In vitro and in vivo analysis of human herpesvirus-6 U90 protein expression

In order to establish a reliable method for the detection of human herpesvirus-6 (HHV-6) B antigens in peripheral blood mononuclear cells (PBMCs) collected from HHV-6 infected patients, we created a polyclonal antibody against the HHV-6 B U90 protein (IEA/ex3) and used it to examine the expression of this protein in virus-infected cells and patients' PBMCs. This antibody reacted with 170 and 195 kDa proteins in HHV-6 B-infected cord blood mononuclear cells. The IEA/ex3 antigen was detected in cord blood mononuclear cells at 6 hr post-infection, and the number of infected cells reached its maximum at 48 hr post-infection. The antigen stained in a punctate pattern and partially localized to the promyelocytic leukemia (PML) protein body. We also examined 60 PBMC samples from 60 febrile children (3-19 months old) and detected IEA/ex3 antigen in the PBMCs by laser-scanning microscopy. HHV-6 was isolated from 31 of the 60 samples. The sensitivity and specificity of the antigen detection were 84% (26/31) and 97% (28/29), respectively, in the samples with virus detected. The mean number of antigen-positive PBMCs was 409/10(6) cells in 20 samples with viral isolation. A significant correlation (r = 0.566; P = 0.008) was observed between the viral load and number of antigen-positive cells. Although IEA/ex3 antigen was detected by laser-scanning microscopy in PBMCs (without cultivation) collected from six patients with isolated virus, it was detected in only one sample by conventional fluorescence microscopy. Increasing the intensity by cultivation (24 hr) resulted in a higher detection rate (5/6) even by conventional fluorescence microscopy, which is available in most hospital laboratories.

DNA base alignment and taxonomic study of genus Malassezia based upon partial sequences of mitochondrial large subunit ribosomal RNA gene

The sequences of the large subunit of mitochondrial ribosomal RNA (LsmtrRNA) gene of Malassezia species were analysed. The sequences of the seven species of Malassezia are well separated in each species. Therefore the LsmtrRNA gene is thought to be one of the gene targets for species identification in the genus Malassezia. The dendrogram obtained from this gene supports the previous study of Malassezia species based upon the chromosomal genes. This is the first report of taxonomic analysis of Malassezia species based upon the mitochondrial gene.

Relapse of neonatal herpes simplex virus infection

BACKGROUND

Neonatal herpes simplex virus (HSV) infection is a severe disease with high mortality and morbidity. Recurrence of skin vesicles is common.

OBJECTIVE

To determine the features of relapse and identify the factors related to relapse.

DESIGN

Thirty two surviving patients with neonatal herpes virus infections were enrolled. All patients received acyclovir treatment. Clinical and virological data were analysed and compared between relapsed and non-relapsed cases.

RESULTS

Thirteen (41%) had either local skin or central nervous system relapse between 4 and 63 days after completing the initial antiviral treatment. Nine patients exhibited local skin relapses, and four developed central nervous system relapses. In one skin and two central nervous system relapse cases, neurological impairment later developed. Type 2 virus infection was significantly related to relapse (odds ratio 10.4, 95% confidence interval 1.1 to 99.0). Patients with relapse had worse outcomes than those without relapse.

CONCLUSION

Neonates with HSV type 2 infections have a greater risk of relapse. Relapsed patients have poorer prognoses.

Comparative whole-body 201Tl and bone scintigraphies for the detection of bone marrow involvement in multiple myeloma

The objectives of this study were to investigate the role of whole-body 201Tl-chloride scintigraphy in comparison with bone scintigraphy in the detection of bone marrow involvement in patients with multiple myeloma and to assess the follow-up evaluation using 201Tl-chloride. Twenty-one patients with untreated multiple myeloma were evaluated. 201Tl-chloride images were acquired 10 min (early) and 2 h (delayed) after the injection of 111 MBq 201Tl-chloride. Bone images were acquired 3 h after the intravenous injection of 740 MBq 99mTc-hydroxymethylene diphosphonate (HMDP). The 201Tl-chloride scan patterns were classified as normal, diffuse (presence of bone marrow), focal (localized areas of uptake) and diffuse+focal. The bone scan patterns were classified as normal and abnormal. Eight of the 21 patients also underwent 201Tl-chloride scintigraphy after chemotherapy for the evaluation of the therapeutic response. On the early 201Tl-chloride image, two patients showed a normal, 13 a diffuse, two a focal and four a diffuse + focal pattern. On the delayed 201Tl-chloride image, nine patients showed a normal, six a diffuse, four a focal and two a diffuse + focal pattern. Bone scintigraphy showed an abnormal accumulation in only five of the 21 patients. Of the eight patients who underwent follow-up 201Tl-chloride studies, the abnormal diffuse pattern was changed to a normal pattern on post-treatment scintigraphy in three, and the degree of abnormal 201Tl-chloride accumulation decreased in comparison with the pre-treatment scan in three. These six patients were considered to be in clinical remission. In the two remaining patients, the degree of abnormal 201Tl-chloride accumulation increased in comparison with the pre-treatment scan, and they were considered to be in clinical progression. 201Tl-chloride scintigraphy is a non-invasive tool, which may be more useful than bone scintigraphy for the diagnosis of multiple myeloma, and may be helpful in the follow-up of multiple myeloma.

99mTc galactosyl human serum albumin liver dynamic SPET for pre-operative assessment of hepatectomy in relation to percutaneous transhepatic portal embolization

We have devised an original predictive residual index (PRI) using 99mTc diethylenetriaminepentaacetic acid galactosyl human serum albumin (99mTc-GSA) liver dynamic SPET for the pre-operative assessment of hepatectomy, including the prediction of residual liver function before hepatectomy. The aim of this study was to evaluate the usefulness of the PRI by using 99mTc-GSA liver dynamic SPET before and after percutaneous transhepatic portal embolization (PTPE) to induce compensatory hypertrophy of the remnant lobe, and to compare the results with the prognosis after hepatectomy. The subjects included eight patients with cholangiocellular carcinoma, five with gallbladder cancer, four with hepatocellular carcinoma and three with metastatic liver cancer. 99mTc-GSA liver dynamic SPET was performed immediately before and 2 weeks after PTPE. Dynamic SPET with 35 continuous rotations was performed to obtain the k-value according to the accumulation curve in each voxel (0.54 cm x 0.54 cm x 1.08 cm) of the liver immediately after a bolus injection of 185 MBq 99mTc-GSA. Each rotation consisted of 180 degrees turn in 64 steps in a 64 x 64 matrix. The acquisition time of each rotation was 35 s. We devised an original PRI by combining the k-value with functional liver volume which were measured by liver dynamic SPET. Hepatectomy was performed following the second SPET. The correlation between the PRI and post-operative patient prognosis was investigated retrospectively. The functional liver volume of the remnant lobe and the PRI significantly increased after PTPE compared with respective values before PTPE (P<0.005 and P<0.0001, respectively). Regarding the relationship between the PRI and the clinical course following surgery, post-operative complications were observed in only two patients. The PRI values of these two patients were 0.323 and 0.394. When the PRI was above 0.400, no patient had symptoms of hepatic failure. The results of this study suggest that, when the PRI value is above 0.400, there is a low probability of hepatic failure after hepatectomy. We conclude that the PRI devised in this study is useful in the pre-operative assessment of hepatectomy after PTPE.

Proliferation of intracellular structure corresponding to reduced affinity of fluconazole for cytochrome P-450 in two low-susceptibility strains of Candida albicans isolated from a Japanese AIDS patient

Three Candida albicans isolates, TIMM 3164, 3165 and 3166 with reduced fluconazole susceptibility, were isolated from two Japanese AIDS patients. We earlier reported that a reduced intracellular accumulation of fluconazole in these isolates played an important role in the resistance mechanism of fluconazole, but we did not exclude the involvement of other factors. We here examined characteristics related to cytochrome P-450 (CYP), especially sterol 14alpha-demethylase encoded by the ERG11 gene which is the target molecule for fluconazole. In TIMM 3164 and 3165, the ergosterol synthesis by cell-free extracts was somewhat less susceptible to fluconazole, due to a decrease in fluconazole affinity for CYP. The nucleotide substitutions in the ERG11 gene were identified to result in three amino acid changes of K143R, E266D and V488I in TIMM 3164, and of E266D, V404L and V488I in TIMM 3165. These amino acid substitutions might contribute to the decreased affinity for CYP in both isolates. However, a single amino acid change, E266D, observed in TIMM 3166 was unrelated to the decreased affinity for CYP. The most prominent finding on the ultrastructure of TIMM 3164 and 3165 was the development of mesh membrane structures of the endoplasmic reticula, which is a location related to sterol synthesis. This phenomenon was not observed in the cells of TIMM 3166 or the susceptible control strains of ATCC 90028 and 10231. In addition to the reduced intracellular accumulation, the decreased affinity of fluconazole for CYP in TIMM 3164 and 3165 is assumed to be associated with the fluconazole-resistance phenotype.

Oncolytic viral therapy using a spontaneously generated herpes simplex virus type 1 variant for disseminated peritoneal tumor in immunocompetent mice

The present study demonstrates that a clonal derivative (HF10) of HSV-1 strain HF effectively treated disseminated peritoneal neoplasm in an immunocompetent animal model and that all of survived mice acquired resistance to rechallenge with tumor cells. The survival time of mice treated with HF10 was longer than that of mice treated with hrR3, indicating that the oncolytic effect of HF10 was more potent than that of hrR3 in this animal model. HF10 induces syncytia formation in vitro, whereas hrR3 forms rounded CPE. The sequential administration of HF10 gave a long term survival of more than 90 days after tumor injection, with no signs of disease, in 8 of the 9 treated mice. The results suggest that treatment of disseminated peritoneal tumor with HF10 induces a specific antitumor immune response. Genomic structure determination showed that HF10 has a deletion of 3.9-kilobase pair (kbp) in the right end of UL and UL/IRL junction, resulting in the loss of UL 56 expression. A 2.3 kbp deletion and extensive rearrangement were also observed in the left end of the genome.

Carrier-dependent specificity of antibodies to a conserved peptide determinant of gp120

Amino acid residues 421-436 constitute a comparatively conserved determinant of gp120 that participates in the binding of host cell CD4 receptors by HIV-1. We compared the immunogenicity of synthetic Cys-gp120 (421-436) conjugated to KLH via the N terminal Cys residue (KLH-I) and gp120 (421-436) extended at its N terminus with a 15 residue tetanus toxoid T cell epitope (T-I) in non-autoimmune mice (BALB/cstrain) and Fas-defective autoimmune mice (MRL/lpr strain). Both immunogens elicited high titer Abs detected as the binding to gp120 (421-436) conjugated to bovine serum albumin (BSA-I) immobilized in ELISA plates. Abs from KLH-I immunized mice displayed binding to full-length gp120 but the Abs from T-I immunized mice did not. Proteins unrelated in sequence to gp120 did not bind the Abs. Soluble I and T-I failed to compete with immobilized BSA-I for binding to anti-KLH-I Abs, whereas these peptides inhibited anti-T-I Ab binding by BSA-I (rank potency order: BSA-I > T-I >> I). These results indicate the influence of the carrier protein on the specificity of Abs to synthetic I. Low level BSA-I and gp120 binding Abs were detected in sera from non-immunized MRL/lpr mice. Similar Ab binding titers and specificity profiles were evident in MRL/lpr and BALB/c mice following immunization with KLH-I and T-I, indicating that pre-existing immunity to gp120 in the former strain does not influence the magnitude or specificity of the Ab response.

In vitro activity of novel imidazole antifungal agent NND-502 against Malassezia species

The in vitro activity of NND-502, a novel antifungal imidazole compound, was tested against the three major Malassezia species by an agar dilution method with modified Dixon medium and compared with the activities of three reference antifungal drugs of topical use, lanoconazole (LCZ), bifonazole (BFZ) and terbinafine (TBF). The geometric mean (GM)-MICs of NND-502 for 25 strains of M. furfur, 15 strains of M. sympodialis and ten strains of M. slooffiae were approximately 1.4, 0.1 and 1.0 mg/l, respectively, showing the greatest activity against M. sympodialis and the least against M. slooffiae. These values were similar to that of LCZ, but four to 69 times lower than that of BFZ and two to three times lower than that of TBF. The results suggest that NND-502 might be beneficial in the treatment of Malassezia-associated skin diseases.

A novel mechanism of fluconazole resistance associated with fluconazole sequestration in Candida albicans isolates from a myelofibrosis patient

A series of 10 strains of Candida albicans, from TIMM 3309 to TIMM 3318, were repeatedly isolated in one myelofibrosis-complicated patient with recurrent candidemia. The latter five isolates, from TIMM 3314 to TIMM 3318, became suddenly resistant to fluconazole during the 10 to 16 weeks after antimycotic therapy. We investigated the resistant mechanism of fluconazole using one susceptible isolate and two of the five resistant isolates in the series. The ergosterol synthesis by cell-free extracts from the two resistant isolates was less susceptible to fluconazole partly as a result of a decreased affinity of cytochrome P-450. Unexpectedly, these two resistant isolates showed higher levels of an intracellular accumulation of [H]fluconazole than the susceptible isolate and the control strain of C. albicans ATCC 10231. In the resistant isolate, TIMM 3318, most intracellular incorporated fluconazole was distributed in the 12,000 X g pellet (P-120) fraction by centrifugation unlike the two susceptible strains. An observation of the ultrastructure of TIMM 3318 showed the most notable alteration to be the characteristic appearance of numerous vesicular vacuoles (diameter, 150 to 400 nm); these vacuoles were not observed, however, in either of the susceptible strains. A direct observation of the subcellular fraction prepared from TIMM 3318 by the electron microscopy negative-staining method suggests that most of the vesicular vacuoles were recovered in the P-120 fraction. These results suggest that fluconazole sequestration caused by vesicular vacuoles of the resistant isolate might act as a novel mechanism of fluconazole resistance besides the decreased affinity of cytochrome P-450.

X-ray structure of mercerized cellulose II at 1 a resolution

A revised crystal structure for mercerized cellulose based on high-resolution synchrotron X-ray data collected from ramie fibers is reported (space group P2(1), a = 8.10(3) A, b = 9.03(3) A, c = 10.31(5) A, gamma = 117.10(5) degrees; 751 reflections in 304 composite spots; theta < 21.11 degrees; lambda = 0.7208 A; LALS refinement with d > 1.5 A, R' ' = 0.16; SHELX97 refinement with d > 1 A, R = 0.21). As with regenerated cellulose the crystal structure consists of antiparallel chains with different conformations but with the hydroxymethyl groups of both chains near the gt position. However, the conformation of the hydroxymethyl group of the center chain in the structure reported here differs significantly from the conformation in regenerated cellulose. This may be related to a large observed difference in the amount of hydroxymethyl group disorder: approximately 30% for regenerated cellulose and approximately 10% for mercerized cellulose.

Expression of tegument protein pp65 of human cytomegalovirus (CMV) and its application to the analysis of viral-specific cellular immunity in CMV-infected individuals

Investigations into human cytomegalovirus (CMV)-specific cellular immunity are important to better understand and manage CMV infections. CMV phosphoprotein pp65 is thought to be a major antigen for CMV-specific cellular immunity. We newly synthesized protein pp65 with a baculovirus expression system and purified it via metal affinity chromatography in a soluble form. The recombinant protein pp65 was antigenic in an enzyme immuno-linked assay for pp65-specific IgG in sera from 196 children. Traditional lymphoproliferation assays have shown that pp65 protein promotes specific lymphoproliferation in CMV-seropositive donors. Using an intracellular cytokine detection system, we showed that this recombinant protein stimulated CD4-positive T cells to express interferon-gamma. The results of these assays using protein pp65 were comparable with the use of CMV whole antigen. pp65- and CMV-specific cellular immunity, and CMV DNA load were also compared in four recipients of unrelated cord blood transplantation. The delay in re-constitution in CMV-specific cellular immunity was associated with reactivation of CMV. These results indicated that the recombinant protein pp65 can be used to study specific immunity in CMV infections.

99mTc-MIBI and 201Tl SPET in the detection of recurrent brain tumours after radiation therapy

The purpose of this study was to evaluate whether Tc-hexakis-2-methoxyisobutylisonitrile ( Tc-MIBI) or Tl single photon emission tomography (SPET) could detect recurrent tumours in patients with previous radiation therapy for brain tumours. Dual SPET with Tc-MIBI and Tl was performed in 21 patients suspected of having recurrent brain tumours. SPET images were acquired 15 min (early) and 2 h (delayed) after injection. The ratio of the average counts for the region of interest in the lesion area and its mirror image in normal brain tissue was obtained. Early and delayed ratios were calculated. On the basis of histological and/or clinical findings, the final diagnosis was considered as recurrent tumours in 15 patients and radiation necrosis in six. Both ratios using Tc-MIBI and Tl were significantly higher in recurrent tumours than in radiation necrosis. Based on a cut-off of 5.89 of the early ratio using Tc-MIBI to distinguish between recurrent tumours and radiation necrosis, the accuracy was 90%. Based on a cut-off of 6.77 of the delayed ratio using Tc-MIBI, the accuracy was 86%. The corresponding values using cut-offs of 2.40 and 1.85 with Tl were 90% and 86%, respectively. However, within recurrent tumours, both ratios for Tc-MIBI were significantly higher than those for Tl. Early Tc-MIBI SPET may be especially useful for the detection of recurrent tumours in patients who have previously undergone radiation therapy for brain tumours.

Comparison of different methods for extraction of mitochondrial DNA from human pathogenic yeasts

Methods of rapidly extracting chromosomal DNA from human pathogenic yeasts were used in mitochondrial DNA (mtDNA) studies. This paper is concerned with rapid and reliable methods of extracting mtDNA for sequence analysis for species or strain identification, and epidemiological study of medically important fungi and fungal infections. To determine the optimal method of mtDNA extraction without isolating mitochondria, we examined three commonly used methods: 1). boiling, 2). glass bead disruption, and 3). a commercially available kit. We assessed the amount and quality of DNAs using a spectrophotometer and specific polymerase chain reaction (PCR). The DNA yield depended on the extraction method used and the yeast species. An adequate amount of mtDNA was obtained with both glass beads and a commercially available kit to amplify the mitochondrial gene using PCR without isolating the mitochondria. These techniques are convenient for extracting DNA from a variety of small-scale samples.

Critical involvement of CD40 in protection against herpes simplex virus infection in a murine model of genital herpes

We studied the requirement for CD40+ cells in the resolution of vaginal infection with avirulent herpes simplex virus type I (HSV-1) in vivo using CD40-deficient mice, which were susceptible to infection with avirulent HSV-1. Compared with wild-type mice, CD40-deficient mice could not eliminate HSV-1 virus effectively from the vaginal mucosa and produced lower amounts of interleukin-12 and interferon-gamma. These results show that the induction and activation of CD40+ cells are important for HSV prevention, facilitating the activation of T cells to induce an efficient HSV clearance from the vaginal mucosa and to prevent lethal illness due to HSV infection.

Comparison of 201 Tl- with 67 Ga single photon emission tomography in the diagnosis of head and neck cancer recurrence

The purpose of this study was to evaluate the usefulness of 201Tl single photon emission tomography (SPET) in comparison with 67Ga SPET for distinguishing recurrent tumours in patients previously treated for head and neck cancer. A total of 37 patients with suspicion of recurrent cancer were investigated. SPET images with 201Tl were acquired 10min (early) and 3h (delayed) and SPET images with 67Ga were acquired 72h, after injection. The visual and semiquantitative (T/N ratio) analysis were performed. On visual analysis, results from early 201Tl SPET were the same as those from delayed 201Tl SPET. The sensitivity, specificity and accuracy of the diagnosis of local recurrence using 201Tl SPET were all 100%. The three values using 201Tl SPET for neck lymph node metastases were 73%, 100% and 91%. The corresponding values using 67Ga SPET for local recurrence were 57%, 100% and 89%, respectively, and those using 67Ga SPET for neck lymph node metastases 55%, 100% and 84%, respectively. In the semiquantitative analysis, there was a statistically higher T/N ratio obtained using 201Tl when compared with 67Ga. 201Tl early SPET, especially, has the potential to replace 67Ga SPET in the follow-up of patients with head and neck cancer.

The US2 gene product of herpes simplex virus type 2 interacts with cytokeratin 18

In order to clarify the biological role of US2 gene product of herpes simplex virus type 2 (HSV-2), a HeLa cDNA library was screened in the yeast two-hybrid system using US2 protein as bait, and several interacting proteins were identified, including cytokeratin 18. US2 protein was co-immunoprecipitated with cytokeratin 18 from HSV-2 infected cell lysates. Analysis of infected orA431 cells by immunofluorescence showed that US2 protein gave filamentous or dot-like cytoplasmic staining pattern, and that it co-localized with cytokeratin 18. When US2 protein was expressed alone, it co-localized with cytokeratin 18. To define the domain interacting with cytokeratin 18, deletion mutant proteins were constructed and cells transfected with mutants were analyzed by indirect immunofluorescence. These results suggest that the N-terminal half of the US2 protein, especially the region containing amino acids 42-77, is important for interaction with cytokeratin 18.

Fungal flora on board the Mir-Space Station, identification by morphological features and ribosomal DNA sequences

This report is on the morphological and molecular biological identification, using 18S- and ITS1-rDNA sequences, of the "space fungi" isolated on board the Russian Mir-Space Station as the major constituents of the fungal flora. The six fungal strains were isolated from air by using an air sampler or from condensation. Strains were identified as Penicillium chrysogenum, Aspergillus versicolor, or Penicillium sp. by both methods. The species of space fungi were common saprophytic fungi in our living environment, potential pathogens, and allergens. This study concluded that the environment on board the space station Mir allows the growth of potentially pathogenic fungi as true in residential areas on the earth. Therefore, to prevent infection or other health disorders caused by these fungi, easy and reliable methods should be established to survey the fungal flora in a space station.

Morphological changes of Candida albicans induced by micafungin (FK463), a water-soluble echinocandin-like lipopeptide

Micafungin (FK463), a novel water-soluble echinocandin-like lipopeptide, exerted fungicidal action toward growing cells of Candida albicans at concentrations of 0.1 microg ml(-1) or above. The drug at these levels induced osmotically fragile cells and the resulting fungicidal effect was partially reversed when cultures were grown in the presence of an osmotic stabilizer. Candida cells incubated with fungicidal concentrations of micafungin gradually increased in size and/or became deformed. An electron microscopic study of such micafungin-treated cells revealed morphological alterations in the cell wall; deformation in contour, abnormal septum formation and decrease in thickness of the intermediate layer of the cell wall were prominent. In addition, the structure of cell membranes as well as of membranous cytoplasmic organelles was slightly impaired. These data suggest that micafungin principally affects the normal formation of the cell wall in growing Candida cells.

Comparative evaluation of 99mTc-MIBI and 99mTc-HMDP scintimammography for the diagnosis of breast cancer and its axillary metastases

The purpose of the present study was to compare scintimammography using technetium-99m hexakis 2-methoxyisobutylisonitrile (MIBI) with that using 99mTc-hydroxymethylene diphosphonate (HMDP) in the detection of breast cancer and its axillary lesions. The study population comprised 50 consecutive females with breast cancer who were scheduled for surgery. All patients underwent scintimammography with 99mTc-MIBI and 99mTc-HMDP. The images were acquired 5 min (early) and 2 h (delayed) after injection of each radiopharmaceutical. Regions of interest were placed over the breast tumour (T), the axillary lesion (A) and the normal ipsilateral breast tissue (N). The two count ratios were calculated, i.e. the tumour to normal breast tissue ratio (T/N) and the axillary lymph node to normal breast tissue ratio (A/N). For the breast tumours, using 99mTc-MIBI the positive rate was 86% (43/50) for the early and 72% (36/50) for the delayed images. The corresponding values using 99mTc-HMDP were 72% (36/50) and 40% (20/50), respectively. Histopathological examination revealed metastatic lymph node involvement in 22 patients. For the axillary lesions, using 99mTc-MIBI the positive rate was 72.7% (16/22) for the early and 54.5% (12/22) for the delayed images. Using 99mTc-HMDP, the positive rate was only 18.2% (4/22) for the early and 4.5% (1/22) for the delayed images. Using 99mTc-MIBI, the mean T/N (+/- SD) ratios on early and delayed images were 2.69 +/- 1.64 and 2.03 +/- 1.16, respectively, and the mean A/N (+/- SD) ratios on early and delayed images were 2.20 +/- 1.23 and 1.80 +/- 1.20, respectively. The corresponding values using 99mTc-HMDP were 1.77 +/- 0.91, 1.42 +/- 0.72, 1.27 +/- 0.63 and 1.08 +/- 0.25, respectively. The T/N and A/N ratios on the early and delayed 99mTc-MIBI images were both significantly higher than those obtained using 99mTc-HMDP. 99mTc-MIBI scintimammography is more sensitive than 99mTc-HMDP scintimammography for the detection of breast cancer and its axillary lymph node metastases.