Application of deep learning on mammographies to discriminate between low and high-risk DCIS for patient participation in active surveillance trials

BACKGROUND

Ductal Carcinoma In Situ (DCIS) can progress to invasive breast cancer, but most DCIS lesions never will. Therefore, four clinical trials (COMET, LORIS, LORETTA, AND LORD) test whether active surveillance for women with low-risk Ductal carcinoma In Situ is safe (E. S. Hwang et al., BMJ Open, 9: e026797, 2019, A. Francis et al., Eur J Cancer. 51: 2296-2303, 2015, Chizuko Kanbayashi et al. The international collaboration of active surveillance trials for low-risk DCIS (LORIS, LORD, COMET, LORETTA),  L. E. Elshof et al., Eur J Cancer, 51, 1497-510, 2015). Low-risk is defined as grade I or II DCIS. Because DCIS grade is a major eligibility criteria in these trials, it would be very helpful to assess DCIS grade on mammography, informed by grade assessed on DCIS histopathology in pre-surgery biopsies, since surgery will not be performed on a significant number of patients participating in these trials.

OBJECTIVE

To assess the performance and clinical utility of a convolutional neural network (CNN) in discriminating high-risk (grade III) DCIS and/or Invasive Breast Cancer (IBC) from low-risk (grade I/II) DCIS based on mammographic features. We explored whether the CNN could be used as a decision support tool, from excluding high-risk patients for active surveillance.

METHODS

In this single centre retrospective study, 464 patients diagnosed with DCIS based on pre-surgery biopsy between 2000 and 2014 were included. The collection of mammography images was partitioned on a patient-level into two subsets, one for training containing 80% of cases (371 cases, 681 images) and 20% (93 cases, 173 images) for testing. A deep learning model based on the U-Net CNN was trained and validated on 681 two-dimensional mammograms. Classification performance was assessed with the Area Under the Curve (AUC) receiver operating characteristic and predictive values on the test set for predicting high risk DCIS-and high-risk DCIS and/ or IBC from low-risk DCIS.

RESULTS

When classifying DCIS as high-risk, the deep learning network achieved a Positive Predictive Value (PPV) of 0.40, Negative Predictive Value (NPV) of 0.91 and an AUC of 0.72 on the test dataset. For distinguishing high-risk and/or upstaged DCIS (occult invasive breast cancer) from low-risk DCIS a PPV of 0.80, a NPV of 0.84 and an AUC of 0.76 were achieved.

CONCLUSION

For both scenarios (DCIS grade I/II vs. III, DCIS grade I/II vs. III and/or IBC) AUCs were high, 0.72 and 0.76, respectively, concluding that our convolutional neural network can discriminate low-grade from high-grade DCIS.

The type 2 inflammatory response favors recognition of tumor antigens by IgE in breast cancer

BACKGROUND

Several studies describe an inverse statistical relationship between the presence of an allergy and development of cancer. However, the immunological mechanism involved in the relationship between these two degenerative diseases has not been explored.

AIMS

The main objective of this study was to explore the possibility that the lymphocyte T helper (Th) 2 response, a characteristic of allergy, induces recognition of tumor antigens.

METHODS AND RESULTS

Patients with a clinical diagnosis of breast ductal carcinoma were included. Histopathological markers related to proliferation of tumor cells were determined (Her-2-neu, Ki-67, estrogen receptor, and progesterone receptor). IHC was performed using IgE antibodies purified from an allergy patient and from each biopsy donor patient. Serum concentrations of cytokines representative of Th1 and Th2 inflammatory responses were determined. A total of 14 patients with a confirmed diagnosis of breast ductal carcinoma were included. IHC performed on biopsies showed a weak response when using purified IgE antibodies from an allergy patient; however, IHC using the IgE of each patient as the primary antibody showed an intense and highly specific signal. Serum concentrations of cytokines of the Th2 response, that is, IL-4 (130.5 pg/mL (116-135 pg/mL)), IL-5 (202 pg/mL (191-213 pg/mL)), and IL-13 (105.5 pg/mL (98-117 pg/mL)), were significantly higher than those of the Th1 response, that is, IL-6 (86 pg/mL (79-90 pg/mL)) and INF-γ (93 pg/mL (79-99 pg/mL)).

CONCLUSION

Purified IgE antibodies specifically recognize tumor cells in breast ductal carcinoma.

Granulomatous lobular mastitis co-existing with ductal carcinoma in situ: Report of three cases and review of the literature

Granulomatous lobular mastitis (GLM) is a benign and infrequent chronic breast ailment. Although this lesion can be clinically and radiographically mistaken for early-onset breast cancer, it is a rare occurrence for the two to coexist. This report describes three such cases. In all three patients, the primary signs and symptoms were related to the formation of diffuse breast masses or abscesses. Breast ultrasound and MRI revealed glandular edema and dilated breast ducts. The biopsies of all lesions exhibited both granulomatous inflammation confined to the lobules of the breast, abundant interstitial inflammatory cell infiltrates, and apparently cancerous cells located in dilated ducts with intact basement membranes. The surgically excised specimens confirmed the diagnosis of GLM and ductal carcinoma in situ (DCIS) in all three patients who underwent breast mass resection. By clinical imaging and clinical manifestations, GLM may obscure a concurrent DCIS, as highlighted by the cases reported herein.

Cytomorphological Assessment in Aspirates of Ductal Carcinoma in situ: Correlations with Histopathologic Grade, Architectural Pattern, and Invasion

INTRODUCTION

Fine-needle aspiration biopsy (FNAB) of the breast is an effective and widely adopted diagnostic technique. Histopathologic grading of ductal carcinoma in situ (DCIS) has prognostic significance. In this current study, FNAB of DCIS was reviewed to identify parameters that predict grading, histopathologic architecture, and presence of invasion in DCIS.

METHODS

Aspirates from histopathology-proven cases of DCIS were retrieved and reviewed for cytomorphologic parameters including cellularity, composition, epithelial fragment architecture cellular/nuclear features.

RESULTS

In total 104 aspirates were reviewed. Cytopathologic cellular features - large nuclear size (p = 0.005), prominent nucleoli (p = 0.011), increased nuclear membrane irregularity (p = 0.043), high variation in nuclear size (p = 0.025), and presence of apoptotic figures in epithelial structures (p < 0.001); and background debris (p = 0.033) correlated with a high-grade diagnosis. Cytoplasmic vacuolation (p = 0.034) was seen exclusively in non-high-grade aspirates. Epithelial fragment architecture did not correlate with grading. A predominance (≥50%) of solid aggregates and papillary fragments on FNAB correlated with histopathologically solid (p = 0.039, p = 0.005) and papillary (p = 0.029, < p = 0.001) patterns. No parameter showed correlation with invasion.

CONCLUSION

FNAB is effective in predicting DCIS grading. Epithelial fragment architecture assessment is limited to papillary or solid types, and FNAB cannot predict focal invasion in DCIS.

Additional occult cancers identified on staging breast MRI: imaging appearances and pathologic characteristics

INTRODUCTION

Breast magnetic resonance imaging (MRI) is increasingly being used for staging of patients with breast cancer due to its high sensitivity in detecting additional cancers (ACs). However, the clinical impact of diagnosing and treating these cancers remains unclear.

METHODS

A retrospective study was undertaken of patients with newly diagnosed breast cancer who underwent staging MRI at The American University of Beirut Medical Centre (AUBMC) between 2012 and 2020. Pathology reports and breast MRI examinations were reviewed. Eighteen breast cancer patients with 19 pathology-proven index cancers (ICs) and 19 pathology-proven MRI-detected ACs were included. Chi-square and Fisher's exact tests for categorical variables and Wilcoxon signed rank test for numerical variables were used to compare ICs to ACs.

RESULTS

The ICs consisted of four ductal carcinoma in situ (DCIS), 13 invasive ductal carcinomas (IDC), of which five with associated DCIS, and two invasive lobular carcinomas, (ILC) of which one with associated DCIS. ACs comprised 12 DCIS, five IDC, two with associated DCIS and two ILC, one with associated DCIS. Interval cancers were more frequently invasive whereas ACs were more frequently in situ (P = 0.021). ACs were more frequently nuclear grade 2 (P = 0.009). There was no statistically significant difference between ICs and ACs in lesion type (P = 0.062), shape (P = 0.073), initial enhancement (P = 1), delayed enhancement (P = 0.732), hormonal receptor profile (P = 0.68) and Ki67 (P = 0.388). Among ACs, ten (53%) were larger than 10 mm of which five (26%) were invasive cancers, and five (26%) were larger than the ICs.

CONCLUSIONS

ACs detected by breast MRI were more likely to be in situ and to show a nuclear grade 2. Although not reaching statistical significance, some ACs tend to be clinically significant by their type, size or nuclear grade. The impact on clinical management remains to be determined.

Axillary lymph node status and invasive lobular breast cancer : Analysis of the Clinical Tumor Register of the AGO Austria

BACKGROUND

Invasive lobular carcinoma (ILC) represents the second most common type of invasive breast cancer (BC). Although ILC generally have good prognostic properties (positive estrogen receptor, ER, low tumor grade), they are generally diagnosed at a more advanced stage. The data on the axillary lymph node status in ILC compared to invasive ductal carcinoma (IDC) are considered controversial. Therefore, the aim of this study was to compare the pathological node stage (pN) between ILC and IDC in an Austria-wide register.

METHODS

Data of the Clinical Tumor Register (Klinisches TumorRegister, KTR) of the Austrian Association for Gynecological Oncology (AGO) were retrospectively analyzed. Patients with primary early BC, invasive lobular or ductal, diagnosed between January 2014 and December 2018, and primary surgery were included. A total of 2127 tumors were evaluated and compared in 2 groups, ILC n = 303, IDC n = 1824.

RESULTS

A total of 2095 patients were analyzed in the study. In the multivariate analysis, pN2 and pN3 were observed significantly more frequently in ILC compared with IDC (odds ratio, OR 1.93; 95% confidence interval, CI 1.19-3.14; p = 0.008 and OR 3.22; 95% CI: 1.47-7.03; p = 0.003; respectively). Other factors associated with ILC were tumor grades 2 and 3, positive ER, and pathological tumor stage (pT) 2 and pT3. In contrast, concomitant ductal carcinoma in situ, overexpression of the human epidermal growth factor receptor 2 (HER2), and a moderate and high proliferation rate (Ki67) were found less frequently in ILC.

CONCLUSION

The data show an increased risk of extensive axillary lymph node metastasis (pN2/3) in ILC.

Patients with Invasive Lobular Carcinoma Show a Significant Increase in IRS-4 Expression Compared to Infiltrative Ductal Carcinoma—A Histopathological Study

Background and Objectives: Breast cancer (BC) is the first diagnosed type of cancer and the second leading cause of cancer-related mortality in women. In addition, despite the improvement in treatment and survival in these patients, the global prevalence and incidence of this cancer are rising, and its mortality may be different according to the histological subtype. Invasive lobular carcinoma (ILC) is less common but entails a poorer prognosis than infiltrative ductal carcinoma (IDC), exhibiting a different clinical and histopathological profile. Deepening study on the molecular profile of both types of cancer may be of great aid to understand the carcinogenesis and progression of BC. In this sense, the aim of the present study was to explore the histological expression of Insulin receptor substrate 4 (IRS-4), cyclooxygenase 2 (COX-2), Cyclin D1 and retinoblastoma protein 1 (Rb1) in patients with ILC and IDC. Patients and Methods: Thus, breast tissue samples from 45 patients with ILC and from 45 subjects with IDC were analyzed in our study. Results: Interestingly, we observed that IRS-4, COX-2, Rb1 and Cyclin D1 were overexpressed in patients with ILC in comparison to IDC. Conclusions: These results may indicate a differential molecular profile between both types of tumors, which may explain the clinical differences among ILC and IDC. Further studies are warranted in order to shed light onto the molecular and translational implications of these components, also aiding to develop a possible targeted therapy to improve the clinical management of these patients.

Evolution of an invasive ductal carcinoma to a small cell carcinoma of the breast: A case report

RATIONALE

Small cell carcinoma (SCC) is a rare subtype of breast cancer and presents a complex diagnostic and treatment challenge, due to paucity of data. To the best of our knowledge, most cases of breast SCC reported in the literature describe a de novo breast primary. Our case is unique as it describes the evolution of an invasive ductal carcinoma after treatment into a SCC of the breast.

PATIENT CONCERNS AND DIAGNOSIS

We report a case of a 53-year-old female, lifelong non-smoker, who initially presented with breast mass noted on self examination. Breast and axillary lymph node biopsy demonstrated a hormone receptor positive invasive ductal carcinoma with a metastatic T3 lesion.

INTERVENTION

She was treated with first-line palbociclib/letrozole with initial clinical response, and at progression was switched to capecitabine with no response. Repeat biopsy of the axillary lesion showed evolution of the tumor into a triple negative breast cancer. She was then treated with third-line paclitaxel and radiation therapy with good initial response. She eventually had further disease progression and presented with a new mediastinal lymphadenopathy causing SVC syndrome. Biopsy of this showed a small cell variant of breast neuroendocrine carcinoma. Due to the evolution of histology in this case, a retrospective review of her initial breast specimen as well as the second biopsy from the axilla was conducted which confirmed that the mediastinal lymphadenopathy was metastatic from the original breast tumor.

OUTCOMES AND LESSONS

We speculate that the initial treatment allowed a minority of treatment-resistant neuroendocrine cells to grow and become the dominant face of the tumor. Our patient had an excellent response to carboplatin/etoposide and consolidative locoregional radiotherapy but presented with an early intracranial recurrence. This is a similar pattern of metastases as seen in lung SCC and highlights a potential role for prophylactic cranial irradiation in breast SCC. Further studies are needed to better understand the biology and treatment of breast SCC which continues to present a challenge for clinicians.

Primary Ectopic Breast Carcinoma in Man Mimicking Keloid

Background:

Case report:

Conclusion:

Epidemiology of Ductal Carcinoma In Situ

Ductal carcinoma in situ (DCIS) is thought to be a direct precursor of most cases of breast cancer and its incidence increases with age. However, the globally impressive rise of DCIS cases is probably an epidemiologic "artifact" that is mainly attributed to the establishment of screening mammography in developed countries. Furthermore, considering that usually there are no clinical findings of the disease, the initial detection of DCIS is a mammographic "event" in most cases. The risk factors for DCIS are similar to those for invasive cancer including, among others, deleterious mutations in the BRCA genes, family history of breast cancer, nulliparity, late age at first birth, increased breast density, personal history of benign breast disease, and postmenopausal obesity.

Is Axillary Assessment of Ductal Carcinoma In Situ of the Breast Necessary in All Cases?

BACKGROUND

Staging of the axilla in women with ductal carcinoma in situ (DCIS) is a point of controversy. We aimed to assess whether there is a group of patients in whom axillary assessment can be avoided and whether the likelihood of underdiagnosis of infiltrating carcinoma is sufficient to justify this evaluation.

MATERIALS AND METHODS

This was a multicenter, prospective, observational study of patients who were operated on between 2008 and 2018 in three Spanish hospitals, with a diagnosis by radiological or excisional biopsy of DCIS and clinically and radiologically negative axilla.

RESULTS

A total of 530 patients with a preoperative diagnosis of DCIS were studied. An axillary assessment was performed in 77% of the patients. In 397 patients, selective sentinel lymph node biopsy was performed. Axillary involvement was found in 7.2% of all patients, which dropped to 2.15% if we only included DCIS diagnosed after a definitive anatomical pathology analysis. Underdiagnosis was correlated with the type of biopsy performed: the risk was 1.34 times as high if the biopsy was performed with a core needle. The risk of lymph node metastasis was higher when there was lymphovascular invasion and when mastectomy was performed.

CONCLUSIONS

We propose an axilla management algorithm in patients with a preoperative diagnosis of DCIS. The patients who would benefit from sentinel lymph node biopsy would be those who are not candidates for breast-conserving surgery, those with a BIRADS 5 lesion biopsied by core-needle biopsy, and those whose definitive diagnosis is lymphovascular invasion.

Breast invasive ductal carcinoma diagnosis with a three-miRNA panel in serum

Aim: Breast cancer, especially invasive ductal carcinoma (IDC), is the cause of a great clinical burden. miRNA could be considered as a noninvasive biomarkers for IDC diagnosis. Materials & methods: Two hundred and sixty participants (135 IDC patients and 125 healthy controls) were enrolled in a three-cohort study. The expression of 28 miRNAs in serum were detected with quantitative reverse transcription-PCR. Bioinformatic analysis was used for predicting the target genes of three selected miRNAs. Results: The expression level of seven miRNAs (miR-9-5p, miR-34b-3p, miR-1-3p, miR-146a-5p, miR-20a-5p, miR-34a-5p, miR-125b-5p) was discrepant at the validation cohort. Through statistical test, a three-miRNA panel (miR-9-5p, miR-34b-3p, miR-146a-5p) was significant for IDC diagnosis (AUC = 0.880, sensitivity = 86.25%, specificity = 81.25%). Conclusion: The three-miRNA panel in serum could be used as a noninvasive biomarker in the diagnosis of IDC.

An Unusual Case of BIA-ALCL Associated with Prolonged/Complicated Biocell-Textured Expander, followed by Smooth Round Breast Implant Exposure, and Concurrent Use of Adalimumab

SUMMARY

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a malignancy associated with textured breast implants. BIA-ALCL is typically restricted to the periprosthetic capsule, presenting as a unilateral recurrent seroma years after placement of a textured breast implant. Current estimates suggest an incidence of one in 3300 for patients with Allergan Biocell textured implants. As of February 6, 2019, U.S. Medical Device Reporting associated with BIA-ALCL showed 457 unique cases of BIA-ALCL, with 24 "unverified and potentially inaccurate" cases associated with a nontextured implant. As of February of 2019, there were 688 reported cases to date worldwide. To date, there are no published case reports of BIA-ALCL associated exclusively with smooth implants or with smooth implants after textured expanders, and there has been no reported smooth-only case in any registry, database, or journal worldwide. The authors present a case of BIA-ALCL associated with smooth round implants and textured tissue expanders. A 56-year-old woman was treated for left stage IIA invasive ductal carcinoma with bilateral mastectomies and immediate reconstruction with bilateral subpectoral textured tissue expanders. She underwent exchange to Mentor smooth-round implants, and completed adjuvant chemotherapy. Magnetic resonance imaging and examination 4.5 years after implant placement showed no abnormal findings. The patient had left breast trauma 5 years following implant placement while taking adalimumab, and developed an open wound requiring explantation. A recurrent seroma developed, and tested positive for BIA-ALCL on cytology. Surgical pathologic examination after total capsulectomy demonstrated stage IA BIA-ALCL. To the authors' knowledge, this is the first case report of BIA-ALCL in a patient with textured expanders followed by prolonged exposure to smooth round implants.

Prognostic Value of ER and PgR Expression and the Impact of Multi-clonal Expression for Recurrence in Ductal Carcinoma in situ: Results from the UK/ANZ DCIS Trial

PURPOSE

The prognostic value of estrogen receptor (ER)/progesterone receptor (PgR) expression in ductal carcinoma in situ (DCIS) is unclear. We observed multi-clonality when evaluating ER/PgR expression in the UK/ANZ DCIS trial, therefore, we investigated the prognostic role of both uni-clonal and multi-clonal ER/PgR expression in DCIS.

EXPERIMENTAL DESIGN

Formalin-fixed paraffin embedded tissues were collected from UK/ANZ DCIS trial participants (n = 755), and ER/PgR expression was evaluated by IHC in 181 cases (with recurrence) matched to 362 controls by treatment arm and age. Assays were scored by the Allred method and by a newly devised clonal method-analyses categorizing multi-clonal DCIS as ER/PgR-positive as per current practice (Standard) and as ER/PgR-negative (clonal) were performed.

RESULTS

ER expression was multi-clonal in 11% (39/356) of ER-positive (70.6%, 356/504) patients. Ipsilateral breast event (IBE) risk was similarly higher in ER-multi-clonal and ER-negative DCIS as compared with DCIS with uni-clonal ER expression. ER-negative DCIS (clonal) had a higher risk of in situ IBE [OR 4.99; 95% confidence interval (CI), 2.66-9.36; P < 0.0001], but the risk of invasive IBE was not significantly higher (OR 1.72; 95% CI, 0.84-3.53; P = 0.14), P heterogeneity = 0.03. ER was an independent predictor in multivariate analyses (OR 2.66; 95% CI, 1.53-4.61). PgR status did not add to the prognostic information provided by ER.

CONCLUSIONS

ER expression is a strong predictor of ipsilateral recurrence risk in DCIS. ER-positive DCIS with distinct ER-negative clones has a recurrence risk similar to ER-negative DCIS. ER should be routinely assessed in DCIS, and ER scoring should take clonality of expression into account.

Nonmass enhancement lesions of the breast on core needle biopsy: outcomes, frequency of malignancy, and pathologic findings

Nonmass enhancement (NME) on breast magnetic resonance imaging (MRI) is defined as an area whose internal enhancement characteristics can be distinguished from the normal surrounding breast parenchyma, without an associated mass in the Breast Imaging Reporting and Data System lexicon. In this study, we evaluated the pathologic correlates of NME lesions of the breast identified on MRI at our institution, including the frequency of atypical or malignant lesions in the core needle biopsies (CNBs), performed after such a radiologic finding. A retrospective study was performed on all CNBs performed for NME on breast MRI between 2010 and 2019. A total of 443 biopsies from 411 patients were identified, comprising 5.5% of all CNBs over the study period. The pathologic diagnoses were benign in the majority of the biopsies (68.0%), whereas 11.5% and 20.5% of the cases were atypical and malignant lesions, respectively. Of the malignant cases, 69.2% were ductal carcinoma in situ (DCIS) and 30.8% were invasive carcinomas. The most common invasive cancer was invasive ductal carcinoma (50%), followed by invasive lobular carcinoma (39.3%). NME identified on breast MRI carried a significant (32%) risk of atypia and malignancy in our cohort, which confirms that biopsy evaluation of these lesions is warranted. DCIS was the most commonly identified malignancy. Notably, among invasive cancers, invasive lobular carcinoma was identified at a substantially higher frequency that would be expected for that histotype.

Total Tumor Load of mRNA Cytokeratin 19 in the Sentinel Lymph Node as a Predictive Value of Axillary Lymphadenectomy in Patients with Neoadjuvant Breast Cancer

Although sentinel lymph node biopsy (SLNB) has proved to be able to diagnose axillary lymph node status safely and reliably, there is still not enough evidence to suggest that it can be used in patients who have undergone neoadjuvant chemotherapy (NAC) for lymph node-sparing surgery. The present study used molecular approaches to determine whether SLNB can be reliably used in patients who have been treated with NAC before SLN surgery, and whether the total tumor load of the SLN can be used as a predictive factor in axillary lymphadenectomy (ALD). We used one-step nucleic acid amplification (OSNA) to analyze a total of 111 consecutive patients who presented operable invasive breast carcinomas and who had been treated with NAC. SLN was positive in 55 patients and the identification rate was 100%. In 9 of these 55 patients, ALD showed that other lymph nodes were also involved. In all of the other 46 patients, the only lymph node to be identified as positive was SLN. Metastasis was not found in any of the axillary lymph nodes in the isolated tumor cell group. The total tumor load, defined as the amount of cytokeratin 19 mRNA copy numbers in all positives SLN (copies/µL), showed three risk groups related to the possibility of positive non-sentinel nodes. OSNA is a diagnostic technique that is highly sensitive, specific, and reproducible and it can be used to analyze sentinel lymph nodes after NAC. Total tumor load may be able to help predict additional metastases in axillary lymphadenectomy.

CDX2-positive breast cancer presented with axillary lymph node metastases: A case report

BACKGROUND

The caudal type homeobox 2 transcription factor (CDX2) is a specific and sensitive marker for intestinal carcinoma, but usually not expressed in breast cancer. In CDX2-positive metastatic cancer of occult primary, the origin is highly suspicious of an enteric carcinoma.

CASE PRESENTATION

A 50-year-old woman complained of enlarged lymph nodes (LNs) in the right axilla. Mammography and ultrasonography scans showed no abnormal findings in her breasts. Core needle biopsy (CNB) revealed metastatic adenocarcinoma. Immunohistochemical staining was positive for CDX2 intensely. The primary tumor was suspicious of intestinal adenocarcinoma. A dynamic contrast-enhanced magnetic resonance imaging scan revealed an accentuated lesion which was detected using a second-look ultrasound, and diagnosed invasive ductal carcinoma by CNB. A partial mastectomy of the right breast with level I and II axillary LN dissection was performed. A few cells of primary cancer were expressed CDX2 and estrogen receptor. The final pathological diagnosis was T1bN3aM0 stage IIIC. The fluorescent double staining showed that CDX2 simultaneously expressed on the Ki67 positive cells of metastatic tumors. The adjuvant treatment included chemotherapy and radiation, followed by tamoxifen administration. The patient survived without any recurrences over the following 36 months.

CONCLUSIONS

We report a rare case of CDX2-positive metastatic breast cancer in the axillary LNs. As some literatures reported vitamin D pathways induced cancer cell apoptosis and inhibition, these metastatic cells of our case might play the effort of autoregulation of inhibiting progression.

Nonpalpable breast masses: One-year ultrasound follow-up and morbidity outcomes in Shanghai

Women with nonpalpable breast masses are at a high risk of developing breast cancer (BC) due to misdiagnosis during the follow-up period.A total of 40,334 women were divided into palpable and nonpalpable breast mass groups. We assessed the risk factors for cancer development in patients with nonpalpable breast masses during a 1-year follow-up period.Of the 1335 patients in the nonpalpable breast mass group, we found 50 patients of BC, of which 35 patients accepted surgery and were confirmed with biopsy at the beginning of the study. The remaining 15 (1.1%) were diagnosed with BC during follow-up, and included 10 in situ and 5 invasive carcinomas. Four of the 10 patients in the in situ subgroup, and 2 out of the 5 in the invasive subgroup were overweight (Body mass index > 24 kg/m). Nine in situ BC patients had breast-conserving surgery, 1 had a mastectomy. No patient in the in situ group received chemotherapy or radiotherapy. All 5 patients with invasive disease received 6 cycles of chemotherapy. Only 3 (20%) of the 15 patients with BC had a positive family history. We found 131 BC cases, including BC detected during screening (81) and follow-up (50). The incidence of BC was 240.2 per 100,000 inhabitants.Patients with nonpalpable breast masses require regular follow-up as they have a high risk of cancer occurrence. Regular follow-up can lead to early diagnosis and effective treatment of these early-stage BC patients.

Gestational breast cancer: current challenges in staging and treatment of breast cancer

Gestational breast cancer (GBC) is the most common form of invasive cancer in pregnancy and has unique challenges in both staging and treatment given the dual goal of appropriate cancer management and minimising the risk of fetal toxicity. A 38-year-old woman with no significant medical history and 21 weeks pregnant presented with a palpable right breast mass. She was diagnosed with human epidermal growth factor receptor 2-positive infiltrating ductal carcinoma with advanced disease. The patient underwent treatment; however, unfortunately, she passed away after developing devastating distant disease recurrence.We highlight both the challenges and current guidelines for management of GBC. Our goal is to discuss the current limitations of GBC management and the necessity of further investigation for safe novel imaging and treatment modalities for pregnant women. It is crucial to increase awareness across multiple subspecialities, as a multidisciplinary team is necessary for proper treatment of GBC.

Annular erythema as a cutaneous sign of recurrent ductal breast carcinoma, misdiagnosed as erythema chronicum migrans

Annular erythema as a clinical manifestation of locoregional recurrence of breast cancer is extremely rare. Only three papers with the description of five cases have been published in the current literature to our knowledge. Herein, we describe two additional cases of annular erythema as a cutaneous sign of recurrent ductal breast carcinoma; both were misdiagnosed as erythema chronicum migrans.

[Adenopathy and mammary carcinoma: It is sometimes in the details that one encounters hypersensitivity pneumonitis!]

INTRODUCTION

Hypersensitivity pneumonitis (HP) is an interstitial lung disease due to an immunological reaction to exposure, by inhalation, to a large variety of antigens. The patho-physiological mechanism remains poorly understood. The diagnosis can be challenging and requires a detailed medical history taking especially when the clinical presentation is atypical or when the causal agent remains unknown.

CASE REPORT

We report the case of a 75-year-old woman with a history of mammary carcinoma who presented with recently identified intramammary adenopathy. Biopsy of the adenopathy revealed non-necrotising, giant cell epithelioid granuloma. A diagnosis of hot tub lung with extra-pulmonary granulomatous lymph node involvement was made based on the clinical, functional, radiological and microbiological investigations. The evolution was favorable following antigen avoidance.

CONCLUSION

Extrapulmonary lymph node involvement is rare in HP, suggesting a systemic inflammatory involvement.

Fractal Analysis Method for the Complexity of Cell Cluster Staining on Breast FNAB

OBJECTIVE

Because of the increased precision of ultrasound breast cancer screening, early cancer cases with no clear mass or extraction of microcysts on imaging have recently increased, and improvement of the accuracy of breast fine-needle aspiration biopsy (FNAB) cytology is needed. The objective of this study was to investigate the usefulness of cluster gray image-fractal analysis evaluating the darkness of clusters, cluster unevenness, and complexity of hyperchromicity (cluster density) of deep-stained cell clusters, known as hyperchromatic crowded cell groups (HCG), on FNAB as a cytology assistance system for breast FNAB.

STUDY DESIGN

One hundred clusters collected from 10 patients with fibroadenoma (FA), 90 clusters from 9 patients with ductal carcinoma in situ (DCIS), and 122 clusters from 11 patients with invasive breast carcinoma of no special type (IBC-NST) were used. (1) Cluster size classification: clusters were classified into small, middle, and large clusters (small cluster: smaller than 40 × 102 μm2; large cluster: 100 × 102 μm2 or larger; middle cluster: intermediate), and their frequency was calculated. (2) Cluster gray image-fractal analysis: (a) the darkness of clusters (luminance), (b) cluster unevenness (complexity), and (c) complexity of cluster density (roundness-corrected fractal value) were assessed. For statistical analysis, the multiple comparison Steel-Dwass test was used, with a significance level of p < 0.05.

RESULTS

(1) Cluster size classification: in FA, small, middle, and large clusters appeared at a similar frequency, and the frequency (30%) of large clusters was significantly higher than that in other diseases. In IBC-NST, many small clusters (61%) appeared and their frequency was significantly higher than that in other diseases, whereas the frequency of large clusters was significantly lower. (2) Cluster gray image-fractal analysis: in IBC-NST, the luminance of small clusters was low (dark), the cluster unevenness was high, and the complexity of cluster density was high, whereas the luminance of large clusters was high (bright), the cluster unevenness was high, and complexity of cluster density was high compared with those in FA.

CONCLUSION

Cluster gray image-fractal analysis evaluating the darkness of clusters, cluster unevenness, and complexity of cluster density in breast FNAB HCG is a useful cytology assistance system for breast FNA.

[Histological lesions of risk of breast carcinoma. Survival guide for the general pathologist]

Proliferative epithelial lesions are risk factors for breast cancer. They are a heterogeneous group of lesions in which the presence of atypia is related to varying degrees of risk. They should be considered in the differential diagnosis with benign lesions, in situ ductal carcinoma and infiltrating carcinoma. An accurate histopathological diagnosis is important in choosing the best therapeutic option, including vacuum assisted biopsy and surgery. We revise diagnostic criteria and the differential diagnosis of usual ductal hyperplasia, radial scar and complex sclerosing lesions, distinct types of adenosis, papillary lesions, atypical ductal hyperplasia, flat epithelial atypia and lobular neoplasia in situ. Furthermore, we summarize the degree of risk associated with the different conditions and management possibilities.

GALNT6 promotes breast cancer metastasis by increasing mucin-type O-glycosylation of α2M

Breast cancer is the most lethal malignancy in women. N-acetylgalactosaminyltransferase 6 (GALNT6) is an enzyme which mediates the initial step of mucin-type O-glycosylation, and has been reported to be involved in mammary carcinogenesis. However, the molecular mechanism of GALNT6 in breast cancer metastasis has not been fully explored. In this study, based on online database analyses and tissue microarrays, the overall survival (OS) of breast cancer patients with high expression of GALNT6 was found to be shorter than those with low expression of GALNT6. Also, high GALNT6 expression was positively correlated with advanced pN stage and pTNM stage. GALNT6 was shown to be able to promote the migration and invasion of breast cancer cells, and enhance the level of mucin-type O-glycosylation of substrates in the supernatants of breast cancer cells. Qualitative mucin-type glycosylomics analysis identified α2M as a novel substrate of GALNT6. Further investigation showed that GALNT6 increased O-glycosylation of α2M, and the following activation of the downstream PI3K/Akt signaling pathway was involved in the promotion of migration and invasion of breast cancer cells. This study identified a new substrate of GALNT6 and provides novel understanding of the role of GALNT6 in promoting metastasis and poor prognosis in breast cancer.

PIK3CA Mutational Status Is Associated with High Glycolytic Activity in ER+/HER2- Early Invasive Breast Cancer: a Molecular Imaging Study Using [18F]FDG PET/CT

PURPOSE

In PIK3CA mutant breast cancer, downstream hyperactivation of the PI3K/AKT/mTOR pathway may be associated with increased glycolysis of cancer cells. The purpose of this study was to investigate the functional association of PIK3CA mutational status and tumor glycolysis in invasive ER+/HER2- early breast cancer.

PROCEDURES

This institutional review board-approved retrospective study included a dataset of 67 ER+/HER2- early breast cancer patients. All patients underwent 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography/X-ray computed tomography ([¹⁸F]FDG PET/CT) and clinico-pathologic assessments as part of a prospective study. For this retrospective analysis, pyrosequencing was used to detect PIK3CA mutations of exons 4, 7, 9, and 20. Tumor glucose metabolism was assessed semi-quantitatively with [¹⁸F]FDG PET/CT using maximum standardized uptake values (SUV_max). SUV_max values were corrected for the partial volume effect, and metabolic tumor volume was calculated using the volume of interest automated lesion growing function 2D tumor size, i.e., maximum tumor diameter was assessed on concurrent pre-treatment contrast-enhanced magnetic resonance imaging.

RESULTS

PIK3CA mutations were present in 45 % of all tumors. Mutations were associated with a small tumor diameter (p < 0.01) and with low nuclear grade (p = 0.04). Glycolytic activity was positively associated with nuclear grade (p = 0.01), proliferation (p = 0.002), regional lymph node metastasis (p = 0.015), and metabolic tumor volume (p = 0.001) but not with tumor size/T-stage. In invasive ductal carcinomas, median SUV_max was increased in PIK3CA-mutated compared to wild-type tumors; however, this increase did not reach statistical significance (p = 0.05). Multivariate analysis of invasive ductal carcinomas revealed [¹⁸F]FDG uptake to be independently associated with PIK3CA status (p = 0.002) and nuclear tumor grade (p = 0.046). Size, volume, and regional nodal status had no influence on glycolytic activity. PIK3CA mutational status did not influence glycolytic metabolism in lobular carcinomas. Glycolytic activity and PIK3CA mutational status had no significant influence on recurrence-free survival or disease-specific survival.

CONCLUSIONS

In ER+/HER2- invasive ductal carcinomas of the breast, glucose uptake is independently associated with PIK3CA mutations. Initial data suggest that [¹⁸F]FDG uptake reflects complex genomic alterations and may have the potential to be used as candidate biomarker for monitoring therapeutic response and resistance mechanisms in emerging therapies that target the PI3K/AKT/mTOR pathway.

PD-L1 diagnostics in the neoadjuvant setting: implications of intratumoral heterogeneity of PD-L1 expression in triple negative breast cancer for assessment in small biopsies

PURPOSE

PD-L1 expression is a predictive biomarker for anti-PD-L1 immunotherapy in triple negative breast cancer (TNBC). In the neoadjuvant setting, immunohistochemical (IHC) evaluation of PD-L1 expression can only be performed on small tissue biopsies. In our study we investigated heterogeneity of PD-L1 expression in TNBC, and how reliably PD-L1 expression in small tissue samples reflects PD-L1 expression in larger tumor sections in TNBC.

METHODS

Tissue microarrays (TMAs) were constructed from surgical specimens of 110 patients with TNBC. TMAs contained 4 cores (1 mm in diameter) per patient. To evaluate PD-L1 expression, TMAs were stained with PD-L1 IHC 22C3 PharmDx. Single-core PD-L1 expression was compared to overall PD-L1 expression of each patient's tumor, to ascertain how often small samples of tumor tissue show the same PD-L1 expression as larger tumor samples.

RESULTS

Our study found substantial heterogeneity of PD-L1 expression between different TMA cores from the same patient. Heterogeneity was greater in immune cells (ICs) than in tumor cells, in large part due to the uneven distribution of ICs in the tumor. For IC PD-L1 expression, we found that sensitivity can be as low as 0.81 for detecting PD-L1 expression at the 1% threshold most commonly used in breast cancer. Negative predictive value for ICs was 0.7.

CONCLUSIONS

There is substantial heterogeneity of PD-L1 expression between small tissue samples from the same TNBC tumor, especially for IC expression. This poses challenges for evaluation of PD-L1 expression in the neoadjuvant setting. Negative biopsies should prompt further investigation, and multiple biopsies might be necessary.

Breast cancer diagnosis by analysis of serum N-glycans using MALDI-TOF mass spectroscopy

Blood and serum N-glycans can be used as markers for cancer diagnosis, as alterations in protein glycosylation are associated with cancer pathogenesis and progression. We aimed to develop a platform for breast cancer (BrC) diagnosis based on serum N-glycan profiles using MALDI-TOF mass spectroscopy. Serum N-glycans from BrC patients and healthy volunteers were evaluated using NosQuest’s software “NosIDsys.” BrC-associated “NosID” N-glycan biomarkers were selected based on abundance and NosIDsys analysis, and their diagnostic potential was determined using NosIDsys and receiver operating characteristic curves. Results showed an efficient pattern recognition of invasive ductal carcinoma patients, with very high diagnostic performance [area under the curve (AUC): 0.93 and 95% confidence interval (CI): 0.917–0.947]. We achieved effective stage-specific differentiation of BrC patients from healthy controls with 82.3% specificity, 84.1% sensitivity, and 82.8% accuracy for stage 1 BrC and recognized hormone receptor-2 and lymph node invasion subtypes based on N-glycan profiles. Our novel technique supplements conventional diagnostic strategies for BrC detection and can be developed as an independent platform for BrC screening.

Male axillary accessory breast cancer: A case report

RATIONALE

Accessory breast cancer is extremely rare among all cancerous diseases, especially in male patients. There were only few male axillary accessory breast cancer cases that have been reported in scientific literatures so far. Hereby, we would like to discuss a case of male axillary accessory breast cancer found in our hospital.

PATIENT CONCERNS

We report a male senile patient suffering from a painful, enlarged, and hardened right axillary mass for more than 20 years. He came for further treatments due to progressive growth of the mass for 11 months with bloody ulceration for more than 1 month.

DIAGNOSIS

Pathological examination manifested a grade II infiltrating ductal carcinoma derived from the accessory mammary gland (right axilla), with invasion of local skin. Immunohistochemical examination result: estrogen receptor (++) 90%, progesterone receptor (+++) 100%, human epidermal growth factor receptor-2 (1+), ki67 (20% positive), prostate specific antigen (-), caudal-related homeobox-2 (-), thyroid transcription factor-1 (-), Synaptophysin (+), NapsinA (1), and CK7 (-).

INTERVENTIONS

Modified radical mastectomy and axillary lymph nodes clearance were performed on the accessary breast cancer under general anesthesia. Postoperatively, endocrine therapy was provided for the patient, orally-taken Letrozole was recommended for the rest of the patient's life.

OUTCOMES

The patient recovered uneventfully and was discharged 3 days after the operation. The patient continued to take Letrozole orally regularly at home and no signs of recurrence were observed.

CONCLUSION

Axillary accessory breast cancer in males is extremely rare, with no conspicuous and typical clinical presentations, which leads to inevitable neglect by clinicians. Therefore, there is significant necessity for clinicians to be cautious with this type of disease.

Computer-assisted Diagnosis of Breast Cancer by Cell Network Matrix Extraction and Multilayer Perceptron Analysis

OBJECTIVE

Diagnosis of breast cancer is based on identification of various morphologic features by histopathologic examination of the specimen. Ancillary immunohistochemical and molecular analyses provide additional information that is prognostic and guides therapy. Because of subjectivity in this approach, we sought to develop a computer model which could assist in differentiating normal or benign tissue from malignant breast carcinoma.

METHODS

Cases of benign sclerosing adenosis (20) and high-grade invasive ductal carcinomas (20) of breast were retrieved and re-examined. Five images of the diagnostic areas from each case were captured (400x). Each image was divided into quadrants and saved as 1-megapixel each. These 800 images were then binarized and segmented using the watershed method. The cell graphs were extracted to identify the matrix of adjacent cells and the network properties were determined for each image. The local network features were fed into a PAM model and global network features were fed into a multilayer perceptrons (MLP) to distinguish between benign and malignant samples. These characteristics were evaluated by training the models on 40% (320) of the randomly assigned images followed by real-time testing of the remaining 60% (480) images. In addition, normal breast tissue from five cases was retrieved and forty (40) images were captured to further test the model.

RESULTS

Both local and global network feature models had high area under the curve (AUC) (0.63 and 0.99 respectively), with their adjusted Rand indices (ARI) being 0.61 and 0.87, respectively. Pooling the pseudoprobabilities of the two neural networks greatly increased the accuracy of the model with predictions of the combined model at image level being 100% accurate with AUC of 1.

CONCLUSION

This study shows that using a combination of cell-graph extraction and a deep learning algorithm computers can accurately distinguish between benign and malignant breast lesions.

STAT3 expression is correlated with pathological stage in luminal subtypes of breast carcinoma

AIM

STATs and HIFs in human solid tumors play an important role in mechanisms of tumor growth. The aim of this study was to determine the prognostic role of STATs and HIFs in breast cancers.

METHODS

Twenty‑four breast carcinoma cases who underwent mastectomy and axillary dissection were included into the study. The presence of STATs and HIFs in 24 breast cancer cases was evaluated immunohistochemically. We evaluated the differences in tumor grade, diameter, limits, intratumor desmoplasia, inflammatory infiltration, necrosis, axillary lymph node involvement, estrogen, progesterone and CerbB2 staining.

RESULTS

In this study, the presence of STATs and HIFs expressions in breast tumors is shown. In our study, no statistically significant correlation was found between tumor grade, diameter, limits, intratumor desmoplasia, inflammatory infiltration, necrosis, axillary lymph node involvement, CerbB2 staining status and STATs and HIFs expressions. However, STAT5a and estrogen staining and HIF2α and progesterone staining were found statistically significant. In addition, STAT3 expression was found to have significantly higher correlation with luminal breast cancer.

CONCLUSIONS

The findings suggest that STATs and HIFs may play a role in the development of invasive ductal carcinomas; concerning their future use as treatment options due to their association with hormone receptors, new studies are required (Tab. 6, Fig. 7, Ref. 65).

Internal Mammary Sentinel Lymph Node Biopsy in Clinically Axillary Lymph Node-Positive Breast Cancer: Diagnosis and Implications for Patient Management

BACKGROUND

Routine performance of internal mammary sentinel lymph node biopsy (IM-SLNB) remains a subject of debate due to no clinical relevance in breast cancer, because it was performed only in clinically axillary lymph node (ALN)-negative patients. In this study, IM-SLNB was performed in clinically ALN-positive patients, and its impact on nodal staging and therapeutic strategy were subsequently analyzed.

METHODS

Clinically ALN-positive patients who underwent IM-SLNB were enrolled in this prospective study. Statistical analysis was performed using Chi square test, Mann-Whitney U and logistic regression models with a significance level of 0.05.

RESULTS

Among the 352 recruited patients, the internal mammary sentinel lymph node (IMSLN) visualization rate of patients who received initial surgery and neoadjuvant systemic therapy (NST) was 71.9% (123/171) and 33.1% (60/181), respectively. The 183 patients who underwent IM-SLNB successfully had the average time duration of 7 min and the median IMSLN number of 2. There were 87 positive IMSLNs in all the 347 removed IMSLNs, which were mainly concentrated in the second (50.6%) and third (34.5%) intercostal space. The IMSLN metastasis rate was 39.8% (initial surgery) and 13.3% (NST), respectively. All of the 183 IM-SLNB patients received more accurate nodal staging, 57 of whom had stage elevated, which might have prompted modifications to the therapeutic strategy.

CONCLUSIONS

IM-SLNB should be routinely performed in clinically ALN-positive patients, and thus more accurate nodal staging and perfect pathologic complete response definition could be put forward. The identification of IMLN metastases by IM-SLNB might potentially influence therapeutic strategies.

The Role of Sentinel Lymph Node Biopsy in Patients With B5c Breast Cancer Diagnosis

BACKGROUND/AIM

The histopathological assessment of the B5c category may sometimes be hampered by simple artifacts that may lead to over- or underestimation of that particular breast cancer so that its management is still controversial, especially with regard to the decision to proceed immediately to sentinel lymph node (SLN) biopsy. Hence, a retrospective study was performed in 174 patients undergoing breast-conserving surgery with a preoperative diagnosis of B5c in order to assess the usefulness of axillary node staging by means of SLN biopsy.

PATIENTS AND METHODS

Pre- and post-operative parameters including imaging data, histology of the primary tumor and SLN biopsy, biological prognostic factors, type of operation, and adjuvant regimens were computed.

RESULTS

Invasive carcinoma and carcinoma in situ were diagnosed in 46 (26.5%) and 128 patients (73.5%), respectively. Preoperative tumor size was significantly related to post-operative diagnosis of invasive carcinoma (p=0.020), retaining its predictive value at logistic regression analysis (p=0.046). Post-operative predictive factors of invasion were represented by tumor stage (p=0.008) and grading (p=0.008).

CONCLUSION

B5c preoperative diagnosis in patients undergoing breast conservative surgery would suggest an immediate wide local excision avoiding any further preoperative histologic assessment. Conversely, one-stage SLN biopsy might be suggested for patients eligible to mastectomy, similar to patients with carcinoma in situ, although its impact on the therapeutic and prognostic assessment seems negligible.

Statistical modelling of HER2-positivity in breast cancer: Final analyses from two large, multicentre, non-interventional studies in Germany

Background

The German NIU HER2 model was developed based on five variables found to have statistically significant influences on HER2-positivity, to allow exploration of deviations between model-predicted and actual HER2-positivity rates as a measure of testing quality. The prospective, non-interventional EPI HER2 BC study (NCT02666261) compared NIU and EPI data, aiming to validate the NIU model.

Methods

HER2 status and patient-/tumour-related information were collected from eligible patients with invasive breast cancer. The influence of variables on HER2-positivity was compared between studies and the NIU model validated using EPI data with cut-off and variable coefficients from the NIU study. The influences of additional variables, centre effects and laboratory-specific parameters were also explored.

Results

The study included 14,729 EPI and 15,281 NIU samples; HER2-positivity rates were comparable (13.5% versus 14.2%). The five covariates from NIU were shown to significantly affect HER2-positivity using EPI data. The Youden Index for the NIU model refitted to EPI data (0.3632) and the NIU model for prediction of HER2-positivity in EPI (0.3552) was close to that for the NIU model fitted to NIU data (0.3888), validating the NIU model. Replacing hormone receptor status with progesterone and oestrogen receptor expression, and adding method of sample extraction as a variable improved the model’s predictive strength (ROC AUC 0.7402; Youden Index 0.3935).

Conclusions

Reliable, high-quality HER2-testing methods are essential for selection of patients with HER2-positive breast cancer for HER2-tageted treatment. Integration of our model into a locally used software or website may improve its viability for use in clinical practice.

•

Five covariates significantly influenced HER2-positivity in the NIU study.

•

The same five covariates also influenced HER2-positivity in the EPI study.

•

The NIU HER2 model was successfully validated using the EPI study data.

•

Integration of novel variables into the EPI model improved the predictive strength.

Breast Cancer, Version 4.2017, NCCN Clinical Practice Guidelines in Oncology

Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions in the breast ducts. The goal for management of DCIS is to prevent the development of invasive breast cancer. This manuscript focuses on the NCCN Guidelines Panel recommendations for the workup, primary treatment, risk reduction strategies, and surveillance specific to DCIS.

Diagnosis and Treatment of Breast Cancer in Men

Breast cancer occurs in about 1% of men, but the number of men receiving a diagnosis is increasing. Data on male breast cancer (MBC) is limited, and treatment for men is based primarily on treatments used for women. However, some argue that breast cancer in men is a different disease than breast cancer in women. Multiple risk factors, including those with genetic and environmental origins, affect the likelihood of men receiving a breast cancer diagnosis. This article discusses types of MBC, risk factors, treatment options, and ethical concerns men encounter after they receive a breast cancer diagnosis.

The NCCN Criterion "Young Age at Onset" Alone is Not an Indicator of Hereditary Breast Cancer in Iranian Population

Because the contribution of genetic factors to the burden of breast cancer is not well investigated in Iran, we aimed to examine the prevalence of mutations in breast cancer susceptibility genes, BRCA1/2 and PALB2, and to investigate the predictive potential of hereditary breast cancer risk criteria for genetic testing in Iranian population. Next-generation sequencing was conducted on a population consisting of 299 and 125 patients with breast cancer, with and without hereditary cancer risk criteria for genetic testing, respectively. The pathogenic mutation frequency rate was 10.7% in patients with hereditary cancer criteria versus 1.6% in no criteria group (P = 0.0017). None of the 107 tested patients with only young age at onset (<40) criterion had a pathogenic mutation. Patients who had only a single heritable risk criterion [OR, 6.15; 95% confidence interval (CI), 1.26-58.59; P = 0.009] and patients with multiple heritable risk criteria (OR, 22.5; 95% CI, 5.19-201.31; P < 0.0001) had higher probabilities of carrying a mutation compared with no criteria group. Our results showed that young age at onset alone is not an indicator of hereditary breast cancer at least in the Iranian population. This is while women with multiple hereditary breast cancer risk criteria were enriched for BRCA1/2 mutations. Given such high risk of identification of a disease-causing mutation, multiple hereditary criteria should be regarded as a strong predictor for a hereditary breast cancer syndrome. These findings are important concerning the optimization of genetic counseling and furthermore establishing criteria for BRCA1/2 testing of the Iranian population.

Long-term excess risk of breast cancer after a single breast density measurement

AIM

Breast density is a risk factor for breast cancer. As density changes across a woman's life span, we studied for how long a single density measurement taken in (post-)menopausal women remains informative.

METHODS

We used data from Singaporean women who underwent a single mammography screen at age 50-64 years. For each case with breast cancer diagnosed at screening or in the subsequent 10 years, whether screen detected or diagnosed following symptoms, two age-matched controls were selected. We studied the excess risk of breast cancer, calculated as an odds ratio (OR) with conditional logistic regression and adjusted for body mass index, associated with 26-50% and with 51-100% density compared with ≤25% density by time since screening.

RESULTS

In total, 490 women had breast cancer, of which 361 were diagnosed because of symptoms after screening. Women with 51-100% breast density had an excess risk of breast cancer that did not seem to attenuate with time. In 1-3 years after screening, the OR was 2.22 (95% confidence interval [CI]: 1.07-4.61); in 4-6 years after screening, the OR was 4.09 (95% CI: 2.21-7.58), and in 7-10 years after screening, the OR was 5.35 (95% CI: 2.57-11.15). Excess risk with a stable OR of about 2 was also observed for women with 26-50% breast density. These patterns were robust when the analyses were limited to post-menopausal women, non-users of hormonal replacement therapy and after stratification by age at density measurement.

CONCLUSION

A single breast density measurement identifies women with an excess risk of breast cancer during at least the subsequent 10 years.

Novel chemometrics‑assisted spectroscopic methods for diagnosis and monitoring of invasive ductal carcinoma in breast tissue

OBJECTIVES

Early diagnosis of breast cancer is extremely important because it is the most common female cancer and a leading cause of cancer death in adult women. In this study, it is aimed to create Raman mapping with developed chemometrics‑assisted Raman and FT-IR spectroscopy methods for the diagnosis of invasive ductal carcinoma (IDC) in breast tissue samples.

METHODS

Samples were deparaffinized and 20‑micron layers of each tissue were located on a coverslip. Mapping of both healthy and cancerous tissues were performed by exposing them to Raman laser at 532 and 758 nm while excitation was recorded at wavenumbers in range of 100-4,000 cm-1. Orthogonal partial least square (OPLS) algorithm was applied to evaluate obtained Raman spectra. Latent variable was selected to explain the whole model.

RESULTS

Healthy and IDC tissues were accurately and precisely clustered with Raman mapping and obtained results were compared to those obtained by means of histopathology and FT-IR methods. It is claimed that the proposed method has a great potential in clustering and separating IDC tissues from the healthy ones.

CONCLUSION

This novel, rapid, precise, easy and objective diagnosis method may be an alternative to conventional diagnostic methods for IDC in breast tissue (Fig. 5, Ref. 22).

DSCAM-AS1 up-regulation in invasive ductal carcinoma of breast and assessment of its potential as a diagnostic biomarker

BACKGROUND

The long non-coding RNA (lncRNA) DSCAM-AS1 has been demonstrated to participate in the pathogenesis of breast cancer and tamoxifen resistance.

OBJECTIVE

To evaluate expression profile of DSCAM-AS1 in invasive ductal carcinoma of breast and its suitability as a biomarker for diagnosis of breast cancer.

METHODS

We evaluated expression of DSCAM-AS1 in 108 breast tissues including tumoral and adjacent non-cancerous tissues (ANCTs) by means of quantitative real time PCR.

RESULTS

DSCAM-AS1 was up-regulated in tumoral tissues compared with ANCTs (Fold change = 2.86, P = 0.011). Its expression was significantly higher in patients aged less than 55 compared with older patients (P = 0.02). However, its expression levels had not a good performance as a diagnostic biomarker for breast cancer.

CONCLUSIONS

The significant up-regulation of DSCAM-AS1 in tumoral tissues compared with ANCTs provides further evidences for participation of this lncRNA in the pathogenesis of breast cancer.

Misconceptions surrounding pregnancy-associated breast cancer

This case report describes a 31-year-old woman who presented with a right painless breast lump. A mammogram and ultrasound scan showed the lump was suspicious of cancer. Core biopsy and immunohistochemistry of the lump confirmed a triple negative, poorly differentiated, invasive ductal carcinoma of the right breast. One week following her diagnosis, the patient found out she was pregnant. The patient was worried about what the implications this diagnosis would have on both her baby and her own cancer treatment.

Mixed Invasive Ductal and Lobular Carcinoma of the Breast: Prognosis and the Importance of Histologic Grade

BACKGROUND

The diagnosis of mixed invasive ductal and lobular carcinoma (IDC-L) in clinical practice is often associated with uncertainty related to its prognosis and response to systemic therapies. With the increasing recognition of invasive lobular carcinoma (ILC) as a distinct disease subtype, questions surrounding IDC-L become even more relevant. In this study, we took advantage of a detailed clinical database to compare IDC-L and ILC regarding clinicopathologic and treatment characteristics, prognostic power of histologic grade, and survival outcomes.

MATERIALS AND METHODS

In this retrospective cohort study, we identified 811 patients diagnosed with early-stage breast cancer with IDC-L or ILC. Descriptive statistics were performed to compare baseline clinicopathologic characteristics and treatments. Survival rates were subsequently analyzed using the Kaplan-Meier method and compared using the Cox proportional hazards model.

RESULTS

Patients with ILC had more commonly multifocal disease, low to intermediate histologic grade, and HER2-negative disease. Histologic grade was prognostic for patients with IDC-L but had no significant discriminatory power in patients with ILC. Among postmenopausal women, those with IDC-L had significantly better outcomes when compared with those with ILC: disease-free survival (DFS) and overall survival (OS; adjusted hazard ratio [HR], 0.54; 95% confidence interval [CI] 0.31-0.95). Finally, postmenopausal women treated with an aromatase inhibitor had more favorable DFS and OS than those treated with tamoxifen only (OS adjusted HR, 0.50; 95% CI, 0.29-0.87), which was similar for both histologic types (p = .212).

CONCLUSION

IDC-L tumors have a better prognosis than ILC tumors, particularly among postmenopausal women. Histologic grade is an important prognostic factor in IDC-L but not in ILC.

IMPLICATIONS FOR PRACTICE

This study compared mixed invasive ductal and lobular carcinoma (IDC-L) with invasive lobular carcinomas (ILCs) to assess the overall prognosis, the prognostic role of histologic grade, and response to systemic therapy. It was found that patients with IDC-L tumors have a better prognosis than ILC, particularly among postmenopausal women, which may impact follow-up strategies. Moreover, although histologic grade failed to stratify the risk of ILC, it showed an important prognostic power in IDC-L, thus highlighting its clinical utility to guide treatment decisions of IDC-L. Finally, the disease-free survival advantage of adjuvant aromatase inhibitors over tamoxifen in ILC was consistent in IDC-L.

[A Case of Invasive Ductal Carcinoma with Paget's Disease of the Breast]

Paget's disease of the breast is usually localized in the nipple epidermis and lactiferous duct located near the nipple. Here, we report a rare case of synchronous breast carcinoma with Paget's disease and invasive ductal carcinoma. A 50-year-old woman was admitted to our hospital because of abnormalities in screening mammography findings. Ultrasonography(US) findings showed a 2.4×1.3×1.6 cm sized hypoechoic lesion in a region of the left mammary gland. Computed tomography (CT)findings did not reveal distant metastasis. Magnetic resonance imaging(MRI)revealed an approximately 2.2 cm sized irregular tumor. The pretreatment diagnosis was left non-invasive ductal carcinoma(cTisN0M0, Stage 0), and surgery was performed. The tumor was found in the range of 40.2×15.0 mm, many of which were breast ductal growth. An infiltrated image was confirmed at multiple sites, but the maximum size was 2.5×1.5 mm. Pathological findings of the main lesion revealed papillotubular carcinoma. Agglomeration of heterotypic cells with abundant cytoplasm was observed in the epidermis of the papilla. The final diagnosis was invasive breast cancer(pT1aN3M0, Stage Ⅲc, Luminal HER2)coexisting with Paget's disease.

[A Case of Neuroendocrine Carcinoma with Long-Term Abnormal Nipple Discharge]

We diagnosed invasive breast ductal cancer in a 42-year-old woman. About 10 years previously, she noticed an abnormal nipple discharge, and core needle biopsy indicated intraductal papilloma of the breast. However, the secretion continued, and we performed core needle biopsy again, which suggested invasive breast ductal cancer. Ultrasonography showed a hypoechoic tumor and an irregular low echo area. Breast MRI showed cystography tuberculum in the whole left breast. Pathological findings indicated solid papillary carcinoma with neuroendocrine differentiation, T2N0M0, stage ⅡA, ER(+), PgR(+), HER2 0. In this case, although needle biopsy was performed, the patient's long-term course provided key insights into the diagnosis. Moreover, the long-term bloody discharge from the nipple was a pathognomonic finding of intraneural secretory breast cancer, and it seemed important to take this morbus into consideration and follow-up on it.

[A Case of Breast Cancer with Metastatic Nodules in Additionally Resected Specimens]

A 68-year-old woman who had leftbreastcancer (cT2N0M0, cStage ⅡA)underwentbreast -conserving therapy and sentinel lymph node biopsy. Pathological diagnosis of the resected specimen revealed a 60mm cancer lesion including a 50 mm invasive ductal carcinoma with surrounding ductal carcinoma in situ, although the pre-operative MRI suggested a 30mm invasive cancer. The surgical margin was positive with the exposure of ductal carcinoma in situ. Additional resection was performed with a resection margin of 20mm from the head-side stump of the previous surgery. Pathological diagnosis of the additionally resected specimen revealed a 6mm invasive carcinoma with its exposure on the surface of the specimen around the new surgical stump distant from the initial surgical margin, where no remnant cancer was noted. She underwent left mastectomy. Pathological diagnosis further revealed 7mm and 2mm invasive carcinomas in the remnant breast. The preoperative imaging was reviewed retrospectively, and it was found that identifying the nodules in the remnant breast was quite difficult based on the images, including MRI. We report a case of breast cancer with metastatic nodules in additionally resected specimens.

What could be the reasons of late diagnosis of breast cancer in Tunisia?

INTRODUCTION

Breast cancer is often diagnosed at a late stage in Tunisia with long delay in time to consultation and to diagnosis. The aim of the study was to identify explanatory factors to delayed diagnosis.

METHODS

A case control analytical was performed from January 2013 to December 2014 in the department of Medical Oncology in FarhatHachedUniveristy Hospital.Patients with the diagnosis of ductal breast carcinoma were included in the study.Characteristics of a first group of 200 women with locally advanced or metastatic breast cancer (G1)were compared to a second group of 200 patients with early stage (G2).

RESULTS

Median delay in consultation and mean tumor size were significantly more important in group G1 (p<0,001).A low level of schooling, a rural origin, poor socio-economic conditions and no encouragement by the patient relatives do not allow an early diagnosis.Misinterpretation of clinical breast signs was the only explanatory factor related to the system. In multivariate study, a low level of schooling(adjusted OR=2.72; CI 95% [1,65-4,49]), no encouragement by the patient's relatives(adjusted OR=7.86; CI 95% [4,24-14,57])and more than three dependants(adjusted OR=2.49; CI 95% [1,58-3,93]) were the independent factors that could explain the delay in diagnosis.

CONCLUSION

Our study confirm the inverse relationship between socio-economic and scholar level and disease stage. Health education campaigns particularly among women with a low schooling level and of rural origin could reduce time for consultation. Promoting continuing medical education could avoid diagnostic errors.

[Treatment Experience of Palbociclib as a New Checkpoint Inhibitor]

We encountered a case of multiple metastases from breast cancer. The patient was administered palbociclib, which was a new checkpoint inhibitor. The patient received various chemotherapies and endocrine therapies. We observed episode of care, a harm phenomenon, and tolerability. We did not recognize adverse events more severe than Grade 3 during the 6 weeks after initiating palbociclib therapy. Diagnostic imaging showed that the metastatic lesions maintained stable disease during the 6 weeks after initiating palbociclib therapy. This case suggested that palbociclib therapy is useful for patients with metastatic breast cancer.

Correlation of tumor uptake on breast-specific gamma imaging and fluorodeoxyglucose PET/CT with molecular subtypes of breast cancer

Mechanisms of technetium-99m sesta-methoxyisobutylisonitrile (sestamibi) and F-fluorodeoxyglucose (FDG) uptake by tumor are different. The purpose of this study was to investigate the association between the tumor uptake of these 2 tracers in invasive ductal carcinoma and to examine thecorrelation of uptake of each tracer with prognostic factors and tumor molecular subtypes.A total of 96 patients with invasive ductal carcinoma who underwent preoperative breast-specific gamma imaging and FDG positron-emission tomography/computed tomography were retrospectively enrolled. Tumor-to-background ratio (TBR) of sestamibi and maximum standardized uptake value (SUVmax) of FDG were correlated with each other. Each of them was then compared with prognostic factors and molecular subtypes.In all tumors, there was a moderate positive correlation between TBR and SUVmax (r = 0.520, P < .001). Both TBR and SUVmax were significantly correlated with tumor size, incidence of axillary lymph node metastasis, histologic grade, estrogen receptor, progesterone receptor status, and Ki-67.There is a moderate degree of association between TBR of sestamibi and SUVmax of FDG in the invasive breast cancer. Two imaging indexes showed the similar tendency related with prognostic factors and molecular subtypes. While both TBR and SUVmax were significantly different between luminal A and nonluminal A tumors, neither of them had high enough sensitivity or specificity to obviate pathologic and molecular diagnosis.

Metaplastic carcinoma of the breast with mesenchymal differentiation (carcinosarcoma). A unique presentation of an aggressive malignancy and literature review

Metaplastic carcinoma of the breast with mesenchymal differentiation (MCMD), previously known as carcinosarcoma, is a very rare and aggressive tumor that has been recently classified as a subtype of metaplastic breast carcinoma. It accounts for 0.08%-0.2% of all breast cancers, with only a few cases reported in the literature. Histologically, MCMD is characterized by a biphasic pattern of malignant epithelial and sarcomatous components without evidence of a transition zone between the two elements. We herein describe a unique case of metaplastic carcinoma of the breast with chondrosarcomatous differentiation in a postmenopausal woman who presented with a large, rapidly growing, ulcerated, bleeding mass and signs of impending sepsis. Metaplastic breast carcinomas (MBC) are rare and aggressive tumors. They are characterized by larger size, lower rates of axillary node involvement, higher rates of triple negativity and distal metastases, earlier local recurrence and poorer survival compared with classic invasive breast cancer. Because of the rarity of MBC, the optimal treatment has not been well defined. Surgery is the main curative treatment modality since MBC has shown a suboptimal response to standard chemotherapy. Patients with MBC may be appropriate candidates for novel targeted therapies.