The Daily Sign-Out

New Device to Check Margins in Breast Cancer Surgery

Just a follow-up to yesterday's post regarding surgical margins in breast cancer. Will this device obviate inking the specimen or the debate about how much margin is "enough"?

Quoted from Medscape article by Zosia Chustecka:

The new device, MarginProbe (Dune Medical Devices Inc), consists of a single-use probe that analyzes breast tissue removed during a lumpectomy. Using radiofrequency spectroscopy, the probe analyzes "electromagnetic signatures" at the margins of the surgically removed breast tissue and compares them to an internal library of signatures taken from both healthy and cancerous tissue. Within the space of 5 minutes, the probe provides an assessment of the excised tissue, indicating whether or not it is cancerous.

 

Controversy: Surgical Margins in Breast Cancer

What is a clear margin in breast-conserving cancer surgery?

ASCO Connection (link) hosts a point-counterpoint discussion by two contributors regarding surgical margins in breast cancer that would be of general interest to surgical pathologists.  It is fairly brief (you can read in about 10 minutes) but also is well-referenced and would be a good resource to have.

The issues around surgical margin assessment and reporting is one that I find and have found vexing and exasperating. One of my professors while I was a resident refused to report margins on lumpectomies--much to the irritation of the oncologists, radiation oncologists, and surgeons--on the principle that the structure of fat and the extravasation of ink rendered any judgment of the margin status based upon the microscopic absence of (non-cauterized) recognizable tumor painted with ink meaningless. Although I couldn't understand his perspective at the time, I certainly do understand where he was coming from after years of experience and numerous clinical conversations about "close," "negative," and "positive" margins.  Yet, the "standard-of-care" dictates that we report margins, so we do.

Take a look at our colleagues' take on this subject. I found Dr. Silverstein's presentation of the split reduction excision particularly interesting and wonder if there are any readers who have had experience with this type of specimen and would be willing to "guest post" on this.

ASCO/CAP clarifications to ER/PR/HER2 testing guidelines

ASCO is publishing a clinical notice regarding clarifications to previously published guidelines for HER2 testing and estrogen receptor (ER) and progesterone receptor (PR) testing in breast cancer.  A summary can be found at the CAP Web site.

The clarifications were needed since these tests are generally run on the same specimen in routine practice and reconcile discrepancies between the two guidelines regarding cold ischemia time, handling of remotely obtained specimens, appropriate fixation times in NBF, and selection of optimal areas for testing.

This is a welcomed development for us practicing grunts (who must acknowledge, explain and document this stuff) but shouldn't affect current routine practice or patient testing.

P53 in tumor-associated fibroblasts in invasive ductal carcinoma

Hasebe et al. have authored an interesting article in a recent Modern Pathology (2010;23:662-672) which builds on their earlier work that showed P53 expression in tumor-stromal fibroblasts (TSF) not forming fibrotic foci to be an important predictor of outcome in patients with invasive ductal carcinoma.

The fibrotic focus has been shown to be a prognostic factor in breast cancer.  Moreover, criteria for fibrotic foci proposed by Van den Eynden et al. in 2007 (Dr. Hasebe was a co-author) appear to both clinically significant and reproducible in daily practice.  I am surprised that the use of this feature has not been adopted for routine use since presenting breast cancer cases with prominent fibrotic foci never fails to elicit curiosity and questions in Tumor Board.  Further, a fibrotic focus has been proposed as a marker for tumor hypoxia and angiogenesis.

The purpose of the current study was to determine whether the combined assessment of P53 expression in tumor-stromal fibroblasts both forming and not forming fibrotic foci serves as a significant predictor of outcome in patients with invasive ductal carcinoma using multivariate analysis with well-established prognostic factors.

The authors studied 1,039 consecutive patients at a single Japanese institution who received surgery including axillary dissection; 873 also received conventional chemotherapy, endocrine therapy, or both.  Using FFPE serial sections of each tumor, the authors evaluated 8 different histological factors, including measuring the fibrotic focus using 8 mm as the cutoff per the Van den Eynden criteria.  Immunohistochemical staining for P53 was evaluated using the Dako mouse monoclonal antibody clone DO7 and staining of tumor-stromal fibroblasts was scored according to modified Allred scoring.  Furthermore, the authors stratified P53 staining in tumor-stromal fibroblasts into 3 groups each for those tumors with and without fibrotic foci.

373 out of 1,039 cases had fibrotic foci.  Notably, in 97 of these 373 (26%) P53 staining could not be evaluated because the tumor tissue sections examined by P53 IHC did not contain a fibrotic focus identified initially at routine examination.

The authors found significantly higher P53 Allred scores in TSFs not forming compared with TSFs forming fibrotic foci.  But P53 Allred scores >4 in TSFs forming fibrotic foci were also associated with fibrotic focus diameter > 8 mm: the size previously established as a cut-off for predicting adverse outcome independent of stage.

Based on Allred scores, the authors segregated P53 expression for TSFs forming and not forming fibrotic foci into risk classes.  Patients in pTNM stages I-III with intermediate to high risk classes of P53 expression showed a significantly higher tumor recurrence rate than patients in the low risk classes.  In addition, stage II and III patients with intermediate to high risk classes of P53 expression showed a significantly higher disease-related mortality rate.

By multivariate analysis, for stage I patients, intermediate to high risk classes of P53 expression in TSFs forming and not forming fibrotic foci and histological grade 3 were significantly associated with tumor recurrence (but not disease-specific death).  For stage II patients, intermediate to high risk classes of P53 expression in TSFs forming and not forming fibrotic foci were associated with increased tumor recurrence and tumor-related death.  Lymphovascular invasion and blood vessel invasion were significantly associated with increased tumor recurrence, whilst pT1 and fibrotic focus > 8 mm were significantly associated with increased tumor-related death.

(Next to) Bottom Line: P53-expression TSFs located both in the inner fibrotic foci an outer invasive front increase the malignant potential of invasive ductal carcinomas across stages I to III.

SO--should we start doing P53 IHC on all invasive ductal carcinomas?  Perhaps not ready yet for prime-time, but this study provides evidence that may, at least in part, explain the prognostic value of fibrotic focus diameter.  Measuring the fibrotic focus, however, may just be ready for prime-time and you may want to consider reviewing the original paper by Van den Eynden et al published in Histopathology 2007;51:440-451.

BUT I do have a few points to consider.  First, this is a single institution paper, so the methodology needs to be independently validated and a larger, multi-insitutional patient cohort needs to be studied to confirm the association between patient outcomes and P53 staining.  Second, other P53 antibodies should be evaluated to optimize the assay.  Third, the number of invasive ductal carcinomas with fibrotic foci that were excluded from the study is disquieting and may be a major source of observational bias.  Finally, the role of image analysis in providing quantitative P53 cut-offs may provide better discrimination between prognostically different groups.

ER/PR testing guidelines: Joint CAP/ASCO recommendations

The College of American Pathologists (CAP) and the American Society of Clinical Oncology (ASCO) issue a joint guideline on April 19, 2010 in an effort to improve the accuracy of immunohistochemistry testing for estrogen (ER) and progesterone receptors (PgR) expression in breast cancer. This is similar to the joint effort the groups made with HER2 testing guideline in 2007.  The guideline is being published in the April 19 issues of ASCO’s Journal of Clinical Oncology (JCO) and the CAP’s Archives of Pathology & Laboratory Medicine in June 2010 but is available in electronic form here.  The ASCO Web page on the guidelines (http://www.asco.org/guidelines/erpr) has links to the unabridged version (yikes!) as well as downloadable slides.

The major recommendation are summarized from the CAP's press release (quoted):

• Testing ER and PgR status on all newly diagnosed invasive breast cancers (primary site and/or metastatic site), and whenever appropriate, repeat testing in patients with a known breast cancer diagnosis who now present with a local or distant recurrence.
• Establishing uniform testing measures that focus on proven, reliable and reproducible assays and procedures.
• Having testing laboratories validate their assays against existing and clinically validated tests. Results should agree at least 90 percent of the time with those of the clinically validated assays for positive receptor status and at least 95 percent for negative receptor status.
• Transporting breast tissue specimens from the operating room to the pathology laboratory as soon as they are available for gross assessment. The time from tumor removal to initiation of fixation should be kept to one hour or less. Fixation of the sample in neutral buffered formalin must extend for at least six hours and no longer than 72 hours.
• Performing ER and PgR testing in a CAP-accredited laboratory or in a laboratory that meets the accreditation requirements spelled out in the guideline. The CAP will require that every accredited lab performing testing participate in a mandatory proficiency testing program.
• Considering an ER and PgR test performed by an IHC assay as positive if at least one percent of the tumor in the sample tests positive, which helps predict whether a patient is likely to benefit with endocrine treatment. The panel recognized that it is reasonable for oncologists to discuss the pros and cons of endocrine therapy with patients whose tumors contain low levels of ER by IHC (one percent to ten percent weakly positive cells) and to make an informed decision based on available information.

As with the ASCO/CAP HER2 guidelines, the ER/PR guideline is an excellent state-of-the-art reference.  I welcome the direction it provides for reporting, specifically, for defining a threshold for determining a positive status and, in general, for thoroughly discussing the role of pre-analytic factors in receptor preservation.

Fortunately, my lab has already been reporting most of the elements in the guideline, such as which clone we are using, fixation time, percent of cells positive, staining intensity and Allred score, etc.  BUT 

One troubling recommendation, however, is the mandate that cold ischemia time be documented: "The time of tissue collection (defined as the time that the tissue is handed from the surgical field) and the time the tissue is placed in fixative both must (my emphasis) be recorded on the tissue specimen requisition to document the time to fixation of the specimen."  While I do completely agree with the idea that "cold ischemia time" should be minimized and we need to educate surgeons, radiologists, and OR staff regarding this, to state this categorically in a recommendation with an explicit instruction on how to do it is a mistake.  This creates an unnecessary burden on the pathology department to police the surgeon.  Are we then to reject a specimen as unacceptable for testing whenever this time is not documented?  What if it is documented somewhere else in the medical record (like we document the time the specimen is placed in fixative in our gross description)?  The over-weighted academic composition of the guideline panel really comes through with stuff like this.  It is really a shame that more community pathologist input is not sought for these guideline panels since most breast cancer is diagnosed at the community level.

Another annoying thing is the list of "well-validated" clones for ER and PR listed in Table 3.  The implication is that if your lab is not using one of these clones, then your lab is not in compliance with the guidelines.  Really?  I thought this was the responsibility of the laboratory medical director to validate a new antibody with a clinically validated assay.  For example, I could not approve the validation of the 1A6 clone for PR in my lab using cell lines controls with low, medium and high defined receptor content because of low sensitivity but was able to validate a different clone (which itself was compared with the 1A6 clone by the manufacturer).  Given the authors' disclosures of potential conflicts of interest (yes, I do actually read this stuff!  not that I'm paranoid or anything), I think the panel might have avoided implying in any way that labs must be using these specific clones for testing.

In summary, the guidelines are very welcome indeed and provide support for what many of us are already doing and may also encourage those labs that are unwilling or unable to comply to send-out these tests to another lab.

NIH State-of-the-Science Statement on Breast DCIS

The conference statement from the recent NIH "State-of-the-Science" conference on ductal carcinoma-in situ (held September 22-24, 2009) is available online.  You can download a pdf for free.

Some interesting findings:

1. While the incidence of "noncomedo" DCIS continues to increase, the incidence of the (to me, more biologically worrisome) comedo type peaked in 1995 and has been declining (through 2006).
2. MRI in DCIS?  Most studies show that MRI is more sensitive in detecting multicentric disease but is not specific.  MRI also reportedly over- and under-estimates the extent of DCIS compared to pathological exam.
3. Although the absolute numbers are small (due to the overall high survival rates in DCIS), there are higher breast cancer recurrence and mortality rates in Black women diagnosed with DCIS compared with White women.
4. No molecular markers have been identified to stratify prognostic groups.  High grade, comedo pattern, margin involvement and size have been related to increased risk of recurrent DCIS and progression to invasive carcinoma--but hard numbers are hard to come by.
5. DCIS is a heterogenous disease with a high probability of long-term disease-free survival--whatever therapy is received.

Micrometastases and ITCs in breast cancer: the controversy continues

This week's Journal of Clinical Oncology (October 1, 2009) has an article by Hansen et al (abstract) from the John Wayne Cancer Institute reporting a prospective study of invasive breast cancer patients with micrometastases in sentinel lymph node biopsies and its impact on survival.

They studied 790 patients with sentinel lymph nodes categorized as pN0(i-), pN0(i+), pN1mi, or pN1 and compared disease-free survival (DFS) and overall survival (OS).  Median follow-up was 72.5 months.

The results showed that pNO(i+) and pN1mi patients had a similar 8-year DFS and OS compared with pN0(i-) patients.  As expected, pN1 patients had significantly shorter 8-year DFS and OS compared with the other 3 groups.  Multivariate analysis showed macrometastases, tumor size and histologic type were predictive of shorter DFS, while OS was predicted by macrometastases, patient age, and ER status.

This is a well-designed, prospective study and worth taking note and the accompanying editorial by Dr. Thomas Julian is also notable.

These findings are in contrast to a recently published NEJM article by a Dutch group from Maastricht University Medical Center (de Boer et al. NEJM 2009 Aug 13: 353-363).  This study was also prospective but studied non-sentinel pN0(i+) and pN1mi regional LN involvement in early-stage breast cancer patients.  It compared DFS in pNo(i+) and pN1mi patients who had not received adjuvant therapy with those pNo(i+) and pN1mi patients who did receive adjuvant therapy and with node-negative (pN0) patients.  The authors found that the pN0(i+)/N1mi, no adjuvant therapy group had a shorter 5-year DFS compared with those who did received adjuvant therapy.  This same Dutch group, furthermore, published a "scary" (to me!) meta-analysis study in JNCI in November 2008 examining the association of isolated tumor cells in sentinel LN with non-sentinel LN metastases.  The study included 29 studies and found an overall risk of non-sentinel lymph node metastases when there was ITCs in the sentinel node of 12.3% (95% C.I. 9.5% to 15.7%)--roughly one-and-a-half to two times the published false negative rate for SLN biopsy.  Here's the scary part: nearly two-thirds (64%) of patients with ITCs in their SLN also had non-sentinel LN macrometastases!

It seems that when the pN0(+) situation arises in my practice, there are multiple phone calls questioning the result, its meaning, and what to do next.  First, the designation of pN0(+) whether positive by H&E or IHC is confusing (at best) and basically, er, wrong--as it seems pathologically, clinically, and biologically.  Yet, it also appears that each patient's treatment plan must be evaluated individually.  The current evidence supports completion axillary dissection in these patients, although perhaps this just kicks the can down the street if those nodes are negative.  Two ongoing studies which have completed accrual, NSABP B-32 (retrospective IHC analysis) and ACOSOG Z0010 (prospective study), should help clarify this problem.

Progress on integrated diagnostics for breast cancer

This will be the first in, hopefully, a series of blog entries that will chronicle my institution's effort to establish integrated diagnostic reporting for radiology-pathology testing for breast disease.

The lab admin director with whom I work is also enthusiastic about this project and we have talked informally about this for a couple of months while gathering information from various sources, especially from LabSoftNews.  The first person with whom we met was her counterpart in radiology.  This conversation was open-ended and basically explored our "visions" of what something like this might look like and then a rough idea of where we needed to go to get started.  Unfortunately, my counterpart in rads was on vacation for the following week but the plan was for me to meet with him as soon as he returned.  In the meantime, the lab and rads admin directors were planning to present to the hospital administration a list of necessary resources and a projection of revenue and value to the organization.

I am fortunate to be working with a radiologist, Dr. Jeff Mendell, who shares my enthusiam for pursuing this project.  We hope to build on an initiative that he started in December of 2008 where we began presenting a monthly breast radiology-pathology correlation conference.  After a few months, it was decided to make this part of a weekly tumor board, so once a month we devote one weekly conference to breast with rad-path correlation.  After meeting last week, we outlined five initial goals:

1. Perform "real-time" mammographic-ultrasound/pathologic biopsy correlation prior to final report.
2. Develop an integrated report combining radiographic findings, pathologic findings, an assessment of correlation, and recommendations for follow-up.
3. Identify the IS barriers to #2 since radiology and pathology currently report from different systems.
4. Discuss with our radiology and pathology colleagues.
5. Discuss with surgical, gynecologists, key internists, medical oncology, and radiation therapy colleagues to get additional ideas from end-users.
6. Identify measures of "success" of this effort.
7. Develop indicators to track outcomes.

The recent The Dark Daily audioconference on integrated diagnostics lacked objective measures for University of Kansas Medical Center's integrated diagnostics project.  I think it is fair to ask: what is the value of doing this?  Intuitively, it seems logical to pursue this in one form or another--but before an administration commits resources, one must be prepared to demonstrate what the tangible benefits will be.  We are currently working this out and I will blog on this at some point.  But, for now, we are looking at reducing out-migration of patients from our area, reducing patients lost to follow-up, reducing TAT from time of screening mammography to postbiopsy follow-up recommendation.

If anyone has their own experience, please share comments or email me offline and I will post as a blog.

Conference reminder--NIH State-of-the-Science Conference on DCIS

You can still register for the Webcast.  Dr. D. Craig Allred speaking at 9 am (Eastern) on "Terminology, Natural History and Taxonomy of DCIS" to kick things off.

The National Institutes of Health (NIH) has organized a free state-of-the-art conference on the Diagnosis and Management of Ductal Carcinoma in Situ from September 22-24, 2009 in Bethesda, Maryland.

European Congress of Pathology annual meeting

Clipped from The Dark Daily report:

"Next to speak was Bent Ejlertsen, M.D., Ph.D., of the Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark. The title of his presentation was “Prediction of Responsiveness to Adjuvant Anthracyclines in High-Risk Breast Cancer Patients.”

He reported on the extensive studies about the TOP2A marker that he and his colleagues have conducted. Their goal was to learn how to use this biomarker for both prognostic and predictive evaluations to identify which breast cancer patients would benefit from therapy with adjuvant anthracyclines. The TOP2A marker is scored in a similar fashion as the HER2 marker. Ejlertsen stressed that improved patient safety would result as the pathology profession achieved more standardized processing and diagnosis when working with the TOP2A marker.

Third speaker at this special seminar on histopathology workflow and patient safety was Professor Giuseppe Viale, M.D., of the University of Milan School of Medicine and European Institute of Oncology in Milan, Italy. Viale emphasized the importance of achieving improved standardization for estrogen receptor (ER) and progesterone receptor (PgR) assays in breast cancer. Of particular note, Viale is a member of the international committee working to develop recommendations for standardizing the preparation and evaluation of tests utilizing ER and PgR immunohistochemical probes.

He opened his presentation by describing the importance of achieving improved standardization in ER and PgR testing. Viale stated that assessment of hormone receptor status is “the first and most important clue” in tailoring treatment of a breast cancer patient. Additionally, he noted that the importance of avoiding false positive results for this testing, because Tamoxifen is detrimental for patients with nonendocrine-responsive tumors."

My comments:

The topoIIA story is still not settled.  Most studies have not demonstrated the utility of this marker as a predictive or prognostic marker.

ER testing recommendations/standards are supposedly forthcoming from ASCO/CAP.  Participation in CAP Proficiency Testing or some other external validation program is a minimum.  As I've stated previously, attention to preanalytical variables that affect IHC staining as well as testing protocols, especially with respect to antigen retrieval, are crucial and yet, curiously, seem to be not taken seriously.  Choosing a control that has been externally validated to show negative, weak, and positive staining increased my confidence in our process and really helped "dial-in" our results with CAP-PT surveys.