The importance of biopsy in clinically diagnosed metastatic lesions in patients with breast cancer

Jejunal Gastrointestinal Stromal Tumor: A Diagnostic Challenge

Gastrointestinal stromal tumors (GISTs) are a common type of soft tissue sarcoma that originates from the interstitial cells of Cajal in the gastrointestinal (GI) tract. These tumors usually affect people above 50 years of age and can be difficult to diagnose, as symptoms can be vague and nonspecific, with some patients remaining asymptomatic. Early diagnosis and treatment are crucial because GISTs can be aggressive and may metastasize. We present a case of a 74-year-old man who presented to our hospital with GI bleeding and anemia. Despite initial investigations, the source of bleeding was not identified until capsule endoscopy and then balloon enteroscopy revealed an ulcerated mass in the jejunum. The tumor was successfully removed using a minimally invasive laparoscopic approach, and the histopathologic report confirmed the diagnosis of GIST. The patient had an uneventful postoperative course. This case highlights the importance of considering GISTs in the differential diagnosis of obscure GI bleeding. A multidisciplinary approach is essential to ensure the best outcomes for these patients. Additionally, the use of minimally invasive surgery should be considered whenever possible to minimize postoperative complications and promote faster recovery.

A Rare Metastatic Site of Invasive Lobular Breast Carcinoma: A Case Report

Here, we report a case of a 42-year-old female patient with left lobular breast cancer-gastric metastasis (initially misdiagnosed five years ago as an invasive ductal carcinoma) presenting with dyspepsia, weight loss, and persistent vomiting lasting for four weeks. Upper GI endoscopy revealed evidence of linitis plastica, and histological and immunocytochemical analyses of the biopsy confirmed gastric metastasis secondary to invasive lobular breast carcinoma.

Association of Biomarker Discrepancy and Treatment Decision, Disease Outcome in Recurrent/Metastatic Breast Cancer Patients

Background

Biomarker discrepancy between primary and recurrent/metastatic breast cancer is well known, however its impact on prognosis and treatment after relapse is still unclear. Current study aims to evaluate biomarkers discrepancy between primary and recurrent/metastatic lesions as well as to investigate its association with following treatment pattern and disease outcome.

Patients and methods

We retrospectively included consecutive breast cancer patients undergoing surgery in our center from Jan. 2009 to Dec. 2016 and reported disease recurrence. Patients with re-biopsy and paired biomarkers statuses on primary and recurrent/metastatic lesions were further analyzed. Kappa test was used to analyze the concordance rate of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor-2 (HER2) status. Post-recurrence survival (PRS) was compared between subgroups by Kaplan-Meier curve. Cox regression model was applied to identify impact factors for PRS.

Results

A total of 156 patients were finally included, of whom 70 and 86 had loco-regional and distant recurrence, respectively. Concordance rates of ER, PR and HER2 were 83.3%, 66.7%, and 97.1%, respectively, which was similarly distributed among different recurrent sites (all P > 0.05). Primary ER-positivity (vs ER-negativity, P = 0.014) and loco-regional recurrence (vs distant metastasis, P = 0.001) were independently associated with superior PRS, while patients with visceral metastasis (P < 0.001) had the worst disease outcome. Hormone receptor/HER2 status discrepancy was observed in 28 patients. Fifteen of them changed systemic treatment based on biomarker statuses of recurrent lesion, however, their PRS was not improved compared to those 13 patients who continued the same treatment according to primary biomarkers statuses (P = 0.298).

Conclusion

Biomarker discrepancy was observed between primary and recurrent/metastatic breast cancer lesions and had certain influence on treatment strategies after relapse. However, its impact on disease outcome wasn’t established in the current study, which deserves further evaluation.

Biopsy of distant metastasis is not a significant prognostic factor for synchronous metastatic nasopharyngeal carcinoma: a propensity score-matched analysis from the Surveillance Epidemiology and End-Results Registry

Introduction: Biopsy is essential for some patients with suspected distant metastasis, so we aim to figure out whether biopsy of distant metastasis is associated with impaired survival in NPC.

Methods: A total of 743 synchronous metastatic NPC patients from 2004 to 2016 were analyzed from the population-based Surveillance, Epidemiology, and End Results program. Propensity score matching was used to control confounders and create a well-balanced cohort. Five-year survival rate estimates and Kaplan-Meier survival curves were calculated. Cox proportional hazard ratios (HRs) were used to identify independent prognostic factors for survival.

Results: Of 743 eligible patients, 194 (26.11%) underwent biopsy of distant metastasis. After control for demographic and clinicopathologic characteristics, patients with biopsy of distant metastasis achieved comparable 5-year overall survival (OS) (20.3% vs 24.7%; P = 0.41) and 5-year cancer specific survival (CSS) (31.0% vs 33.6%; P = 0.35) with patients without biopsies. Multivariate analysis further confirmed that biopsy of distant metastasis was not associated with impaired OS (HR = 1.03, 95% CI = 0.84-1.25; P = 0.80) or CSS (HR = 1.07, 95% CI = 0.86-1.34; P = 0.54).

Conclusions: Biopsy of distant metastasis was not associated with impaired survival outcomes for synchronous metastatic NPC patients. Biopsy of distant metastasis could be another diagnosed choice for patients with suspected distant metastasis.

Sterile, abscess-like cerebral lesion during trastuzumab therapy after HER2 status switch in a triple negative breast cancer patient: a case report and literature review

Background

Breast cancer is a global health problem – it is the most common malignancy among women. Triple negative breast cancers (TNBC) account for 10–20% of female breast cancer. Most TNBC cases confer poor prognosis. Brain metastasis appears in more than 15% in the triple negative breast cancer population, which causes serious decrease in survival. Changes of immunophenotype are not uncommon in breast cancer, offering new therapeutic options in cases where targetable proteins or pathways are being identified.

Case presentation

After five lines of chemotherapy and 82 months following the first diagnosis, our patient with brain metastatic triple negative breast cancer had human epidermal growth factor receptor 2 (HER2) genetic heterogeneity in the metastatic tissue sample interpreted as HER2 status conversion. After the removal of the metastasis, we started first line therapy for metastatic HER2 positive cancer with trastuzumab and paclitaxel. After the first cycle of trastuzumab, on day 8, she had a seizure, and neurosurgical examination showed an abscess-like lesion. The punctate proved to be sterile by microbiological and pathological examination, so we continued cytostatic therapy without the anti-HER2 antibody. 3 months later, we could not identify the previous abscess-like lesion in the control computer tomography (CT) scan, and our patient had no neurological deficits.

Conclusion

We emphasize the importance of regular tissue confirmation of predictive markers in progressive tumorous disease even if our presented case is not unequivocally a “conversion case”. Tumor subtype is determined according to algorithms and definitions published in guidelines, nevertheless, use of different guidelines may lead to controversial interpretation in cases where HER2 genetic heterogeneity is present. Furthermore, we suggest that seronegative, aseptic intracranial fluid effusion after the removal of a brain metastasis may possibly be a side effect of trastuzumab.

[Role of biological heterogeneity in recurrent and metastatic breast cancer]

Breast cancer (BC) is a heterogeneous tumor, the biological characteristics of which vary with its growth and progression. Information on key tumor receptors (ER, PR, HER2, and Ki-67) is the basis for individualizing the diagnostic and treatment algorithm at all BC stages; however, the feasibility of biopsy of distant metastases and the re-testing of the biological subtype of BC in its suspected progression are being actively discussed in clinical practice. This review presents an update on the features of metastasis in different biological BC subtypes and assesses the clinical and prognostic role of biopsy of distant metastases in the lung, bones, liver, and brain. It shows the frequency of discordance in receptor status between primary and recurrent tumors at different sites of metastases, as well as the impact of changes in receptor status on survival rates in different biological BC subtypes. The relevance of performing biopsies in BC progression is shown to be beyond question, because it makes it possible to confirm the fact that the disease progresses, to re-test the biological subtype of recurrent BC, and to find new targets that allow the most effective drug treatment regimens to be used.

Clinical Potential of Estrogen and Progesterone Receptor Imaging

Molecular imaging using 16α-[18F]fluoro-17β-estradiol (FES) and 18F-fluoro-furanyl-norprogesterone PET can assess in vivo function of steroid hormone receptors in breast cancer. These experimental agents have been tested in many single-center clinical trials and show promise to elucidate prognosis and predict endocrine therapy response. The current multicenter trial of FES-PET imaging will help bring this radiotracer closer to clinical use. There is tremendous potential for these tracers to advance drug development, enhance understanding of estrogen receptor-positive tumor biology, and personalize treatment.

Gastric metastasis from invasive lobular breast cancer, mimicking primary gastric cancer: A case report

RATIONALE

Gastric metastasis from invasive lobular breast cancer is relatively rare, commonly presented among multiple metastases, several years after primary diagnosis of breast cancer. Importantly, gastric cancer that is synchronously presented with lobular breast cancer can be misdiagnosed as primary gastric cancer; therefore, accurate differential diagnosis is required.

PATIENT CONCERNS

A 39-year-old woman was visited to our hospital because of right breast mass and progressive dyspepsia.

DIAGNOSES

Invasive lobular carcinoma of breast was diagnosed on core needle biopsy. Gastroscopy revealed a diffuse scirrhous mass at the prepyloric antrum and diagnosed as poorly differentiated adenocarcinoma on biopsy. Synchronous double primary breast and gastric cancers were considered. Detailed pathological analysis focused on immunohistochemical studies of selected antibodies, including those of estrogen receptors, gross cystic disease fluid protein-15, and caudal-type homeobox transcription factor 2, were studied. As a result, gastric lesion was diagnosed as metastatic gastric cancer originating from breast.

INTERVENTIONS

Right breast conserving surgery was performed, and duodenal stent was inserted under endoscopic guidance to relieve the patient's symptoms. Systemic chemotherapy with combined administration of paclitaxel and trastuzumab was initiated.

OUTCOMES

Forty-one months after the diagnosis, the patient is still undergoing the same therapy. No recurrent lesion has been identified in the breast and evidence of a partial remission of gastric wall thickening has been observed on follow-up studies without new metastatic lesions.

LESSONS

Clinical suspicion, repeat endoscopic biopsy, and detailed histological analysis, including immunohistochemistry, are necessary for diagnosis of metastatic gastric cancer from the breast.

Biopsy of breast cancer metastases: patient characteristics and survival

BACKGROUND

Discordance in hormone receptors (HR) and human epidermal growth factor receptor 2 (HER2) status between primary tumors and metastatic sites for breast cancer is well established. However, it is uncertain which patient-related factors lead to biopsy when metastases are suspected and whether having a biopsy impacts survival.

METHODS

The medical charts of metastatic breast cancer (MBC) patients diagnosed January 2000-August 2014 were retrospectively reviewed. A biopsy was defined as a procedure where tissue was obtained and assessed for both HR and HER2. Both bivariate and multivariate analyses were performed to assess patient characteristics related to biopsy and whether having a biopsy was associated with improved survival.

RESULTS

Of 409 patients suspected of having MBC, 165 (40%) had a biopsy, and 34% of these had discordant HR or HER2 status when compared to the initial diagnosis. In multivariate analysis, having a biopsy was associated with: recurrence in years 2010-2014, disease-free interval of > =3 years, stage 0-IIA at presentation, suspected locoregional recurrence, being HR+/HER2-, or missing HR/HER2 at diagnosis. A similar multivariate analysis revealed that having a biopsy was associated with improved survival (HR = 0.67, p = 0.002). The association of biopsy and improved survival was noted in specific subgroups: patients with missing HR and HER2 data at initial diagnosis (p = 0.001), those without metastases in liver, lung or brain (p = 0.001), and being younger than 70 years old at recurrence (p < 0.001).

CONCLUSIONS

Specific clinical factors were associated with biopsy at the time of suspected recurrence. Having a biopsy was associated with reduced mortality.

Primary or metastatic hepatic carcinoma? A breast cancer patient after adjuvant chemotherapy and radiotherapy postoperatively with intrahepatic cholangiocarcinoma and review of the literature

Background

The liver is a common site of metastases, followed by the bone and lung in breast cancer. The symptoms of hepatic metastases are similar to intrahepatic cholangiocarcinoma (ICC). ICC is rare, with an overall incidence rate of 0.95 cases per 100,000 adults. The incidence of ICC for patients with breast cancer is very uncommon. Breast cancer patient with ICC is easily misdiagnosed as hepatic metastases.

Case presentation

We report a breast cancer patient postoperatively who was hospitalized because of having continuous irregular fever for 1 month. Antibiotics were given for 1 week without any significant effect. Her admission bloods revealed elevated levels of carcino-embryonic antigen. Magnetic resonance imaging diagnosis showed multiple liver metastases. We believed that the woman had hepatic metastases until biopsy guided by computed tomography. The liver biopsy pathology analysis considered the possibility of primary intrahepatic cholangiocarcinoma.

Conclusions

Breast cancer patient with space-occupying lesions in the liver is easily considered to be progressed hepatic metastases. Image-guided biopsy is the best diagnostic method for breast cancer with liver mass to avoid misdiagnosis and classify the molecular subtypes to make appropriate treatment.

Molecular Concordance Between Primary Breast Cancer and Matched Metastases

Clinical management of breast cancer is increasingly personalized and based on molecular profiling. Often, primary tumors are used as proxies for systemic disease at the time of recurrence. However, recent studies have revealed substantial discordances between primary tumors and metastases, both with respect to traditional clinical treatment targets and on the genomic and transcriptomic level. With the increasing use of molecularly targeted therapy, discordance of actionable molecular targets between primary tumors and recurrences can result in nonoptimal treatment or unnecessary side effects. The purpose of this review is to illuminate the extent of cancer genome evolution through disease progression and the degree of molecular concordance between primary breast cancers and matched metastases. We present an overview of the most prominent studies investigating the expression of endocrine receptors, transcriptomics, and genome aberrations in primary tumors and metastases. In conclusion, biopsy of metastatic lesions at recurrence of breast cancer is encouraged to provide optimal treatment of the disease. Furthermore, molecular profiling of metastatic tissue provides invaluable mechanistic insight into the biology underlying metastatic progression and has the potential to identify novel, potentially druggable, drivers of progression.

EpCAM-Independent Enrichment of Circulating Tumor Cells in Metastatic Breast Cancer

Circulating tumor cells (CTCs) are the potential precursors of metastatic disease. Most assays established for the enumeration of CTCs so far-including the gold standard CellSearch-rely on the expression of the cell surface marker epithelial cell adhesion molecule (EpCAM). But, these approaches may not detect CTCs that express no/low levels of EpCAM, e.g. by undergoing epithelial-to-mesenchymal transition (EMT). Here we present an enrichment strategy combining different antibodies specific for surface proteins and extracellular matrix (ECM) components to capture an EpCAMlow/neg cell line and EpCAMneg CTCs from blood samples of breast cancer patients depleted for EpCAM-positive cells. The expression of respective proteins (Trop2, CD49f, c-Met, CK8, CD44, ADAM8, CD146, TEM8, CD47) was verified by immunofluorescence on EpCAMpos (e.g. MCF7, SKBR3) and EpCAMlow/neg (MDA-MB-231) breast cancer cell lines. To test antibodies and ECM proteins (e.g. hyaluronic acid (HA), collagen I, laminin) for capturing EpCAMneg cells, the capture molecules were first spotted in a single- and multi-array format onto aldehyde-coated glass slides. Tumor cell adhesion of EpCAMpos/neg cell lines was then determined and visualized by Coomassie/MitoTracker staining. In consequence, marginal binding of EpCAMlow/neg MDA-MB-231 cells to EpCAM-antibodies could be observed. However, efficient adhesion/capturing of EpCAMlow/neg cells could be achieved via HA and immobilized antibodies against CD49f and Trop2. Optimal capture conditions were then applied to immunomagnetic beads to detect EpCAMneg CTCs from clinical samples. Captured CTCs were verified/quantified by immunofluorescence staining for anti-pan-Cytokeratin (CK)-FITC/anti-CD45 AF647/DAPI. In total, in 20 out of 29 EpCAM-depleted fractions (69%) from 25 metastatic breast cancer patients additional EpCAMneg CTCs could be identified [range of 1-24 CTCs per sample] applying Trop2, CD49f, c-Met, CK8 and/or HA magnetic enrichment. EpCAMneg dual-positive (CKpos/CD45pos) cells could be traced in 28 out of 29 samples [range 1-480]. By single-cell array-based comparative genomic hybridization we were able to demonstrate the malignant nature of one EpCAMneg subpopulation. In conclusion, we established a novel enhanced CTC enrichment strategy to capture EpCAMneg CTCs from clinical blood samples by targeting various cell surface antigens with antibody mixtures and ECM components.