Prognostic factors in breast cancer. College of American Pathologists Consensus Statement 1999

Risk Factors of the Invasive Breast Cancer Locoregional Recurrence

Background. The aim of the research was to estimate the frequency of the locoregional breast cancer recurrence appearance, the recurrence-free period continuance, and the 3- and 5-year survival depending on the scope of the surgical intervention, menstrual profile, and histological and molecular-biologic characteristics of the primary tumor. Patients and Methods. Among 218 patients with a breast cancer, 99 patients had breast-conserving surgery (BCS) and 119 underwent radical mastectomy (RME); all patients had regional lymphatic nodes dissection. The size and the primary tumor differentiation degree, metastasis presence in the regional lymph nodes, ER expression, PR, and Her/2neu were assessed as the prognostics factors. Results. It was defined that the locoregional recurrence appearance frequency in patients with BCS turned out to be 13%, and in patients after RME it turned out to be 9%; the recurrence-free period continuance was 53 ± 8 months and 56 ± 10 months, respectively. Conclusions. The locoregional cancer recurrence frequency is higher in women with the menstrual function being preserved at the moment of the primary tumor detection than in postmenopausal patients and also in patients having the hyperexpression of the Her/2neu. The ipsilateral cancer recurrence decreases the 3-year survival by 7,1% and the 5-year one by 20,3%, respectively.

Yeast as a tool to explore cathepsin D function

Cathepsin D has garnered increased attention in recent years, mainly since it has been associated with several human pathologies. In particular, cathepsin D is often overexpressed and hypersecreted in cancer cells, implying it may constitute a therapeutic target. However, cathepsin D can have both anti- and pro-survival functions depending on its proteolytic activity, cellular context and stress stimulus. Therefore, a more detailed understanding of cathepsin D regulation and how to modulate its apoptotic functions is clearly needed. In this review, we provide an overview of the role of cathepsin D in physiological and pathological scenarios. We then focus on the opposing functions of cathepsin D in apoptosis, particularly relevant in cancer research. Emphasis is given to the role of the yeast protease Pep4p, the vacuolar counterpart of cathepsin D, in life and death. Finally, we discuss how insights from yeast cathepsin D and its role in regulated cell death can unveil novel functions of mammalian cathepsin D in apoptosis and cancer.

Quantitation of the Regional Lymph Node Metastatic Burden and Prognosis in Malignant Mammary Tumors of Dogs

BACKGROUND

As in women, regional lymph node status impacts survival in dogs with malignant mammary tumors. However, few studies have evaluated regional lymph node metastases in dogs with malignant mammary gland tumors.

OBJECTIVES

To estimate overall survival based on the assessments of the lymph node status and the morphologic and morphometric features in female dogs with malignant mammary gland tumors.

MATERIALS AND METHODS

In total, 178 lymph nodes from 97 female dogs were assessed and reviewed, and after confirmation by immunohistochemistry (IHC), 161 lymph nodes were selected for analysis of metastases. Animals were considered metastasis-free (negative lymph nodes) only after IHC analysis for cytokeratin AE1/AE3. The number of positive lymph nodes, the number of metastatic foci, the maximum diameter and the area of metastasis were analyzed, and estimates of overall survival were made.

RESULTS

Dogs with metastasis had lower mean survival than those with metastasis-free regional lymph nodes, showing a direct relationship between the number of affected lymph nodes and shorter survival. However, histologic analysis of the lymph nodes identified lower survival rates in animals with macrometastases and isolated tumor cells, areas of metastasis >20.11 mm², and metastatic diameters >7.32 mm.

CONCLUSION

The identification of ≥1 lymph nodes positive for metastasis and morphometric characterization of lymphatic metastases indicate the prognostic relevance of lymph nodes status in dogs with mammary tumors.

Pathogenetic mechanisms of heavy metals effect on proapoptotic and proliferative potential of breast cancer

MATERIALS AND METHODS

Chemical composition was studied with the help of the scanning electron microscope with energy-dispersion spectrometer. Immunohistochemical reaction showed the p53 and Ki-67 receptors expression. The study of DNA fragmentation was performed in agarose gel.

RESULTS

There was an interrelation between the accumulations of the trace elements with the degree of cancer malignancy. There were 85% of cases with positive reaction to Ki-67 and 40% cases with positive reaction to p53. We found a moderate correlation between the accumulation of microelements in the breast cancer tissue and the level of proliferative activity. We noted the combination of the increase of DNA fragmentation with the expression of p53 and Ki-67 receptors.

CONCLUSIONS

The trace elements can cause the initiation and the progression of the tumorous growth, which is expressed in the increased proliferation of tumor cells. This leads to the destabilization of the genetic material which can be expressed in the synthesis of mutant p53 protein. Finally, it leads to the block of apoptosis and regulatory effects of cells. This can cause the tumor progression and the destabilization of the genome, which is reflected in the increased DNA fragmentation.

Breast Cancer Patients Undergoing Sentinel Node Biopsy: Additional Axillary Tumor Burden as a Function of the Total Number of Excised Sentinel Nodes-A Multicenter Study

BACKGROUND

Recent studies have challenged the long-standing assumption that breast cancer prognosis is determined by lymph node regional status. We assessed locoregional relapse, distant metastases, and mortality alongside additional axillary disease in breast cancer patients undergoing sentinel node (SN) biopsy.

PATIENTS AND METHODS

This prospective study assessed 1070 women with clinical T1-T2 invasive breast cancer with negative clinical/ultrasound axillae.

RESULTS

A total of 25.1% of patients had positive SN biopsy findings, of whom 69.2% had only 1 involved SN. The rate of axillary recurrence was 0.7%, with no significant differences found between patients with positive or negative SN (0.6% vs. 1.1%). There were also no significant differences in the rate of distant metastases or breast cancer-specific mortality. If we had applied the Z0011 trial suggestions, residual axillary disease would have reached 16.2%: 13.5% in patients over 50% and 21.3% in patients under 50. The rate of residual axillary disease would have been 25.2% in patients with only 1 SN (20.2% in patients over 50% and 38.2% in patients under 50). In patients with 2 SN, residual disease would have ranged from 12.0% in patients over 50% to 19.0% in patients under 50. From 3 SN on, residual disease seems negligible.

CONCLUSION

There were no significant differences in locoregional relapse, distant metastases, or mortality between patients with negative and positive SN. Patients with 3 or more SN have no additional axillary disease. In patients younger 50, one must be extremely cautious if the Z0011 suggestions are to be applied, especially if there is only 1 SN.

The clinicopathological and prognostic significance of CD24, CD44, CD133, ALDH1 expressions in invasive ductal carcinoma of the breast: CD44/CD24 expression in breast cancer

BACKGROUND

Recently, there are several studies about cancer stem cells (CSC), indicating that they are the cells that initiate the tumor, provide progression, metastasis and responsible for the aggressive tumor behavior.

MATERIALS AND METHODS

The purpose of this study is to investigate the expressions of CD24, CD44, their different combinations, ALDH1 and CD133 in invasive ductal carcinoma. Their relationships with clinicopathologic parameters, such as tumor grade, lymphovascular invasion, tumor size, axillary lymph node involvement, stage, hormone receptors, HER2 expression, basal like tumors, triple negative status and prognosis were also investigated. Tissue microarray method was used to investigate ımmunohistochemical CD24, CD44, ALDH1 and CD133 expressions in 105 invasive ductal carcinoma cases.

RESULTS

CD133 expression was significantly associated with tumor size (p=0.023) and stage (p=0.009). CD133 expression was decreased in tumors with larger tumor size, higher stage and lymphovascular invasion. CD133 expression was positively correlated with CD44 (r=0.212, p=0.032) and CD44(+)/CD24(+) (r=0.202, p=0.040) expressions. CD44, CD24 and ALDH1 expressions showed no significant relationship and correlation with clinicopathologic features. There was a significant relationship (p=0.048) between CD44(+)/CD24(-/low) phenotype and basal like tumors. EGFR expression was positively correlated with CD44(+)/CD24(-/low) phenotype (r=0.211, p=0.036).

CONCLUSIONS

Basal like tumors are enriched for CSCs with CD44(+)/CD24(-/low) phenotype. CD133 can detect a different population of CSC in breast carcinoma.

Hormone-receptor expression and survival patterns in operated cases of female invasive ductal breast carcinoma in Kerala: a retrospective cohort study

Background

Though breast cancer is the most common cancer among women in Kerala, India, epidemiological data on breast cancer in the state is largely lacking. The objectives of this study were to analyze the survival pattern of female breast carcinoma in this region of the country and to compare the differences in survival with different hormone-receptor expressions.

Methods

One hundred eighty-nine female breast cancer patients who were operated between 1 August 2008 and 3 July 2009 were followed up over telephone to obtain data on five-year survival. Grade, stage of the disease, and hormone-receptor (HR) status were obtained from treatment records. Logistic regression and the Kaplan-Meier survival analysis were used for statistical analysis.

Results

The mean age of the study population was 49.07 (SD, 10.35) years. A majority of the patients had estrogen receptor (ER)+/progesterone receptor (PR) + tumors (n = 103, 54.5%), followed by 72 (38.1%) ER−/PR−, 10 (5.3%) ER−/PR+, and 4 (2.1%) ER+/PR−. Stage of the disease, axillary nodal status, and hormone-receptor status showed statistically significant association with overall survival in breast cancer. Overall survival rate at the end of 5 years was 71.4%. Mortality was found to be highest for the ER − PR − group (47.2%).

Conclusions

Women in Kerala are diagnosed with breast carcinoma at a relatively younger age, yet the overall five-year survival for the disease is low when compared to developed nations. It is imperative that comprehensive breast cancer screening and treatment strategies be developed to enable earlier diagnosis and improve the survival of breast cancer in the state.

Cytological grading of breast carcinoma on fine needle aspirates and its relation with histological grading

Background:

Grading of breast carcinoma on fine needle aspiration cytology (FNAC) is beneficial for selecting patients for neoadjuvant chemotherapy.

Aims:

To grade the breast carcinoma on FNAC using Robinson grading system and to assess the concordance of cytological grading (CG) with histological grading (HG) using Elston-Ellis modification of Scarff-Bloom-Richardson grading system.

Materials and Methods:

The study was conducted for 1-year, comprising of 50 female patients attending outpatient departments (OPD) as well as admitted in various surgical wards of a teaching hospital, diagnosed as breast carcinoma. FNAC smears were stained with May–Grunwald–Giemsa and Papanicolaou (Pap) stains and CG was done using Robinson system on Pap stained smears. The results were compared with HG system after resection of tumors.

Results:

Of 50 cases, 14 (28%) cases were graded as grade I, 24 (48%) grade II, and 12 (24%) grade III by CG, whereas 9 (18%), 28 (56%) and 13 (26%) cases were graded as grade I, II and III by HG. The result showed overall 72% concordance of CG with HG, with grade II and grade III showing highest degree of concordance (83.33%), which is comparable to previous studies. Kappa measurement showed a higher degree of agreement in high-grade tumors compared with low-grade tumors (0.73 in grade III, 0.53 in grade II and 0.39 in grade I).

Conclusion:

Cytological grading is comparable to HG in majority of cases. Because neoadjuvant chemotherapy is becoming increasingly popular as primary treatment modality of breast cancer, CG could be a useful parameter in selecting the mode of therapy and predicting tumor behavior.

Accumulation of p53 is prognostic for aromatase inhibitor resistance in early-stage postmenopausal patients with ER-positive breast cancer

Objective

Studies have indicated that p53 protein accumulation exerts an adverse effect on the survival of breast cancer patients; however, the prognostic value of p53 protein accumulation for aromatase inhibitor (AI) resistance in ER-positive breast cancer is uncertain.

Methods

The expression level of p53 protein was detected by immunohistochemistry in primary early-stage ER-positive breast tumor specimens from 293 postmenopausal breast cancer patients who received first-line AI treatment (letrozole, anastrozole, or exemestane) until relapse, and analysis was performed to determine whether expression of p53 protein affected the response to endocrine therapy.

Results

Of the 293 invasive ductal carcinomas, 65.4% were positive for p53 protein expression. All patients received AI therapy as first-line treatment until relapse. The 5-year disease-free survival rates in p53-positive and p53-negative patients were 78% and 89%, respectively. Patients with primary breast tumors that had p53 protein accumulation showed significantly more resistance to AI treatment (hazard ratio=1.729, 95% confidence interval=1.038–2.880, P=0.035).

Conclusion

This study demonstrated that p53 protein accumulation was helpful in choosing patients who may benefit from AI treatment and is a prognostic marker in ER-positive early-stage breast cancer.

Parameters of dynamic contrast-enhanced MRI as imaging markers for angiogenesis and proliferation in human breast cancer

Background

Breast cancer is the most common malignancy and the leading cause of cancer death in women worldwide; however, early diagnosis has been difficult due to its complex pathological structure. This study evaluated the value of morphological examination in conjunction with dynamic contrast-enhanced MRI (DCE-MRI) for more precise diagnosis of breast cancer, as well as their correlation with angiogenesis and proliferation biomarkers.

Material/Methods

DCE-MRI parameters (including K^trans: volume transfer coefficient reflecting vascular permeability, K_ep: flux rate constant, V_e: extracellular volume ratio reflecting vascular permeability, and ADC: apparent diffusion coefficient) were obtained from 124 patients with breast cancer (124 lesions). Microvessel density (MVD) was evaluated by the immunohistochemical analysis of tumor vessels for CD31 and CD105 expression. The proliferation was assessed by analyzing Ki67.

Results

K^trans values were in the order of: malignant lesions > benign lesions > normal glands. Similar results were observed for K_ep. The opposite changes were seen with V_e. K^trans and K_ep values were significantly higher in invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS) than in mammary ductal dysplasia (MDD; ANOVA followed by Dunnett’s test). In sharp contrast, ADC values were lower in IDC and DCIS than in MDD, and V_e was not significantly different among the three groups. The data from MIP (maximum intensity projection) showed that benign breast lesions had no or only one blood vessel, whereas malignant lesions had two or more blood vessels. In addition, expression of CD105 and Ki67, the commonly recognized markers for angiogenesis and proliferation, respectively, were closely correlated with MRI parameters as revealed by Pearson analysis.

Conclusions

Determination of K^trans, K_ep and ADC values permits estimation of tumor angiogenesis and proliferation in breast cancer and DCE-MRI parameters can be used as imaging biomarkers to predict patient prognosis and the biologic aggressiveness of the tumor.

Breast cancer histopathology image analysis: a review

This paper presents an overview of methods that have been proposed for the analysis of breast cancer histopathology images. This research area has become particularly relevant with the advent of whole slide imaging (WSI) scanners, which can perform cost-effective and high-throughput histopathology slide digitization, and which aim at replacing the optical microscope as the primary tool used by pathologist. Breast cancer is the most prevalent form of cancers among women, and image analysis methods that target this disease have a huge potential to reduce the workload in a typical pathology lab and to improve the quality of the interpretation. This paper is meant as an introduction for nonexperts. It starts with an overview of the tissue preparation, staining and slide digitization processes followed by a discussion of the different image processing techniques and applications, ranging from analysis of tissue staining to computer-aided diagnosis, and prognosis of breast cancer patients.

Metastatic axillary lymph node ratio (LNR) is prognostically superior to pN staging in patients with breast cancer--results for 804 Chinese patients from a single institution

The number of axillary lymph nodes involved and retrieved are important prognostic factors in breast cancer. The purpose of our study was to investigate whether the lymph node ratio (LNR) is a better prognostic factor in predicting disease-free survival (DFS) for breast cancer patients as compared with pN staging. The analysis was based on 804 breast cancer patients who had underwent axillary lymph node dissection between 1999 and 2008 in Sun Yat-Sen University Cancer Center. Optimal cutoff points of LNR were calculated using X-tile software and validated by bootstrapping. Patients were then divided into three groups (low-, intermediate-, and high-risk) according to the cutoff points. Predicting risk factors for relapse were performed according to Cox proportional hazards analysis. DFS was estimated using the Kaplan-Meier method and compared by the log-rank test. The 5-year DFS rate decreased significantly with increasing LNRs and pN. Univariate analysis found that the pT , pN, LNR, molecule type, HER2, pTNM stage and radiotherapy well classified patients with significantly different prognosis. By multivariate analysis, only LNR classification was retained as an independent prognostic factor. Furthermore, there was a significant prognostic difference among different LNR categories for pN2 category, but no apparent prognostic difference was seen between different pN categories in any LNR category. Therefore, LNR rather than pN staging is preferable in predicting DFS in node positive breast cancer patients, and routine clinical decision-making should take the LNR into consideration.

Magnetic resonance imaging and clinicopathological factors for the detection of occult nipple involvement in breast cancer patients

Purpose

Nipple sparing mastectomy provides good cosmetic results and low local recurrence rates for breast cancer patients. However, there is a potential risk of leaving an occult tumor within the nipple, which could lead to cancer relapse and poor prognosis for the patient. The objective of this study was to investigate the occult nipple involvement rate in mastectomy specimens, and to identify preoperative magnetic resonance imaging (MRI) findings and the clinicopathological characteristics of the primary tumor that may correlate with nipple invasion.

Methods

Four hundred sixty-six consecutive mastectomy samples with grossly unremarkable nipples were evaluated. Demographic and clinicopathological data were collected. Nipple involvement was evaluated using serial histological sections. The tumor size and tumor-nipple distance were measured using preoperative MRI images.

Results

Thirty-six of the 466 therapeutic mastectomy specimens (7.7%) were found to have occult nipple involvement. In univariate analysis, tumor size, tumor-nipple distance, lymph node status, p53 mutation, and lymphovascular invasion (LVI) were found to influence the likelihood of nipple involvement. Multivariate logistic regression analysis, adjusted by lymph node status, p53 mutation, and LVI, showed that tumor size and tumor-nipple distance were predictive factors indicating nipple involvement. With regard to tumor location, only tumors in the central area of the breast showed a significant association with nipple involvement.

Conclusion

In this study, a statistically significant association was found between occult nipple involvement and tumor size, tumor-nipple distance, axillary lymph node status, LVI, and p53 mutation. A cutoff point of 2.2 cm for tumor size and 2 cm for tumor-nipple distance could be used as parameters to predict occult nipple involvement.

Evaluation of the stage IB designation of the American Joint Committee on Cancer staging system in breast cancer

PURPOSE

The seventh edition of the American Joint Committee on Cancer (AJCC) staging system for breast cancer differentiates patients with T1 tumors and lymph node micrometastases (stage IB) from patients with T1 tumors and negative nodes (stage IA). This study was undertaken to determine the utility of the stage IB designation.

PATIENTS AND METHODS

The following two cohorts of patients with breast cancer were identified: 3,474 patients treated at The University of Texas MD Anderson Cancer Center from 1993 to 2007 and 4,590 patients from the American College of Surgeons Oncology Group (ACOSOG) Z0010 trial. Clinicopathologic and outcomes data were recorded, and disease was staged according to the seventh edition AJCC staging system. Recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) were determined using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Median follow-up times were 6.1 years and 9.0 years for the MD Anderson Cancer Center and ACOSOG cohorts, respectively. In both cohorts, there were no significant differences between patients with stage IA and stage IB disease in 5- or 10-year RFS, DSS, or OS. Estrogen receptor (ER) status and grade significantly stratified patients with stage I disease with respect to RFS, DSS, and OS.

CONCLUSION

Among patients with T1 breast cancer, individuals with micrometastases and those with negative nodes have similar survival outcomes. ER status and grade are better discriminants of survival than the presence of small-volume nodal metastases. In preparing the next edition of the AJCC staging system, consideration should be given to eliminating the stage IB designation and incorporating biologic factors.

Mechanical phenotyping of breast cancer using MEMS: a method to demarcate benign and cancerous breast tissues

The mechanical properties of tissue change significantly during the progression from healthy to malignant. Quantifying the mechanical properties of breast tissue within the tumor microenvironment can help to delineate benign from cancerous stages. In this work, we study high-grade invasive ductal carcinoma in comparison with their matched tumor adjacent areas, which exhibit benign morphology. Such paired tissue cores obtained from eight patients were indented using a MEMS-based piezoresistive microcantilever, which was positioned within pre-designated epithelial and stromal areas of the specimen. Field emission scanning electron microscopy studies on breast tissue cores were performed to understand the microstructural changes from benign to malignant. The normal epithelial tissues appeared compact and organized. The appearance of cancer regions, in comparison, not only revealed increased cellularity but also showed disorganization and increased fenestration. Using this technique, reliable discrimination between epithelial and stromal regions throughout both benign and cancerous breast tissue cores was obtained. The mechanical profiling generated using this method has the potential to be an objective, reproducible, and quantitative indicator for detecting and characterizing breast cancer.

Contralateral prophylactic mastectomy after unilateral breast cancer: a systematic review and meta-analysis

OBJECTIVE

To examine whether contralateral prophylactic mastectomy (CPM) is associated with improved survival, incidence of contralateral breast cancer (CBC), and recurrence in patients with unilateral breast cancer (UBC).

BACKGROUND

Despite conflicting data, CPM rates continue to increase. Here we present the first meta-analysis to assess post-CPM outcomes in women with UBC.

METHODS

We searched 5 databases and retrieved papers' bibliographies for relevant studies published through March 2012. Fixed- and random-effects meta-analyses were conducted on the basis of tests of study heterogeneity. We examined potential confounding via stratification and meta-regression. We report pooled relative risks (RRs) and risk differences (RDs) with 95% confidence intervals (CIs) at 2-tailed P < 0.05 significance.

RESULTS

Of 93 studies reviewed, 14 were included in meta-analyses. Compared with nonrecipients, CPM recipients had higher rates of overall survival [OS; RR = 1.09 (95% CI: 1.06, 1.11)] and lower rates of breast cancer-specific mortality [BCM; RR = 0.69 (95% CI: 0.56, 0.85)] but saw no absolute reduction in risk of metachronous CBC (MCBC). Among patients with elevated familial/genetic risk (FGR, ie, BRCA carrier status and/or family history of breast cancer), both relative and absolute risks of MCBC were significantly decreased among CPM recipients [RR = 0.04 (95% CI: 0.02, 0.09); RD = -24.0% (95% CI: -35.6%, -12.4%)], but there was no improvement in OS or BCM.

CONCLUSIONS

CPM is associated with decreased MCBC incidence but not improved survival among patients with elevated FGR. The superior outcomes observed when comparing CPM recipients with nonrecipients in the general population are likely not attributable to a CPM-derived decrease in MCBC incidence. UBC patients without known FGR should not be advised to undergo CPM.

Evolution of sentinel lymph node biopsy in breast cancer, in and out of vogue?

Sentinel lymph node biopsy (SLNB) was introduced 2 decades ago and thereafter validated for routine surgical management of breast cancer, including cases treated with neoadjuvant chemotherapy. As the number of lymph nodes for staging has decreased, pathologists have scrutinized SLN with a combination of standard hematoxylin and eosin, levels, immunohistochemistry (IHC), and molecular methods. An epidemic of small-volume metastases thereby arose, leading to modifications in the American Joint Committee on Cancer staging to accommodate findings such as isolated tumor cells (ITC) and micrometastases. With the goal of determining the significance of these findings, retrospective followed by prospective trials were performed, showing mixed results. The ACOSOG Z10 and NSABP B-32 trials both independently showed that ITC and micrometastases were not significant and thus discouraged the use of levels and IHC for detecting them. However, the Surveillance Epidemiology and End Results database showed that patients with micrometastases had an overall decreased survival. In addition, the MIRROR (Micrometastases and ITC: Relevant and Robust or Rubbish?) trial, showed that patients with ITC and micrometastases treated with adjuvant therapy had lower hazard ratios compared with untreated patients. Subsequently, the ACOSOG Z0011 trial randomized patients with up to 2 positive SLN to axillary lymph node dissection (ALND) or not, all treated with radiation and chemotherapy, showing no difference in survival or recurrence rates between the 2 groups and causing a shift from ALND. As the rate of ALND has declined, the necessity of performing levels, IHC, frozen section, and molecular studies on SLN needs to be revisited.

Transducin (β)-like 1 X-linked receptor 1 promotes proliferation and tumorigenicity in human breast cancer via activation of beta-catenin signaling

Introduction

Transducin (β)-like 1 X-linked receptor 1(TBLR1) is an F-box-like and WD repeat-containing protein which functions as a switch in transcriptional activation, However, the clinical significance and biological role of TBLR1 in breast cancer remains largely unknown.

Methods

Western blotting, immunocytochemistry and real-time PCR were used to evaluate TBLR1 expression in normal breast epithelial cells and breast cancer cell lines, clinical tissue samples and adjacent nontumor tissues, and in 214 paraffin-embedded specimens. Statistical analyses were used to test for the prognostic and diagnostic associations. The biological role of TBLR1 -induced proliferation and tumorigenicity in breast cancer cells was explored in vitro and in vivo. The effect of TBLR1 on the expression of cyclin D1 and β-catenin signaling was examined by Western blotting, luciferase reporter assay and by several immunoprecipitation techniques.

Results

TBLR1 was significantly upregulated in breast cancer cells and tissues compared to normal control samples. Immunohistochemical analysis revealed high expression of TBLR1 in 113 of 214 (52.8%) paraffin-embedded archival breast cancer. The overall expression level of TBLR1 was significantly correlated with clinical stage (P <0.001), the tumor classification (P <0.001), node classification (P =0.024), and metastasis classification (P = 0.004), histological grade (P = 0.044), as well as with the expression level of c-erbB2 (P = 0.036) and Ki-67 (P <0.001). Patients with higher TBLR1 expression had shorter overall survival time, whereas patients with lower TBLR1 expression had better survival. Multivariate analysis suggested that TBLR1 expression might be an independent prognostic indicator for the survival of breast cancer patients. TBLR1 overexpression promoted, whereas TBLR1 silencing inhibited, proliferation and tumorigenicity in breast cancer cells both in vitro and in vivo. We found that TBLR1 expression was implicated in the upregulation of cyclin D1, phosphorylation of cell-cycle control protein Rb (pRb) and activation of β-catenin signaling in breast cancer.

Conclusions

TBLR1 plays a key role in the development and progression of breast cancer cells via cyclin D1-transactivation and activation of the β-catenin signaling pathway. TBLR1 may be a novel prognostic marker and a potential therapeutic target in the treatment human breast cancer.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-014-0465-z) contains supplementary material, which is available to authorized users.

Frozen section evaluation of breast carcinoma sentinel lymph nodes: a retrospective review of 1,940 cases

Many sentinel lymph node biopsies (SLNBs) are evaluated intraoperatively by frozen section, which may impact the need for further axillary dissection (AD). However, the need for AD in patients with small metastases has been recently called into question, meaning that frozen SLNB may be unnecessary. Furthermore, frozen section can compromise tissue for further study. At our institution, we grossly evaluate all SLNB and freeze half of the node. Here, we evaluate the frozen SLNB discrepancy rate using this method, focusing on cause of discrepancy and need for further surgery. We reviewed surgical pathology records for all breast cancer resections with frozen section of SLNB examined from 2003 to 2012. For cases with a frozen section discrepancy, we compiled clinicopathologic data. In total, 1,940 cases involved frozen section evaluation of SLNB. In 95 cases (4.9% of total cases, 23.8% of positive node cases), the SLNB was called negative on frozen but positive on final examination (false negatives). The majority of missed metastases are isolated tumor cells or micrometastases. A trend was observed toward fewer patients receiving completion AD after a discrepant frozen SLNB in the later years of the study. The protocol of freezing half of a SLNB is a reasonable method, with results similar to or better than other studies. The main adverse outcome is the need for separate AD; however, additional positive nodes are uncommon. The trend of fewer patients getting additional AD after a discrepant frozen SLNB suggests that clinicians may be using this information differently recently.

[Disease-free survival related factors in breast cancer]

OBJECTIVE

To evaluate the relationship between the clinical and pathological parameters of the primary tumor and disease-free survival (DFS) in a sample of hospital cases of invasive breast cancer.

MATERIAL AND METHOD

We performed a retrospective cohort study in 635 patients recruited at San Cecilio University Hospital in Granada (Spain) between 1994 and 2006. Information on the primary tumor and the outcomes of patients was collected by reviewing the medical records. Predictors of recurrence and/or metastasis and DFS (follow up of 3, 5 and 10 years) were analyzed by using Cox regression analysis.

RESULTS

Multivariate models adjusted for age, tumor size, lymph nodal status, histological grade and estrogen and progesterone receptor expression showed a higher risk of recurrence and/or metastasis and lower DFS (adjusted relative risk, 95% confidence intervals) with tumor size (3 yrs: 3.00, 1.79-5.03; 5 yrs: 2.56, 1.65-3.98; 10 yrs: 2.16, 1.44-3.24), lymph nodal status (3 yrs: 4.58, 2.42-8.65; 5 yrs: 3.84, 2.35-6.30; 10 yrs: 3.08, 2.05-4.61), lymphovascular invasion (5 yrs: 1.88, 1.16-3.04; 10 yrs: 2.19, 1.43-3.35), multifocal and/or multicenter tumors (3 yrs: 2.69, 1.46-4.96; 5 yrs: 1.90, 1.08-3.35) and p53 protein expression (3 yrs: 2.03, 1.00-4.09). DFS was positively associated with an increased expression of progesterone receptor (3 yr: 0.48, 0.26-0.89; 5 yrs: 0.58, 0.35-0.97; 10 yrs: 0.59, 0.38-0.90).

CONCLUSIONS

The biological characteristics of the primary tumor can be used to identify patients with distinctive prognoses and DFS, and could be helpful in making individual follow up strategies.

Is axillary sonographic staging less accurate in invasive lobular breast cancer than in ductal breast cancer?

OBJECTIVES

The purpose of this study was to determine whether axillary sonography is less accurate in invasive lobular breast cancer than in ductal breast cancer.

METHODS

Patients with invasive breast cancer were retrospectively identified from histologic records from 2010 to 2012. Staging axillary sonograms from 96 patients with primary breast cancer in each of 2 subgroups, invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC), were reviewed. Preoperative sonographically guided 14-gauge core biopsy was performed on morphologically abnormal lymph nodes.

RESULTS

Thirty-one of 96 patients (32%) in each subgroup were node positive on final postoperative histopathologic analysis. Axillary staging sensitivity was 17 of 31 patients (54%) in the IDC subgroup and 15 of 31(48%) in the ILC subgroup. Further analysis of the data showed no statistically significant differences between these subgroups.

CONCLUSIONS

We found that there was no statistically significant difference in the accuracy of axillary sonographic staging between ILC and IDC.

Nuclear Ep-ICD accumulation predicts aggressive clinical course in early stage breast cancer patients

Background

Regulated intramembrane proteolysis of Epithelial cell adhesion molecule (EpCAM) results in release of its intracellular domain (Ep-ICD) which triggers oncogenic signalling. The clinical significance of Ep-ICD in breast cancer remains to be determined. Herein, we examined the expression of nuclear and cytoplasmic Ep-ICD, and membranous extracellular domain of EpCAM (EpEx) in breast cancer patients, to determine its potential utility in predicting aggressive clinical course of the disease.

Methods

In this retrospective study, 266 breast cancers and 45 normal breast tissues were immunohistochemically analyzed to determine the expression patterns of nuclear and cytoplasmic Ep-ICD and membranous EpEx and correlated with clinicopathological parameters and follow up. Disease-free survival was determined by Kaplan-Meier method and multivariate Cox regression analysis.

Results

Nuclear Ep-ICD was more frequently expressed in breast cancers compared to normal tissues. Significant association was observed between increased nuclear Ep-ICD expression and reduced disease-free survival in patients with ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) (p < 0.001). Nuclear Ep-ICD was positive in all the 13 DCIS and 25 IDC patients who had reduced disease-free survival, while none of the nuclear Ep-ICD negative DCIS or IDC patients had recurrence during the follow up period. Notably, majority of IDC patients who had recurrence had early stage tumors. Multivariate Cox regression analysis identified nuclear Ep-ICD as the most significant predictive factor for reduced disease-free survival in IDC patients (p = 0.011, Hazard ratio = 80.18).

Conclusion

Patients with nuclear Ep-ICD positive breast cancers had poor prognosis. The high recurrence of disease in nuclear Ep-ICD positive patients, especially those with early tumor stage suggests that nuclear Ep-ICD accumulation holds the promise of identifying early stage patients with aggressive disease who are likely to be in need of more rigorous post-operative surveillance and/or treatment.

Immunohistochemical detection improves the prognostic value of lymphatic and blood vessel invasion in primary ductal breast cancer

Background

Lymphovascular invasion (LBVI) including lymphatic (LVI) and blood (BVI) vessel invasion is a critical step in cancer metastasis. In breast cancer, the optimal detection method of LBVI remains unclear. This research aimed to compare the prognostic value of different assessments of the LVI and BVI in patients with early breast cancer.

Methods

The study cohort included 360 patients with a median follow-up of 168 months. LBVI on H&E sections (LBVI_H&_E) was reviewed centrally and blinded to the pathology report. Immunohistochemical staining for D2-40 and Factor VIII was performed to identify LVI_D2–40 and BVI_FVIII.

Results

LBVI_H&_E, LVI_D2–40 and BVI_FVIII were present in 102 (28%), 127 (35%) and 59 (16%) patients respectively. In node-negative patients (206), LBVI_H&_E, LVI_D2–40 and BVI_FVIII were present in 41 (20%), 53 (26%) and 21 (10%) respectively. In triple-negative patients (120), LBVI_H&_E, LVI_D2–40 and BVI_FVIII were present in 35 (29%), 46 (38%) and 16 (13%) respectively. LBVI_H&_E was significantly associated with tumour recurrence in the whole cohort (P < 0.001), node-negative patients (P = 0.001) and triple-negative patients (P = 0.004). LVI_D2–40 and BVI_FVIII were significantly associated with tumour recurrence in whole cohort, node-negative (all P < 0.001) and triple-negative patients (P = 0.002). In multivariate survival analysis, only LVI_D2–40 and BVI_FVIII were independent predictors of cancer specific survival in the whole cohort (P = 0.023 and P < 0.001 respectively), node-negative patients (P = 0.004 and P = 0.001 respectively) and triple-negative patients (P = 0.014 and P = 0.001 respectively).

Conclusion

Assessment of LVI and BVI by IHC using D2-40 and Factor VIII improves prediction of outcome in patients with node-negative and triple-negative breast cancer.

Clinicopathologic and demographic evaluation of triple- negative breast cancer patients among a turkish patient population: a single center experience

BACKGROUND

To evaluate the clinicopathologic and demographic characteristics of triple-negative breast cancer (TNBC) patients and to determine differences from non-triple-negative cases.

MATERIALS AND METHODS

A detailed review of the medical records of 882 breast cancer (BC) patients was conducted to obtain information regarding age, menopausal status, height and weight at the time of diagnosis, presence of diabetes or hypertension, and pathologic characteristics of the tumor (tumor size, lymph node status, histologic grade, ER status, PR status, HER2 status, p53 mutation). Body mass index (BMI) was calculated and a value of ≥30 was considered as indicative of obesity.

RESULTS

14.9% (n=132) of the patients had TNBC. There was no difference among the patients in terms of median age, comorbid conditions and menopausal status. The proportion of medullary, tubular and mucinous carcinomas was significantly higher (15.9%) in the triple-negative (TN) group, while invasive lobular histology was more frequent (8.2%) among non-triple negative (NTN) cases (p<0.001). Grade 3 (G3) tumors were more frequent in the triple-negative group (p<0.001). The rate of p53 mutation was 44.3% in TN tumors versus 28.2% in the NTN group (p<0.001). The two groups were similar in terms of LN metastasis. In the NTN group, the rate of patients with BMI ≥30 was 53% among postmenopausal patients, while it was 36% among premenopausal women, and the difference was statistically significant (p<0.001). No significant difference was observed in terms of BMI between postmenopausal and premenopausal patients in the TN group (p=0.08).

CONCLUSIONS

TNBC rates and clinicopathologic characteristics of the Turkish patient population were consistent with the data from Europe and America. However, no relationship between obesity and TNBC was observed in our study. The association between TNBC and obesity needs to be evaluated in a larger patient population.

Tumor characteristics of breast cancer in predicting axillary lymph node metastasis

Background

Tumor characteristics was sought to be related to axillary lymph node metastasis (ALNM), the paramount prognostic factor in patients with invasive breast cancer. This study was aimed to identify the ALNM-associated tumor characteristics and to determine the predictive clinical pathway.

Material/Methods

Data from 1325 patients diagnosed with invasive breast cancer between January 2004 and January 2010 were retrospectively reviewed. The structure equation model (SEM) was used to build the predictive clinical pathway.

Results

Among the factors found in the final model, the status of human epidermal growth factor receptor 2 is the primary influence on ALNM through histology grade (β=0.18), followed by tumor size (β=0.16). Tumor size was highly relevant to lymphovascular invasion (LVI) and influenced ALNM through LVI (β=0.26), the strongest predictor of ALNM in the final model (β=0.46) and the highest risk of ALNM (odds ratio=9.282; 95% confidence interval: 7.218–11.936).

Conclusions

The structure equation model presented the relation of these important predictors, and might help physicians to assess axillary nodal condition and appropriate surgical procedures.

Memo is a copper-dependent redox protein with an essential role in migration and metastasis

Memo is an evolutionarily conserved protein with a critical role in cell motility. We found that Memo was required for migration and invasion of breast cancer cells in vitro and spontaneous lung metastasis from breast cancer cell xenografts in vivo. Biochemical assays revealed that Memo is a copper-dependent redox enzyme that promoted a more oxidized intracellular milieu and stimulated the production of reactive oxygen species (ROS) in cellular structures involved in migration. Memo was also required for the sustained production of the ROS O2- by NADPH (reduced form of nicotinamide adenine dinucleotide phosphate) oxidase 1 (NOX1) in breast cancer cells. Memo abundance was increased in >40% of the primary breast tumors tested, was correlated with clinical parameters of aggressive disease, and was an independent prognostic factor of early distant metastasis.

Circulating Tumor Cells in Metastatic Breast Cancer: A Prognostic and Predictive Marker

The role of circulating tumor cells (CTCs) as a marker for disease progression in metastatic cancer is controversial. The current review will serve to summarize the evidence on CTCs as a marker of disease progression in patients with metastatic breast cancer. The immunohistochemistry(IHC)-based CellSearch^® is the only FDA-approved isolation technique for quantifying CTCs in patients with metastatic breast cancer. We searched PubMed and Web of Knowledge for clinical studies that assessed the prognostic and predictive value of CTCs using IHC-based isolation. The patient outcomes reported include median and Cox-proportional hazard ratios for overall-survival (OS) and progression-free-survival (PFS). All studies reported shorter OS for CTC-positive patients versus CTC-negative. A subset of the selected trials reported significant lower median PFS for CTC-positive patients. The reported trials support the utility of CTC enumeration for patient prognosis. But further studies are required to determine the utility of CTC enumeration for guiding patient therapy. There are three clinical trials ongoing to test this hypothesis. These studies, and others, will further establish the role of CTCs in clinical practice.

Vascular measurements correlate with estrogen receptor status

Background

Breast carcinoma can be classified as either Estrogen Receptor (ER) positive or negative by immunohistochemical phenotyping, although ER expression may vary from 1 to 100% of malignant cells within an ER + tumor. This is similar to genetic variability observed in other tumor types and is generally viewed as a consequence of intratumoral evolution driven by random genetic mutations. Here we view cellular evolution within tumors as a classical Darwinian system in which variations in molecular properties represent predictable adaptations to spatially heterogeneous environmental selection forces. We hypothesize that ER expression is a successful adaptive strategy only if estrogen is present in the microenvironment. Since the dominant source of estrogen is blood flow, we hypothesized that, in general, intratumoral regions with higher blood flow would contain larger numbers of ER + cells when compared to areas of low blood flow and in turn necrosis.

Methods

This study used digital pathology whole slide image acquisition and advanced image analysis algorithms. We examined the spatial distribution of ER + and ER- cells, vascular density, vessel area, and tissue necrosis within histological sections of 24 breast cancer specimens. These data were correlated with the patients ER status and molecular pathology report findings.

Results

ANOVA analyses revealed a strong correlation between vascular area and ER expression and between high fractional necrosis and absent ER expression (R² = 39%; p < 0.003 and R² = 46%; p < 0.001), respectively). ER expression did not correlate with tumor grade or size.

Conclusion

We conclude that ER expression can be understood as a Darwinian process and linked to variations in estrogen delivery by temporal and spatial heterogeneity in blood flow. This correlation suggests strategies to promote intratumoral blood flow or a cyclic introduction of estrogen in the treatment schedule could be explored as a counter-intuitive approach to increase the efficacy of anti-estrogen drugs.

Changes in breast cancer reports after pathology second opinion

Breast cancer pathology reports contain valuable information about the histologic diagnosis, prognostic factors and predictive indicators of therapeutic response. A second opinion may be requested by medical oncologists and surgeons, when a patient is referred from another institution for treatment. We report the experience with pathology second opinion in selected patients referred to the Breast Oncology Unit. 205 cases referred to the Breast Oncology Unit were selected for second opinion after clinical evaluation, between 2002 and 2012. The cases reviewed included 102 core needle biopsies, 88 surgical specimens from the breast and 18 lymphadenopathies, 14 from the axillary region. Pathology second opinion was based on a review of hematoxylin-eosin preparations, recuts of submitted paraffin blocks and written external pathology reports. Immunohistochemical studies for hormone receptors, HER2, myoepithelial cells, and other markers were performed in selected cases. A case was reclassified as showing major change when second opinion showed a potential for significant change in prognosis or treatment. Otherwise, it was considered to represent minor change or to be concordant. In 52 cases (25.4%), the pathology review showed changes. Thirty-three (16%) patients were reclassified for major changes and 19 (9.2%) as minor changes. In six patients, more than one major change was identified. The major discrepancies identified were related to the histologic classification (12 cases), the presence or absence of invasion in ductal carcinoma (15 cases), the results of hormone receptors (5 cases), and HER2 (7 cases). Major changes in histologic classification included two cases diagnosed as invasive ductal carcinoma and reclassified as benign, four cases with diagnosis of breast cancer reclassified as metastatic lung cancer, one case diagnosed as small cell carcinoma of lung metastatic in the breast, reclassified as primary carcinoma of the breast, and three cases with diagnosis of breast cancer in the axilla reclassified as primary cutaneous adnexal carcinomas (2) and metastatic melanoma (1), respectively. In two cases, the histologic type of the primary breast tumor was changed. Second opinion in breast pathology may uncover significant discrepancies that impact on patient management and prognosis. Major discrepancies are most frequently related to the assessment of the presence or absence of invasion in ductal carcinoma, the results of predictive makers of therapeutic response, and the differential diagnosis of breast cancer and nonmammary tumors in the breast, the axilla, and at distant sites.

High sensitivity of touch imprint cytology in young patients with invasive lobular carcinoma of the breast

Invasive lobular carcinoma (ILC) of the breast is a rare type of breast cancer. Metastatic ILC is difficult to identify in sentinel lymph nodes (SLNs) because of its low-grade cytomorphology and its tendency to resemble lymphocytes. Touch imprint cytology (TIC) is a rapid method for evaluating SLNs intraoperatively. We sought to evaluate this technique in the identification of SLN metastases in ILC. A total of 230 SLNs from 88 patients diagnosed with ILC were examined with TIC, and the results were compared with their histological diagnosis. We first confirmed some typical cytological features of SLN metastases in ILC such as a thick eosinophilic background and hyperplasia of small cell lacking adhesion. Further analysis showed that sensitivity of TIC was 60.5 % on per-node basis and 58.3 % on per-patient basis; specificity of TIC was 100 % on per-node basis and 100 % on per-patient basis. Interestingly, when we divided patients according to their ages, the sensitivity of TIC in patients younger than 50 years old greatly increased to 90.9 % on per-node basis and 85.7 % on per-patient basis, whereas the specificity remained 100 % on both per-node basis and per-patient basis. However, different tumor sizes did not clearly change the sensitivity of TIC compared to the overall sensitivity. Patients with tumor size bigger than 1 cm revealed a TIC sensitivity of 59.4 % on per-node basis and 55.0 % on per-patient basis. These results suggest that TIC can be used as a reliable method of detecting SLN metastasis only in young patients with ILC.

Osteosarcoma microenvironment: whole-slide imaging and optimized antigen detection overcome major limitations in immunohistochemical quantification

BACKGROUND

In osteosarcoma survival rates could not be improved over the last 30 years. Novel biomarkers are warranted to allow risk stratification of patients for more individual treatment following initial diagnosis. Although previous studies of the tumor microenvironment have identified promising candidates, novel biomarkers have not been translated into routine histopathology. Substantial difficulties regarding immunohistochemical detection and quantification of antigens in decalcified and heterogeneous osteosarcoma might largely explain this translational short-coming. Furthermore, we hypothesized that conventional hot spot analysis is often not representative for the whole section when applied to heterogeneous tissues like osteosarcoma. We aimed to overcome these difficulties for major biomarkers of the immunovascular microenvironment.

METHODS

Immunohistochemistry was systematically optimized for cell surface (CD31, CD8) and intracellular antigens (FOXP3) including evaluation of 200 different antigen retrieval conditions. Distribution patterns of these antigens were analyzed in formalin-fixed and paraffin-embedded samples from 120 high-grade central osteosarcoma biopsies and computer-assisted whole-slide analysis was compared with conventional quantification methods including hot spot analysis.

RESULTS

More than 96% of osteosarcoma samples were positive for all antigens after optimization of immunohistochemistry. In contrast, standard immunohistochemistry retrieved false negative results in 35-65% of decalcified osteosarcoma specimens. Standard hot spot analysis was applicable for homogeneous distributed FOXP3+ and CD8+ cells. However, heterogeneous distribution of vascular CD31 did not allow reliable quantification with hot spot analysis in 85% of all samples. Computer-assisted whole-slide analysis of total CD31- immunoreactive area proved as the most appropriate quantification method.

CONCLUSION

Standard staining and quantification procedures are not applicable in decalcified formalin-fixed and paraffin-embedded samples for major parameters of the immunovascular microenvironment in osteosarcoma. Whole-slide imaging and optimized antigen retrieval overcome these limitations.

Cisplatin plus gemcitabine for treatment of breast cancer patients with brain metastases; a preferential option for triple negative patients?

BACKGROUND

To assess the efficacy and tolerability of Cisplatin plus Gemcitabine combination in patients with brain metastases (BM) from breast cancer (BC).

MATERIALS AND METHODS

Eighteen BC patients with BM who were treated with Cisplatin plus Gemcitabine regimen between 2003-2011 were evaluated.

RESULTS

A median of 6 cycles of this regimen were received, in fifteen patients (83.3%) as first-line chemotherapy, in 2 as second- line and in 1 as third-line after diagnosis of BM. Dose reduction was performed in 11 (61.1%) patients; major reasons were neutropenia and leukopenia. Grade III neutropenia and Grade II trombocytopenia rates were 33.3% and 16.7% respectively. Overall response rate (ORR; complete+partial response rate) was 33.4% (n=6) for the entire study population; triple negative patients achieved an 66.6% ORR while hormone receptor (HR) positive patients had 25% and HER2 positive patients 12.5%. Median progression-free survival was 5.6 months (2.4-8.8 months, 95%CI) and longer in patients with triple negative breast cancer (TNBC) (median 7.4 months, 95%CI, 2.4-12.3 months) than the patients with other subtypes (median 5 months for HER2 positive and 3.6 months for HR positive patients). Median PFS of the patients with TNBC who received this regimen as first-line was 9.2 months (5.2-13.2 months, 95%CI).

CONCLUSIONS

Cisplatin plus Gemcitabine may be a treatment option for patients with BM from breast cancer. Longer PFS and higher response rates are results that support the usage of this regimen especially for the triple negative subtype. However, further prospective and randomized trials are clearly required to provide more exact information.

Proteomics for breast cancer urine biomarkers

Although the survival of breast cancer (BC) patients has increased over the last two decades due to improved screening programs and postoperative adjuvant systemic therapies, many patients die from metastatic relapse. Current biomarkers used in the clinic are not useful for the early detection of BC, or monitoring its progression, and have limited value in predicting response to treatment. The development of proteomic techniques has sparked new searches for novel protein markers for many diseases including BC. Proteomic techniques allow for a high-throughput analysis of samples with the visualization and quantification of thousands of potential protein and peptide markers. Human urine is one of the most interesting and useful biofluids for routine testing and provides an excellent resource for the discovery of novel biomarkers, with the advantage over tissue biopsy samples due to the ease and less invasive nature of collection. In this review, we summarize the results from studies where urine was used as a source for BC biomarker research and discuss urine sample preparation, its advantage, challenges, and limitation. We focus on the gel-based proteomic approaches as well as the recent development of quantitative techniques in BC urine biomarker detection. Finally, the future use of modern proteomic techniques in BC biomarker identification will be discussed.

Strain elastography for prediction of breast cancer tumor grades

OBJECTIVES

The purpose of this study was to determine whether the elasticity imaging/B-mode ratio on strain elastography can predict breast cancer tumor grades.

METHODS

A retrospective review of patients with breast lesions who underwent strain elastography and had a diagnosis of breast cancer by image-guided or surgical biopsy was performed. The axis of the maximum elastographic dimension was compared to the B-mode dimension to form an elasticity imaging/B-mode ratio. Lesions were categorized according to their pathologic type, including atypical ductal hyperplasia (ADH), mucinous or colloid cancer, ductal carcinoma in situ (DCIS), grade I invasive ductal carcinoma (IDC), grade II IDC, grade III IDC, invasive lobular carcinoma (ILC), and lymphoma. The mean elasticity imaging/B-mode ratio of each tumor type was calculated. The elasticity imaging/B-mode ratio of the tumor was compared to the tumor type by Kruskal-Wallis and Tukey-Kramer tests (lymphoma and ADH excluded because of small numbers).

RESULTS

Tumor grades included lymphoma (n = 3), ADH (n = 2), mucinous cancer (n = 11), DCIS (n = 19), IDC (grades I-III; n = 200), and ILC (n = 31). The mean elasticity imaging/B-mode ratio varied with increasing tumor grade. Tumor grades could not have been selected at random from one population (P < .0001, χ(2) test). Invasive lobular carcinoma and grade III IDC were statistically different from mucinous or colloid cancer, DCIS, and grade I and II IDC.

CONCLUSIONS

The elasticity imaging/B-mode ratio on strain elastography is related to the tumor grade.

Evaluation of mitotic activity index in breast cancer using whole slide digital images

Introduction

Mitotic Activity Index (MAI) is an important independent prognostic factor and an integral part of the breast cancer grading system. Thus, correct estimation of this prognostically relevant feature is essential for guiding treatment decision and assessing patient prognosis.

The aim of this study was to validate the use of high resolution Whole Slide Images (WSI) in estimating MAI in breast cancer specimens.

Methods

MAI was evaluated in 100 consecutive breast cancer specimens by three observers on two occasions, microscopically and on WSI with a wash out period of 4 months. MAI was also translated to mitotic scores as in grading. Inter- and intra-observer agreement between microscopic and digital MAI counts and scores was measured.

Results

Almost perfect inter-observer agreements were obtained from counting MAI using a conventional microscope (intra-class correlation coefficient (ICCC) 0.879) as well as on WSI (ICCC 0.924). K coefficients reflected good inter-observer agreements among observers' microscopic mitotic scores (average kappa 0.642). Comparable results were also observed among digital mitotic scores (average kappa 0.635). There was strong to perfect intra-observer agreements between MAI counts and mitotic scores for the two diagnostic modalities (ICCC 0.716–0.863, kappa 0.506–0.617). There were no significant differences in mitotic scores using both diagnostic modalities.

Conclusion

Scoring mitoses using WSI in breast cancer seems to be just as reliable and reproducible as when using a microscope. Further development of software and image quality will definitely encourage the use of WSI in routine pathology practice.

Does shear wave ultrasound independently predict axillary lymph node metastasis in women with invasive breast cancer?

Shear wave elastography (SWE) shows promise as an adjunct to greyscale ultrasound examination in assessing breast masses. In breast cancer, higher lesion stiffness on SWE has been shown to be associated with features of poor prognosis. The purpose of this study was to assess whether lesion stiffness at SWE is an independent predictor of lymph node involvement. Patients with invasive breast cancer treated by primary surgery, who had undergone SWE examination were eligible. Data were retrospectively analysed from 396 consecutive patients. The mean stiffness values were obtained using the Aixplorer^® ultrasound machine from SuperSonic Imagine Ltd. Measurements were taken from a region of interest positioned over the stiffest part of the abnormality. The average of the mean stiffness value obtained from each of two orthogonal image planes was used for analysis. Associations between lymph node involvement and mean lesion stiffness, invasive cancer size, histologic grade, tumour type, ER expression, HER-2 status and vascular invasion were assessed using univariate and multivariate logistic regression. At univariate analysis, invasive size, histologic grade, HER-2 status, vascular invasion, tumour type and mean stiffness were significantly associated with nodal involvement. Nodal involvement rates ranged from 7 % for tumours with mean stiffness <50 kPa to 41 % for tumours with a mean stiffness of >150 kPa. At multivariate analysis, invasive size, tumour type, vascular invasion, and mean stiffness maintained independent significance. Mean stiffness at SWE is an independent predictor of lymph node metastasis and thus can confer prognostic information additional to that provided by conventional preoperative tumour assessment and staging.