Lymph node,peritoneal and bone marrow micrometastases in gastric cancer:Their clinical significance

The 7th TNM classification clearly states that micro-metastases detected by morphological techniques(HE stain and immunohistochemistry) should always be reported and calculated in the staging of the disease(pN1mi or M1),while patients in whom micrometas-tases are detected by non-morphological techniques(e.g.,ow cytometry,reverse-transcriptase polymerase chain reaction) should still be classif ied as N0 or M0.In gastric cancer patients,micrometastases have been de-tected in lymph nodes,the peritoneal cavity and bone marrow.However,the clinical implications and/or their prognostic signif icance are still a matter of debate.Cur-rent literature suggests that lymph node micrometasta-ses should be encountered for the loco-regional staging of the disease,while skip lymph node micrometastases should also be encountered in the total number of infiltrated lymph nodes.Peritoneal fluid cytology ex-amination should be obligatorily performed in pT3 or pT4 tumors.A positive cytology classif ies gastric cancer patients as stage Ⅳ.Although a curative resection is not precluded,these patients face an overall dismal prognosis.Whether patients with a positive cytology should be treated similarly to patients with macroscopic peritoneal recurrence should be evaluated further.Gas-tric cancer cells are detected with high incidence in the bone marrow.However,the published results make comparison of data between groups almost impossible due to severe methodological problems.If these meth-odological problems are overcome in the future,specif ic target therapies may be designed for specif ic groups of patients.

DETECTION OF MICROMETASTASES OF LUNG CANCER BY USING LUNX mRNA SPECIFIC REVERSE TRANSCRIPTION-POLYMERASE CHAIN REACTION

Objective: To detect of lung cancer micrometastases in peripheral blood and regional lymphatic nodes by using lunx mRNA specific reverse transcription-polymerase chain reaction (RT-PCR). Methods: RT-PCR was used to detect lunx mRNA in peripheral blood of 26 patients with lung cancer. We also detected 44 regional lymphatic nodes obtained from 25 patients with lung cancer who underwent curative lobectomy. All the 44 regional lymphatic nodes were also examined by histopathology. Micrometastatic tumor cells in the peripheral blood and regional lymphatic nodes were semiquantitatively determined with the ratio of lunx band intensity to the glyceraldehydes-3-phosphate dehydrogenase band intensity. Results: The positive detection rate of lunx mRNA in peripheral blood for non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) patients were 60% (12/20) and 67% (4/6) respectively. 16 (36.4%) of regional lymphatic nodes from 44 lung cancer patients were positive by RT-PCR while 6 (13.6%) were positive by histopathology (x 2=6.06, P=0.014). However, no blood samples and lymphatic nodes from patients with benign pulmonary diseases or normal volunteers were positive for lunx mRNA. The positive detection rate of lunx mRNA in bone marrow of NSCLC amd SCLC patients were 65% (13/20) and 67% (4/6) respectively. Conclusion: RT-PCR amplification of lunx mRNA is an sensitive and specific means to detect early haematogenous and regional lymphatic nodes dissemination of cancer cells for patients with lung cancer.

Locoregional treatment of early breast cancer with isolated tumor cells or micrometastases on sentinel lymph node biopsy

The advent of sentinel lymph-node technique has led to a shift in lymph-node staging,due to the emergence of new entities namely micrometastases(p N1mi) and isolated tumor cells [p N0(i+)].The prognostic significance of this low positivity in axillary lymph nodes is currently debated,as is,therefore its management.This article provides updates evidence-based medicine data to take into account for treatment decision-making in this setting,discussing the locoregional treatment in p N0(i+) and p N1 mi patients(completion axillary dissection,axillary irradiation with or without regional nodes irradiation,or observation),according to systemic treatment,with the goal to help physicians in their daily practice.

Detection of micrometastases in bone marrow and sentinel lymph nodes of breast cancer patients

To study the sensitivity and clinical significance of HE-staining,IHC and RT-PCR in detecting breast cancer micrometastases in bone marrow and sentinel lymph nodes （SLNs）. Methods ：After general anesthesia, all patients underwent bone marrow puncture and sentinel lymph node biopsy （SLNB） by 1% isosulfan blue, and then HE-staining,IHC and RT-PCR were used to detect micrometastases. Results：Of 62 patients with breast cancer whose axillary lymph nodes showed negative HE-staining results, 15 cases presented with positive RT-PCR and 9 cases showed positive IHC results positive in bone marrow micrometastases detection. PT-PCR and IHC showed good uniformity（kappa=0.6945）and there was significant difference in detective rate between these two methods （X2=4.1667,P = 0.0412）. In SLN samples, 13 showed positive RT-PCR results, while 7 showed positive IHC results. PT-PCR and IHC showed good uniformity （kappa=0.64.83）and significant difference was also found in detective rate between these two methods （X^2=4.1667 ,P = 0.0412）. Both bone marrow and SLN samples were RT-PCR positive in 3 cases, which indicated that bone marrow did not always accompany SLN micrometastases（X^2=0.067,P = 0.796）. Conclusion： Even if no axillary lymph node involvement or distant metastases are present in routine preoperative examination, micrometastases can still be detected in bone marrow or SLNs. Because the bone marrow micrometastases and axillary node micrometastses are not present simultaneously, combination test of multiple indicators will detect micrometastases more accurately.

DETECTION OF BREAST CANCER MICROMETASTASES IN BONE MARROW USING REVERSE-TRANSCRIPTASE CHAINREACTION AND SOUTHERN HYBRIDIZATION

Objective: The aim of this study was to detect micrometastases in bone marrow of primary breast cancer patients, and compare with other clinical parameters. Methods: Cytokeratin 19 (CK-19) gene mRNA expression was detected by reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern blot hybridization. Human breast cancer cell line T47D was mixed with bone marrow cells in different proportions. The positive detection rate was compared among RT-PCR, Southern blotting and immunohistochemistry (IHC) methods. Results: Cytokeratin 19 gene was expressed in all 6 positive control samples while the expression was not seen in 8 negative control samples. In all 54 patients 14 cases were CK-19 positive (25.9%) by RT-PCR, another positive signal was obtained in 5/54 (9.3%) of bone marrow samples by Southern blotting. The total positive cases are 19/54 (35.2%). CK-19 IHC+ cells were detected at a dilution of one T47D cell in 5×104 bone marrow cells, while the sensitivity detected by PCR and Southern blot hybridization was at 1∶5×105 and 1∶1×106, respectively. This demonstrates that RT-PCR and Southern blotting was at least 20 times more sensitive than the IHC method. The micrometastases positive rate of the larger tumor size group (>5.0 cm) was significantly (P<0.05) greater than that of the smaller tumor size group (0–2.0 cm). Conclusion: detection of micrometastases in bone marrow by RT-PCR and Southern blotting, using CK-19 as a biological marker, is highly sensitive and it is a method to be used for anticipating the prognosis of breast cancer patients.

COMBINED DETECTION OF BREAST CANCER MICROMETASTASES IN THE LYMPH NODES AND BONE MARROW USING REVERSETRANSCRIPTASE CHAIN REACTION AND SOUTHERN HYBRIDIZATION

Objective: The presence of lymph nodes and bone marrow micrometastases of patients with breast carcinoma by immunohistochemistry (IHC) methods has been strongly correlated to early recurrence and shorter overall survival. The aim of this study was to detect micrometastases in matched sample pairs of lymph nodes and the bone marrow of primary breast cancer patients using a more sensitive method, and compare with other clinical parameters. Methods: Cytokeratin 19 (CK-19) gene mRNA expression was detected by reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern blot hybridization. Human breast cancer cell line T47D was mixed with bone marrow cells at different proportions. The positive detection rate was compared among RT-PCR, Southern blotting and IHC methods. Results: Cytokeratin 19 gene was expressed in all 6 positive control samples, while the expression wasn’t seen in 18 negative control samples. CK-19 IHC positive cells were detected at a dilution of one T47D cell in 5×105 bone marrow cells, while the sensitivity detected by PCR and Southern blot hybridization was at 1:5×104 and 1:106, respectively. In the samples from the 35 patients, we found CK-19 positive cells in 2 cases (5.7%) by IHC. CK-19 gene expression signal was detected in 14/35 (40%) by RT-PCR, and 17/35 (48.6%) by southern blotting. Four cases were micrometastases positive both in lymph node and bone marrow (11.4%). There was no correlation between CK-19 detection and other clinical parameters. Conclusion: combined detection of micrometastases in lymph node and bone marrow by RT-PCR and Southern blotting, using CK-19 as a biological marker, is a highly sensitive method for breast cancer.

DETECTION AND SIGNIFICANCE OF LYMPH NODE MICROMETASTASES IN PATIENTS WITH NODE-NEGATIVE GASTRIC CARCINOMA

Objective: To study micrometastases in lymph nodes from patients with node-negative gastric carcinoma by routine histologic examination and discuss their prognostic significance and the relationship between micrometastases and each of the clinicopathologic factors. Methods: A total of 1245 perigastric lymph nodes from 105 patients with node-negative gastric carcinoma was immunohisto-chemically detected using a monoclonal antibody against low molecular weight cytokeratin AE1. The characteristics of the micrometastases, their related factors and effect on patients’ survival after surgery were analysed and tested with statistical methods. Results: Micrometastases were observed in 81 lymph nodes (6.5%) of 31 patients (29.5%). The incidence of lymph node micrometastases was significantly higher in the diffuse type (41.5%) than in the intestinal type gastric carcinoma (17.6%,P<0.01,x 2test). In addition, the presence of micrometastases was closely correlated with the size and invasion depth of the primary tumor, but had no relation to patient’s age, sex and the location of primary tumor. The patients with micrometastases had significantly worse prognosis shown by Log-rank test. Their five-year survival rate after surgery was 61.29%; for those without micrometastases the rate was 82.43%,P=0.0116. When the number of patient’s lymph nodes with micrometastases was three or more, the five-year survival rate of these patients was much lower (41.67%,P=0.0012). Conclusion: The detection of lymph node micrometastases is necessary to more accurately determine the prognosis and clinical staging of patients with node-negative gastric carcinoma by routine histologic examination. The presence of micrometastases may be regarded as one of the clues in adjuvant therapy of those patients.

Clinical effects of apatinib mesylate for treatment of multiple brain micrometastases:Two case reports

BACKGROUND Apatinib is a small-molecule multitargeted tyrosine kinase inhibitor.Apatinib has demonstrated encouraging antitumor activities.This study aimed to observe the efficacy and safety of apatinib for the treatment of multiple brain micrometastases.CASE SUMMARY We report two patients with multiple brain micrometastases after failure of second-line treatment.Both patients had extracerebral metastases.When the patients took 250 mg/d apatinib orally,the intracerebral lesions disappeared.The extracerebral lesions were partially alleviated.Both patients had a progressionfree survival of more than 12 mo and were still stable.The safety was good.The main adverse events(AEs)were mild hypertension and proteinuria,which could be controlled.CONCLUSION Apatinib has clear efficacy and good tolerance in patients with multiple brain micrometastases after failure of second-line treatment.

Early stage colon cancer

Evidence has now accumulated that colonoscopy and removal of polyps,especially during screening and surveillance programs,is effective in overall risk reduction for colon cancer.After resection of malignant pedunculated colon polyps or early stage colon cancers,long-term repeated surveillance programs can also lead to detection and removal of asymptomatic high risk advanced adenomas and new early stage metachronous cancers.Early stage colon cancer can be defined as disease that appears to have been completely resected with no subsequent evidence of involvement of adjacent organs,lymph nodes or distant sites.This differs from the clinical setting of an apparent"curative"resection later pathologically upstaged following detection of malignant cells extending into adjacent organs,peritoneum,lymph nodes or other distant sites,including liver.This highly selected early stage colon cancer group remains at high risk for subsequent colon polyps and metachronous colon cancer.Precise staging is important,not only for assessing the need for adjuvant chemotherapy,but also for patient selection for continued surveillance.With advanced stages of colon cancer and a more guarded outlook,repeated surveillance should be limited.In future,novel imaging technologies(e.g.,confocal endomicroscopy),coupled with increased pathological recognition of high risk markers for lymph node involvement(e.g.,"tumor budding")should lead to improved staging and clinical care.

AN IMMUNOHISTOCHEMICAL STUDY OF OCCULT MICRO- METASTASES IN REGIONAL LYMPH NODES OF 94 PATIENTS WITH STAGE I NON-SMALL CELL LUNG CARCINOMA

In the study, 739 regional lymph nodes from 94 patients with stage I non- small cell lung carcinoma (NSCLC) were studied by immunohistochemical techniques. These lymph nodes contained no metastatic tumor as assessed by conventional histopatholgy were recut. A series of consecutive sections from the original blocks were immunostained with poly-and monoclonal antibodies to cytokeratins, carcinoembryonic antigen (CEA), and human milk fat globulin membrane antigen (HMFG-2). Single tumor cells or small clusters of tumor cells, not visible on routine examination, were readily detected. The actual number of lymph nodes that contained occult tumor cells was 123 (16.6%) from 53 patients (56.4%). The majority of 102 immunostalned positive nodes were distributed in the hllar (29% ) and peribronchlal (25%) regions. Our data indicate that (1) a series of consecutive sections and immunohistochemistry may greatly Increase the diagnostic yield of occult micrometastases in lymph nodes; (2) the high incidence of occult metastases in NSCLC may be of Importance in relation to their rapid dissemination and high death rates; (3) the high frequencyof occult nodal metastases in NSCLC raises questions in regard to our presently used criteria for staging, prognosis and treatment of ostensibly stage I disease; and (4) perhaps dissections of hllar and peribronchlal nodes will have an Importantly clinical significance in prevention of wide dissemination of tumor cells.