) of 371. CONCLUSIONS Based on an analysis of data from clinical trials of patients with BE, detection of lesions by AFI has little effect on the diagnosis of early stage neoplasia or therapeutic decision making. AFI therefore has a limited role in routine surveillance or management of patients with BE.

HER2 gene amplification in patients with breast cancer with equivocal IHC results

Aims Equivocal human epidermal growth factor receptor 2 protein (HER2) (2+) immunohistochemistry (IHC) is subject to significant interobserver variation and poses a challenge in obtaining a definitive positive or negative test result. This equivocal test result group accounts for approximately 15% of all tumours, and for optimal guidance of HER2 targeted therapy, a further analysis of quantification of gene copy number and amplification status is needed for patients with early or metastatic breast cancer. Methods 553 breast-cancer specimens with equivocal HER2 IHC(2+) test results were collected and subsequently centrally retested by chromogenic in situ hybridisation (CISH), and HER2 gene copy numbers per tumour cell nucleus were determined. Results Using CISH, 77 of 553 equivocal HER2 IHC(2+) test result cases (13.9% of total) showed high levels of HER2 gene amplification (≥10.0 gene copies per nucleus), and 41 of 553 (7.4% of total) showed low-level HER2 gene amplification (6.0–9.9 gene copies per nucleus). In 73.6% of cases, no amplification of the HER2 gene was shown, and in only 4.9% of cases was an equivocal test result by CISH observed (4.0–5.9 gene copies per nucleus). Conclusions Testing by CISH of all equivocal HER2 IHC(2+) test result provides a definitive guidance in HER2 targeted therapy in 95.1% of cases. A significant proportion (21.3%) of patients with equivocal IHC(2+) test results show amplification of the HER2 gene.