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Surgical resection of the primary tumor occurs in almost half of women with stage IV breast cancer alive 1 year after diagnosis, and is increasingly occurring after systemic therapy. Coordinated multidisciplinary care remains highly relevant in the setting of metastatic breast cancer, where surgical decisions should be made on an individual basis and may affect survival in select women.

Implantable and extracorporeal cardiovascular devices are commonly made from titanium (Ti) (e.g. Ti-coated Nitinol stents and mechanical circulatory assist devices). Endothelializing the blood-contacting Ti surfaces of these devices would provide them with an antithrombogenic coating that mimics the native lining of blood vessels and the heart. We evaluated the viability and adherence of peripheral blood-derived porcine endothelial progenitor cells (EPCs), seeded onto thin Ti layers on glass slides under static conditions and after exposure to fluid shear stresses. EPCs attached and grew to confluence on Ti in serum-free medium, without preadsorption of proteins. After attachment to Ti for 15 min, less than 5 % of the cells detached at a shear stress of 100 dyne/cm2. Confluent monolayers of EPCs on smooth Ti surfaces (Rq of 10 nm), exposed to 15 or 100 dyne/cm2 for 48 hours, aligned and elongated in the direction of flow and produced nitric oxide dependent on the level of shear stress. EPC-coated Ti surfaces had dramatically reduced platelet adhesion when compared to uncoated Ti surfaces. These results indicate that peripheral blood-derived EPCs adhere and function normally on Ti surfaces. Therefore EPCs may be used to seed cardiovascular devices prior to implantation to ameliorate platelet activation and thrombus formation.

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The overall goal of this method is to describe a technique to subject adherent cells to laminar flow conditions and evaluate their response to well quantifiable fluid shear stresses 1 .Our flow chamber design and flow circuit ( Fig. 1) contains a transparent viewing region that enables testing of cell adhesion and imaging of cell morphology immediately before flow (Fig. 11A, B), at various time points during flow (Fig. 11C), and after flow (Fig. 11D). These experiments are illustrated with human umbilical cord blood-derived endothelial progenitor cells (EPCs) and porcine EPCs 2,3 . This method is also applicable to other adherent cell types, e.g. smooth muscle cells (SMCs) or fibroblasts.The chamber and all parts of the circuit are easily sterilized with steam autoclaving. In contrast to other chambers, e.g. microfluidic chambers, large numbers of cells (> 1 million depending on cell size) can be recovered after the flow experiment under sterile conditions for cell culture or other experiments, e.g. DNA or RNA extraction, or immunohistochemistry ( Fig. 11E), or scanning electron microscopy 5 . The shear stress can be adjusted by varying the flow rate of the perfusate, the fluid viscosity, or the channel height and width. The latter can reduce fluid volume or cell needs while ensuring that one-dimensional flow is maintained. It is not necessary to measure chamber height between experiments, since the chamber height does not depend on the use of gaskets, which greatly increases the ease of multiple experiments. Furthermore, the circuit design easily enables the collection of perfusate samples for analysis and/or quantification of metabolites secreted by cells under fluid shear stress exposure, e.g. nitric oxide (Fig. 12) . Video LinkThe video component of this article can be found at https://www.jove.com/video/3349/ Protocol 1. Endothelial progenitor cell isolation 1. Prior to any collection of peripheral human blood, submit your research protocol to your Institutional Review Board (IRB), and after its approval, obtain the volunteer donors' informed consent (peripheral blood collection and EPC isolation had been approved by the Duke University IRB and is in full compliance with U.S. regulatory requirements related to the protection of human research participants). 2. When working with animal-derived EPCs, have your research protocol approved by your Institutional Animal Care and Use Committee (IACUC). All our porcine experiments had been approved by the Duke University IACUC and were conducted in accordance with the highest standards of humane care. 3. For isolation of endothelial progenitor cells, collect 50 ml of peripheral blood via standard phlebotomy technique from a consented volunteer donor into blood collection bags filled with the anticoagulant citrate phosphate dextrose and dilute the solution 1:1 with Hank's buffered salt solution (without CaCl 2 , MgCl 2 , MgSO 4 ) and layer on equal volumes of Histopaque to create well-defined layers. 4. Centrifuge (30 min, 740 g, low break setting) and colle...

Objective The aim of this study was to determine whether hospital volume was associated with mortality in breast cancer, and what thresholds of case volume impacted survival. Background Prior literature has demonstrated improved survival with treatment at high volume centers among less common cancers requiring technically complex surgery. Methods All adults (18 to 90 years) with stages 0–III unilateral breast cancer diagnosed from 2004 to 2012 were identified from the American College of Surgeons National Cancer Data Base (NCDB). A multivariable Cox proportional hazards model with restricted cubic splines was used to examine the association of annual hospital volume and overall survival, after adjusting for measured covariates. Intergroup comparisons of patient and treatment characteristics were conducted with X2 and analysis of variance (ANOVA). The log-rank test was used to test survival differences between groups. A multivariable Cox proportional hazards model was used to estimate hazard ratios (HRs) associated with each volume group. Results One million sixty-four thousand two hundred and fifty-one patients met inclusion criteria. The median age of the sample was 60 (interquartile range 50 to 70). Hospitals were categorized into 3 groups using restricted cubic spline analysis: low-volume (<148 cases/year), moderate-volume (148 to 298 cases/year), and high-volume (>298 cases/year). Treatment at high volume centers was associated with an 11% reduction in overall mortality for all patients (HR 0.89); those with stage 0–I, ER+/PR+ or ER+/PR− breast cancers derived the greatest benefit. Conclusions Treatment at high volume centers is associated with improved survival for breast cancer patients regardless of stage. High case volume could serve as a proxy for the institutional infrastructure required to deliver complex multidisciplinary breast cancer treatment.

Titanium (Ti) is commonly utilized in many cardiovascular devices, e.g. as a component of Nitinol stents, intra- and extracorporeal mechanical circulatory assist devices, but is associated with the risk of thromboemboli formation. We propose to solve this problem by lining the Ti blood-contacting surfaces with autologous peripheral blood-derived late outgrowth endothelial progenitor cells (EPCs) after having previously demonstrated that these EPCs adhere to and grow on Ti under physiological shear stresses and functionally adapt to their environment under flow conditions ex vivo. Autologous fluorescently-labeled porcine EPCs were seeded at the point-of-care in the operating room onto Ti tubes for 30 minutes and implanted into the pro-thrombotic environment of the inferior vena cava of swine (n = 8). After 3 days, Ti tubes were explanted, disassembled, and the blood-contacting surface was imaged. A blinded analysis found all 4 cell-seeded implants to be free of clot, whereas 4 controls without EPCs were either entirely occluded or partially thrombosed. Pre-labeled EPCs had spread and were present on all 4 cell-seeded implants while no endothelial cells were observed on control implants. These results suggest that late outgrowth autologous EPCs represent a promising source of lining Ti implants to reduce thrombosis in vivo.

Background: Despite increasing emphasis on reducing racial disparities in breast cancer care in the United States, it remains unknown whether access to breast reconstruction has improved over time. The authors characterized contemporary patterns of breast reconstruction by race and ethnicity. Methods: The Surveillance, Epidemiology, and End Results database was used to identify women undergoing mastectomy for stage 0 to III breast cancer from 1998 to 2014. Multivariable logistic regression was used to estimate the association of demographic factors with likelihood of postmastectomy reconstruction. Multivariable logistic regression was used to predict reconstruction subtype. Patients undergoing reconstruction were grouped by diagnosis year to assess change in the population over time by race and ethnicity. Results: Of 346,418 patients, 21.8 percent underwent immediate reconstruction. Non-Hispanic black race (OR, 0.71) and Hispanic ethnicity (OR, 0.63) were associated with a decreased likelihood of reconstruction (all p < 0.001). Race was predictive of reconstruction type, with non-Hispanic black (OR, 1.52) and Hispanic women (OR, 1.22) more likely to undergo autologous versus implant-based reconstruction (p < 0.001). Although rates of reconstruction increased over time across all races, non-Hispanic black and Hispanic patients had a higher adjusted per-year increase in rate of reconstruction compared with non-Hispanic white patients (interaction p < 0.001). Conclusions: Rates of postmastectomy reconstruction have increased more quickly over time for minority women compared with white women, suggesting that racial disparities in breast reconstruction may be improving. However, race continues to be associated with differences in