Significance of axillary lymph node metastasis in primary breast cancer

Ultrasonographic signs as predictors of metastatic involvement in the axillary lymph nodes in breast cancer patients: from minimal changes to the appearance of the pathological lymph node. A retrospective analysis

INTRODUCTION

The aim of this study was to retrospectively analyse the ultrasound findings in the axillary lymph nodes in breast cancer patients with morphological changes that required biopsy. In most cases the morphological changes were minimal.

MATERIALS AND METHODS

Between January 2014 and September 2019 examination of axillary lymph nodes with subsequent core-biopsy was performed in 185 breast cancer patients at the Department of Radiology. Lymph node metastases were detected in 145 cases, while in the remaining 40 cases benign changes or normal lymph node (LN) histology was observed. Ultrasound morphological characteristics and the sensitivity and specificity were evaluated retrospectively. Seven ultrasound characteristics were evaluated - diffuse cortical thickening, focal cortical thickening, absence of the hilum, cortical non-homogeneities, L/T ratio (longitudinal to transverse axis), type of vascularization and perinodal oedema.

RESULTS AND CONCLUSION

It is a diagnostic challenge to recognize metastases in the lymph nodes with minimal morphological changes. The most specific signs are non-homogeneities in the cortex of the lymph node as well as the absence of fat hilum and perinodal oedema. Metastases are significantly more frequent in LNs with a lower L/T ratio, in LNs with perinodal oedema and with a peripheral type of vascularization. Biopsy of these lymph nodes is necessary to confirm or exclude metastases, especially if it affects the type of treatment.

Lymphatic system regulation of anti-cancer immunity and metastasis

Cancer dissemination to lymph nodes (LN) is associated with a worse prognosis, increased incidence of distant metastases and reduced response to therapy. The LN microenvironment puts selective pressure on cancer cells, creating cells that can survive in LN as well as providing survival advantages for distant metastatic spread. Additionally, the presence of cancer cells leads to an immunosuppressive LN microenvironment, favoring the evasion of anti-cancer immune surveillance. However, recent studies have also characterized previously unrecognized roles for tumor-draining lymph nodes (TDLNs) in cancer immunotherapy response, including acting as a reservoir for pre-exhausted CD8+ T cells and stem-like CD8+ T cells. In this review, we will discuss the spread of cancer cells through the lymphatic system, the roles of TDLNs in metastasis and anti-cancer immune responses, and the therapeutic opportunities and challenges in targeting LN metastasis.

The impact of the COVID-19 pandemic on symptomatic breast cancer presentations in an Irish breast cancer unit: a retrospective cohort study

BACKGROUND

The coronavirus-19 (COVID-19) pandemic caused delays in the diagnosis and management of breast cancer which may have affected disease presentation. The aim of this study was to compare rates of metastatic disease, tumour characteristics and management in breast cancer patients diagnosed before and after the onset of COVID-19.

METHODS

A retrospective chart review was conducted on patients in a university teaching hospital who were diagnosed with invasive symptomatic breast cancer in 2019 (prepandemic control group) and in 2020, 2021, and 2022 (pandemic study groups). Rates of new metastatic presentations, tumour histopathological characteristics, operation type, and therapies administered were statistically compared.

RESULTS

A total of 1416 patients were identified. There was a significant increase in new metastatic breast cancer presentations in 2022 compared to 2019 (14.0% vs 3.8%, p ≤ 0.001), with non-significant increases in 2020 and 2021. Rates of adjuvant radiotherapy increased in 2020 and decreased in 2022 compared to 2019, with no significant change in neoadjuvant or adjuvant chemotherapy rates. Rates of axillary surgery increased during 2020 and 2021. There was an increase in high-grade tumours and lymphovascular invasion (LVI), and less frequent oestrogen receptor (ER) positivity in pandemic groups. No significant change was noted in BCS to mastectomy ratios, overall nodal positivity rates, or median tumour size.

CONCLUSION

Symptomatic breast cancers diagnosed since the onset of COVID-19 demonstrated an increase in new metastatic presentations and more aggressive histopathological characteristics when compared to a pre-pandemic control group. Rates of adjuvant radiotherapy and axillary surgery increased during the pandemic.

Nanoparticles Targeting Lymph Nodes for Cancer Immunotherapy: Strategies and Influencing Factors

Immunotherapy has emerged as a potent strategy in cancer treatment, with many approved drugs and modalities in the development stages. Despite its promise, immunotherapy is not without its limitations, including side effects and suboptimal efficacy. Using nanoparticles (NPs) as delivery vehicles to target immunotherapy to lymph nodes (LNs) can improve the efficacy of immunotherapy drugs and reduce side effects in patients. In this context, this paper reviews the development of LN-targeted immunotherapeutic NP strategies, the mechanisms of NP transport during LN targeting, and their related biosafety risks. NP targeting of LNs involves either passive targeting, influenced by NP physical properties, or active targeting, facilitated by affinity ligands on NP surfaces, while alternative methods, such as intranodal injection and high endothelial venule (HEV) targeting, have uncertain clinical applicability and require further research and validation. LN targeting of NPs for immunotherapy can reduce side effects and increase biocompatibility, but risks such as toxicity, organ accumulation, and oxidative stress remain, although strategies such as biodegradable biomacromolecules, polyethylene glycol (PEG) coating, and impurity addition can mitigate these risks. Additionally, this work concludes with a future-oriented discussion, offering critical insights into the field.

Discordance of Biomarker Expression Profile between Primary Breast Cancer and Synchronous Axillary Lymph Node Metastasis in Preoperative Core Needle Biopsy

Background: Breast cancer (BC) is a heterogeneous disease made up of clones with different metastatic potential. Intratumoral heterogeneity may cause metastases to show divergent biomarker expression, potentially affecting chemotherapy response. Methods: We investigated the immunohistochemical (IHC) and FISH profile of estrogen receptors (ER), progesterone (PR) receptors, Ki67, and HER2 in a series of BC-matched primary tumors (PTs) and axillary lymph node (ALN) metastases in pre-operative core needle biopsies (CNBs). Phenotypical findings were correlated to morphological features and their clinical implications. Results: Divergent expression between PTs and ALNs was found in 10% of the tumors, often involving multiple biomarkers (12/31, 39%). Most (52%) displayed significant differences in ER and PR staining. HER2 divergences were observed in almost three-quarters of the cases (23/31, 74%), with five (16%) switching from negativity to overexpression/amplification in ALNs. Roughly 90% of disparities reflected significant morphological differences between PTs and ALN metastases. Less than half of the discrepancies (12/31, 39%) modified pre/post-operative treatment options. Conclusions: We observed relevant discrepancies in biomarker expression between PTs and metastatic ALNs in a noteworthy proportion (10%) of preoperative BC CNBs, which were often able to influence therapies. Hence, our data suggest routine preoperative assessment of biomarkers in both PTs and ALNs in cases showing significant morphological differences.

Prognostic value of axillary lymph node metastases in invasive lobular breast carcinoma

BACKGROUND

Axillary lymph node involvement is a well-established prognostic factor for recurrence in breast cancer, specifically the number of nodes affected and the ratio of the number of affected nodes to the number of harvested nodes for non-specific invasive breast cancer (invasive ductal carcinoma). However, there is limited information on the impact of lymph node involvement in the case of invasive lobular carcinoma.

OBJECTIVES

our study aimed to evaluate the prognostic impact of lymph node involvement on overall survival and distant metastatic-free survival according to the number of nodes affected and the ratio of positive nodes (LNR) for patients managed for invasive lobular carcinoma.

METHODS

This is a monocentre, comparative, observational study of patients managed for invasive lobular carcinoma at the Gynaecology Department of the University Hospital Center of Tours between January 1, 2007 and December 31, 2018. The LNR cut-off values used were: low risk if LNR ≤ 0.2; intermediate risk if LNR > 0.2 and ≤ 0.65, and high risk for LNR >0.659.

RESULTS

Our study demonstrated a significant difference in overall survival and distant metastasis free survival (p < 0.0001). The 5-years Overall survival was 94 % for N0 patients, 92.4 % for low-risk patients, 85.6 % for intermediate-risk patients and 58.5 % for high-risk patients. The 5-year distant metastasis-free survival was 98.2 % for N0 patients, 95.9 % for low-risk patients, 80.1 % for intermediate-risk patients, and 60.3 % for high-risk patients. Multivariate analysis identified age, invasive lobular histologic type, presence of clinical inflammation, and intermediate and high risk classes of LNR ratio as independent factors affecting overall survival. For metastatic-free survival, the presence of clinical inflammation, the presence of LVSI and the low, intermediate, or high-risk classes of LNR ratio were identified as independent factors. However, age and invasive lobular histologic type did not appear to be independent factors affecting metastatic-free survival.

CONCLUSION

Our study highlights the significant prognostic impact of lymph node involvement in patients with invasive lobular carcinoma. The LNR ratio can be used as a reliable predictor of overall survival and metastatic-free survival in these patients.

Nomogram based on multiparametric analysis of early-stage breast cancer: Prediction of high burden metastatic axillary lymph nodes

BACKGROUND

The Z0011 and AMAROS trials found that axillary lymph node dissection (ALND) was no longer mandatory for early-stage breast cancer patients who had one or two metastatic axillary lymph nodes (mALNs). The aim of our study was to establish a nomogram which could be used to quantitatively predict the individual likelihood of high burden mALN (≥3 mALN).

METHODS

We retrospectively analyzed 564 women with early breast cancer who had all undergone both ultrasound (US) and magnetic resonance imaging (MRI) to examine axillary lymph nodes before radical surgery. All the patients were divided into training (n = 452) and validation (n = 112) cohorts by computer-generated random numbers. Their clinicopathological features and preoperative imaging associated with high burden mALNs were evaluated by logistic regression analysis to develop a nomogram for predicting the probability of high burden mALNs.

RESULTS

Multivariate analysis showed that high burden mALNs were significantly associated with replaced hilum and the shortest diameter >10 mm on MRI, with cortex thickness >3 mm on US (p < 0.05 each). These imaging criteria plus higher grade (grades II and III) and quadrant of breast tumor were used to develop a nomogram calculating the probability of high burden mALNs. The AUC of the nomogram was 0.853 (95% CI: 0.790-0.908) for the training set and 0.783 (95% CI: 0.638-0.929) for the validation set. Both internal and external validation evaluated the accuracy of nomogram to be good.

CONCLUSION

A well-discriminated nomogram was developed to predict the high burden mALN in early-stage breast patients, which may assist the breast surgeon in choosing the appropriate surgical approach.

Simultaneous 18F-FDG PET/MRI Radiomics and Machine Learning Analysis of the Primary Breast Tumor for the Preoperative Prediction of Axillary Lymph Node Status in Breast Cancer

In this prospective study, 117 female patients (mean age = 53 years) with 127 histologically proven breast cancer lesions (lymph node (LN) positive = 85, LN negative = 42) underwent simultaneous 18F-FDG PET/MRI of the breast. Quantitative parameters were calculated from dynamic contrast-enhanced (DCE) imaging (tumor Mean Transit Time, Volume Distribution, Plasma Flow), diffusion-weighted imaging (DWI) (tumor ADCmean), and PET (tumor SUVmax, mean and minimum, SUVmean of ipsilateral breast parenchyma). Manual whole-lesion segmentation was also performed on DCE, T2-weighted, DWI, and PET images, and radiomic features were extracted. The dataset was divided into a training (70%) and a test set (30%). Multi-step feature selection was performed, and a support vector machine classifier was trained and tested for predicting axillary LN status. 13 radiomic features from DCE, DWI, T2-weighted, and PET images were selected for model building. The classifier obtained an accuracy of 79.8 (AUC = 0.798) in the training set and 78.6% (AUC = 0.839), with sensitivity and specificity of 67.9% and 100%, respectively, in the test set. A machine learning-based radiomics model comprising 18F-FDG PET/MRI radiomic features extracted from the primary breast cancer lesions allows high accuracy in non-invasive identification of axillary LN metastasis.

Multi-center study on predicting breast cancer lymph node status from core needle biopsy specimens using multi-modal and multi-instance deep learning

The objective of our study is to develop a deep learning model based on clinicopathological data and digital pathological image of core needle biopsy specimens for predicting breast cancer lymph node metastasis. We collected 3701 patients from the Fourth Hospital of Hebei Medical University and 190 patients from four medical centers in Hebei Province. Integrating clinicopathological data and image features build multi-modal and multi-instance (MMMI) deep learning model to obtain the final prediction. For predicting with or without lymph node metastasis, the AUC was 0.770, 0.709, 0.809 based on the clinicopathological features, WSI and MMMI, respectively. For predicting four classification of lymph node status (no metastasis, isolated tumor cells (ITCs), micrometastasis, and macrometastasis), the prediction based on clinicopathological features, WSI and MMMI were compared. The AUC for no metastasis was 0.770, 0.709, 0.809, respectively; ITCs were 0.619, 0.531, 0.634, respectively; micrometastasis were 0.636, 0.617, 0.691, respectively; and macrometastasis were 0.748, 0.691, 0.758, respectively. The MMMI model achieved the highest prediction accuracy. For prediction of different molecular types of breast cancer, MMMI demonstrated a better prediction accuracy for any type of lymph node status, especially in the molecular type of triple negative breast cancer (TNBC). In the external validation sets, MMMI also showed better prediction accuracy in the four classification, with AUC of 0.725, 0.757, 0.525, and 0.708, respectively. Finally, we developed a breast cancer lymph node metastasis prediction model based on a MMMI model. Through all cases tests, the results showed that the overall prediction ability was high.

Clinical relevance of biomarker discordance between primary breast cancers and synchronous axillary lymph node metastases

Clinical decision-making for patients with breast cancer (BC) is still primarily based on biomarker characteristics of the primary tumor, together with the evaluation of synchronous axillary lymph node metastasis (LNM). In this study, we investigated the prevalence of discordance in the biomarkers and surrogate subtyping between the primary BC and the LNM, and whether subsequent changes would have altered clinical treatment recommendations. In this retrospective study, 94 patients treated for unifocal primary BC and synchronous LNM at Sahlgrenska UniversityHospital during 2018 were included. Estrogen (ER) and progesterone (PR) receptor, Ki67, and HER2 status were assessed in the primary tumor and LNM using immunohistochemistry. Discordances between the primary tumor and the LNM were analyzed for each individual biomarker and surrogate subtyping. The concordance between the primary tumor and the LNM for ER, PR, Ki67, and HER2 status was 98.9%, 89.4%, 72.3%, and 95.8%, respectively. Discordance in surrogate subtyping was found in 28.7% of the tumors and matched LNMs, the majority (81.5%) of which changed to a more favorable subtype in the LNM; most commonly from Luminal B to Luminal A (48.6%). No changes in surrogate subtyping were detected where ER or HER2 status changed from negativity in the BC to positivity in the LNM, thereby showing no additional value in performing immunohistochemistry on the LNM from a treatment decision-making perspective. However, large studies need to be performed that test both the primary BCs and synchronous LNMs for more accurate diagnostics.

Detection of Axillary Lymph Node Involvement in Early-Stage Breast Cancer: Comparison between Staging 18F-2-Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography-Computed Tomography Scans, Mammography, and Sentinel Lymph Node Biopsy

Aims

The aim of this study was to evaluate the role of 18F-2-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography-computed tomography (PET-CT) scan in the detection of axillary lymph node (ALN) involvement and comparison with sentinel lymph node biopsy (SLNB) in operable early-stage breast cancer (EBC).

Settings and Design

It is a retrospective analysis of staging PET-CT scan of EBC.

Methods

A total of 128 patients with histopathologically proven breast cancer (BC) were included in the study. Preoperative mammography supplemented with ultrasonography and staging 18F-FDG PET-CT scan was done for all patients. Surgery was done within 30 (mean ± standard deviation = 13.8 ± 10.5) days of staging. SLNB was performed in patients without PET-positive ALNs. All patients with positive sentinel nodes and PET-positive ALNs underwent axillary lymph node dissection (ALND).

Statistical Analysis Used

The comparison between categorical variables was made by Chi-square/Fisher's exact test as applicable. For continuous variables comparisons, Student's t-test and one-way analysis of variance tests were used.

Results

Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT scan for detection of ALN involvement were 41.7%, 93.2%, 92.1%, and 45.6%, respectively. Sensitivity, specificity, PPV, and NPV of mammography were 84.5%, 54.5%, 78.0%, and 68.6%, respectively. Sixteen out of 46 (34.7%) patients with negative ALNs in PET-CT scan finally showed involvement in histopathology report after SLNB resulting in upstage of the disease. The size of tumor deposits in sentinel nodes was significantly smaller than PET-positive ALNs (P = 0.01). Our observations correlate with the results of earlier studies published in the literature.

Conclusions

18F-FDG PET-CT scan cannot substitute SLNB for ALN screening in EBC. The limitations are most marked in smaller and micrometastatic tumor deposits in ALNs and may be attributed to limitations of PET resolution. However, PET-positive nodes showed good specificity for disease involvement in our study. Therefore, ALND can safely be performed by omitting SLNB in such cases.

Who Needs Level III Lymph Node Dissection in Carcinoma Breast-Study from a Tertiary Care Center

In Indian females, breast cancer is the most common cancer with a late stage of presentation leading to one-third of patients undergoing modified radical mastectomy (MRM). Our study is undertaken to find out predictors of level III axillary lymph node metastasis in breast cancer and who needs complete axillary lymph node dissection (ALND). Retrospective study of 146 patients who undergone MRM or breast-conserving surgery (BCS) with complete ALND at Kidwai Memorial Institute of Oncology was done, and data was analyzed to find out the frequency of level III lymph nodes and the demographic relation and its relation to positive lymph nodes in level I + II. Positive metastatic level III lymph node was found in 6% of patients, with the median age of the patient in our study with level III positivity was 48.5 years with 63% pathological stage II with 88% perinodal spread (PNS)- and lymphovascular invasion (LVI)-positive. Involvement of level III lymph node was associated with gross disease in level I + II lymph node having more than four lymph node-positive and with pT3 stage or more which has higher chances of level III lymph node involvement. Level III lymph node involvement, though rare in early-stage breast cancer, is associated with larger clinical and pathological sizes (T3 or more), more than 4 lymph node-positive in level I + II and with PNS and LVI. Hence, based on these results, we recommend that for inpatient with more than 5-cm tumor size and those with the gross disease in axilla, complete ALND is recommended.

Multiple Bone Metastatic Invasion with Clinical Implications due to Ductal Mammary Carcinoma – Case report and Short Literature Review

Multidisciplinary approach of clinical cases in rehabilitations units can be very complex and divers. Method: We present a case of a woman 30 years old, whose oncological histo-ry begins 9 years ago, when the diagnosis of invasive ductal mammary infiltrating ca-nelular carcinoma grade I was made and treated by tumorectomy (lumpectomy). The pa-tient refused oncological treatment at that time and resorted to alternative medicine dur-ing a period of 7 years: diet without sugar and animal products; regular vitamin B17 treatments; almond kernel cure; high-dose intravenous vitamin C treatment for; intrave-nous ozone therapy; apitherapy with bee venom; oral administration of cannabis oil dur-ing the past four years until now; physical therapy. Results: The evolution is marked by the appearance of multiple bone metastatic lesions. The most worst clinical consequence was a hyperalgesic cervicobrachial neuralgia, due to multiple C6-T3 lytic lesions diag-nosed 2 years ago and C7 compression (close to spinal cord injury), situation which had as medical approach two surgeries interventions, radiotherapy and chemotherapy. Con-clusions: The rehabilitation program was adapted to every stage of clinical evolution and was marked by many complications. All the steps were made for functional improvement and for increase the quality of life.

A new label-free optical imaging method for the lymphatic system enhanced by deep learning

Our understanding of the lymphatic vascular system lags far behind that of the blood vascular system, limited by available imaging technologies. We present a label-free optical imaging method that visualizes the lymphatic system with high contrast. We developed an orthogonal polarization imaging (OPI) in the shortwave infrared range (SWIR) and imaged both lymph nodes and lymphatic vessels of mice and rats in vivo through intact skin, as well as human mesenteric lymph nodes in colectomy specimens. By integrating SWIR-OPI with U-Net, a deep learning image segmentation algorithm, we automated the lymph node size measurement process. Changes in lymph nodes in response to cancer progression were monitored in two separate mouse cancer models, through which we obtained insights into pre-metastatic niches and correlation between lymph node masses and many important biomarkers. In a human pilot study, we demonstrated the effectiveness of SWIR-OPI to detect human lymph nodes in real time with clinical colectomy specimens.

One Sentence Summary

We develop a real-time high contrast optical technique for imaging the lymphatic system, and apply it to anatomical pathology gross examination in a clinical setting, as well as real-time monitoring of tumor microenvironment in animal studies.

Feasibility of Breast Cancer Metastasis Assessment of Ex Vivo Sentinel Lymph Nodes through a p-H&E Optical Coherence Microscopic Imaging System

Frozen-sectioned hematoxylin-eosin (H&E) image evaluation is the current method for intraoperative breast cancer metastasis assessment through ex vivo sentinel lymph nodes (SLNs). After frozen sectioning, the sliced fatty region of the frozen-sectioned specimen is easily dropped because of different freezing points for fatty tissues and other tissues. Optical-sectioned H&E images provide a nondestructive method for obtaining the insight en face image near the attached surface of the dissected specimen, preventing the freezing problem of fatty tissue. Specimens from 29 patients at Wanfang Hospital were collected after excision and were analyzed at the pathology laboratory, and a fluorescence-in-built optical coherence microscopic imaging system (OCMIS) was then used to visualize the pseudo-H&E (p-H&E) images of the SLNs for intraoperative breast cancer metastasis assessment, and the specificity, sensitivity, and accuracy were 100%, 88.9%, and 98.8% (n = 83), respectively. Compared with gold-standard paraffin-sectioned H&E images, the specificity, sensitivity, and accuracy obtained with the frozen-sectioned H&E images (n = 85) of the specimens were the same as those obtained with the p-H&E images (n = 95). Thus, OCMIS is a useful noninvasive image-assisted tool for breast cancer metastasis assessment based on SLN images.

Hypoxic activation of PFKFB4 in breast tumor microenvironment shapes metabolic and cellular plasticity to accentuate metastatic competence

Cancer cells encounter a hostile tumor microenvironment (TME), and their adaptations to metabolic stresses determine metastatic competence. Here, we show that the metabolic enzyme 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase-4 (PFKFB4) is induced in hypoxic tumors acquiring metabolic plasticity and invasive phenotype. In mouse models of breast cancer, genetic ablation of PFKFB4 significantly delays distant organ metastasis, reducing local lymph node invasion by suppressing expression of invasive gene signature including integrin β3. Photoacoustic imaging followed by metabolomics analyses of hypoxic tumors show that PFKFB4 drives metabolic flexibility, enabling rapid detoxification of reactive oxygen species favoring survival under selective pressure. Mechanistically, hypoxic induction triggers nuclear translocation of PFKFB4 accentuating non-canonical transcriptional activation of HIF-1α, and breast cancer patients with increased nuclear PFKFB4 in their tumors are found to be significantly associated with poor prognosis. Our findings imply that PFKFB4 induction is crucial for tumor cell adaptation in the hypoxic TME that determines metastatic competence.

Axillary Lymphadenopathy Associated With COVID-19 Vaccination: Updates and Recommendations

Lymphadenopathy (LAD) associated with vaccination has been documented as complicating the evaluation of metastatic malignancy. In the past this was a limited finding, primarily documented in association with smallpox and H1N1 vaccination.The advent of the novel mRNA vaccine for COVID-19 in December of 2021, and subsequent large scale vaccination effort, has resulted in a marked increase in the identification of LAD associated with vaccination. Because axillary LAD is a concerning sign of metastatic disease in breast cancer, identifying the difference between benign inflammatory reaction and concerning LAD and avoiding unnecessary additional imaging and biopsy is an essential skill. This article describes the current literature, recommendations for follow-up, and interventions to improve diagnostics.

Role of Lymphatic Endothelium in Vascular Escape of Engineered Human Breast Microtumors

Introduction

Lymphatic vasculature provides a route for metastasis to secondary sites in the body. The role of the lymphatic endothelium in mediating the entry of breast cancer cells into the vasculature remains unclear.

Methods

In this study, we formed aggregates of MDA-MB-231 human breast carcinoma cells next to human microvascular lymphatic endothelial cell (LEC)-lined cavities in type I collagen gels to model breast microtumors and lymphatic vessels, respectively. We tracked invasion and escape of breast microtumors into engineered lymphatics or empty cavities under matched flow rates for up to sixteen days.

Results

After coming into contact with a lymphatic vessel, tumor cells escape by moving between the endothelium and the collagen wall, between endothelial cells, and/or into the endothelial lumen. Over time, tumor cells replace the LECs within the vessel wall and create regions devoid of endothelium. The presence of lymphatic endothelium slows breast tumor invasion and escape, and addition of LEC-conditioned medium to tumors is sufficient to reproduce nearly all of these inhibitory effects.

Conclusions

This work sheds light on the interactions between breast cancer cells and lymphatic endothelium during vascular escape and reveals an inhibitory role for the lymphatic endothelium in breast tumor invasion and escape.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12195-022-00745-9.

Spatial genomics maps the structure, nature and evolution of cancer clones

Genome sequencing of cancers often reveals mosaics of different subclones present in the same tumour1-3. Although these are believed to arise according to the principles of somatic evolution, the exact spatial growth patterns and underlying mechanisms remain elusive4,5. Here, to address this need, we developed a workflow that generates detailed quantitative maps of genetic subclone composition across whole-tumour sections. These provide the basis for studying clonal growth patterns, and the histological characteristics, microanatomy and microenvironmental composition of each clone. The approach rests on whole-genome sequencing, followed by highly multiplexed base-specific in situ sequencing, single-cell resolved transcriptomics and dedicated algorithms to link these layers. Applying the base-specific in situ sequencing workflow to eight tissue sections from two multifocal primary breast cancers revealed intricate subclonal growth patterns that were validated by microdissection. In a case of ductal carcinoma in situ, polyclonal neoplastic expansions occurred at the macroscopic scale but segregated within microanatomical structures. Across the stages of ductal carcinoma in situ, invasive cancer and lymph node metastasis, subclone territories are shown to exhibit distinct transcriptional and histological features and cellular microenvironments. These results provide examples of the benefits afforded by spatial genomics for deciphering the mechanisms underlying cancer evolution and microenvironmental ecology.

Real-world outcomes for Chinese breast cancer patients with tumor location of central and nipple portion

Background

The association between tumor location and breast cancer prognosis has been controversial. We sought to explore the relationship between tumors located in central and nipple portion (TCNP) and Chinese breast cancer.

Patients and methods

A total of 1,427 breast cancer patients were recruited. There were 328 cases of TCNP and 1,099 cases of tumors in the breast peripheral quadrant (TBPQ). The chi-square test was used to compare different variables between TCNP and TBPQ groups. A one-to-one propensity score matching (PSM) was applied to construct a matched sample consisting of pairs of TCNP and TBPQ groups. Kaplan–Meier curves were used for survival analysis of disease-free survival (DFS), breast cancer-specific survival (BCSS) and overall survival (OS). The Cox proportional hazards regression model was applied to identify prognostic risk factors.

Results

The median follow-up time was 58 months. Compared to TBPQ, TCNP patients had significantly larger tumor size, more frequent metastasis to lymph nodes (LN) and more proportions of TNM stage II–III. DFS, OS and BCSS rates were markedly lower in the TCNP group as compared to the TBPQ group before and after PSM (all p < 0.05). Multivariate Cox analysis showed that TCNP was an independent prognostic factor for breast cancer. Subgroup analysis indicated that for breast molecular subtypes and TNM stage II-III breast cancer, TCNP were related to worse prognosis. Multivariate logistic regression revealed that TCNP was an independent contributing factor for LN metastasis.

Conclusion

In Chinese breast cancer, compared to TBPQ, TCNP is associated with more LN metastasis and poorer prognosis.

Factors Associated with Axillary Lymph Node Status in Clinically Node-Negative Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy

Adequate axillary lymph node (ALN) staging is critical for patients with invasive breast cancer. However, neoadjuvant chemotherapy (NAC) was associated with a lower risk of ALN metastasis compared with those who underwent primary surgery among clinically node-negative (cN0) patients. This study aimed to investigate the factors associated with ALN status among patients with cN0 breast cancer undergoing NAC. A total of 222 consecutive patients with cN0 breast cancer undergoing NAC between January 2012 and December 2021 were reviewed. Univariate and multivariate analyses were performed to compare factors associated with positive ALN status. Seventeen patients (7.7%) had ALNs metastases. Here, 90 patients (40.5%) achieved pathologic complete response in the breast (breast-pCR), and all had negative ALN status. Lymphovascular invasion (odds ratio: 29.366, p < 0.0001) was an independent risk predictor of ALN metastasis in all study populations. Among patients without breast-pCR, mastectomies were performed more frequently in patients with ALN metastasis (52.9%) than in those without metastasis (20.9%) (p = 0.013). Our findings support the omission of axillary surgery in patients who achieve breast-pCR. Prospective studies are needed to confirm the feasibility of a future two-stage surgical plan for breast-conserving surgery in patients who are likely to achieve breast-pCR during clinical evaluation.

Role of dynamic and parametric whole-body FDG PET/CT imaging in molecular characterization of primary breast cancer: a single institution experience

AIM

The aim of this pilot study was to assess the role of dynamic whole-body PET and parametric imaging in the biological characterization of primary breast cancer.

MATERIALS AND METHOD

In total 24 histologically proven primary breast cancer lesions in 21 consecutive patients were retrospectively analyzed. Each patient underwent 18F-fluoro-deoxyglucose whole-body dynamic PET-CT before any treatment. Dynamic PET images were acquired in the list mode for a total duration of 70 min. The reconstructed parametric imaging generated Patlak plot-based 'Slope' and 'Intercept' images, from which parametric indices ki and DV were obtained. The standard uptake value (SUV) metric was also obtained by summing the last few frames of the dynamic study. ki, distribution volume (DV) and SUV were correlated with the histological tumor grade, biomarkers [hormone receptors and human epidermal growth factor receptor 2 (HER-2) neu expression] and molecular subtypes (A, B and C) as well as with tumor size, regional nodal metastases and distant metastases.

RESULTS

The mean ki was found to be significantly higher in grade III than II lesions (P = 0.005), HER-2 neu positive status (P = 0.04) and molecular subtype B (P = 0.04) as well as in greater than T1 lesions(P = 0.0003 and P = 0.04, respectively) and node-positive lesions (P = 0.009). Though mean ki was not found to be significant for the hormone receptors status (P = 0.08), it showed the best correlation compared to the other parameters (P = 0.8 for DV and P = 0.1 for SUV). Spearman's correlation test, area under the curve (AUC) and mismatch percentage also revealed ki to predict tumor grade (AUC, 0.95; r = 0.7; P = 0.0001), HER-2 neu status and molecular subtypes (AUC, 0.81; r = 0.49 and P = 0.01) along with the hormone receptors status (AUC, 0.83; r = 0.32; P = 0.1). The mean DV failed to show any association with any of the biological or anatomical staging parameters. Though ki was found to be comparable to that of SUV in almost all the assessed parameters, it appeared to be better for predicting hormone receptors status even though both parameters were not statistically significant.

CONCLUSION

Our initial observation in a small cohort of breast cancer patients suggests that ki is promising in stratifying primary breast cancer lesions according to the tumor grade and biological characteristics.

Different Imaging Modalities for the Diagnosis of Axillary Lymph Node Metastases in Breast Cancer: A Systematic Review and Network Meta-Analysis of Diagnostic Test Accuracy

BACKGROUND

Accurate diagnosis of axillary lymph node metastasis (ALNM) of breast cancer patients is important to guide local and systemic treatment.

PURPOSE

To evaluate the diagnostic performance of different imaging modalities for ALNM in patients with breast cancer.

STUDY TYPE

Systematic review and network meta-analysis (NMA).

SUBJECTS

Sixty-one original articles with 8011 participants.

FIELD STRENGTH

1.5 T and 3.0 T.

ASSESSMENT

We used the QUADAS-2 and QUADAS-C tools to assess the risk of bias in eligible studies. The identified articles assessed ultrasonography (US), MRI, mammography, ultrasound elastography (UE), PET, CT, PET/CT, scintimammography, and PET/MRI.

STATISTICAL ANALYSIS

We used random-effects conventional meta-analyses and Bayesian network meta-analyses for data analyses. We used sensitivity and specificity, relative sensitivity and specificity, superiority index, and summary receiver operating characteristic curve (SROC) analysis to compare the diagnostic value of different imaging modalities.

RESULTS

Sixty-one studies evaluated nine imaging modalities. At patient level, sensitivities of the nine imaging modalities ranged from 0.27 to 0.84 and specificities ranged from 0.84 to 0.95. Patient-based NMA showed that UE had the highest superiority index (5.95) with the highest relative sensitivity of 1.13 (95% confidence interval [CI]: 0.93-1.29) among all imaging methods when compared to US. At lymph node level, MRI had the highest superiority index (6.91) with highest relative sensitivity of 1.13 (95% CI: 1.01-1.23) and highest relative specificity of 1.11 (95% CI: 0.95-1.23) among all imaging methods when compared to US. SROCs also showed that UE and MRI had the largest area under the curve (AUC) at patient level and lymph node level of 0.92 and 0.94, respectively.

DATA CONCLUSION

UE and MRI may be superior to other imaging modalities in the diagnosis of ALNM in breast cancer patients at the patient level and the lymph node level, respectively. Further studies are needed to provide high-quality evidence to validate our findings.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Radiomic Signature Based on Dynamic Contrast-Enhanced MRI for Evaluation of Axillary Lymph Node Metastasis in Breast Cancer

Background. To construct and validate a radiomic-based model for estimating axillary lymph node (ALN) metastasis in patients with breast cancer by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods. In this retrospective study, a radiomic-based model was established in a training cohort of 236 patients with breast cancer. Radiomic features were extracted from breast DCE-MRI scans. A method named the least absolute shrinkage and selection operator (LASSO) was applied to select radiomic features based on highly reproducible features. A radiomic signature was built by a support vector machine (SVM). Multivariate logistic regression analysis was adopted to establish a clinical characteristic-based model. The performance of models was analysed through discrimination ability and clinical benefits. Results. The radiomic signature comprised 6 features related to ALN metastasis and showed significant differences between the patients with ALN metastasis and without ALN metastasis ( $P<0.001$ ). The area under the curve (AUC) of the radiomic model was 0.990 and 0.858, respectively, in the training and validation sets. The clinical feature-based model, including MRI-reported status and palpability, performed slightly worse, with an AUC of 0.784 in the training cohort and 0.789 in the validation cohort. The radiomic signature was confirmed to provide more clinical benefits by decision curve analysis. Conclusions. The radiomic-based model developed in this study can successfully diagnose the status of lymph nodes in patients with breast cancer, which may reduce unnecessary invasive clinical operations.

Node foretold: Cancer cells in lymph node rewire the immune system to enable further metastases

A Cell article reports that lymph node metastases can suppress the immune system, thereby promoting further cancer spread in mouse models; this is corroborated in patients as described in a letter in this issue of Cancer Cell. The lymph node thus actively generates a cancer-permissive environment and is an untapped target to manipulate the immune system.

Induction of potassium channel regulator KCNE4 in a submandibular lymph node metastasis model

Cancer cells often metastasize to the lymph nodes (LNs) before disseminating throughout the body. Clinically, LN metastasis correlates with poor prognosis and influences treatment options. Many studies have shown that cancer cells communicate with immune and stromal cells to prepare a suitable niche for metastasis. In this study, mice were injected with B16-F10 murine melanoma cells to generate a tongue submandibular lymph node (SLN) metastasis model in which genes of interest could be investigated. Microarray analyses were performed on SLNs, identifying 162 upregulated genes, some of which are known metastasis genes. Among these upregulated genes, Kcne4, Slc7a11, Fscn1, and Gadd45b were not associated with metastasis, and increased expression of Kcne4 and Slc7a11 was confirmed by real-time PCR and immunohistochemistry. The roles of KCNE4 in chemokine production and cell adhesion were examined using primary lymphatic endothelial cells, and demonstrated that Ccl17 and Ccl19, which are involved in melanoma metastasis, were upregulated by KCNE4, as well as Mmp3 matrix metalloproteinase. Expression of KCNE4 was detected in human LNs with metastatic melanoma. In conclusion, we found that LN metastatic melanoma induces KCNE4 expression in the endothelium of LNs.

Luminal A Breast Cancer: How Feasible is Omitting Axillary Dissection Without Neoadjuvant Therapy

Background. Luminal A breast cancer has a good prognosis and the criteria for adjuvant and neoadjuvant chemotherapy (NAC) are not clear. The aim of this study was to present our results of upfront surgery and long-term survival in luminal A tumors as well as the rates of protection from axillary dissection. Material and Methods. 271 Luminal A breast cancer patients who had operated at our center were evaluated retrospectively. In patients with 2 or less sentinel lymph node (SLN) positivity who did not receive neoadjuvant therapy and underwent breast-conserving surgery, axillary lymph node dissection was omitted (OAD). Axillary lymph node dissection (ALND) was performed in patients with positive SLN who did not meet these criteria (axillary dissection after sentinel/ADAS). Results. While Sentinel Lymph Node Biopsy (SLNB) was performed in 212 (77.9%) patients, SLNB + Axillary Dissection (AD) was performed in 58 (21.3%), and direct axillary dissection was performed in 1 (0.8%) patient. OAD was applied to 18 (23.6%) of the positive patients. Discussion/Conclusions. ALND rates are still strikingly high in luminal A breast cancer treatment, despite the disease’s milder clinical course. In order to avoid complications of axillary dissection, patients should be considered for NAC as much as possible. Novel neoadjuvant or other therapy options are also required.

Diffusion Breast MRI: Current Standard and Emerging Techniques

The role of diffusion weighted imaging (DWI) as a biomarker has been the subject of active investigation in the field of breast radiology. By quantifying the random motion of water within a voxel of tissue, DWI provides indirect metrics that reveal cellularity and architectural features. Studies show that data obtained from DWI may provide information related to the characterization, prognosis, and treatment response of breast cancer. The incorporation of DWI in breast imaging demonstrates its potential to serve as a non-invasive tool to help guide diagnosis and treatment. In this review, current technical literature of diffusion-weighted breast imaging will be discussed, in addition to clinical applications, advanced techniques, and emerging use in the field of radiomics.

Effectiveness of the Sanyin Formula Plus Chemotherapy on Survival in Women With Triple-Negative Breast Cancer: A Randomized Controlled Trial

Purpose

To evaluate the efficacy of the Sanyin formula (SYF) plus conventional standard chemotherapy in operable triple-negative breast cancer (TNBC) patients, a randomized controlled trial was implemented at 5 hospitals and cancer centers in China between May 23, 2016, and October 31, 2019.

Materials and Methods

Female patients aged 18 to 80 years with operable TNBC after definitive surgery were screened and enrolled. The exclusion criteria included metastatic disease, other tumors, or locally advanced disease. Patients were randomly divided into groups SYF plus conventional standard chemotherapy and placebo plus conventional standard chemotherapy at a ratio of 1:1. The primary endpoint of the investigation was disease-free survival (DFS), and secondary endpoints included overall survival (OS) and toxicity.

Results

A total of 252 operable female TNBC patients were randomized to receive SYF plus conventional standard chemotherapy (N = 127) or a placebo plus conventional standard chemotherapy (N = 125). At a median follow-up of 51 months, 5-year DFS time was longer in those assigned to SYF plus conventional standard chemotherapy compared with placebo plus conventional standard chemotherapy (94.2%vs 85.5%, hazard ratio [HR] = 0.40; 95%CI, 0.17-0.97; P = 0.034). The absolute benefit for 5-year DFS was 8.7% in the SYF plus conventional standard chemotherapy group. No statistically significant difference was observed in OS between the two groups (P = 0.23). Patients with negative node status benefited more from SYF plus conventional standard chemotherapy treatment (HR = 0.21, P-interaction = 0.013) in accordance with the exploratory subgroup analyses of DFS.

Conclusions

The results of the present study suggest that the traditional Chinese medicine SYF plus conventional chemotherapy regimens is an effective alternative adjuvant chemotherapy strategy for female operable TNBC patients.

Clinical Trial Registration

https://www.chictr.org.cn/searchproj.aspx, identifier ChiCTR-IPR-16008590.

Lymph node colonization induces tumor-immune tolerance to promote distant metastasis

For many solid malignancies, lymph node (LN) involvement represents a harbinger of distant metastatic disease and, therefore, an important prognostic factor. Beyond its utility as a biomarker, whether and how LN metastasis plays an active role in shaping distant metastasis remains an open question. Here, we develop a syngeneic melanoma mouse model of LN metastasis to investigate how tumors spread to LNs and whether LN colonization influences metastasis to distant tissues. We show that an epigenetically instilled tumor-intrinsic interferon response program confers enhanced LN metastatic potential by enabling the evasion of NK cells and promoting LN colonization. LN metastases resist T cell-mediated cytotoxicity, induce antigen-specific regulatory T cells, and generate tumor-specific immune tolerance that subsequently facilitates distant tumor colonization. These effects extend to human cancers and other murine cancer models, implicating a conserved systemic mechanism by which malignancies spread to distant organs.

Evaluation of Lymph Node Metastasis in Invasive Micropapillary Breast Carcinoma and Other Its Related Variables

Background: The rate of lymph node metastasis in patients with invasive micropapillary carcinoma (IMPC) could be considered a critical prognostic factor whose measurement may enhance therapeutic outcomes in these patients. Objectives: The current study aims at determining the rate of lymph node involvement in IMPC patients and comparing it with that of invasive ductal carcinoma, not otherwise specified (IDC-NOS) patients. Methods: In this case-control study, a total of 124 participated, including 61 patients with IMPC and 63 patients with IDC-NOS. The rate of lymph node metastasis and its possible connection with the patient's age, tumor size, grade and focality, lymphovascular invasion, and proportion of micropapillary component were determined in patients with IMPC and compared to that of IDC-NOS patients. Results: Lymph node involvement was detected in 80.3% of patients with IMPC, which is significantly higher compared to patients with IDC-NOS. No significant correlation was found between lymph node metastasis and the patients’ age, tumor size, and focality in both IMPC and IDC-NOS groups. Furthermore, no significant relationship was observed between lymph node metastasis and tumor grade in IMPC, while metastasis to lymph nodes was directly correlated with higher tumor grades of NOS type. Moreover, in both types of cancer, lymph node metastasis was significantly associated with lymphovascular invasion. In patients with IMPC, no statistically significant relevance was observed between lymph node metastasis and the percentage of micropapillary components. Conclusions: According to the results of this study, patients with IMPC had a significantly higher rate of lymph node involvement compared to IDC-NOS. Hence, the rate of lymph node involvement could be used as a prognostic factor in these patients.

Predictors of axillary node response in node-positive patients undergoing neoadjuvant chemotherapy for breast cancer

Background:

The ability to accurately predict which patients will achieve a pathologic complete response (pCR) after neoadjuvant chemotherapy could help identify those who could safely be spared the potential morbidity of axillary lymph node dissection. We performed a retrospective analysis of a cohort of clinically node-positive patients managed with neoadjuvant chemotherapy with the goal of identifying predictors of axillary pCR.

Methods:

Eligible patients were aged 18 years or older, had clinical T1–T4, N1–N3, M0 breast cancer and received neoadjuvant chemotherapy followed by surgical axillary lymph node staging between 2001 and 2017 at Misericordia Hospital, Edmonton, Alberta. Patient data, including tumour characteristics, details of neoadjuvant chemotherapy, imaging results before and after neoadjuvant chemotherapy, and final pathologic analysis, were collected from the appropriate provincial electronic data repositories. We summarized the data using descriptive statistics. We characterized associations between clinical/tumour characteristics and pCR using univariate and multivariate regression analysis.

Results:

Of the 323 patients included in the study, 130 (40.2%) achieved axillary pCR. Absence of residual disease in the breast was associated with axillary pCR (odds ratio 6.74, 95% confidence interval 2.89–15.67). HER2-positive, triple-negative and ER-positive/PR-negative/HER2-negative tumours were significantly associated with a pCR on univariate analysis; the association trended toward significance on multivariate analysis.

Conclusion:

Our findings support the routine use of neoadjuvant chemotherapy and sentinel lymph node biopsy in patients with an absence of residual disease in the breast, and potentially in those with HER2-positive or triple-negative subtypes, and highlight the ER-positive/PR-negative biomarker subtype as a potential predictor of nodal response.

Solid stress impairs lymphocyte infiltration into lymph-node metastases

Strong and durable anticancer immune responses are associated with the generation of activated cancer-specific T cells in the draining lymph nodes. However, cancer cells can colonize lymph nodes and drive tumour progression. Here, we show that lymphocytes fail to penetrate metastatic lesions in lymph nodes. In tissue from patients with breast, colon, and head and neck cancers, as well as in mice with spontaneously developing breast-cancer lymph-node metastases, we found that lymphocyte exclusion from nodal lesions is associated with the presence of solid stress caused by lesion growth, that solid stress induces reductions in the number of functional high endothelial venules in the nodes, and that relieving solid stress in the mice increased the presence of lymphocytes in lymph-node lesions by about 15-fold. Solid-stress-mediated impairment of lymphocyte infiltration into lymph-node metastases suggests a therapeutic route for overcoming T-cell exclusion during immunotherapy.

Omission of sentinel node biopsy for breast cancer: Historical context and future perspectives on a modern controversy

For older patients with clinically lymph node-negative breast cancer who have estrogen receptor-positive tumors and are treated with tamoxifen, randomized trials comparing axillary lymph node dissection (ALND) versus no ALND show that the omission of ALND improves patient quality of life and has no adverse effects on mortality. These results have served to justify sentinel node biopsy (SNB) omission in selected older patients with breast cancer. More recently, clinical trials were launched to assess SNB omission in younger patients, with recurrence and survival as the primary outcomes of interest. Three important considerations serve as the basis for these ongoing trials. First, it is assumed that SNB omission will improve patient quality of life, although, to date, there is no level I evidence to support this assumption. Second, axillary surgery has never been shown to reduce breast cancer mortality, but it does reduce the risk of axillary recurrences, although adjuvant systemic therapy and radiotherapy also reduce these recurrence risks. Finally, nodal status is losing importance as a guide for adjuvant systemic therapy decision making because these decisions are now increasingly predicated on tumor biomarkers and gene profiling, but it is gaining importance for adjuvant radiotherapy decision making. Because quality-of-life considerations are the primary motivation for abandoning SNB, there is a need for randomized trials comparing SNB versus no SNB/no axillary surgery, with quality of life as the primary end point (level I evidence). Moreover, suitable alternatives to guide adjuvant radiotherapy decision making will require validation before SNB omission can be justified for patients of all ages who have clinically node-negative breast cancer. LAY SUMMARY: In this review article, the authors provide a brief historical overview of the role of axillary surgery in breast cancer management and discuss additional studies and ramifications that should be considered before abandoning the sentinel node biopsy (SNB) procedure. Specifically, there is a need for level I evidence demonstrating that omission of the SNB procedure will improve patient quality of life and a need to validate suitable alternatives to SNB as a guide for adjuvant radiotherapy decision making.

Prediction of Metastasis in the Axillary Lymph Nodes of Patients With Breast Cancer: A Radiomics Method Based on Contrast-Enhanced Computed Tomography

Background

The use of traditional techniques to evaluate breast cancer is restricted by the subjective nature of assessment, variation across radiologists, and limited data. Radiomics may predict axillary lymph node metastasis (ALNM) of breast cancer more accurately.

Purpose

The aim was to evaluate the diagnostic performance of a radiomics model based on ALNs themselves that used contrast-enhanced computed tomography (CECT) to detect ALNM of breast cancer.

Methods

We retrospectively enrolled 402 patients with breast cancer confirmed by pathology from January 2016 to October 2019. Three hundred and ninety-six features were extracted for all patients from axial CECT images of 825 ALNs using Artificial Intelligent Kit software (GE Medical Systems, Version V3.1.0.R). Next, the radiomics model was trained, validated, and tested for predicting ALNM in breast cancer by using a support vector machine algorithm. Finally, the performance of the radiomics model was evaluated in terms of its classification accuracy and the value of the area under the curve (AUC).

Results

The radiomics model yielded the best classification accuracy of 89.1% and the highest AUC of 0.92 (95% CI: 0.91-0.93, p=0.002) for discriminating ALNM in breast cancer in the validation cohorts. In the testing cohorts, the model also demonstrated better performance, with an accuracy of 88.5% and an AUC of 0.94 (95% CI: 0.93-0.95, p=0.005) for predicting ALNM in breast cancer.

Conclusion

The radiomics model based on CECT images can be used to predict ALNM in breast cancer and has significant potential in clinical noninvasive diagnosis and in the prediction of breast cancer metastasis.

Modulation of Immune System - Strategy in the Treatment of Breast Cancer

BACKGROUND/AIM

In women, breast cancer is the most commonly diagnosed cancer type and at the same time the main cause of cancer-related death. Many mechanisms are involved in the tumor microenvironment to restrict the anti-tumor activity by the immune system. Identification of novel prognostic tools based on immunological data could make significant impact in developing innovative immunotherapy strategies that will restore the anti-tumor immune system efficacy.

PATIENTS AND METHODS

The study was performed on patients diagnosed with breast cancer, who were divided into two groups depending on the expression of HER2. For the studied group, first we described the infiltrate inflammatory on slides stained with haematoxylin eosin (HE) and in the second part we used flow cytometry in order to measure the percentage of T lymphocytes from the peripheral blood before and after breast cancer treatment.

RESULTS

High presence of tumor-infiltrating lymphocytes (TILs) was associated with prognostic improvement, better disease-free survival, distant disease-free survival and overall survival. In breast cancer, the presence of TILs predicts the full pathological response rate (pCR) after neoadjuvant chemotherapy. TILs are one of the best examples of the strict relationship existing between natural defence and carcinogenesis.

CONCLUSION

Modulation of the immune system is a promising strategy in the treatment of breast cancer, especially in triple-negative and HER2-positive molecular subtypes, the most immunogenic subtypes with a poor prognosis.

The Dual Role of High Endothelial Venules in Cancer Progression versus Immunity

Secondary lymphoid organs (SLOs) are important initiators and regulators of immunity. To carry out this function, the blood vasculature must deliver oxygen and nutrients and recruit circulating lymphocytes into the SLO parenchyma, where they encounter cognate antigen. High endothelial venules (HEVs) are specialised postcapillary venules that specifically serve this function and are found in all SLOs except spleen. It is becoming clear that alterations to HEV network density and/or morphology can result in immune activation or, as recently implicated, in providing an exit route for tumour cell dissemination and metastases. In this review, the structural plasticity of HEVs, the regulatory pathways underpinning this plasticity, and the relevance of these pathways to cancer progression will be discussed.

Risk factors and their diagnostic values for ocular metastases in invasive ductal carcinoma

Invasive ductal carcinoma (IDC) is a major type of breast cancer. Ocular metastasis (OM) in IDC is rarely seen, but patients with OM often have a poor prognosis. Furthermore, OM is difficult to detect in the early stages by common imaging examinations. In the present study, we tried to figure out the risk factors of OM in IDC and evaluate their diagnostic values for early detection. There were 1192 IDC patients who were divided into two groups according to ocular metastasis involved in this study. Clinical parameters of those patients were used to detect differences. The binary logistic regression test was then used to determine the risk factors of OM in IDC. Furthermore, ROC curves of both single and combined risk factors were established to examine their diagnostic values. The incidence of axillary lymph node metastases was significantly higher in the OM group (p = 0.002). Higher carbohydrate antigen 153 (CA153), lower apolipoprotein A1 (ApoA1), and hemoglobin (Hb) were risk factors for OM in IDC (p < 0.001, p < 0.001, p = 0.038, respectively). In the single risk factor ROC analysis, cutoff values of CA153, ApoA1, and Hb were 43.3 u/mL (CI: 0.966-0.984, p < 0.001), 1.11 g/L (CI: 0.923-0.951, p < 0.001), and 112 g/L (CI: 0.815-0.857, p < 0.001), respectively. Among the ROC curves of combined risk factors, CA153+ApoA1+Hb had the best accuracy, with the sensitivity and specificity of 89.47% and 99.32%, respectively (CI: 0.964-0.983, p < 0.001). CA153, ApoA1, and Hb are risk factors for OM in IDC. In clinical practice, the three parameters could be used as predictive factors for the early detection of OM.

A Comparison of the Diagnostic Value of Positron Emission Tomography/Computed Tomography and Ultrasound for the Detection of Metastatic Axillary Nodal Disease in Treatment-Naive Breast Cancer

ABSTRACT

The objective of this study was to describe the diagnostic value of positron emission tomography/computed tomography (PET/CT) and ultrasound (US) for identifying metastatic axillary disease in primary breast cancer. This is a retrospective review of 240 patients with treatment-naive unilateral primary breast cancer of at least stage T2. Eighty-five patients met our inclusion criteria. Initial whole-body PET/CT and axillary US examinations were reviewed and compared with the criterion standard of fine-needle aspiration cytology. Sensitivity, accuracy, and positive predictive value (PPV) for each modality were computed. Because of all positive US cases, specificity and negative predictive value of US were not determined. Sensitivity and accuracy between modalities were compared using McNemar test. The majority of the patients were White women with clinical inflammatory breast cancer and with histologically invasive ductal carcinoma. The most common tumor and nodal stage was T4N3. The tumors were predominantly estrogen receptor positive, progesterone receptor negative, and human epidermal growth factor receptor 2 negative. The sensitivities of PET/CT and US were 96.2% and 100%, respectively. The accuracies for PET/CT and US were 91.8% and 94.1%, respectively. The PPV for PET/CT was 95.1%, and for US, the PPV was 94.1%. No significant difference in sensitivity or accuracy was shown between PET/CT and US for the diagnosis of metastatic axillary nodal disease. Three of 85 cases showed discordance between negative PET/CT and positive US and fine-needle aspiration cytology.

Tissue Expression Of LPHN3 in Breast Cancer: An Immunohistochemistry Method

OBJECTIVE

Breast cancer is one of the most important public health problems among women worldwide. It is a major cause of morbidity especially among women in developing countries including Thailand. The purpose of this study was to study the expression of LPHN3 protein in normal breast tissue compared to breast cancer tissue.

METHODS

We had studied the expression of LPHN3 in 65 breast tissues using an immunohistochemistry method. The association between LPHN3 expression and breast cancer metastasis to nearby axillary lymph nodes was also examined.

RESULTS

Among the 65 breast cancer and normal breast tissues examined, LPHN3 expression with an immunohistochemistry index (IHC index) greater than 4 was more frequently found in breast cancer tissues than in normal breast tissues (P-value = 0.001, OR (95% CI) = 7.04 (2.16-23)). Moreover, a high expression of LPHN3 (IHC index > 4) was more frequently found in breast cancer tissues with negative axillary lymph nodes than in those with positive ones (P-value = 0.038, OR (95% CI) = 0.25 (0.07-0.96)). LPHN3 protein might be a new metastasis suppressor gene in breast cancer and a marker for breast cancer metastasis prevention.

CONCLUSIONS

The present study indicated that a decrease of LPHN3 protein expression in breast cancer tissue might be a marker indicating the aggressiveness of breast cancer. These results also suggested that a decrease of LPHN3 expression could be functionally involved in breast cancer progression and metastasis.

Preoperative Prediction of Axillary Lymph Node Metastasis in Breast Carcinoma Using Radiomics Features Based on the Fat-Suppressed T2 Sequence

RATIONALE AND OBJECTIVES

To investigate the value of radiomics method based on the fat-suppressed T2 sequence for preoperative predicting axillary lymph node (ALN) metastasis in breast carcinoma.

MATERIALS AND METHODS

The data of 329 invasive breast cancer patients were divided into the primary cohort (n = 269) and validation cohort (n = 60). Radiomics features were extracted from the fat-suppressed T2-weighted images on breast MRI, and ALN metastasis-related radiomics feature selection was performed using Mann-Whitney U-test and support vector machines with recursive feature elimination; then a radiomics signature was constructed by linear support vector machine. The predictive models were constructed using a linear regression model based on the clinicopathologic factors and radiomics signature, and nomogram was used for a visual prediction of the combined model. The predictive performances are evaluated with the sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve.

RESULTS

A total of 647 radiomics features were extracted from each patient. About 23 ALN metastasis-related radiomics features were selected to construct the radiomics signature, including 17 texture features, 5 first-order statistical features, and one shape feature; patient age, tumor size, HER2 status, and vascular cancer thrombus accompanied or not were selected to construct the cilinicopathologic feature model. The sensitivity, specificity, accuracy, and are under the curve value of radiomics signature, clinicopathologic feature model, and the nomogram were 65.22%, 81.08%, 75.00%, and 0.819 (95% confidence interval [CI]: 0.776-0.861), 30.44%, 81.08%, 61.67%, and 0.605 (95% CI: 0.571-0.624) and 60.87%, 89.19%, 78.33%, and 0.810 (95% CI: 0.761-0.855), respectively.

CONCLUSION

Radiomics methods based on the fat-suppressed T2 sequence and the nomogram are helpful for preoperative accurate predicting ALN metastasis.

Deep Learning Signature Based on Staging CT for Preoperative Prediction of Sentinel Lymph Node Metastasis in Breast Cancer

RATIONALE AND OBJECTIVES

To evaluate the noninvasive predictive performance of deep learning features based on staging CT for sentinel lymph node (SLN) metastasis of breast cancer.

MATERIALS AND METHODS

A total of 348 breast cancer patients were enrolled in this study, with their SLN metastases pathologically confirmed. All patients received contrast-enhanced CT preoperative examinations and CT images were segmented and analyzed to extract deep features. After the feature selection, deep learning signature was built with the selected key features. The performance of the deep learning signatures was assessed with respect to discrimination, calibration, and clinical usefulness in the primary cohort (184 patients from January 2016 to March 2017) and then validated in the independent validation cohort (164 patients from April 2017 to December 2018).

RESULTS

Ten deep learning features were automatically selected in the primary cohort to establish the deep learning signature of SLN metastasis. The deep learning signature shows favorable discriminative ability with an area under curve of 0.801 (95% confidence interval: 0.736-0.867) in primary cohort and 0.817 (95% confidence interval: 0.751-0.884) in validation cohort. To further distinguish the number of metastatic SLNs (1-2 or more than two metastatic SLN), another deep learning signature was constructed and also showed moderate performance (area under curve 0.770).

CONCLUSION

We developed the deep learning signatures for preoperative prediction of SLN metastasis status and numbers (1-2 or more than two metastatic SLN) in patients with breast cancer. The deep learning signature may potentially provide a noninvasive approach to assist clinicians in predicting SLN metastasis in patients with breast cancer.

Predictive performance of ultrasonography-based radiomics for axillary lymph node metastasis in the preoperative evaluation of breast cancer

PURPOSE

The purpose of this study was to evaluate the predictive performance of ultrasonography (US)-based radiomics for axillary lymph node metastasis and to compare it with that of a clinicopathologic model.

METHODS

A total of 496 patients (mean age, 52.5±10.9 years) who underwent breast cancer surgery between January 2014 and December 2014 were included in this study. Among them, 306 patients who underwent surgery between January 2014 and August 2014 were enrolled as a training cohort, and 190 patients who underwent surgery between September 2014 and December 2014 were enrolled as a validation cohort. To predict axillary lymph node metastasis in breast cancer, we developed a preoperative clinicopathologic model using multivariable logistic regression and constructed a radiomics model using 23 radiomic features selected via least absolute shrinkage and selection operator regression.

RESULTS

In the training cohort, the areas under the curve (AUC) were 0.760, 0.812, and 0.858 for the clinicopathologic, radiomics, and combined models, respectively. In the validation cohort, the AUCs were 0.708, 0.831, and 0.810, respectively. The combined model showed significantly better diagnostic performance than the clinicopathologic model.

CONCLUSION

A radiomics model based on the US features of primary breast cancers showed additional value when combined with a clinicopathologic model to predict axillary lymph node metastasis.

Peritumoral Fat Content Correlates with Histological Prognostic Factors in Breast Carcinoma: A Study Using Iterative Decomposition of Water and Fat with Echo Asymmetry and Least-Squares Estimation (IDEAL)

Purpose:

To correlate peritumoral fat content using iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) with histologic prognostic factors in breast carcinoma.

Methods:

This study consisted of 100 patients who were diagnosed with invasive carcinoma of breast and underwent breast MRI including IDEAL before surgery. The scan time of IDEAL fat fraction (FF) map imaging was 33 s. Four regions of interests (ROIs), which are a distance of 5 mm from the tumor edge, and one ROI in the mammary fat of the healthy side were set on the FF map. Then average peritumoral FF values (FFt), average FF values in the healthy side (FFh), and peritumoral fat ratio (pTFR: defined as FFt/FFh) were calculated. Histologically, the presence of lymph node metastasis and the MIB-1 index were evaluated.

Results:

FFt and pTFR for breast carcinoma with lymph node metastasis (79.27 ± 10.36 and 0.897 ± 0.078) were significantly lower than those without (86.23 ± 4.53 and 0.945 ± 0.032) (P < 0.001 and P = 0.005). Spearman rank correlation suggested that the FFt correlated with the MIB-1 index (r = −340, P = 0.001).

Conclusion:

Quantification of peritumoral fat using IDEAL-iron quantification is associated with the histologic prognostic factors, and may be a practical tool for therapeutic strategy of breast carcinoma.

Association between negative preoperative axillary node staging and surgical sentinel node biopsy in patients with newly diagnosed breast cancer: A retrospective analysis

AIM

The aim of this retrospective study was to analyse the preoperative ultrasound findings in patients with minimal or almost no morphological changes of axillary lymph nodes (LN) and to correlate these findings with the results of sentinel node (SN) biopsy.

MATERIALS AND METHODS

Between January 2014 and September 2018, 289 female patients with newly diagnosed breast cancer and negative preoperative axillary staging were examined with preoperative ultrasound evaluation of axillary LNs. Patients with no evidence of LN metastases underwent primary surgical treatment with SN biopsy. Negative predictive value (NPV) of preoperative ultrasound was evaluated and the histopathological findings in positive SN biopsies were correlated with tumour type and preoperative ultrasound LN imaging.

RESULTS

Of 289 patients with negative preoperative axillary staging who had primary surgical treatment, 268 patients had negative SN biopsy while SN metastases were detected in 21 patients. Of patients with positive SN biopsies, 2 patients had negative core biopsy of axillary LN before surgery. The preoperative ultrasound examination was negative in the remaining 19 patients with SN metastases.

CONCLUSIONS

Preoperative ultrasonography is very accurate in the detecting of axillary LN metastases. Patients with primary tumour size ≥ 1 cm, with grade ≥ 2 no special type carcinomas (NST - no special type, also known as invasive ductal carcinoma) or multicentric lobular invasive cancer should undergo a more thorough ultrasound evaluation.

Proposal of the minimal number of retrieved regional lymph nodes for accurate staging of distal bile duct cancer and clinical validation of the three-tier lymph node staging system (AJCC 8th edition)

BACKGROUND

The minimal required number of retrieved lymph nodes (MNRLNs) to enable accurate staging of distal bile duct (DBD) adenocarcinoma remains unclear. The three-tier 8th N staging system of the American Joint Committee on Cancer (AJCC) for DBD adenocarcinoma has been recently released. The present study is aimed at proposing the MNRLNs for accurate staging and validating the 8th N stage.

METHODS

Between 1991 and 2015, patients with pathologically confirmed DBD adenocarcinoma who underwent pancreatoduodenectomy were enrolled. MNRLN was calculated via a log-rank test based on cut-off values. The concordance index (C-index) was utilized to compare the discrimination capability of the two- and three-tier N stages.

RESULTS

A total of 780 patients were enrolled. Lymph node (LN) positivity and 5-year overall survival (5-YOS) rates stabilized and significant survival differences between node-negative and -positive patients were observed when ≥12 LNs were retrieved. 5-YOS rates between each 8th N stage significantly differ (N0 vs. N1, P = 0.037; N1 vs. N2, P = 0.003). The C-index of the 8th N stage was higher than that of the 7th (0.59 vs. 0.57).

CONCLUSIONS

For accurate staging, at least 12 LNs should be retrieved. The three-tier N staging system is valid for clinical practice and has a more accurate prognostic predictability than the two-tier system.

Risk stratification of triple-negative breast cancer with core gene signatures associated with chemoresponse and prognosis

PURPOSE

Neoadjuvant chemotherapy studies have consistently reported a strong correlation between pathologic response and long-term outcome in triple-negative breast cancer (TNBC). We aimed to define minimal gene signatures for predicting chemoresponse by a three-step approach and to further develop a risk-stratification method of TNBC.

METHODS

The first step involved the detection of genes associated with resistance to docetaxel in eight TNBC cell lines, leading to identification of thousands of candidate genes. Through subsequent second and third step analyses with gene set enrichment analysis and survival analysis using public expression profiles, the candidate gene list was reduced to prognostic core gene signatures comprising ten or four genes.

RESULTS

The prognostic core gene signatures include three up-regulated (CEBPD, MMP20, and WLS) and seven down-regulated genes (ASF1A, ASPSCR1, CHAF1B, DNMT1, GINS2, GOLGA2P5, and SKA1). We further develop a simple risk-stratification method based on expression profiles of the core genes. Relative expression values of the up-regulated and down-regulated core genes were averaged into two scores, Up and Down scores, respectively; then samples were stratified by a diagonal line in a xy plot of the Up and Down scores. Based on this method, the patients were successfully divided into subgroups with distinct chemoresponse and prognosis. The prognostic power of the method was validated in three independent public datasets containing 230, 141, and 117 TNBC patients with chemotherapy. In multivariable Cox regression analysis, the core gene signatures were significantly associated with prognosis independent of tumor stage and age at diagnosis. In meta-analysis, we found that five core genes (CEBPD, WLS, CHAF1B, GINS2, and SKA1) play opposing roles, either tumor promoter or suppressor, in TNBC and non-TNBC tumors respectively, depending on estrogen receptor status.

CONCLUSIONS

The results may provide a promising prognostic tool for predicting chemotherapy responders among TNBC patients prior to initiation of chemotherapeutic treatment.

Hormone receptor, human epidermal growth factor receptor-2, and Ki-67 status in primary breast cancer and corresponding recurrences or synchronous axillary lymph node metastases

The therapeutic strategy for breast cancer is determined by the surrogate subtype, which is defined by biomarkers, such as estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor-2 (HER2), and Ki-67. In previous reports, the rate of discordance in ER, PgR, and HER2 between primary breast cancer and recurrent lesions or synchronous axillary lymph node metastasis was 15-25, 25-40, and 5-25 or 7-50, 10-50, and 3-30%, respectively. Overall, hormone receptors tended to weaken during the metastatic process, while patterns of HER2 were not uniform. Regarding the Ki-67 labeling index, an increase in metastatic lesions compared with primary lesions was the dominant pattern, suggesting that aggressive subclones with high proliferative potential form metastases. The loss of expression of hormone receptor or an increase in the Ki-67 labeling index in metastasis seemed to be associated with a poor prognosis. However, most previous studies did not report the background characteristics of patients, or they included subjects with varied characteristics, including those on systemic therapy, and were based on relatively small populations; therefore, definitive conclusions could not be drawn. Future studies should explore how to select therapies according to the biomarkers in primary breast cancer and/or its metastasis.