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1–21 Pathologic Features of Breast Cancer Associated With Complete Response to Neoadjuvant Chemotherapy: Importance of Tumor Necrosis
1–20
The Detection of Isolated Tumor Cells in Bone Marrow Comparing Bright-Field Immunocytochemistry and Multicolor Immunofluorescence Krag DN, Kusminsky R, Manna E, et al (Univ of Vermont, Burlington; Charleston Area Med Ctr Inst, WVa; Fletcher Allen Health Care, Burlington, Vt) Ann Surg Oncol 12:753-760, 2005
Background.—The detection of isolated tumor cells in bone marrow by immunocytochemistry (ICC) has been reported to predict progression of earlystage breast cancer. The most common staining procedure uses bright-field ICC with cytokeratin (CK) antibodies to label isolated tumor cells. However, this method can result in false-positive staining events. We used multicolor immunofluorescence (IF) to develop a more specific assay for detecting isolated tumor cells in marrow samples from breast cancer patients. Methods.—We compared ICC and IF side by side for detection of cancer cells and false-positive staining events on bone marrow aspirates from breast cancer
1–21
Pathologic Features of Breast Cancer Associated With Complete Response to Neoadjuvant Chemotherapy: Importance of Tumor Necrosis Pu RT, Schott AF, Sturtz DE, et al (Univ of Michigan, Ann Arbor) Am J Surg Pathol 29:354-358, 2005
Abstract.—Breast cancer patients with a complete pathologic response after neoadjuvant chemotherapy have a better
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patients, bone marrow from healthy donors, and healthy donor blood spiked with cancer cells. The primary target for isolated tumor cell detection was CK for both methods. IF used an additional set of antibodies to label hematopoietic cells (HCs). Results.—The detection rate of CK+ events in breast cancer patient bone marrow aspirates was 18 (58%) of 31 for ICC and 21 (68%) of 31 for IF. However, with IF, 17 of 21 CK+ cases were stained with HC markers and thus were identified as false-positive events. A surprisingly high CK+ event rate was observed in healthy donor blood and marrow. In all healthy donor samples, CK+ events were readily identified as HCs by IF. Detection sensitivity of spiked cancer cells in donor blood was similar for both methods. Conclusions.—There is a high frequency of CK+ events in blood and marrow, and it is important to note that this is observed both in patients with and those without cancer. IF with multiple HC markers allows straightforward discrimination between CK+ cells of hematopoietic and nonhematopoietic origin. As more sophisticated tests to identify circulating tumor cells are im-
prognosis than incomplete responders. The predictive value of the histologic characteristics of the tumor prior to neoadjuvant treatment has not been well defined, and there are no guidelines for reporting tumor characteristics in the core biopsy report. Histologic and nuclear grades, presence of tumor necrosis and angiolymphatic invasion (ALI), and estrogen receptor (ER), progesterone receptor (PR), and HER-2/neu expression were assessed in core biopsies of 55 patients with invasive carcinomas. Patients were then uniformly treated with four cycles of
Breast Diseases: A Year Book Quarterly Vol 17 No 1 2006
plemented, ensuring the specificity of the findings becomes increasingly important. Currently the most common method to identify individual cancer cells is by using an immunologic approach to identify epithelial components such as CKs. Both specific and nonspecific staining are known to depend heavily on methodology. In this study, Krag and colleagues found a very high incidence of CK-positive events in both patients with cancer and in those without cancer. Some of these false-positive results may have resulted from the choice of CK antibodies. CAM 5.2, an antibody used in this study, is known to stain some normal marrow and circulating cells. Their multiple-marker approach allowed the authors to discriminate between CKpositive hematopoetic cells (falsepositive) and CK-positive nonhematopoetic cells (presumed cancer). A judicious choice of markers and a carefully controlled approach such as this will be very important in evaluating such techniques in research and clinical practice. J. L. Connolly, MD
doxorubicin/docetaxel followed by excisions and lymph node dissections. Complete pathologic response (pCR) was defined as having no invasive carcinoma at excision. Noncomplete pathologic response was defined as having invasive carcinoma at excision. Five of the 55 patients (9%) achieved pCR. Of the 5 complete responders, 4 (80%) had tumor necrosis in the core biopsy specimens, while only 8 of the 46 (17%) noncomplete responders (pNR) had this feature (P = 0.0086). Higher histologic and nuclear grades, ER, PR status, and HER-
2/neu overexpression were not associated with pCR. The presence of ALI in the core biopsy, post-therapy excision, or both was associated with axillary lymph node metastases (P = 0.0062, P = 0.0249, and P = 0.0021, respectively). Although preliminary, our study suggests that the presence of tumor necrosis and ALI in the core biopsy may be important features to be included in the standard report. The pCR of a primary breast cancer to chemotherapy, though an important prognostic factor for survival, is observed only in a small proportion of patients. The ability to identify histologic and molecular characteristics of breast cancer that predict a pCR to primary chemotherapy would be important in designing specific therapy regimens in clinical settings. Many studies, including this one by Pu and colleagues, have investigated histopathologic and molecular features
of breast cancer in samples of the initial tumor, collected by core biopsy or fine-needle aspiration, before chemotherapy. Many of these studies have shown that hormone receptor status, histologic type and grade, proliferation index, and apoptosis are useful for predicting response to therapy. However, most such studies, including this one, had only small numbers of cases and evaluated only a few markers. Pu and colleagues found tumor necrosis in the biopsy sample to be a significant predictive factor. Two main issues must be considered in attempts to use a single pathologic parameter to make decisions about therapy in clinical settings. The first issue is tumor heterogeneity, which is a well recognized characteristic of many solid tumors, especially breast cancer. A single histopathologic finding, such as tumor necrosis identified in a prechemotherapy sample, may or may not be representa-
tive of the entire tumor. The second issue is the need to standardize evaluations of histopathologic features in small samples; no such criterion has been established for tumor necrosis. In this study, tumor necrosis was defined as the presence of groups of cells with pyknosis, karyorrhexis, and eosinophilic debris, a definition that is not very specific. The reproducibility of this feature as assessed by different pathologists would require large multicenter studies. Many of the histologic features of breast cancer such as proliferation, grade, and tumor necrosis are related to each other, and they most likely reflect tumor differentiation. Molecular profiling is perhaps the most promising technology for evaluating multiple markers related to tumor differentiation. A. A. Sahin, MD
ANNOTATED BIBLIOGRAPHY Accuracy of Intraoperative Frozen-Section Analysis of Breast Cancer Lumpectomy-Bed Margins Cendán JC, Coco D, Copeland EM III J Am Coll Surg 201:194-198, 2005 At present across the United States, roughly 40% of patients who have undergone lumpectomy for breast cancer have to return to the operating room for positive or close surgical margins, as would have been the case in this study if intraoperative frozen-section evaluation of margins had not been used. Cendan and colleagues found that the need for a second operation was avoided in nearly half of the patients who had positive margins on final pathologic analysis. Careful evaluation of surgical margins, whether by palpation, frozen-section analysis, touch preparation cytology,1 or intraoperative sonography,2 is important for optimal results after conservative breast surgery.3 V. S. Klimberg, MD
References 1. Klimberg VS, Westbrook KC, Korourian S: Use of touch preps for diagnosis and evaluation of surgical margins in breast cancer. Ann Surg Oncol 5:220-226, 1998.
2. Henry-Tillman R, Johnson AT, Smith LR, et al: Intraoperative ultrasound and other techniques to achieve negative margins. Semin Surg Oncol 20:206-213, 2001. 3. Pinotti JA, Carvalho FM: Intraoperative pathological monitorization of surgical margins: A method to reduce recurrences after conservative treatment for breast cancer. Eur J Gynaecol Oncol 23:11-16, 2002.
Fibroepithelial Lesions With Cellular Stroma on Breast Core Needle Biopsy: Are There Predictors of Outcome on Surgical Excision? Jacobs TW, Chen Y-Y, Guinee DG Jr, et al Am J Clin Pathol 124:342-354, 2005 Fibroepithelial lesions in core biopsy specimens are the most problematic diagnostically when a moderate degree of stromal hypercellularity is present. Jacobs and colleagues retrospectively evaluated the pathologic features of fibroepithelial lesions on core biopsy and correlated the results with histologic findings in the corresponding surgical excision specimens, with particular emphasis on those lesions with moderate stromal hypercellularity in the core biopsy specimen.
®
Breast Diseases: A Year Book Quarterly Vol 17 No 1 2006
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The Detection of Isolated Tumor Cells in Bone Marrow Comparing Bright-Field Immunocytochemistry and Multicolor Immunofluorescence Krag DN, Kusminsky R, Manna E, et al (Univ of Vermont, Burlington; Charleston Area Med Ctr Inst, WVa; Fletcher Allen Health Care, Burlington, Vt) Ann Surg Oncol 12:753-760, 2005
Background.—The detection of isolated tumor cells in bone marrow by immunocytochemistry (ICC) has been reported to predict progression of earlystage breast cancer. The most common staining procedure uses bright-field ICC with cytokeratin (CK) antibodies to label isolated tumor cells. However, this method can result in false-positive staining events. We used multicolor immunofluorescence (IF) to develop a more specific assay for detecting isolated tumor cells in marrow samples from breast cancer patients. Methods.—We compared ICC and IF side by side for detection of cancer cells and false-positive staining events on bone marrow aspirates from breast cancer
1–21
Pathologic Features of Breast Cancer Associated With Complete Response to Neoadjuvant Chemotherapy: Importance of Tumor Necrosis Pu RT, Schott AF, Sturtz DE, et al (Univ of Michigan, Ann Arbor) Am J Surg Pathol 29:354-358, 2005
Abstract.—Breast cancer patients with a complete pathologic response after neoadjuvant chemotherapy have a better
56 56
®
patients, bone marrow from healthy donors, and healthy donor blood spiked with cancer cells. The primary target for isolated tumor cell detection was CK for both methods. IF used an additional set of antibodies to label hematopoietic cells (HCs). Results.—The detection rate of CK+ events in breast cancer patient bone marrow aspirates was 18 (58%) of 31 for ICC and 21 (68%) of 31 for IF. However, with IF, 17 of 21 CK+ cases were stained with HC markers and thus were identified as false-positive events. A surprisingly high CK+ event rate was observed in healthy donor blood and marrow. In all healthy donor samples, CK+ events were readily identified as HCs by IF. Detection sensitivity of spiked cancer cells in donor blood was similar for both methods. Conclusions.—There is a high frequency of CK+ events in blood and marrow, and it is important to note that this is observed both in patients with and those without cancer. IF with multiple HC markers allows straightforward discrimination between CK+ cells of hematopoietic and nonhematopoietic origin. As more sophisticated tests to identify circulating tumor cells are im-
prognosis than incomplete responders. The predictive value of the histologic characteristics of the tumor prior to neoadjuvant treatment has not been well defined, and there are no guidelines for reporting tumor characteristics in the core biopsy report. Histologic and nuclear grades, presence of tumor necrosis and angiolymphatic invasion (ALI), and estrogen receptor (ER), progesterone receptor (PR), and HER-2/neu expression were assessed in core biopsies of 55 patients with invasive carcinomas. Patients were then uniformly treated with four cycles of
Breast Diseases: A Year Book Quarterly Vol 17 No 1 2006
plemented, ensuring the specificity of the findings becomes increasingly important. Currently the most common method to identify individual cancer cells is by using an immunologic approach to identify epithelial components such as CKs. Both specific and nonspecific staining are known to depend heavily on methodology. In this study, Krag and colleagues found a very high incidence of CK-positive events in both patients with cancer and in those without cancer. Some of these false-positive results may have resulted from the choice of CK antibodies. CAM 5.2, an antibody used in this study, is known to stain some normal marrow and circulating cells. Their multiple-marker approach allowed the authors to discriminate between CKpositive hematopoetic cells (falsepositive) and CK-positive nonhematopoetic cells (presumed cancer). A judicious choice of markers and a carefully controlled approach such as this will be very important in evaluating such techniques in research and clinical practice. J. L. Connolly, MD
doxorubicin/docetaxel followed by excisions and lymph node dissections. Complete pathologic response (pCR) was defined as having no invasive carcinoma at excision. Noncomplete pathologic response was defined as having invasive carcinoma at excision. Five of the 55 patients (9%) achieved pCR. Of the 5 complete responders, 4 (80%) had tumor necrosis in the core biopsy specimens, while only 8 of the 46 (17%) noncomplete responders (pNR) had this feature (P = 0.0086). Higher histologic and nuclear grades, ER, PR status, and HER-
2/neu overexpression were not associated with pCR. The presence of ALI in the core biopsy, post-therapy excision, or both was associated with axillary lymph node metastases (P = 0.0062, P = 0.0249, and P = 0.0021, respectively). Although preliminary, our study suggests that the presence of tumor necrosis and ALI in the core biopsy may be important features to be included in the standard report. The pCR of a primary breast cancer to chemotherapy, though an important prognostic factor for survival, is observed only in a small proportion of patients. The ability to identify histologic and molecular characteristics of breast cancer that predict a pCR to primary chemotherapy would be important in designing specific therapy regimens in clinical settings. Many studies, including this one by Pu and colleagues, have investigated histopathologic and molecular features
of breast cancer in samples of the initial tumor, collected by core biopsy or fine-needle aspiration, before chemotherapy. Many of these studies have shown that hormone receptor status, histologic type and grade, proliferation index, and apoptosis are useful for predicting response to therapy. However, most such studies, including this one, had only small numbers of cases and evaluated only a few markers. Pu and colleagues found tumor necrosis in the biopsy sample to be a significant predictive factor. Two main issues must be considered in attempts to use a single pathologic parameter to make decisions about therapy in clinical settings. The first issue is tumor heterogeneity, which is a well recognized characteristic of many solid tumors, especially breast cancer. A single histopathologic finding, such as tumor necrosis identified in a prechemotherapy sample, may or may not be representa-
tive of the entire tumor. The second issue is the need to standardize evaluations of histopathologic features in small samples; no such criterion has been established for tumor necrosis. In this study, tumor necrosis was defined as the presence of groups of cells with pyknosis, karyorrhexis, and eosinophilic debris, a definition that is not very specific. The reproducibility of this feature as assessed by different pathologists would require large multicenter studies. Many of the histologic features of breast cancer such as proliferation, grade, and tumor necrosis are related to each other, and they most likely reflect tumor differentiation. Molecular profiling is perhaps the most promising technology for evaluating multiple markers related to tumor differentiation. A. A. Sahin, MD
ANNOTATED BIBLIOGRAPHY Accuracy of Intraoperative Frozen-Section Analysis of Breast Cancer Lumpectomy-Bed Margins Cendán JC, Coco D, Copeland EM III J Am Coll Surg 201:194-198, 2005 At present across the United States, roughly 40% of patients who have undergone lumpectomy for breast cancer have to return to the operating room for positive or close surgical margins, as would have been the case in this study if intraoperative frozen-section evaluation of margins had not been used. Cendan and colleagues found that the need for a second operation was avoided in nearly half of the patients who had positive margins on final pathologic analysis. Careful evaluation of surgical margins, whether by palpation, frozen-section analysis, touch preparation cytology,1 or intraoperative sonography,2 is important for optimal results after conservative breast surgery.3 V. S. Klimberg, MD
References 1. Klimberg VS, Westbrook KC, Korourian S: Use of touch preps for diagnosis and evaluation of surgical margins in breast cancer. Ann Surg Oncol 5:220-226, 1998.
2. Henry-Tillman R, Johnson AT, Smith LR, et al: Intraoperative ultrasound and other techniques to achieve negative margins. Semin Surg Oncol 20:206-213, 2001. 3. Pinotti JA, Carvalho FM: Intraoperative pathological monitorization of surgical margins: A method to reduce recurrences after conservative treatment for breast cancer. Eur J Gynaecol Oncol 23:11-16, 2002.
Fibroepithelial Lesions With Cellular Stroma on Breast Core Needle Biopsy: Are There Predictors of Outcome on Surgical Excision? Jacobs TW, Chen Y-Y, Guinee DG Jr, et al Am J Clin Pathol 124:342-354, 2005 Fibroepithelial lesions in core biopsy specimens are the most problematic diagnostically when a moderate degree of stromal hypercellularity is present. Jacobs and colleagues retrospectively evaluated the pathologic features of fibroepithelial lesions on core biopsy and correlated the results with histologic findings in the corresponding surgical excision specimens, with particular emphasis on those lesions with moderate stromal hypercellularity in the core biopsy specimen.
®
Breast Diseases: A Year Book Quarterly Vol 17 No 1 2006
57 57