The role of lymphatic and blood vessel invasion in predicting survival and methods of detection in patients with primary operable breast cancer

Multiphases DCE-MRI Radiomics Nomogram for Preoperative Prediction of Lymphovascular Invasion in Invasive Breast Cancer

RATIONALE AND OBJECTIVES

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) radiomics had been used to evaluate lymphovascular invasion (LVI) in patients with breast cancer. However, no studies had explored the associations between features from delayed phase as well as multiphases DCE-MRI and the LVI status. Thus, we aimed to develop an efficient nomogram based on multiphases DCE-MRI to predict the LVI status in invasive (IBC) breast cancer patients.

MATERIALS AND METHODS

A retrospective analysis was conducted on preoperative clinical, pathological, and DCE-MRI data of 173 breast cancer patients. All patients were randomly assigned into training set (n=121) and validation set (n=52) in 7:3 ratio. The clinical, pathologic, and conventional MRI characteristics were then subjected to univariate and multivariate logistic regression analysis, and the clinical risk factors with P < 0.05 in the multivariate logistic regression were used to build clinical models. Different single-phase models (early phase, peak phase, and terminal phase), as well as a multiphases model integrating radiomics features from multiple phases, were established. Furthermore, a preoperative radiomics nomogram model was constructed by combining the rad-score of the multiphases model with clinicopathologic independent risk factors. Finally, the performance of the multiphases model, clinical model, and rad-score was compared using receiver operating characteristic (ROC) curves, area under the curve (AUC) values, and decision curve analysis (DCA). The clinical utility of the rad-score was evaluated using calibration curves, and Delong test was used to compare the differences in AUC values among the different models.

RESULTS

The axillary lymph nodes (ALN) status and Ki-67 had been identified as clinicopathologic independent predictors and a clinical model had been constructed. Image features that were extracted from the terminal phase of the DCE-MRI exhibited notably superior predictive performances compared to features from the other single phases. Particularly, in the multiphases model, terminal phase features were identified as potentially providing more predictive information. Among the nine features that were found to be associated with LVI in the multiphase model, one was derived from the early phase, two from the peak phase, and six from the terminal phase, indicating that terminal phase features contributed significantly more information towards predicting LVI. Evaluation of the nomogram performance revealed promising results in both the training set (AUCs: clinical model vs. multiphase model vs. nomogram=0.734 vs. 0.840 vs. 0.876) and the validation set (AUCs: clinical model vs. multiphase model vs. nomogram=0.765 vs. 0.753 vs. 0.832).

CONCLUSION

The DCE-MRI-based radiomics model demonstrated utility in predicting LVI status, features of the terminal phase offered more valuable information particularly. The preoperative radiomics nomogram enhanced the diagnostic capability of identifying LVI status in IBC patients, and might aid clinicians in making personalized treatment decisions.

Prognostic significance and value of further classification of lymphovascular invasion in invasive breast cancer: a retrospective observational study

PURPOSE

To investigate the prognostic significance of lymphovascular invasion in invasive breast cancer and the value of using specific vascular endothelial markers to further classify lymphovascular invasion.

METHODS

We collected 2124 patients with invasive breast cancer who were hospitalized at the First Hospital of Dalian Medical University from 2012 to 2020. Statistical methods were used to investigate the relationship between lymphovascular invasion and clinicopathological characteristics of breast cancer, and the correlation between lymphovascular invasion on overall survival (OS) and disease-free survival (DFS) of various categories of breast cancers. Immunohistochemical staining of breast cancer samples containing lymphovascular invasion using specific vascular endothelial markers D2-40 and CD34 was used to classify lymphovascular invasion and to investigate the relationship between lymphovascular invasion and breast cancer progression.

RESULTS

There was a high correlation between lymphovascular invasion and T stage, N stage and nerve invasion. Survival analyses showed that patients with lymphovascular invasion, especially luminal B, triple-negative, and Her-2 overexpression breast cancer patients, had poorer OS and DFS prognosis, and that lymphovascular invasion was an independent prognostic factor affecting OS and DFS in breast cancer. The immunohistochemical staining results showed that positive D2-40 staining of lymphovascular invasion was linked to the N stage and localized recurrence of breast cancer.

CONCLUSION

Lymphovascular invasion is associated with aggressive clinicopathological features and is an independent poor prognostic factor in invasive breast cancer. Breast cancer localized recurrence rate and lymph node metastases are influenced by lymphatic vessel invasion. Immunohistochemical techniques should be added to the routine diagnosis of lymphovascular invasion.

Prognostic predictive value of Ki-67 in stage I-II triple-negative breast cancer

Aim: Our research aimed to determine an optimal cutoff value and investigate the prognostic predictive function of Ki-67. Materials & methods: We retrospectively enrolled 1146 patients diagnosed with stage I-II triple-negative breast cancer. Disease-free and overall survival were analyzed using the Kaplan-Meier method and the Cox regression model. Results: We classified Ki-67 >45% as the high group (n = 716). A Ki-67 level of >45% was associated with poorer disease-free survival (p = 0.039) and overall survival (p = 0.029). Lymph node stage, neoadjuvant chemotherapy, and radiotherapy were independent predictive variables of prognosis. Conclusion: Triple-negative breast cancer may be further subcategorized according to the Ki-67 level. Neoadjuvant chemotherapy and postoperative radiotherapy can improve the prognosis of early triple-negative breast cancer.

Machine learning based on optimal VOI of multi-sequence MR images to predict lymphovascular invasion in invasive breast cancer

Objectives

Lymphovascular invasion serves as a crucial prognostic indicator in invasive breast cancer, influencing treatment decisions. We aimed to develop a machine learning model utilizing optimal volumes of interest extracted from multisequence magnetic resonance images to predict lymphovascular invasion in patients with invasive breast cancer.

Materials and methods

This study comprised 191 patients postoperatively diagnosed with invasive breast cancer through multi-sequence magnetic resonance imaging. Independent predictors were identified through univariate and multivariate logistic regression analyses, culminating in the construction of a clinical model. Radiomic features were extracted from multi-sequence magnetic resonance imaging images across various volume of interest scales (-2 mm, entire, +2 mm, +4 mm, and +6 mm). Subsequently, various radiomic models were developed using machine learning model algorithms, including logistic regression, support vector machine, k-nearest neighbor, gradient boosting machine, classification and regression tree, and random forest. A hybrid model was then formulated, amalgamating optimal radiomic and clinical models.

Results

The area under the curve of the clinical model was 0.757. Among the radiomic models, the most efficient diagnosis was achieved by the k-nearest neighbor-based radiomics-volume of interest (+2 mm), resulting in an area under the curve of 0.780. The hybrid model, integrating the k-nearest neighbor-based radiomics-volume of interest (+2 mm), and the clinical model surpassed the individual clinical and radiomics models, exhibiting a superior area under the curve of 0.864.

Conclusion

Utilizing a hybrid approach integrating clinical data and multi-sequence magnetic resonance imaging-derived radiomics models based on the multiscale tumor region volume of interest (+2 mm) proved effective in determining lymphovascular invasion status in patients with invasive breast cancer. This innovative methodology may offer valuable insights for treatment planning and disease management.

Tumor heterogeneity and clinically invisible micrometastases in metastatic breast cancer-a call for enhanced surveillance strategies

The biology of metastatic breast cancer (MBC) is understudied, primarily due to the difficulty of procuring multiple samples from patients with oligometastatic breast cancer. We developed a rapid postmortem tissue procurement program that allows the collection and analysis of numerous metastatic lesions, subclinical locations, and potential pre-metastatic niches that fall within this scope. We conducted a rapid postmortem tissue collection study on 9 patients with MBC. Patients and their families consented to donate tissues immediately after death in an IRB-approved study. Various disease subtypes, progression histories, organ involvement, and final causes of death are reported. In patients with hormone receptor-positive (HR+) disease, estrogen receptor (ER), progesterone receptor (PR), HER2, and Ki-67 expression were heterogeneous across metastatic lesions within individual patients. Disease phenotype at the end of life trended toward complete loss of HR expression. Nearly all (n = 7) patients exhibited extensive tumor involvement of additional organs that had not been previously diagnosed clinically and were not retrospectively visible on recent imaging. Of these seven individuals, three included organs uncommonly associated with MBC: kidney, spleen, pancreas, and ovary. Finally, we identified clinically undetectable micrometastases in several organs uncommonly involved in MBC. Our findings raise several clinically relevant questions regarding the mechanisms of metastatic progression. Insights from this study argue for better surveillance strategies for monitoring MBC. We highlight the need to capture more accurate biomarker information in the context of heterogeneous disease and urge the consideration of treatment strategies that combine multiple targeted therapies.

Is Programmed Death-Ligand 1 of Prognostic Significance in Triple-Negative Female Mammary Carcinoma?

Introduction

The most widespread female malignancy is breast cancer (BC), considerable percentage of patients with triple-negative BC (TNBC) experience rapid progression, recurrence, and metastasis. BC has not historically been treated as an immunogenic cancer. Nonetheless, several researchers have started to concentrate on immunotherapy.

Aim

The aim of the study is to investigate the immunohistochemical (IHC) expression of programmed death-ligand 1 (PD-L1) by stromal tumor-infiltrating lymphocytes (TILs) and tumor cells (TC) in female (TNBC) and to correlate with pathological features of such tumors, particularly those determine biologic behavior, such as the grade and stage the overall survival.

Methodology

This is a retrospective study which includes 49 paraffin-embedded tumor tissue sections which were collected from breast surgery specimens either radical or conservative of female patients with TNBC. The samples were analyzed immunohistochemically for PD-L1 expression.

Results

There were statistically significant relations among TC PD-L1 expression and TILs PD-L1 expression as well as relations among TILs PD-L1 expression with histologic grade, stromal TILs, and Ki-67 were statistically significant. Correlations between TC PD-L1 expression and N stage, histologic grade, and anatomic stage were statistically significant. Improved survival was detected within TILs PD-L1-positive cases; however, the correlation between the overall survival and PD-L1 expression in both TCs and stromal TIL was not statistically significant.

Conclusion

PD-L1 expressed in tumors with poor prognostic features such as the high grade, advanced T stage, and high Ki-67 index, TILs PD-L1-positive cases experienced improved survival supporting its prognostic significance. However, the correlation with overall survival was not statistically significant.

Evaluation of Lymphatic Vessel Invasion Determined by D2-40 Using Preoperative MRI-Based Radiomics for Invasive Breast Cancer

RATIONALE AND OBJECTIVES

Preoperative prediction of LVI status can facilitate personalized therapeutic planning. This study aims to investigate the efficacy of preoperative MRI-based radiomics for predicting lymphatic vessel invasion (LVI) determined by D2-40 in patients with invasive breast cancer.

MATERIALS AND METHODS

A total of 203 patients with pathologically confirmed invasive breast cancer, who underwent preoperative breast MRI, were retrospectively enrolled and randomly assigned to the following cohorts: training cohort (n=141) and test cohort (n=62). Then, univariate and multivariate logistic regression were performed to select independent risk factors and build a clinical model. Afterwards, least absolute shrinkage and selection operator (LASSO) logistic regression was performed to select predictive features extracted from the early and delay enhancement dynamic contrast-enhanced (DCE)-MRI images, and a radiomics signature was established. Subsequently, a nomogram model was constructed by incorporating the radiomics score and risk factors. Receiver operating characteristic curves were performed to determine the performance of various models. The efficacy of the various models was evaluated using calibration and decision curves.

RESULTS

Fourteen radiomics features were selected to construct the radiomics model. The size of the lymph node was identified as an independent risk factor of the clinical model. The nomogram model demonstrated the best calibration and discrimination performance in both the training and test cohorts, with an area under the curve of 0.873 (95% confidence interval [CI]: 0.807-0.923) and 0.902 (95% CI: 0.800-0.963), respectively. The decision curve illustrated that the nomogram model added more net benefits, when compared to the radiomics signature and clinical model.

CONCLUSION

The nomogram model based on preoperative DCE-MRI images exhibits satisfactory efficacy for the noninvasive prediction of LVI determined by D2-40 in invasive breast cancer.

MRI radiomics for the preoperative evaluation of lymphovascular invasion in breast cancer: A meta-analysis

PURPOSE

To evaluate the ability of preoperative MRI-based radiomic features in predicting lymphovascular invasion (LVI) in patients with breast cancer.

METHODS

PubMed, Embase, Web of Science, Cochrane Library databases, and four Chinese databases were searched to identify relevant studies published up until June 15, 2023. Two reviewers screened all papers independently for eligibility. We included diagnostic accuracy studies that used radiomics-MRI for LVI in patients with breast cancer, using histopathology as the reference standard. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 and Radiomics Quality Score. Overall diagnostic odds ratio (DOR), sensitivity, specificity and area under the curve (AUC) were calculated to assess the prediction efficacy of MRI-based radiomic features in patients with breast cancer. Spearman's correlation coefficient was calculated and subgroup analysis performed to investigate causes of heterogeneity.

RESULTS

Eight studies comprising 1685 female patients were included. The pooled DOR, sensitivity, specificity, and AUC of radiomics in detecting LVI were 23 [confidence interval (CI) 16,32], 0.89(0.86,0.92), 0.82 (0.78,0.86), and 0.83(0.78,0.87), respectively. The meta-analysis showed significant heterogeneity among the included studies. No threshold effect was detected. Subgroup analysis showed that more than 200 participants, radiomics with clinical factors, semiautomatic segmentation method and peritumoral or intra- and peritumoral model [DOR: 28(18,42), 26(19,37), 34(16,70), 40(10,156), respectively] could improve diagnostic performance compared with less than 200 participants, only radiomics, manual segmentation method, and tumor model [DOR: 16(7,37), 21(6,73), 20(12,32), 21(13,32), respectively], but 3.0 T MR and multiple sequences approach [DOR: 27(15,49),17(8,35)] couldn't improve diagnostic performance compared with 1.5 T and DCE radiomic features [DOR:27(7,99),25(17,37)].

CONCLUSION

Our meta-analysis showed that preoperative MRI-based radiomic features performs well in predicting LVI in patients with breast cancer. This noninvasive and convenient tool may be used to facilitate preoperative identification of LVI in breast cancer.

Negative Survival Impact of Occult Lymph Node Involvement in Small HER2-Positive Early Breast Cancer Treated by Up-Front Surgery

(1) Background: The independent negative prognostic value of isolated tumor cells or micro-metastases in axillary lymph nodes has been established in triple-negative breast cancers (BC). However, the prognostic significance of pN0(i+) or pN1mi in HER2-positive BCs treated by primary surgery remains unexplored. Therefore, our objective was to investigate the impact of pN0(i+) or pN1mi in HER2-positive BC patients undergoing up-front surgery on their outcomes. (2) Methods: We retrospectively analyzed 23,650 patients treated in 13 French cancer centers from 1991 to 2013. pN status was categorized as pN0, pN0(i+), pN1mi, and pNmacro. The effect of pN0(i+) or pN1mi on outcomes was investigated both in the entire cohort of patients and in pT1a-b tumors. (3) Results: Of 1771 HER2-positive BC patients included, pN status distributed as follows: 1047 pN0 (59.1%), 60 pN0(i+) (3.4%), 118 pN1mi (6.7%), and 546 pN1 macro-metastases (30.8%). pN status was significantly associated with sentinel lymph node biopsy, axillary lymph node dissection, age, ER status, tumor grade, and size, lymphovascular invasion, adjuvant systemic therapy (ACt), and radiation therapy. With 61 months median follow-up (mean 63.2; CI 95% 61.5-64.9), only pN1 with macro-metastases was independently associated with a negative impact on overall, disease-free, recurrence-free, and metastasis-free survivals in multivariate analysis. In the pT1a-b subgroup including 474 patients, RFS was significantly decreased in multivariate analysis for pT1b BC without ACt (HR 2.365, 1.04-5.36, p = 0.039) and for pN0(i+)/pN1mi patients (HR 2.518, 1.03-6.14, p = 0.042). (4) Conclusions: Survival outcomes were not adversely affected by pN0(i+) and pN1mi in patients with HER2-positive BC. However, in the case of pT1a-b HER2-positive BC, a negative impact on RFS was observed specifically for patients with pN0(i+) and pN1mi diseases, particularly among those with pT1b tumors without ACt. Our findings highlight the importance of considering the pN0(i+) and pN1mi status in the decision-making process when discussing trastuzumab-based ACt for these patients.

Automated breast volume scanner based Radiomics for non-invasively prediction of lymphovascular invasion status in breast cancer

PURPOSE

Lymphovascular invasion (LVI) indicates resistance to preoperative adjuvant chemotherapy and a poor prognosis and can only be diagnosed by postoperative pathological examinations in breast cancer. Thus, a technique for preoperative diagnosis of LVI is urgently needed. We aim to explore the ability of an automated breast volume scanner (ABVS)-based radiomics model to noninvasively predict the LVI status in breast cancer.

METHODS

We conducted a retrospective analysis of data from 335 patients diagnosed with T1-3 breast cancer between October 2019 and September 2022. The patients were divided into training cohort and validation cohort with a ratio of 7:3. For each patient, 5901 radiomics features were extracted from ABVS images. Feature selection was performed using LASSO method. We created machine learning models for different feature sets with support vector machine algorithm to predict LVI. And significant clinicopathologic factors were identified by univariate and multivariate logistic regression to combine with three radiomics signatures as to develop a fusion model.

RESULTS

The three SVM-based prediction models, demonstrated relatively high efficacy in identifying LVI of breast cancer, with AUCs of 79.00%, 80.00% and 79.40% and an accuracy of 71.00%, 80.00% and 75.00% in the validation cohort for AP, SP and CP plane image. The fusion model achieved the highest AUC of 87.90% and an accuracy of 85.00% in the validation cohort.

CONCLUSIONS

The combination of radiomics features from ABVS images and an SVM prediction model showed promising performance for preoperative noninvasive prediction of LVI in breast cancer.

Immunohistochemical expression of CD155 in invasive female breast carcinoma and its correlation with tumor infiltrating natural killer cells

Background

CD155 is an immune checkpoint protein that interacts with ligands on natural killer cells to regulate the tumor associated immunity. CD155 overexpression has been detected in many human cancer types. CD155 and its pathways are promising tumor immunotherapy targets. We aimed to evaluate the immunohistochemical expression of CD155 in invasive breast carcinomas and to correlate such expression with the pathological parameters of the tumors and also with natural killer - tumor infiltrating lymphocytes (NK-TILs) density in breast carcinomas tissue as highlighted by CD56 immunostaining. This study included 78 cases of breast carcinomas. Immunohistochemistry was performed using antibodies against CD155 which was detected on the tumor cells and CD56 as a marker for stromal NK cells.

Results

CD155 expression by the tumor cells was detected in 30.8% of the cases and correlated significantly with advanced prognostic stage, Estrogen receptor (ER) and Progesterone receptor (PR) negativity, high Ki-67 index and Human epidermal receptor 2 (HER2) enriched molecular subtype. High stromal TILs CD56 expression was detected in 28.2% of the cases and correlated significantly with high histologic grade, PR negativity, HER2 neu over-expression, high Ki-67 index, high stromal TILs and more aggressive molecular subtypes; triple negative breast cancer, HER2 enriched and Luminal B-HER2 positive. Finally, statistically significant direct correlation was detected between Tumor cells CD155 expression and high TILs CD56 expression.

Conclusions

Our results support tumor cell CD155 expression and TILs CD56 expression in breast cancers that are high grade, TILs rich and hormone receptors negative, highlighting those cases as possible candidates for CD155 targeted therapy.

Vascular regulation of disseminated tumor cells during metastatic spread

Cancer cells can travel to other organs via interconnected vascular systems to form new lesions in a process known as metastatic spread. Unfortunately, metastasis remains the leading cause of patient lethality. In recent years, it has been demonstrated that physical cues are just as important as chemical and genetic perturbations in driving changes in gene expression, cell motility, and survival. In this concise review, we focus on the physical cues that cancer cells experience as they migrate through the lymphatic and blood vascular networks. We also present an overview of steps that may facilitate organ specific metastasis.

Survival and clinicopathological significance of blood vessel invasion in operable breast cancer: a systematic review and meta-analysis

BACKGROUND

Lymphovascular invasion, including lymphatic-vessel invasion and blood-vessel invasion, plays an important role in distant metastases. The metastatic pattern of blood-vessel invasion may differ from that of lymphatic-vessel invasion. However, its prognostic significance in breast cancer remains controversial. We evaluated the role of blood-vessel invasion in the prognosis of operable breast-cancer patients and its association with clinicopathological characteristics.

METHODS

We systematically searched EMBASE, PubMed, the Cochrane Library and Web of Science for studies in English through December 2020. Disease-free survival, overall survival and cancer-specific survival were the primary outcomes. Pooled hazard ratios and 95% confidence intervals were assessed using a random-effects model.

RESULTS

Twenty-seven studies involving 7954 patients were included. Blood-vessel invasion occurred in 20.4% of tumor samples. Pooled results showed significant associations of blood-vessel invasion with worse disease-free survival (hazard ratio = 1.82; 95% confidence interval = 1.43-2.31) and overall survival (hazard ratio = 1.86; 95% confidence interval = 1.16-2.99) in multivariate analyses. The results of the univariate analyses were similar. Among the clinicopathological factors, blood-vessel invasion was associated with larger tumor size, lymph-node metastasis, nonspecific invasive type, higher histological grade, estrogen receptor-negative breast cancer, human epidermal growth factor receptor 2-positive breast cancer and lymphatic-vessel invasion. In the lymph-node-negative subgroup analyses, the presence of blood-vessel invasion led to poorer disease-free survival (hazard ratio = 2.46; 95%confidence interval = 1.64-3.70) and overall survival (hazard ratio = 2.94; 95%confidence interval = 1.80-4.80).

CONCLUSIONS

We concluded that blood-vessel invasion is an independent predictor of poor prognosis in operable breast cancer and is associated with aggressive clinicopathological features. Breast-cancer patients with blood-vessel invasion require more aggressive treatments after surgery.

Further predictive value of lymphovascular invasion explored via supervised deep learning for lymph node metastases in breast cancer

Lymphovascular invasion, specifically lymph-blood vessel invasion (LBVI), is a risk factor for metastases in breast invasive ductal carcinoma (IDC) and is routinely screened using hematoxylin-eosin histopathological images. However, routine reports only describe whether LBVI is present and does not provide other potential prognostic information of LBVI. This study aims to evaluate the clinical significance of LBVI in 685 IDC cases and explore the added predictive value of LBVI on lymph node metastases (LNM) via supervised deep learning (DL), an expert-experience embedded knowledge transfer learning (EEKT) model in 40 LBVI-positive cases signed by the routine report. Multivariate logistic regression and propensity score matching analysis demonstrated that LBVI (OR 4.203, 95% CI 2.809-6.290, P < 0.001) was a significant risk factor for LNM. Then, the EEKT model trained on 5780 image patches automatically segmented LBVI with a patch-wise Dice similarity coefficient of 0.930 in the test set and output counts, location, and morphometric features of the LBVIs. Some morphometric features were beneficial for further stratification within the 40 LBVI-positive cases. The results showed that LBVI in cases with LNM had a higher short-to-long side ratio of the minimum rectangle (MR) (0.686 vs. 0.480, P = 0.001), LBVI-to-MR area ratio (0.774 vs. 0.702, P = 0.002), and solidity (0.983 vs. 0.934, P = 0.029) compared to LBVI in cases without LNM. The results highlight the potential of DL to assist pathologists in quantifying LBVI and, more importantly, in exploring added prognostic information from LBVI.

Radiomics Analysis on Digital Breast Tomosynthesis: Preoperative Evaluation of Lymphovascular Invasion Status in Invasive Breast Cancer

RATIONALE AND OBJECTIVES

To develop a digital breast tomosynthesis (DBT)-based radiomics nomogram for preoperative evaluation of lymphovascular invasion (LVI) status in patients with invasive breast cancer (IBC).

MATERIALS AND METHODS

A total of 135 patients with pathologically confirmed IBC who underwent preoperative DBT from July 2018 to May 2020 were retrospectively enrolled and randomized into the training and validation sets. Radiomics feature extraction was performed on the volume of interest (VOI) manually outlined. A four-step algorithmic was applied to screen the features with the highest predictive power in the training set for constructing the radiomics signature and calculating the correspondent radiomics score (Rad-score). Logistic regression analyses were utilized to develop a combined radiomics model that incorporated the DBT-reported clinicoradiological semantic features and Rad-score, which was visualized as a radiomics nomogram.

RESULTS

The percentage of LVI-positive patients was 60.2% and 59.5% in the training and validation sets, respectively. The radiomics signature was constructed based on nine features selected from the 1218 radiomics features extracted. Higher Rad-score, maximum tumor diameter, and spiculate margin were independent risk factors for LVI. The area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, and specificity of the radiomics nomogram were 0.905, 72.7%, and 94.6% in the training set, and 0.835, 80.0%, and 76.5% in the validation set, respectively; this data was higher than models incorporating clinicoradiological semantic features alone or the radiomics signature in both sets.

CONCLUSION

Preoperative DBT-based combined radiomic nomogram could be a potential biomarker for LVI in patients with IBC.

Omission of chemotherapy for hormone receptor-positive and human epidermal growth factor receptor 2-negative breast cancer: patterns of treatment and outcomes from the Korean Breast Cancer Society Registry

Purpose

Although adjuvant chemotherapy (CTx) is still recommended for high-risk patients with hormone receptor-positive and human epidermal receptor (HER)-2-negative breast cancer, recent studies found that selected patients with low disease burden may be spared from CTx and receive hormonal treatment (HT) alone. This study aims to evaluate the trends of treatment (CTx + HT vs. HT alone) in Korea and to assess the impact on overall survival (OS) according to treatment pattern.

Methods

The Korean Breast Cancer Society Registry was queried (2000 to 2018) for women with pT1-2N0-1 hormone receptor-positive and HER2-negative disease who underwent surgery and adjuvant systemic treatment (CTx and HT). Clinicopathologic factors, change in pattern of treatment over time, and OS for each treatment option were analyzed.

Results

A total of 40,938 women were included in the study; 20,880 (51.0%) received CTx + HT, while 20,058 (49.0%) received HT only. In recent years, there has been a steady increase in the use of HT alone, from 21.0% (2000) to 64.6% (2018). In Cox regression analysis, age, type of breast and axillary operations, T and N stages, body mass index, histologic grade, and presence of lymphovascular invasion were prognostic indicators for OS. There was no significant difference between CTx + HT and HT alone in terms of OS (P = 0.126).

Conclusion

Over the years, there has been a shift from CTx + HT to HT alone without a significant difference in OS. Therefore, HT alone could be a safe treatment option in selected patients, even those with T2N1 disease.

Immediate breast reconstruction has no impact on the oncologic outcomes of patients treated with post-mastectomy radiation therapy: a comparative analysis based on propensity score matching

PURPOSE

To investigate the impact of immediate breast reconstruction (iBR) on patients treated with post-mastectomy radiation therapy (PMRT) using propensity score matching (PSM).

METHODS

After a retrospective review of patients treated with PMRT between 2008 and 2017, we included 153 patients who underwent iBR and 872 patients who did not undergo iBR. Among the 153 patients who underwent iBR, 34 received one-stage iBR with autologous tissue and 119 received two-stage iBR. Conventional fractionated PMRT with a total dose of 50-50.4 Gy in 25-28 fractions was performed in all patients. Propensity scores were calculated via logistic regression.

RESULTS

Patients who underwent iBR were younger, had early stage disease, and had more frequent hormone receptor-positive tumor than those who did not undergo iBR. After PSM, 127 patients from each group with well-balanced characteristics were selected. With a median follow-up of 67.5 months, iBR led to better 6-year disease-free survival rates compared to no iBR before PSM (84.8% vs. 71.4%, p = 0.003); after PSM, there was no significant difference (84.8% vs. 75.5%, p = 0.130). On multivariable analysis in the matched cohort, iBR was not associated with inferior disease-free survival (hazard ratio, 0.67; p = 0.175). In the sensitivity analysis, iBR was not associated with a lower disease-free survival across all prognostic groups. The 5-year cumulative incidence of iBR failure was 15.0%.

CONCLUSION

In patients with adverse pathologic factors planning to receive PMRT, iBR did not compromise oncologic outcomes. In addition, iBR can be considered in patients treated with PMRT with several clinicopathologic risk factors.

The role of vascular invasion and lymphatic invasion in predicting recurrent thoracic oesophageal squamous cell carcinoma

Background

Numerous studies have addressed lymphovascular invasion (LVI) in patients with thoracic oesophageal squamous cell carcinoma (ESCC); however, little is known about the individual roles of lymphatic invasion (LI) and vascular invasion (VI). We aimed to analyse the prognostic significance of LI and VI in patients with thoracic ESCC from a single centre.

Methods

This retrospective study included 396 patients with thoracic ESCC who underwent oesophagectomy and lymphadenectomy in our hospital. The relationship between LI, VI and the other clinical features was analysed, and disease-free survival (DFS) was calculated. Survival analysis was performed by univariate and multivariate statistics.

Results

Briefly, VI and LI were present in 25.8% (102 of 396) and 23.7% (94 of 396) of ESCC patients, respectively, with 9.15% patients presenting both LI and VI; the remaining patients did not present LI or VI. We found that LI was significantly associated with pN stage (P<0.001) and pTNM stage (P<0.001), and similar results were found in VI. Moreover, survival analysis showed that pT stage (P<0.001), pN stage (P=0.001), pTNM stage (p<0.001), VI (P=0.001) and LI (P<0.001) were associated with DFS in ESCC. Furthermore, multivariate analysis suggested that pT stage (RR=1.4, P =0.032), pN stage (RR=1.9, P<0.001) and LI (RR=1.5, P=0.008) were independent predictive factors for DFS. Finally, relapse was observed in 110 patients (lymph node metastasis, 78 and distant, 32) and 147 patients with cancer-related deaths. Subanalysis showed that LI-positive patients had higher lymph node metastasis, although there was no significant difference (32.1% vs. 15.6%, P=0.100).

Conclusions

LI and VI were common in ESCC; they were all survival predictors for patients with ESCC, and LI was independent. Patients with positive LI were more likely to suffer lymph node metastasis.

Lymphovascular invasion has a significant prognostic impact in patients with early breast cancer, results from a large, national, multicenter, retrospective cohort study

Background

We determined the prognostic impact of lymphovascular invasion (LVI) in a large, national, multicenter, retrospective cohort of patients with early breast cancer (BC) according to numerous factors.

Patients and methods

We collected data on 17 322 early BC patients treated in 13 French cancer centers from 1991 to 2013. Survival functions were calculated using the Kaplan–Meier method and multivariate survival analyses were carried out using the Cox proportional hazards regression model adjusted for significant variables associated with LVI or not. Two propensity score-based matching approaches were used to balance differences in known prognostic variables associated with LVI status and to assess the impact of adjuvant chemotherapy (AC) in LVI-positive luminal A-like patients.

Results

LVI was present in 24.3% (4205) of patients. LVI was significantly and independently associated with all clinical and pathological characteristics analyzed in the entire population and according to endocrine receptor (ER) status except for the time period in binary logistic regression. According to multivariate analyses including ER status, AC, grade, and tumor subtypes, the presence of LVI was significantly associated with a negative prognostic impact on overall (OS), disease-free (DFS), and metastasis-free survival (MFS) in all patients [hazard ratio (HR) = 1.345, HR = 1.312, and HR = 1.415, respectively; P < 0.0001], which was also observed in the propensity score-based analysis in addition to the association of AC with a significant increase in both OS and DFS in LVI-positive luminal A-like patients. LVI did not have a significant impact in either patients with ER-positive grade 3 tumors or those with AC-treated luminal A-like tumors.

Conclusion

The presence of LVI has an independent negative prognostic impact on OS, DFS, and MFS in early BC patients, except in ER-positive grade 3 tumors and in those with luminal A-like tumors treated with AC. Therefore, LVI may indicate the existence of a subset of luminal A-like patients who may still benefit from adjuvant therapy.

•

In a study of 17 322 early BC patients, LVI had a significant independent negative prognostic impact on survival.

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LVI negatively impacted survival in almost every patient category and cancer subtype, with and without AC.

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LVI did not have a negative survival impact in patients with ER+ grade 3 or with luminal A-like tumors with chemotherapy.

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Results suggest a possible benefit of AC in LVI-positive luminal A-like patients.

Prognostic markers of canine mammary tumours: Retrospective study of 142 cases

Due to relevance of the problem, prediction of biological behaviour of neoplasias in mammary glands of dogs requires using contemporary approaches to the study, first of all, of ways of dissemination of tumour cells. One of them is studying the mechanisms of migration of cancer cells out of the neoplasm tissues with further dissemination and development of metastatic sites in the regional lymphatic nodes and remote tissues. We studied the survival period of bitches with tumours of the mammary glands following regional or unilateral mastectomy. Among malignant mammary tumours in bitches, the most often diagnosed were single tumours (57.5%), which histologically were classified to carcinomas – ductal (26.9%) and mixed type (21.9%). Probability of intratumoral invasion to blood vessels equaled 12.0%, to lymph vessels – 7.8%, lymph nodes – 12.8%. It depends on the histological type of the tumour, the most aggressive potentially being сomedocarcinoma, tubulopapillary carcinoma and ductal carcinoma. Parameters of life expectancy and survival level after mastectomy depend on clinical stage of the disease (increase in the stage from the first to the third was characterized by decrease from 12.8 ± 9.5 to 9.4 ± 7.8 months), presence of angio/lymphatic invasions, presence of angiolymphatic invasion, but had no correlation with the size of the tumours. An important predictor of tumour-related death of dogs suffering neoplasias of the mammary glands is index vet-NPI, which has significant correlation with the clinical stage according to Owen and median survival. In particular, median survival in patients with the index lower than 4 exceeded the corresponding values in dogs with the index above 4 by 1.3 times. A promising direction of further research would be studying biological mechanisms of development of tumour emboli in the blood and lymph vessels, metastatic sites in lymph nodes, and also determining their role in pathogenesis of canine mammary tumours.

Research on the prognosis of different types of microvessels in bladder transitional cell carcinoma

BACKGROUND

At present, there is controversy on the role of microvessel density (MVD) in tumors as a prognostic indicator of bladder transitional cell carcinoma (BTCC). However, the MVD in tumors is simply classified based on the expression of several different vascular markers, which has not been related to analytical research on the prognosis of patients with BTCC.

AIM

To explore the classification of blood vessels in tumors and studied the relationship between MVD and the prognosis of patients with BTCC.

METHODS

The tissue mass was detected by tissue microarray and immunohistochemical analysis with monoclonal antibodies against CD31, CD34, CD105, and vascular smooth muscle actin to investigate the MVD in BTCC. The measurement data are expressed as the mean ± SD. The difference between the groups was analyzed by the t-test, the counting data were analyzed by χ² test. The Kaplan-Meier survival curve was estimated by the product-limit method. The log-rank time-series test was employed to compare the tumor-free survival curves.

RESULTS

The MVD was closely related to the pathological grade, invasive depth, and prognosis of BTCC. Significant differences were found between grade I and grade II, grade II and grade III, superficial and invasive type, and the tumor-free survival group and the recurrence or metastasis group (P < 0.01). Multivariate analysis showed that undifferentiated MVD was an independent prognostic factor for patient survival time. An inverse correlation between undifferentiated tumor MVD and differentiated tumor MVD in BTCC was also shown.

CONCLUSION

The classification of blood vessels in BTCC could act as an important prognostic indicator and may also be of great significance in the treatment of cancer.

Tumor-associated lymphocytes and macrophages are related to stromal elastosis and vascular invasion in breast cancer

The tumor microenvironment plays a critical role in breast cancer progression. Here, we investigated tumor-infiltrating lymphocytes (TILs) and associations with macrophage numbers, tumor stromal elastosis, vascular invasion, and tumor detection mode. We performed a population-based retrospective study using data from The Norwegian Breast Cancer Screening Program in Vestfold County (2004-2009), including 200 screen-detected and 82 interval cancers. The number of TILs (CD45+, CD3+, CD4+, CD8+, and FOXP3+) and tumor-associated macrophages (CD163+) was counted using immunohistochemistry on tissue microarray slides. Lymphatic and blood vessel invasion (LVI and BVI) were recorded using D2-40 and CD31 staining, and the amount of elastosis (high/low) was determined on regular HE-stained slides. High numbers of all TIL subsets were associated with LVI (p ≤ 0.04 for all), and high counts of several TIL subgroups (CD8+, CD45+, and FOXP3+) were associated with BVI (p ≤ 0.04 for all). Increased levels of all TIL subsets, except CD4+, were associated with estrogen receptor-negative tumors (p < 0.001) and high tumor cell proliferation by Ki67 (p < 0.001). Furthermore, high levels of all TIL subsets were associated with high macrophage counts (p < 0.001) and low-grade stromal elastosis (p ≤ 0.02). High counts of CD3+, CD8+, and FOXP3+ TILs were associated with interval detected tumors (p ≤ 0.04 for all). Finally, in the luminal A subgroup, high levels of CD3+ and FOXP3+ TILs were associated with shorter recurrence-free survival, and high counts of FOXP3+ were linked to reduced breast cancer-specific survival. In conclusion, higher levels of different TIL subsets were associated with stromal features such as high macrophage counts (CD163+), presence of vascular invasion, absence of stromal elastosis, as well as increased tumor cell proliferation and interval detection mode. Our findings support a link between immune cells and vascular invasion in more aggressive breast cancer. Notably, presence of TIL subsets showed prognostic value within the luminal A category.

In Vivo Lymphatic Circulating Tumor Cells and Progression of Metastatic Disease

Simple Summary

Deadly metastases occur when tumor cells are shed from primary tumor into lymph and blood that circulate in distinct networks of vessels and disseminate circulating tumor cells (CTCs) through the body. Therefore, detection of CTCs at potentially treatable early disease stage might improve patient survival. However, most efforts have been made to test CTCs in blood only. Here, we explored the clinically relevant photoacoustic and fluorescent flow cytometry for early in vivo detection of lymphatic CTCs using metastatic melanoma and breast cancer mouse models. We demonstrated the presence of detectable lymphatic CTCs at pre-metastatic disease, estimated correlation between CTCs, primary tumor, and metastasis, and observed parallel CTC dissemination by blood and lymph. Our findings suggest the use of lymphatic CTC testing in vivo as a new indicator of metastasis initiation, and combined assessment of two body fluids as a more promising diagnostic platform compared to existing mono-detection of blood CTCs.

Abstract

The dissemination of circulating tumor cells (CTCs) by lymph fluid is one of the key events in the development of tumor metastasis. However, little progress has been made in studying lymphatic CTCs (L-CTCs). Here, we demonstrate the detection of L-CTCs in preclinical mouse models of melanoma and breast cancer using in vivo high-sensitivity photoacoustic and fluorescent flow cytometry. We discovered that L-CTCs are be detected in pre-metastatic disease stage. The smallest primary tumor that shed L-CTCs was measured as 0.094mm×0.094mm, its volume was calculated as 0.0004 mm³; and its productivity was estimated as 1 L-CTC per 30 minutes. As the disease progressed, primary tumors continued releasing L-CTCs with certain individual dynamics. The integrated assessment of lymph and blood underlined the parallel dissemination of CTCs at all disease stages. However, the analysis of links between L-CTC counts, blood CTC (B-CTC) counts, primary tumor size and metastasis did not reveal statistically significant correlations, likely due to L-CTC heterogeneity. Altogether, our results showed the feasibility of our diagnostic platform using photoacoustic flow cytometry for preclinical L-CTC research with translational potential. Our findings also demonstrated new insights into lymphatic system involvement in CTC dissemination. They help to lay the scientific foundation for the consideration of L-CTCs as prognostic markers of metastasis and to emphasize the integrative assessment of lymph and blood.

Elastin and collagen IV double staining: A refined method to detect blood vessel invasion in breast cancer

Blood vessel invasion (BVI) is a prognostic indicator in various cancers. Elastic stain, which highlights blood vessel walls, is commonly used to detect BVI. In the breast, however, its diagnostic usefulness is limited because it also highlights some intraductal carcinoma components, which often mimic BVI. In this study, we aimed to improve BVI detection in breast cancer and developed a double staining: Victoria blue for elastin and immunohistochemistry for collagen IV. Collagen IV fibers were retained along the basement membranes of intraductal carcinoma components, whereas they were rearranged or lost in BVI. From these observations, we defined BVI as the presence of tumor cells inside an elastic ring with a rearrangement or loss of collagen IV fibers. Using these criteria, we found BVI in 148 cases (49%) among 304 cases of primary operable invasive breast carcinoma, and the presence of BVI correlated significantly with poor prognosis. By contrast, we detected BVI in 94 cases (31%) or 14 cases (5%) by elastic van Gieson or CD31 immunostaining among the same cases, respectively, with no statistically significant association with prognosis. Thus, elastin and collagen IV double staining facilitates the detection of BVI in breast cancer and is useful to predict prognosis.

Importance of investigating high-risk human papillomavirus in lymph node metastasis of esophageal adenocarcinoma

High-risk human papillomavirus has been suggested as a risk factor for esophageal adenocarcinoma. Tumor human papillomavirus status has been reported to confer a favorable prognosis in esophageal adenocarcinoma. The size of the primary tumor and degree of lymphatic spread determines the prognosis of esophageal carcinomas. Lymph node status has been found to be a predictor of recurrent disease as well as 5-year survival in esophageal malignancies. In human papillomavirus driven cancers, e.g. cervical, anogenital, head and neck cancers, associated lymph nodes with a high viral load suggest metastatic lymph node involvement. Thus, human papillomavirus could potentially be useful as a marker of micro-metastases. To date, there have been no reported studies regarding human papillomavirus involvement in lymph nodes of metastatic esophageal adenocarcinoma. This review highlights the importance of investigating human papillomavirus in lymph node metastasis of esophageal adenocarcinoma based on data derived from other human papillomavirus driven cancers.

Development of a risk-stratification scoring system for predicting lymphovascular invasion in breast cancer

Background

Lymphovascular invasion (LVI) is a vital risk factor for prognosis across cancers. We aimed to develop a scoring system for stratifying LVI risk in patients with breast cancer.

Methods

A total of 301 consecutive patients (mean age, 49.8 ± 11.0 years; range, 29–86 years) with breast cancer confirmed by pathological reports were retrospectively evaluated at the authors’ institution between June 2015 and October 2018. All patients underwent contrast-enhanced Magnetic Resonance Imaging (MRI) examinations before surgery. MRI findings and histopathologic characteristics of tumors were collected for analysis. Breast LVI was confirmed by postoperative pathology. We used a stepwise logistic regression to select variables and two cut-points were determined to create a three-tier risk-stratification scoring system. The patients were classified as having low, moderate and high probability of LVI. The area under the receiver operating characteristic curve (AUC) was used to evaluate the discrimination ability of the scoring system.

Results

Tumor margins, lobulation sign, diffusion-weighted imaging appearance, MRI-reported axillary lymph node metastasis, time to signal intensity curve pattern, and HER-2 were selected as predictors for LVI in the point-based scoring system. Patients were considered at low risk if the score was < 3.5, moderate risk if the score was 3.5 to 6.0, and high risk if the score was ≥6.0. LVI risk was segmented from 0 to 100.0% and was positively associated with an increase in risk scores. The AUC of the scoring system was 0.824 (95% confidence interval [CI]: 0.776--0.872).

Conclusion

This study shows that a simple and reliable score-based risk-stratification system can be practically used in stratifying the risk of LVI in breast cancer.

Proposal for a Histological Staging System of Mammary Carcinomas in Dogs and Cats. Part 2: Feline Mammary Carcinomas

Background: Feline mammary carcinomas (FMCs) are characterized by a high frequency of metastatic spread. The clinical TNM (Tumor, Node, Metastasis) system is used to describe local, regional, and distant tumor extent within the patient, but few publications confirmed its association with survival in cats with FMC. The purpose of this study was to determine if the histological staging system proposed for dogs in part 1 of this article had significant association with prognosis in cats.

Materials and Methods: This retrospective study included 395 female cats with a surgically removed mammary carcinoma, with a 2-year follow-up. Invasiveness (distinction between in situ and invasive FMCs), the pathologic tumor size (pT), lymphovascular invasion (LVI), and the pathologic nodal stage (pN) defined a 5-stage system: Stage 0 (FMCs in situ), Stage I (pT1, LVI–, pN0–pNX), Stage II (pT2, LVI–, pN0–pNX), Stage IIIA (pT1, LVI+ and/or pN+), and Stage IIIB (pT2, LVI+ and/or pN+), where pT1 was ≤20 mm, pT2 was >20 mm, and pNX corresponded to unsampled draining lymph node.

Results: Higher histological stages were associated with reduced disease-free interval, overall survival, and specific survival. For cancer-specific survival, by univariate analysis (p < 0.0001), median survival times and 1-year specific survival rates (1ySSR) were: stage 0 (1484 days; 1ySSR = 85%; N = 55; 14% of the cats), stage I (808 days; 1ySSR = 76%; N = 103; 26%), stage II (377 days; 1ySSR = 51%; N = 56; 14%), stage IIIA (448 days; 1ySSR = 60%; N = 83; 21%), and stage IIIB (207 days; 1ySSR = 29%; N = 98; 25%). The histological stages were also associated with specific survival by multivariate analysis (Hazard Ratio (HR) = 2.72 for stage IIIB, HR = 1.76 for stage IIIA, HR = 1.50 for stage II compared with stage I), independently of Progesterone Receptor expression (HR = 0.34 for PR+ compared with PR– FMCs) and tumor-associated inflammation (HR = 1.33 when moderate to severe compared with absent to mild).

Conclusion: A same histological staging system could be applied in dogs and cats with mammary carcinoma to refine prognosis assessment. In the near future, a preoperative complete tumor clinical staging and treatment based on the published standard of care should be performed in order to better validate the histological staging system here proposed.

The Difference of Expression of 18 Genes in Axillary Invasion and Vascular Invasion Compared to Control Samples in Breast Cancer

Background & Objective:

Recent studies from gene profiling have revealed some genes that are overexpressed in the epithelial-mesenchymal transition (EMT) process and are responsible for its initiation and activation resulting in tumor progression and metastasis. The present study aimed to assess the role of genes involved in the EMT process and the association of these genes with axillary lymph node and vascular invasion in breast cancer (BC) patients.

Methods:

In this case-control study, the tumor samples were initially extracted from 33 BC patients. The samples of 15 BC tissues without vascular and axillary invasion were also prepared from the biobank as a control group. RNAs from both tumor and control samples were extracted and stabilized. For assessing overexpression in tumor tissues of selected 18 genes, the real time technique was employed.

Results:

There was a significant increase in MMP-2 gene fold expression in tumor cells with vascular invasion regardless of axillary involvement compared to the control group (P=0.0008) and also in the comparison of the control group with those with vascular invasion and not axillary lymph node involvement (P=0.003). In addition, gene fold expression of tissue inhibitors of metalloproteinase-1(TIMP-1) was decreased in axillary involving tumor cells compared to control group (P=0.045), and also in comparison with all samples that did not present any axillary lymph node involvements including the control group and the group with isolated vascular invasion (P=0.012).

Conclusion:

Overexpression of MMP-2 and under-expression of TIMP-1 were associated with more invasive behavior in breast tumor cells.

Immunohistochemistry for diagnosis and prognosis of breast cancer: a review

Breast cancer is the most prevalent malignant tumor and main oncologic cause of mortality in women. Although most diagnosis of breast pathology is accomplished using hematoxylin and eosin stained sections, some cases require immunohistochemistry for proper evaluation. We investigated the latter cases including distinctions between ductal and lobular carcinoma, in situ and invasive carcinoma, typical ductal hyperplasia and atypical ductal hyperplasia/ductal carcinoma in situ, papillary and spindle cell lesion assessment, metastasis evaluation, and assessment of prognostic and therapy markers. E-cadherin is used to differentiate ductal and lobular carcinoma; 34βE12, CK8, p120 catenin and β-catenin also produce consistent results. Myoepithelial cell (MEC) stains are used to evaluate in situ and invasive carcinoma; calponin, smooth muscle myosin heavy chain and p63 are sensitive/specific markers. 34βE12 and CK5/6 are positive in ductal hyperplasia, which enables its differentiation from atypical ductal hyperplasia and ductal carcinoma in situ. CK 5/6, ER and MEC markers are consistent options for evaluating papillary lesions. Spindle cell lesions can be assessed using β-catenin, SMA, CD34, p63, CKs and hormone receptors. It is important to differentiate primary carcinomas from metastases; the most commonly used markers to identify breast origin include mammaglobin, GCDFP-15, GATA3 and ER, although none of these is completely sensitive or specific. Immunohistochemistry can be used to evaluate central prognostic and predictive factors including molecular subtypes, HER2, hormone receptors, proliferation markers (Ki-67) and lymph-vascular invasion markers including ERG, CD31, CD34, factor VIII and podoplanin. Owing to the complexity of mammary lesions, diagnosis also depends on each particular situation, evaluation of cytological characteristics revealed by immunochemistry and correlation with histological findings.

Lymphovascular Invasion and the Decision for Postmastectomy Radiation Therapy: A Cautionary Case Report

Breast reconstruction is frequently adversely affected by postmastectomy radiation therapy. Some radiation therapists recommend postmastectomy radiation therapy based on the finding of lymphovascular invasion in the context of other findings. However, the diagnosis of lymphovascular invasion varies between pathologists and institutions. Sometimes special endothelial cell stains and outside opinions are necessary for the decision for postmastectomy radiation therapy. This case report illustrates the variation in the diagnosis of lymphovascular invasion. Plastic surgeons must remain current on the standard indications for postmastectomy radiation therapy and on the basic findings of lymphovascular invasion.

A Machine Learning Approach for the Association of ki-67 Scoring with Prognostic Factors

ki-67 score is a solid tumor proliferation marker being associated with the prognosis of breast carcinoma and its response to neoadjuvant chemotherapy. In the present study, we aimed to investigate the way of clustering of prognostic factors by ki-67 score using a machine learning approach and multiple correspondence analysis. In this study, 223 patients with breast carcinoma were analyzed using the random forest method for classification of prognostic factors according to ki-67 groups (<14% and >14%). Also the relationship between subgroups of prognostic factors and ki-67 scores was examined by multiple correspondence analysis. There was a clustering of molecular classification LA, 0-3 metastatic lymph node, age <50, absence of LVI, T1 tumor size with ki-67 <14% and grade III, 10 or more metastatic lymph nodes, and presence of LVI and molecular classification LB, age >50, and T3-T4 tumor size categories with ki-67 >14%. The fact that the low scores of ki-67 correlate with early stage diseases and high scores with advanced disease suggests that 14% threshold value is crucial for ki-67 score.

Complementing Cancer Metastasis

Complement is an effector of innate immunity and a bridge connecting innate immunity and subsequent adaptive immune responses. It is essential for protection against infections and for orchestrating inflammatory responses. Recent studies have also demonstrated contribution of the complement system to several homeostatic processes that are traditionally not considered to be involved in immunity. Thus, complement regulates homeostasis and immunity. However, dysregulation of this system contributes to several pathologies including inflammatory and autoimmune diseases. Unexpectedly, studies of the last decade have also revealed that complement promotes cancer progression. Since the initial discovery of tumor promoting role of complement, numerous preclinical and clinical studies demonstrated contribution of several complement components to regulation of tumor growth through their direct interactions with the corresponding receptors on tumor cells or through suppression of antitumor immunity. Most of this work, however, focused on a role of complement in regulating growth of primary tumors. Only recently, a few studies showed that complement promotes cancer metastasis through its contribution to epithelial-to-mesenchymal transition and the premetastatic niche. This latter work has shown that complement activation and generation of complement effectors including C5a occur in organs that are target for metastasis prior to arrival of the very first tumor cells. C5a through its interactions with C5a receptor 1 inhibits antitumor immunity by activating and recruiting immunosuppressive cells from the bone marrow to the premetastatic niche and by regulating function and self-renewal of pulmonary tissue-resident alveolar macrophages. These new advancements provide additional evidence for multifaceted functions of complement in cancer.

Phosphorylation of androgen receptors at serine 515 is a potential prognostic marker for triple negative breast cancer

1.7 million cases of breast cancer are diagnosed every year with 522,000 deaths. Molecular classifications of breast cancer have resulted in improved treatments. However, treatments for triple negative breast cancer (TNBC) are lacking. Analysis of molecular targets for TNBC is a priority. One potential candidate is androgen receptor (AR) phosphorylation. This study assessed the role of AR phosphorylation at ser81/ser515 and their two upstream effectors, cyclin-dependent kinase 1 (pCDK1) and extracellular-regulated kinase 1/2 (pERK1/2) in 332 ductal breast cancer patients by immunohistochemistry.

pERK1/2 combined with AR-515 associated with improved cancer-specific survival (CSS, p = 0.038), decreased size (p = 0.001), invasive grade (p < 0.001), necrosis (p = 0.003), b-lymphocytes (p = 0.020), molecular subtype (p < 0.001) and estrogen receptor (ER)/progesterone receptor (PR)-status (p < 0.001). The cohort was therefore stratified into ER+ve and ER-ve patients. In ER+ve tumours, pERK1/2 combined with AR-515 associated with improved CSS (p = 0.038), smaller size (p = 0.004), invasive grade (p = 0.001), decreased b-lymphocytes (p = 0.013) and increased plasma cells (p = 0.048). In contrast, in TNBC patients, phosphorylation of AR-515 associated with poorer CSS (p = 0.007). pERK1/2 combined with AR-515 associated with decreased inflammation (p = 0.003), increased tumour stroma (p = 0.003) and tumour budding (p = 0.011), with trends towards decrease CSS (p = 0.065) and macrophage levels (p = 0.093).

In Conclusions, AR-515 may be an important regulator of inflammation in breast cancer potential via ERK1/2 phosphorylation. AR-515 is a potential prognostic marker and therapeutic target for TNBC.

The relationship between members of the canonical NF-κB pathway, components of tumour microenvironment and survival in patients with invasive ductal breast cancer

The aim of the present study was to examine the relationship between tumour NF-κB activation, tumour microenvironment including local inflammatory response (LIR) and cancer-specific survival in patients with operable ductal breast cancer.

Immunohistochemistry (tissue microarray of 376 patients) and western blotting (MCF7 and MDA-MB-231 breast cancer cells) was performed to assess expression of key members of the canonical NF-κB pathway (inhibitory kappa B kinase (IKKβ) and phosphorylated p65 Ser-536 (p-p65)). Following silencing of IKKβ, cell viability and apoptosis was assessed in both MCF7 and MDA-MB-231 cell lines.

P-p65 was associated with cancer-specific survival (CSS) (nuclear P=0.042 and total P=0.025). High total p-p65 was associated with increase grade tumour grade (P=0.010), ER positivity (P=0.023), molecular subtype (P=0.005), lower Klintrup-Makinen grade (P=0.013) and decreased CD138 count (P=0.032). On multivariate analysis, total p-p65 expression independently associated with poorer CSS (P=0.020). In vitro work demonstrated that the canonical NF-κB pathway was inducible by exposure to TNFα in ER-positive MCF7 cells and to a lesser extent in ER-negative MDA-MB-231 cells. Reduction of IKKβ expression by siRNA transfection increased levels of apoptosis and reduced cell viability in both MCF7 (P=<0.001, P=<0.001, respectively) and MDA-MB-231 cells (P=>0.001, P=0.002, respectively). This is consistent with the hypothesis that canonical IKKβ-NF-κB signalling drives tumour survival.

These results suggest that activation of the canonical NF-κB pathway is an important determinant of poor outcome in patients with invasive ductal breast cancer.

The relationship of lymphatic vessel density, lymphovascular invasion, and lymph node metastasis in breast cancer: a systematic review and meta-analysis

Lymph node status is one of the key parameters used for determining the stage of breast cancer progression. The relationship of lymphatic vessel density (LVD), lymphovascular invasion (LVI), and lymph node metastasis (LNM) has not been clearly demonstrated yet. Databases of PubMed, Embase, and Web of Science were searched from inception up to 25 May 2016. Spearman correlation coefficient (r) and 95% confidence interval (CI) were used to determine the relationship within each group. Based on pre-established inclusion criteria, 28 studies involving 2920 breast cancer patients were included in this study. The r values of LVD-LVI, LVD-LNM, and LVI-LNM were 0.45 (95% CI: 0.31 to 0.57), 0.32 (95% CI: 0.23 to 0.40), and 0.24 (95% CI: 0.19 to 0.28), respectively. Compared with intratumoral LVD, peritumoral LVD showed more robust correlation with LVI (r = 0.53, 95% CI: 0.27 to 0.72) and LNM (r = 0.33, 95% CI: 0.18 to 0.46). The patients in LNM positive group presented with higher LVI detection rate of 45.85%, while in LNM negative group with detection rate of 23.85%. The results describe a triangle relationship between LVD, LVI, and LNM in breast cancer. Both LVD and LVI are indicated to be valuable predictors of LNM occurrence. Compared with intratumoral lymphatic vessels, peritumoral lymphatics might be the main disseminate route for breast tumor cells.

Tetramethylpyrazine regulates breast cancer cell viability, migration, invasion and apoptosis by affecting the activity of Akt and caspase-3

Tetramethylpyrazine (TMP), an effective component of the traditional Chinese medicine Chuanxiong Hort, has been proven to exhibit a beneficial effect in a number of types of malignant epithelial cancer. However, the mode of action of TMP on breast cancer cells remains unknown. The aim of the present study was to investigate the regulatory effect of TMP on breast cancer cells and its underlying molecular mechanism of action. Different concentrations of TMP were used to treat breast cancer cells, and subsequently, the effects on the viability, apoptosis, and migration and invasion abilities were determined. In addition, the expression and activity levels of the protein kinase B (Akt) signaling pathway and caspase-3 were explored via reverse transcription-quantitative polymerase chain reaction and western blot analysis. The results of the present study revealed that TMP significantly inhibited the viability, migration and invasion rates, and increased the apoptosis of MDA-MB-231 cells in a dose-dependent manner. The minimum effective dose was ~1,600 µM. Additional mechanistic studies demonstrated that 1,600 and 3,200 µM TMP significantly decreased the gene expression and activity of Akt and increased the activity of caspase-3. This mechanism may be responsible for the inhibition of viability, migration and invasion, and activation of apoptosis in breast cancer cells. The results of the present study suggested that TMP may be used in chemotherapy against breast cancer.

Prognostic significance of lymphatic vessel invasion diagnosed by D2-40 in Chinese invasive breast cancers

Lymphatic vessel invasion (LVI) is promising in determining prognosis and treatment strategies, but the application of LVI as a histopathological criterion in breast cancer patients especially those of different subgroups is controversial. This research aims to evaluate the prognostic value of LVI assessed by D2-40 not only in patients with early invasive breast cancer but also in lymph node-negative, lymph node-positive, luminal A-like, luminal B-like, HER2-enriched, and triple-negative subgroups.The study cohort included 255 patients with a median follow-up of 101 months. Immunohistochemical staining for D2-40 was performed to identify LVI.LVI was present in 64 (25.1%), 15 (12.1%), 49 (37.4%), 19 (20.9%), 23 (27.7%), 13 (31.7%), and 9 (22.5%), respectively, in the whole cohort, lymph node-negative, lymph node-positive, luminal A-like, luminal B-like, HER2-enriched, and triple-negative patients. LVI was associated with large tumor size (P = .04), high histological grade (P = .004), involved lymph node (P < .001), and high expression of Ki-67 (P = .003). No significant difference was found among patients with different subtypes and LVI status. The presence of LVI was significantly associated with adverse disease-free survival in the whole cohort (P < .001), lymph node-negative (P < .001), lymph node-positive (P < .001), luminal A-like (P < .001), and luminal B-like patients (P < .001) in both of the univariate and multivariate survival analysis.This study indicated that the presence of LVI stained by D2-40 provided independent prognostic information not only in the whole cohort but also in the subgroup of patients with lymph node-negative, lymph node-positive, luminal A-like, and luminal B-like diseases, which may make a case for routine clinical assessment of LVI using D2-40.

Type of vascular invasion in association with progress of endometrial cancer

Vascular invasion (VI) is a well-established marker for lymph node metastasis and outcome in endometrial cancer. Our study explored whether specific types of VI, defined as lymphatic (LVI) or blood vessel invasion (BVI), predict pattern of metastasis. From a prospectively collected cohort, we conducted a case-control study by selecting three groups of endometrial cancer patients (n = 183): 52 with positive lymph nodes at primary surgery, 33 with negative nodes at primary surgery and later recurrence and death from disease, and 98 with negative nodes and no recurrence. All patients underwent hysterectomy with lymphadenectomy. Immunohistochemical staining with D2-40 and CD31 antibodies was used to differentiate between BVI and LVI. By immunohistochemical staining, detection of VI increased from 24.6 to 36.1% of the cases. LVSI was significantly more often seen in patients with positive lymph nodes compared with patients with negative nodes (p = 0.001). BVI was significantly more often seen in node-negative patients with recurrence compared with node-negative patients without recurrence (p = 0.011). In multivariable analysis, BVI, age, and tumor grade were predictors separating patients with and without recurrence. Lymph node-positive patients showed more often LVI compared with lymph node-negative patients, while BVI seems to be a predictor for recurrent disease.

Epithelial-mesenchymal transition in cancer metastasis through the lymphatic system

It was already in the 18th century when the French surgeon LeDran first noted that breast cancer patients with spread of tumor cells to their axillary lymph nodes had a drastically worse prognosis than patients without spread (LeDran et al., ). Since then, metastatic spread of cancer cells to regional lymph nodes has been established as the most important prognostic factor in many types of cancer (Carter et al., ; Elston and Ellis, ). However, despite its clinical importance, lymph metastasis remains an underexplored area of tumor biology. Fundamental questions, such as when, how, and perhaps most importantly, why tumor cells disseminate through the lymphatic system, remain largely unanswered. Accordingly, no treatment strategies exist that specifically target lymph metastasis. The identification of epithelial-mesenchymal transition (EMT) as a mechanism, which allows cancer cells to dedifferentiate and acquire enhanced migratory and invasive properties, has been a game changer in cancer research. Conceptually, EMT provides an explanation for why epithelial cancers with poor differentiation status are generally more aggressive and prone to metastasize than more differentiated cancers. Inflammatory cytokines, such as TGF-β, which are produced and secreted by tumor-infiltrating immune cells, are potent inducers of EMT. Thus, reactivation of EMT also links cancer-related inflammation to invasive and metastatic disease. Recently, we found that breast cancer cells undergoing TGF-β-induced EMT acquire properties of immune cells allowing them to disseminate in a targeted fashion through the lymphatic system similar to activated dendritic cells during inflammation. Here, we review our current understanding of the mechanisms by which cancer cells spread through the lymphatic system and the links to inflammation and the immune system. We also emphasize how imaging techniques have the potential to further expand our knowledge of the mechanisms of lymph metastasis, and how lymph nodes serve as an interface between cancer and the immune system.

High lymphatic vessel density and presence of lymphovascular invasion both predict poor prognosis in breast cancer

Background

Lymphatic vessel density and lymphovascular invasion are commonly assessed to identify the clinicopathological outcomes in breast cancer. However, the prognostic values of them on patients’ survival are still uncertain.

Methods

Databases of PubMed, Embase, and Web of Science were searched from inception up to 30 June 2016. The hazard ratio with its 95% confidence interval was used to determine the prognostic effects of lymphatic vessel density and lymphovascular invasion on disease-free survival and overall survival in breast cancer.

Results

Nineteen studies, involving 4215 participants, were included in this study. With the combination of the results of lymphatic vessel density, the pooled hazard ratios and 95% confidence intervals were 2.02 (1.69–2.40) for disease-free survival and 2.88 (2.07–4.01) for overall survival, respectively. For lymphovascular invasion study, the pooled hazard ratios and 95% confidence intervals were 1.81 (1.57–2.08) for disease-free survival and 1.64 (1.43–1.87) for overall survival, respectively. In addition, 29.56% (827/2798) of participants presented with lymphovascular invasion in total.

Conclusions

Our study demonstrates that lymphatic vessel density and lymphovascular invasion can predict poor prognosis in breast cancer. Standardized assessments of lymphatic vessel density and lymphovascular invasion are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3338-x) contains supplementary material, which is available to authorized users.

Macroscopic lymphovascular invasion visualized on mammogram and magnetic resonance imaging: Initially misidentified as ductal carcinoma in situ but properly diagnosed by immunohistochemistry

Objectives:

Lymphovascular invasion (LVI) is a pathologic, microscopic finding associated with invasive cancer, and is a poor prognostic indicator, but has no reported imaging findings. This report presents the first documented case of LVI with seen by imaging. Linear branching microcalcifications were identified on mammography and clumped enhancement was noted on MRI, both imaging findings that are highly predictive of ductal carcinoma in situ (DCIS).

Methods:

Ultrasound guided core biopsy of the dominant mass was performed, confirming invasive ductal malignancy. Stereotactic biopsy performed on the microcalcifications was initially interpreted by pathology as DCIS.

Results:

Patient underwent mastectomy. Pathologic evaluation of the surgical specimen confirmed the invasive ductal malignancy. Microcalcifications were re-evaluated with immunohistochemistry (IHC) and re-classified as LVI. Radiology images and IHC stains are shown.

Conclusion:

This is the first report of LVI identified by imaging with findings that mimicked DCIS and initially mis-identified as DCIS by pathology as well. The implications of this overlap in radiologic appearance are discussed.

The influences of peritumoral lymphatic invasion and vascular invasion on the survival and recurrence according to the molecular subtypes of breast cancer

PURPOSE

We aimed to compare the influences of lymphatic invasion (LI) and vascular invasion (VI) on survival and recurrence according to the molecular subtypes of breast cancer.

METHODS

We retrospectively analyzed data on 820 breast cancer patients and assessed overall survival (OS) and disease-free survival (DFS) according to LI and VI using the Kaplan-Meier estimator and the Cox proportional hazards model.

RESULTS

Both positive LI and positive VI showed inferior OS and DFS compared with negative LI and negative VI (all p < 0.001). Both positive LI and positive VI showed higher local, regional, and distant recurrence rates (p = 0.002 for regional recurrence of VI, p < 0.001 for all the others). Although LI was a significant independent predictor of OS (hazard ratio [HR] 1.927; 95% confidence interval [CI] 1.046-3.553) and DFS (HR 1.815; 95% CI 1.063-3.096), VI was not in the multivariate analyses. Regarding OS, both positive LI and positive VI showed worse survival rates in the luminal A (p = 0.016 and p = 0.024, respectively) and triple negative subtypes (both p < 0.001). Regarding DFS, LI was a significant prognosticator in the luminal A and triple negative (both p < 0.001) subtypes. VI was a significant prognosticator across all molecular subtypes, although the prognostic impact was most prominent in the luminal A subtype (p < 0.001).

CONCLUSIONS

Both LI and VI were significant, unfavorable prognostic factors of OS and DFS, especially in the luminal A and triple negative breast cancer subtypes. Although LI was a significant independent predictor of OS and DFS, VI was not after the multivariate analyses.

High IKKα expression is associated with reduced time to recurrence and cancer specific survival in oestrogen receptor (ER)-positive breast cancer

The aim of our study was to examine the relationship between tumour IKKα expression and breast cancer recurrence and survival. Immunohistochemistry was employed in a discovery and a validation tissue microarray to assess the association of tumour IKKα expression and clinico-pathological characteristics. After siRNA-mediated silencing of IKKα, cell viability and apoptosis were assessed in MCF7 and MDA-MB-231 breast cancer cells. In both the discovery and validation cohorts, associations observed between IKKα and clinical outcome measures were potentiated in oestrogen receptor (ER) positive Luminal A tumours. In the discovery cohort, cytoplasmic IKKα was associated with disease-free survival (p = 0.029) and recurrence-free survival on tamoxifen (p < 0.001) in Luminal A tumours. Nuclear IKKα and a combination of cytoplasmic and nuclear IKKα (total tumour cell IKKα) were associated with cancer-specific survival (p = 0.012 and p = 0.007, respectively) and recurrence-free survival on tamoxifen (p = 0.013 and p < 0.001, respectively) in Luminal A tumours. In the validation cohort, cytoplasmic IKKα was associated with cancer-specific survival (p = 0.023), disease-free survival (p = 0.002) and recurrence-free survival on tamoxifen (p = 0.009) in Luminal A tumours. Parallel experiment with breast cancer cells in vitro demonstrated the non-canonical NF-κB pathway was inducible by exposure to lymphotoxin in ER-positive MCF7 cells and not in ER-negative MDA-MB-231 cells. Reduction in IKKα expression by siRNA transfection increased levels of apoptosis and reduced cell viability in MCF7 but not in MDA-MB-231 cells. IKKα is an important determinant of poor outcome in patients with ER-positive invasive ductal breast cancer and thus may represent a potential therapeutic target.

Tumour cell invasion into blood vessels is significantly related to breast cancer subtypes and decreased survival

AIMS

Vascular invasion in breast cancer is associated with increased risk of recurrence, metastases and death from disease. However, there are few studies discriminating between blood vessel invasion (BVI) and lymphatic vessel involvement (LVI).

METHODS

A population-based series of 282 breast cancers was examined (200 screen-detected and 82 interval patients) with respect to BVI and LVI in addition to basic features and molecular subtypes, using CD31 and D2-40 antibodies. This series is part of the prospective Norwegian Breast Cancer Screening Program.

RESULTS

The frequency of LVI and BVI was 25% and 15%, respectively. BVI was associated with HER2-positive and basal-like tumours, and several features of aggressive breast cancer, whereas LVI showed weaker associations. BVI was the strongest factor to predict interval cancer presentation. BVI showed significant associations with recurrence-free survival and disease-specific survival in univariate and multivariate analyses, whereas LVI was not significant.

CONCLUSIONS

Our findings indicate that BVI by tumour cells is strongly associated with aggressive tumour features including a basal-like phenotype, and BVI was an independent prognostic factor in contrast to what was found for LVI.

Spontaneously-forming spheroids as an in vitro cancer cell model for anticancer drug screening

The limited translational value in clinic of analyses performed on 2-D cell cultures has prompted a shift toward the generation of 3-dimensional (3-D) multicellular systems. Here we present a spontaneously-forming in vitro cancer spheroid model, referred to as spheroids^MARY-X, that precisely reflects the pathophysiological features commonly found in tumor tissues and the lymphovascular embolus. In addition, we have developed a rapid, inexpensive means to evaluate response following drug treatment where spheroid dissolution indices from brightfield image analyses are used to construct dose-response curves resulting in relevant IC₅₀ values. Using the spheroids^MARY-X model, we demonstrate the unique ability of a new class of molecules, containing the caged Garcinia xanthone (CGX) motif, to induce spheroidal dissolution and apoptosis at IC₅₀ values of 0.42 +/−0.02 μM for gambogic acid and 0.66 +/−0.02 μM for MAD28. On the other hand, treatment of spheroids^MARY-X with various currently approved chemotherapeutics of solid and blood-borne cancer types failed to induce any response as indicated by high dissolution indices and subsequent poor IC₅₀ values, such as 7.8 +/−3.1 μM for paclitaxel. Our studies highlight the significance of the spheroids^MARY-X model in drug screening and underscore the potential of the CGX motif as a promising anticancer pharmacophore.

Lymph vessels: the forgotten second circulation in health and disease

The lymphatic circulation is still a somewhat forgotten part of the circulatory system. Despite this, novel insights in lymph angiogenesis in health and disease, application of immune markers for lymphatic growth and differentiation and also the introduction of new imaging techniques to visualize the lymphatic circulation have improved our understanding of lymphatic function in both health and disease, especially in the last decade. These achievements yield better understanding of the various manifestations of lymph oedemas and malformations, and also the patterns of lymphovascular spread of cancers. Immune markers that recognize lymphatic endothelium antigens, such as podoplanin, LYVE-1 and Prox-1, can be successfully applied in diagnostic pathology and have revealed (at least partial) lymphatic differentiation in many types of vascular lesions.

Predicting chemoinsensitivity in breast cancer with 'omics/digital pathology data fusion

Predicting response to treatment and disease-specific deaths are key tasks in cancer research yet there is a lack of methodologies to achieve these. Large-scale 'omics and digital pathology technologies have led to the need for effective statistical methods for data fusion to extract the most useful patterns from these diverse data types. We present FusionGP, a method for combining heterogeneous data types designed specifically for predicting outcome of treatment and disease. FusionGP is a Gaussian process model that includes a generalization of feature selection for biomarker discovery, allowing for simultaneous, sparse feature selection across multiple data types. Importantly, it can accommodate highly nonlinear structure in the data, and automatically infers the optimal contribution from each input data type. FusionGP compares favourably to several popular classification methods, including the Random Forest classifier, a stepwise logistic regression model and the Support Vector Machine on single data types. By combining gene expression, copy number alteration and digital pathology image data in 119 estrogen receptor (ER)-negative and 345 ER-positive breast tumours, we aim to predict two important clinical outcomes: death and chemoinsensitivity. While gene expression data give the best predictive performance in the majority of cases, the digital pathology data are much better for predicting death in ER cases. Thus, FusionGP is a new tool for selecting informative features from heterogeneous data types and predicting treatment response and prognosis.

Mapping spatial heterogeneity in the tumor microenvironment: a new era for digital pathology

The emergent field of digital pathology employing automated image analysis techniques is to revolutionize traditional pathology at the center of clinical diagnostics. Histological images provide important tumor features unavailable in molecular profiling or omics data- the spatial context of tumor and stromal cells at single-cell resolution. Methods to map the spatial and morphological patterns of cancer and normal cells can contribute to a more comprehensive understanding of the highly heterogeneous tumor microenvironment. This review focuses on methods that help expand our knowledge of intra-tumoral spatial heterogeneity of the tumor microenvironment and their potential synergies with molecular profiling technologies.