The role of large-format histopathology in assessing subgross morphological prognostic parameters: a single institution report of 1000 consecutive breast cancer cases

High PGAP3 expression is associated with lymph node metastasis and low CD8+T cell in patients with HER2+ breast cancer

BACKGROUND

Breast cancer (BC) stands as the most prevalent malignancy among women and ranks as the second most frequently diagnosed cancer globally among newly identified cases. Post-GPI attachment to proteins factor 3（PGAP3）was reported to involve in lipid remodeling. However, its specific role in breast cancer remains inadequately elucidated. Consequently, the principal objective of this study was to investigate the clinical significance of PGAP3 in breast cancer.

METHODS

We conducted an extensive analysis using both public databases and our own sample cohort to assess the role of PGAP3 in breast cancer. Immunohistochemistry was employed to assess PGAP3 expression, immune markers, and the co-expression of PGAP3 with key susceptibility genes. Data analysis was performed using the R programming language.

RESULTS

Our findings revealed that PGAP3 is significantly overexpressed in breast cancer, particularly in human epidermal growth factor 2 positive (HER2 +) breast cancer cases (p < 0.001). Co-expression analyses demonstrated a significant correlation between PGAP3 and susceptibility genes associated with breast cancer, including BRCA1, BRCA2, PALB2, ATM, CHEK2, RAD51C, and RAD51D (p < 0.05). Logistic regression analysis identified PGAP3 as a significant predictor of estrogen receptor (ER), progesterone receptor (PR), HER2, and lymph node metastasis status (p < 0.01). Furthermore, higher PGAP3 expression was associated with decreased infiltration of CD8 + T cells in breast cancer samples.

CONCLUSION

Our study sheds light on the clinical significance of PGAP3 in breast cancer. PGAP3 is not only overexpressed in breast cancer but also correlates with key susceptibility genes, lymph node metastasis, and CD8 + T cell infiltration. These findings provide valuable insights into the potential role of PGAP3 as a biomarker in breast cancer and may contribute to our understanding of the disease's pathogenesis.

Contrast-enhanced mammography (CEM) versus MRI for breast cancer staging: detection of additional malignant lesions not seen on conventional imaging

BACKGROUND

Contrast-enhanced mammography (CEM) is more available than MRI for breast cancer staging but may not be as sensitive in assessing disease extent. We compared CEM and MRI in this setting.

METHODS

Fifty-nine women with invasive breast cancer underwent preoperative CEM and MRI. Independent pairs of radiologists read CEM studies (after reviewing a 9-case set prior to study commencement) and MRI studies (with between 5 and 25 years of experience in breast imaging). Additional lesions were assigned National Breast Cancer Centre (NBCC) scores. Positive lesions (graded NBCC ≥ 3) likely to influence surgical management underwent ultrasound and/or needle biopsy. True-positive lesions were positive on imaging and pathology (invasive or in situ). False-positive lesions were positive on imaging but negative on pathology (high-risk or benign) or follow-up. False-negative lesions were negative on imaging (NBCC < 3 or not identified) but positive on pathology.

RESULTS

The 59 women had 68 biopsy-proven malignant lesions detected on mammography/ultrasound, of which MRI demonstrated 66 (97%) and CEM 67 (99%) (p = 1.000). Forty-one additional lesions were detected in 29 patients: six of 41 (15%) on CEM only, 23/41 (56%) on MRI only, 12/41 (29%) on both; CEM detected 1/6 and MRI 6/6 malignant additional lesions (p = 0.063), with a positive predictive value (PPV) of 1/13 (8%) and 6/26 (23%) (p = 0.276).

CONCLUSIONS

While MRI and CEM were both highly sensitive for lesions detected at mammography/ultrasound, CEM may not be as sensitive as MRI in detecting additional otherwise occult foci of malignancy.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN 12613000684729.

Pathological Diagnosis, Work-Up and Reporting of Breast Cancer 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

This text is based on the recommendations accepted by the 4th Hungarian Consensus Conference on Breast Cancer, modified on the basis of the international consultation and conference within the frames of the Central-Eastern European Academy of Oncology. The recommendations cover non-operative, intraoperative and postoperative diagnostics, determination of prognostic and predictive markers and the content of cytology and histology reports. Furthermore, they address some specific issues such as the current status of multigene molecular markers, the role of pathologists in clinical trials and prerequisites for their involvement, and some remarks about the future.

Development and External Validation of a Simple-To-Use Dynamic Nomogram for Predicting Breast Malignancy Based on Ultrasound Morphometric Features: A Retrospective Multicenter Study

Background

With advances in high-throughput computational mining techniques, various quantitative predictive models that are based on ultrasound have been developed. However, the lack of reproducibility and interpretability have hampered clinical use. In this study, we aimed at developing and validating an interpretable and simple-to-use US nomogram that is based on quantitative morphometric features for the prediction of breast malignancy.

Methods

Successive 917 patients with histologically confirmed breast lesions were included in this retrospective multicentric study and assigned to one training cohort and two external validation cohorts. Morphometric features were extracted from grayscale US images. After feature selection and validation of regression assumptions, a dynamic nomogram with a web-based calculator was developed. The performance of the nomogram was assessed with respect to calibration, discrimination, and clinical usefulness.

Results

Through feature selection, three morphometric features were identified as being the most optimal for predicting malignancy, and all regression assumptions of the prediction model were met. Combining all these predictors, the nomogram demonstrated a good discriminative performance in the training cohort and in the two external validation cohorts with AUCs of 0.885, 0.907, and 0.927, respectively. In addition, calibration and decision curves analyses showed good calibration and clinical usefulness.

Conclusions

By incorporating US morphometric features, we constructed an interpretable and easy-to-use dynamic nomogram for quantifying the probability of breast malignancy. The developed nomogram has good generalization abilities, which may fit into clinical practice and serve as a potential tool to guide personalized treatment. Our findings show that quantitative morphometric features from different ultrasound machines and systems can be used as imaging surrogate biomarkers for the development of robust and reproducible quantitative ultrasound dynamic models in breast cancer research.

Progress on deep learning in digital pathology of breast cancer: a narrative review

BACKGROUND AND OBJECTIVE

Pathology is the gold standard criteria for breast cancer diagnosis and has important guiding value in formulating the clinical treatment plan and predicting the prognosis. However, traditional microscopic examinations of tissue sections are time consuming and labor intensive, with unavoidable subjective variations. Deep learning (DL) can evaluate and extract the most important information from images with less need for human instruction, providing a promising approach to assist in the pathological diagnosis of breast cancer. To provide an informative and up-to-date summary on the topic of DL-based diagnostic systems for breast cancer pathology image analysis and discuss the advantages and challenges to the routine clinical application of digital pathology.

METHODS

A PubMed search with keywords ("breast neoplasm" or "breast cancer") and ("pathology" or "histopathology") and ("artificial intelligence" or "deep learning") was conducted. Relevant publications in English published from January 2000 to October 2021 were screened manually for their title, abstract, and even full text to determine their true relevance. References from the searched articles and other supplementary articles were also studied.

KEY CONTENT AND FINDINGS

DL-based computerized image analysis has obtained impressive achievements in breast cancer pathology diagnosis, classification, grading, staging, and prognostic prediction, providing powerful methods for faster, more reproducible, and more precise diagnoses. However, all artificial intelligence (AI)-assisted pathology diagnostic models are still in the experimental stage. Improving their economic efficiency and clinical adaptability are still required to be developed as the focus of further researches.

CONCLUSIONS

Having searched PubMed and other databases and summarized the application of DL-based AI models in breast cancer pathology, we conclude that DL is undoubtedly a promising tool for assisting pathologists in routines, but further studies are needed to realize the digitization and automation of clinical pathology.

Mass and non-mass breast MRI patterns: a radiologic approach to sick lobe theory

BACKGROUND

According to sick lobe theory, one or more lobes of the breast are more prone to the development of carcinoma. However, the implications of this theory in breast magnetic resonance imaging (MRI) are unknown.

PURPOSE

To evaluate the MRI appearance of mass type (multifocal and multicentric diseases) and non-mass type (non-mass enhancements) sick lobe patterns, together with the histopathology results.

MATERIAL AND METHODS

MRI reports of 2015 patients in two tertiary breast imaging centers between June 2012 and June 2018 were retrospectively reviewed for multifocal-multicentric diseases and segmental, linear, and regional enhancements. A total of 113 patients were included. The specimens obtained by thick needle, vacuum, excisional biopsy/lumpectomy or mastectomy after breast MRI scans were pathologically assessed. The pathologic results were categorized as invasive carcinoma, precursor, and benign proliferative lesions according to the 2012 World Health Organization Classification of Tumors.

RESULTS

The percentage of underlying benign and precursor invasive lesions was significantly different in patients with mass and non-mass MRI patterns. While the pathology results of mass type patterns were premalignant and malignant in all cases, nearly half of the underlying histologies were benign proliferative subtypes in patients with non-mass type patterns.

CONCLUSION

In this study, the mass and non-mass patterns derived from sick lobe theory were related to different risks of malignancy in the pathological examinations.

Internodal HER2 heterogeneity of axillary lymph node metastases in breast cancer patients

Determination of human epidermal growth factor receptor 2 (HER2) status is important for adequate treatment of breast cancer (BC) patients. The novel HER2 gene protein assay (GPA) is particularly convenient, as it allows the simultaneous assessment of HER2 protein expression and gene amplification at individual cell level. Here we investigated the frequency of internodal HER2 heterogeneity in axillary lymph node macrometastases of BC patients and compared HER2 status between primary breast tumor and its metastases. We included a total of 41 female patients operated between 2014 and 2015 for primary BC with axillary lymph node macrometastases. Representative paraffin blocks of metastatic lymph nodes were sectioned and the slides were stained using the GPA in 38 BC cases. GPA results were assessed according to the ASCO/CAP 2013 criteria. We analyzed 12586 individual tumor cells, 120 cells per section of each metastatic lymph node. HER2 status differed between the primary tumor and its metastases in 5/38 cases (13.2%). In patients with at least two metastatic nodes, the HER2 status of lymph node metastases was only slightly different in 4/23 cases (17.4%). Our results indicate rare but substantial differences in HER2 status between primary breast tumor and its axillary lymph node metastases that may direct the choice and outcomes of targeted therapy in BC patients. The impact of the rare and subtle internodal HER2 heterogeneity evidenced in this study remains uncertain. Determining the HER2 status of lymph node metastases in BC seems to be rational, but assessing a limited number of metastatic nodes may be sufficient.

The subgross morphology of breast carcinomas: a single-institution series of 2033 consecutive cases documented in large-format histology slides

A large-format histology technique represents the most convenient method for documenting and assessing the subgross morphological prognostic parameters of breast cancer (i.e., the distribution of the tumor's invasive and in situ components, disease extent, and tumor size), especially when used in conjunction with systematic radiological-pathological correlation. Here we report a consecutive series of 2033 breast carcinomas operated on in Dalarna, Sweden, with a particular focus on these subgross parameters. We separately analyzed the distributions of the in situ and invasive components of the tumors and then combined these into an aggregate pattern when both components were present. We found that 40% of breast carcinomas had a simple (unifocal) subgross morphology, while 60% had a complex morphology presenting with multifocal or diffuse components. Extensive tumors (occupying a total volume of breast tissue with the greatest dimension being ≥ 40 mm) were more common in complex cases, occurring in 66% of multifocal cases and 88% of diffuse cases, compared with only 5% of unifocal cases. Compared with luminal A-like tumors, HER2-expressing tumors exhibited a significantly larger extent. Triple-negative and basal-like carcinomas tended to have a larger tumor size (based on the largest dimension of the largest invasive focus). In this report, we discuss the prognostic impact of these parameters and the necessity of their correct assessment in the diagnostic routine.

The sick lobe hypothesis, field cancerisation and the new era of precision breast surgery

Understanding the ductal anatomy of the breast provides insights into tumorigenesis, which in turn offers guidance on therapeutic decisions. In this regard, the sick lobe hypothesis, which states that cancer arises from genetically unstable cells through mutations acquired in utero, forms the basis of malignant transformation. These 'at risk' cells line the mammary ductal-lobular system of a single 'sick' lobe and when exposed to noxious events in the surrounding microenvironment, further genetic changes occur which completes conversion to malignancy, in certain defined patterns. This review explores how anatomy, pathology and genomics can merge, not only to guide optimum surgery, but also to provide a more comprehensive portal for precision medicine.

Eccrine ductal and acrosyringeal metaplasia in breast carcinomas: report of eight cases

Eccrine ductal and acrosyringeal metaplasia was described in 2006 as the presence of tumor structures that resemble the epithelium of the eccrine skin ducts and their opening within the epidermis, the acrosyringeum. Here, we report the clinical, morphological, and phenotypic characteristics of eight breast carcinomas that we collected over the past years showing this metaplasia. Unlike squamous metaplasia, acrosyringeal and eccrine ductal metaplasia are luminated structures comprising cells with eosinophilic cytoplasm that are easily detectable in routine histological slides. These lesions invariably appeared in triple-negative carcinomas, but the cases differed in their clinical, radiological, and histological manifestations. Correct interpretation of these changes may facilitate identification of some metaplastic carcinomas.

The new TNM-based staging of breast cancer

This review describes the changes that have been implemented in the Tumor-Node-Metastasis (TNM)-based staging of breast cancers by the new, 8th editions of the relevant Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) publications. After giving a background for TNM being the common language of cancer staging and related activities like cancer treatment and registration, it summarizes not only the changes but reviews some highlights important for pathologists, and lists and comments on the differences between the publications and diagnostic practices based on them. A section is dedicated to the prognostic stages of breast carcinomas introduced in the AJCC Cancer Staging Manual, but not mentioned in the UICC TNM classification of malignant tumors. A few issues that are not appropriately covered by TNM according to the authors' view (e.g., multifocal tumors, larger lymph node metastases identified by molecular methods, the heterogeneous prognosis of M1-defined stage IV disease) close the review with the final thoughts raising the vision of a potential loss of the common staging language.

Integrating anatomy, radiology, pathology, and surgery: An alternative approach in resecting multifocal and multicentric breast carcinoma

The sick lobe hypothesis provides the basis for a lobar approach in radiology, pathology, and surgical treatment of breast cancer. This approach aims to remove the tumor together with the surrounding field of genetic aberrations. Detailed preoperative lobar imaging that properly maps the disease and assesses its extent guides the parenchymal resection. Integration of our knowledge of breast anatomy and pathology with the results of preoperative radiological mapping is critical in assessing the eligibility of patients with multifocal and/or multicentric breast cancer for breast conservation treatment. Through an appropriately selected incision, a multisegment resection of the diseased lobe(s) is performed, which leaves the residual parenchyma in a formation that allows dovetailing of one part into the other, like the way pieces of a jigsaw puzzle fit together. Detailed pathologic analysis of the surgical specimen provides valuable feedback to the radiologist, establishes the completeness of surgical intervention, and generates predictive information for therapeutic decisions. Our approach is a step in continuous search for ideal tailored therapy to avoid under or over-treatment of breast cancer patients.

Diffuse invasive breast carcinoma of no special type

Diffuse invasive breast carcinomas are rare tumors associated with unfavorable prognostic parameters. This growth pattern is often related to invasive lobular cancer (ILC). Diffuse ductal breast carcinoma of no special type (NST) is largely under-recognized in the literature. We identified 70 diffuse invasive breast carcinomas in a consecutive series of 1249 invasive tumors. Based on morphology and E-cadherin expression, 15/70 were NST and 55/70 were ILC. Subgroups differed in mammographic appearance, as more NST tumors than ILCs formed stellate masses (53 vs. 18 %, p = 0.000436) while ILCs displayed more architectural distortion. NST tumors were significantly more often radiologically extensive than ILCs (80 vs. 38 %, p = 0.0042987). Subgroups did not differ significantly in disease extent on histology, lymph node status, progesterone receptor status, and molecular phenotype, with a difference of borderline statistical significance in estrogen receptor status (87 vs. 100 %, p = 0.0434783). Significantly more NST tumors were HER2 positive (27 vs. 4 %, p = 0.0050463) and showed high Ki67 proliferation index (60 vs. 25 %, p = 0.0121808). The most striking differences occurred in the histology grade of the in situ (high grade in 53 vs. 4 %) and invasive (high grade in 27 vs. 2 %) tumor components and in the distribution of the in situ component (diffuse in 73 vs. 11 %). We conclude that diffuse invasive breast carcinomas of NST comprise a small subgroup of breast carcinomas. Most of these cancers are non-high grade and of luminal phenotype, but extensive and lymph node positive with worse prognostic parameters than diffuse ILC.

Clinical implications of multifocality as a prognostic factor in breast carcinoma - a multivariate analysis study comprising 460 cases

BACKGROUND

Multifocality is not listed among prognostic factors in international breast cancer guidelines. This study aims to analyze survival in multiple breast carcinomas (MFMC cc) compared to unifocal ones (UF cc), in order to assess the prognostic impact of multifocality.

METHODS

The study included 460 breast carcinomas (2002-2006) with a median follow-up time of 104 months (74-134 months). We assessed mortality rates, overall survival at 5 years and 10 years in general, overall survival at 5 and 10 years in MFMC cc compared to UF cc, as well as median survival and survival rate according to age, T status and axillary lymph node status in MFMC cc compared to UF cc. We carried out a multivariate analysis in order to identify independent predictor factors for survival.

RESULTS

69/460 (15%) of cases were MFMC cc. Mortality rates were 56.5% in MFMC cc versus 45.1% (UF cc) (P = 0.08). 5-year overall survival was 55.9% in MFMC cc vs. 64.7% UF cc, and the 10-year overall survival was 34.9% MFMC cc vs. 52.7% UF cc (P = 0.27). Median survival in MFMC cc was 78 months (6.5 years), whereas in UF cc it was 126 months (10.5 years). However, in the multivariate analysis, survival was independently influenced only by tumor size and the presence of axillary lymph node metastases (P < 0.0001).

CONCLUSION

Breast cancer multifocality is associated with higher general mortality rates, lower 5 and 10-year overall survival, yields a lower median survival, but it does not constitute an independent prognostic factor in multivariate analysis.

A Proposal to Unify the Classification of Breast and Prostate Cancers Based on the Anatomic Site of Cancer Origin and on Long-term Patient Outcome

The similarity between the structure and function of the breast and prostate has been known for a long time, but there are serious discrepancies in the terminology describing breast and prostate cancers. The use of the large, thick-section (3D) histology technique for both organs exposes the irrationality of the breast cancer terminology. Pathologists with expertise in diagnosing prostate cancer take the anatomic site of cancer origin into account when using the terms AAP (acinar adenocarcinoma of the prostate) and DAP (ductal adenocarcinoma of the prostate) to distinguish between the prostate cancers originating primarily from the fluid-producing acinar portion of the organ (AAP) and the tumors originating either purely from the larger ducts (DAP) or from both the acini and the main ducts combined (DAP and AAP). Long-term patient outcome is closely correlated with the terminology, because patients with DAP have a significantly poorer prognosis than patients with AAP. The current breast cancer terminology could be improved by modeling it after the method of classifying prostate cancer to reflect the anatomic site of breast cancer origin and the patient outcome. The long-term survival curves of our consecutive breast cancer cases collected since 1977 clearly show that the non-palpable, screen-detected breast cancers originating from the milk-producing acini have excellent prognosis, irrespective of their histologic malignancy grade or biomarkers. Correspondingly, the breast cancer subtypes of truly ductal origin have a significantly poorer outcome, despite recent improvements in diagnosis and therapy. The mammographic appearance of breast cancers reflects the underlying tissue structure. Addition of these "mammographic tumor features" to the currently used histologic phenotypes makes it possible to distinguish the breast cancer cases of ductal origin with a poor outcome, termed DAB (ductal adenocarcinoma of the breast), from the more easily managed breast cancers of acinar origin, termed AAB (acinar adenocarcinoma of the breast), which have a significantly better outcome. This simple and easily communicable terminology could lead to better communication between the diagnostic and therapeutic team members and result in more rational treatment planning for the benefit of their patients.

Molecular phenotype of the foci in multifocal invasive breast carcinomas: intertumoral heterogeneity is related to shorter survival and may influence the choice of therapy

BACKGROUND

Multiple synchronous, ipsilateral, invasive foci of breast carcinomas are frequent and are associated with a poorer prognosis. Few studies have investigated the prognostic and therapeutic implications of heterogeneity of such foci.

METHODS

The authors reviewed the tumor type, grade, and size of all invasive foci in a series of 110 multifocal breast carcinomas documented on large-format slides. Molecular phenotype was determined by immunohistochemistry in tissue microarray blocks using 3 classification systems. The survival of patients who had tumors with microscopic (tumor type and/or grade) heterogeneity and of those who had tumors with phenotypic heterogeneity was compared with the survival of patients who had multifocal homogeneous tumors using Kaplan-Meier curves. The hazard ratio of dying from breast cancer was also calculated.

RESULTS

Intertumoral heterogeneity in tumor type and grade was detected in 16 of 110 tumors (14.6%) and in 6 of 110 tumors (5.5%), respectively. The molecular phenotype of invasive tumor foci within the same breast differed in 10% to 12.7% of patients (11-14 of 110 tumors), depending on the classification system used. Patients who had phenotypically heterogeneous, multifocal cancers had a greater risk of dying from disease (HR=2.879; 95%CI=1.084-7.649; P = .034) and had significantly shorter survival (P = .016). Phenotypic differences were most common in patients who had tumors that were homogeneous in terms of tumor type (11 of 18 tumors) and histology grade (14 of 18 tumors). Phenotyping additional tumor foci had the potential to influence the therapeutic decisions in up to 8 patients.

CONCLUSIONS

Phenotyping more than 1 invasive focus of multifocal breast carcinomas only if the individual foci deviate microscopically appears to be insufficient, because phenotypic intertumoral heterogeneity may be observed in microscopically identical foci and has potential prognostic and therapeutic consequences.

Comparison of the subgross distribution of the lesions in invasive ductal and lobular carcinomas of the breast: a large-format histology study

To compare the lesion distribution and the extent of the disease in ductal and lobular carcinomas of the breast, we studied 586 ductal and 133 lobular consecutive cancers. All cases were documented on large-format histology slides. The invasive component of ductal carcinomas was unifocal in 63.3% (371/586), multifocal in 35.5% (208/586), and diffuse in 1.2% (7/586) of the cases. The corresponding figures in the lobular group were 27.8% (37/133), 45.9% (61/586), and 26.3% (35/133), respectively. When the distribution of the in situ and invasive component in the same tumors was combined to give an aggregate pattern, the ductal carcinomas were unifocal in 41.6% (244/586), multifocal in 31.6% (185/586), and diffuse in 26.8% (157/586) of the cases. The corresponding figures in the lobular category were 15.0% (20/133), 54.2% (72/133), and 30.8% (41/133), respectively. Ductal cancers were extensive in 45.7% (268/586), lobular in 65.4% (87/133) of the cases. All these differences were statistically highly significant (P < 0.0001). While the histological tumor type itself (ductal versus lobular) did not influence the lymph node status, multifocal and diffuse distribution of the lesions were associated with significantly increased risk of lymph node metastases in both ductal and lobular cancers.