Evaluation of factors related to late recurrence--later than 10 years after the initial treatment--in primary breast cancer

Epidemiology of early vs late recurrence among women with early stage estrogen receptor-positive breast cancer in the Pathways Study

BACKGROUND

Relatively little is known about the differences in prognostic factors for early vs late recurrence among women with early stage estrogen receptor-positive breast cancer.

METHODS

We analyzed factors related to early (<5 years) vs late (≥5 years) recurrence in 2992 women with stage I-IIB estrogen receptor-positive breast cancer in the Pathways Study, a prospective cohort of women with breast cancer enrolled between 2006 and 2013, with ascertainment of recurrence and death through December 2021.

RESULTS

After a median follow-up of 13.3 years, 341 (13.8%) women had recurrences, including 181 (53.7%) with late recurrence. Higher stage and grade were associated with recurrence regardless of timing, whereas progesterone receptor negativity was associated with early but not late recurrence. Receipt of endocrine therapy was associated with reduced risk of overall recurrence, but the length of endocrine therapy was not statistically significant in multivariable models. Minoritized racial and ethnic groups, including Asian, Black, and Hispanic women, had higher risk of early but not late recurrence compared to non-Hispanic White women. The trend of higher risk of early recurrence among these groups remained after adjustment for clinical, demographic, and socioeconomic factors but was statistically significant only in Asian women.

CONCLUSIONS

Our study revealed potentially important distinctions for early vs late recurrence, including the associations with progesterone receptor negativity and self-identified race and ethnicity. Possible higher risk of early recurrence among Asian, Black, and Hispanic women provides novel evidence for the existence of disparities in cancer outcomes, even within the breast cancer subtype indicative of generally good prognosis.

Delayed and Synchronous Recurrence of Breast Cancer Metastases in Multiple Organs

The most common sites of breast cancer metastasis include the lymph nodes, bones, lungs, liver, and brain. Gastrointestinal tract metastasis is rarely seen, and hypopharyngeal metastasis is extremely rare. We herein report a case of late distant recurrence of breast cancer and synchronous metastasis to the hypopharynx, stomach, ileum, bones, and lymph nodes almost 24 years after surgery. To our knowledge, this is the first case of synchronous metastasis to the hypopharynx, gastrointestinal tract, and other organs, especially after a long interval following primary mastectomy.

Multianalyte liquid biopsy to aid the diagnostic workup of breast cancer

Breast cancer (BC) affects 1 in every 8 women in the United States and is currently the most prevalent cancer worldwide. Precise staging at diagnosis and prognosis are essential components for the clinical management of BC patients. In this study, we set out to evaluate the feasibility of the high-definition single cell (HDSCA) liquid biopsy (LBx) platform to stratify late-stage BC, early-stage BC, and normal donors using peripheral blood samples. Utilizing 5 biomarkers, we identified rare circulating events with epithelial, mesenchymal, endothelial and hematological origin. We detected a higher level of CTCs in late-stage patients, compared to the early-stage and normal donors. Additionally, we observed more tumor-associated large extracellular vesicles (LEVs) in the early-stage, compared to late-stage and the normal donor groups. Overall, we were able to detect reproducible patterns in the enumeration of rare cells and LEVs of cancer vs. normal donors and early-stage vs. late-stage BC with high accuracy, allowing for robust stratification. Our findings illustrate the feasibility of the LBx assay to provide robust detection of rare circulating events in peripheral blood draws and to stratify late-stage BC, early-stage BC, and normal donor samples.

Interactive exploration of a global clinical network from a large breast cancer cohort

Despite unprecedented amount of information now available in medical records, health data remain underexploited due to their heterogeneity and complexity. Simple charts and hypothesis-driven statistics can no longer apprehend the content of information-rich clinical data. There is, therefore, a clear need for powerful interactive visualization tools enabling medical practitioners to perceive the patterns and insights gained by state-of-the-art machine learning algorithms. Here, we report an interactive graphical interface for use as the front end of a machine learning causal inference server (MIIC), to facilitate the visualization and comprehension by clinicians of relationships between clinically relevant variables. The widespread use of such tools, facilitating the interactive exploration of datasets, is crucial both for data visualization and for the generation of research hypotheses. We demonstrate the utility of the MIIC interactive interface, by exploring the clinical network of a large cohort of breast cancer patients treated with neoadjuvant chemotherapy (NAC). This example highlights, in particular, the direct and indirect links between post-NAC clinical responses and patient survival. The MIIC interactive graphical interface has the potential to help clinicians identify actionable nodes and edges in clinical networks, thereby ultimately improving the patient care pathway.

High SLC20A1 Expression Is Associated With Poor Prognosis for Radiotherapy of Estrogen Receptor-positive Breast Cancer

BACKGROUND/AIM

Radiotherapy is one of the main treatments for estrogen receptor-positive (ER+) breast cancer. However, in some ER+ breast cancer cases, radiotherapy is insufficient to inhibit progression and there is a lack of markers to predict radiotherapy insensitivity. Solute carrier family 20 member 1 (SLC20A1) is a sodium/inorganic phosphate symporter, which has been proposed to be a viable prognostic marker for luminal A and B types of ER+ breast cancer. The present study examined the possibility of SLC20A1 as a novel biomarker for the prediction of radiotherapy efficiency.

PATIENTS AND METHODS

The Molecular Taxonomy of Breast Cancer International Consortium dataset was downloaded from cBioportal and the prognosis of patients with high SLC20A1 expression (SLC20A1 ^high ) was compared with that of patients with low SLC20A1 expression, without or with radiotherapy and tumor stages I, II, and III, using the Kaplan-Meier method and multivariate Cox regression analyses of disease-specific and relapse-free survival.

RESULTS

Patients in the SLC20A1 ^high group with radiotherapy showed poor clinical outcomes in both luminal A and luminal B breast cancers. Furthermore, in luminal A breast cancer at tumor stage I, patients in the SLC20A1 ^high  group with radiotherapy also showed poor clinical outcomes. Therefore, these results suggest that radiotherapy is insufficient for patients in the SLC20A1 ^high group for both luminal A and B types, and especially for the luminal A type at tumor stage I.

CONCLUSION

SLC20A1 can be used as a prognostic marker for the prediction of the efficacy of radiotherapy for luminal A and luminal B breast cancers.

High expression of SLC20A1 is less effective for endocrine therapy and predicts late recurrence in ER-positive breast cancer

Estrogen receptor-positive (ER+) breast cancer intrinsically confers satisfactory clinical outcomes in response to endocrine therapy. However, a significant proportion of patients with ER+ breast cancer do not respond well to this treatment. Therefore, to evaluate the effects of endocrine therapy, there is a need for identification of novel markers that can be used at the time of diagnosis for predicting clinical outcomes, especially for early-stage and late recurrence. Solute carrier family 20 member 1 (SLC20A1) is a sodium/inorganic phosphate symporter that has been proposed to be a viable prognostic marker for the luminal A and luminal B types of ER+ breast cancer. In the present study, we examined the possible association of SLC20A1 expression with tumor staging, endocrine therapy and chemotherapy in the luminal A and luminal B subtypes of breast cancer. In addition, we analyzed the relationship between SLC20A1 expression and late recurrence in patients with luminal A and luminal B breast cancer following endocrine therapy. We showed that patients with higher levels of SLC20A1 expression (SLC20A1^high) exhibited poorer clinical outcomes in those with tumor stage I luminal A breast cancer. In addition, this SLC20A1^high subgroup of patients exhibited less responses to endocrine therapy, specifically in those with the luminal A and luminal B subtypes of breast cancer. However, patients with SLC20A1^high showed good clinical outcomes following chemotherapy. Patients tested to be in the SLC20A1^high group at the time of diagnosis also showed a higher incidence of recurrence compared with those with lower expression levels of SLC20A1, at >15 years for luminal A breast cancer and at 10–15 years for luminal B breast cancer. Therefore, we conclude that SLC20A1^high can be used as a prognostic biomarker for predicting the efficacy of endocrine therapy and late recurrence for ER+ breast cancer.

Comparison of Clinical and Pathological Factors Affecting Early and Late Recurrences in Patients with Operable Breast Cancer

In this study, we aimed to assess clinicopathological factors affecting early and late recurrences in patients with operable breast cancer. Patients with early (≤5 years) and late (>5 years) recurrences were assessed. Prognostic factors for disease-free survival (DFS) were also evaluated in patients with recurrence. A total of 854 patients were included. There were 432 and 205 patients in the early and late recurrence groups, respectively. In multivariate analyses, HER2+ disease, lymph node metastasis, lymphovascular invasion (LVI), and high tumor grade were associated with increased risk of early recurrence, while HER2+ disease and LVI were associated with decreased risk of late recurrence. In multivariate analyses, presence of HER2+ disease and triple-negative breast cancer (TNBC) were poor prognostic factors for DFS in patients with early recurrence. Presence of LVI and perineural invasion (PNI) were poor prognostic factors for DFS in patients with late recurrence. Molecular subtypes and LVI were effective on the early and late recurrences. However, lymph node positivity and grade were only associated with the early recurrence. After 5 years, LVI and PNI were the prognostic factors for DFS.

Very Late Recurrence in Breast Cancer: Is Breast Cancer a Chronic Disease?

Although breast cancer treatments have made great strides in recent decades, there are still many recurrences. Late recurrence is one of the characteristics of breast cancer. Here, we present four cases of recurrence more than 10 years after the initial diagnosis. The time from diagnosis to recurrence was 13 to 20 years in our four cases, which were all estrogen receptor (ER)-positive, and one was also human epidermal growth factor receptor 2-positive. Long-term hormone therapy for 10 years is necessary to prevent late recurrence of breast cancer, but we need to know that late recurrence remains common. Risk factors for late recurrence include ER positivity, progesterone receptor positivity, and low Ki67. The most common sites of recurrence are the lungs/pleura and bones, which was also the case in our experience. It is no exaggeration to say that breast cancer is a chronic disease similar to hypertension and diabetes. This is because breast cancer is not completely cured by surgery alone and lasts for a long time, with patients requiring long-term hormone therapy. Moreover, it can recur even after 10 years or more.

Analysis Predictors of the Outcome of Adjuvant of Hormone Therapy on Estrogen Receptor-positive Breast Cancer in Indonesia

BACKGROUND: An existing study reported variation of the outcome of adjuvant hormone therapy on breast cancer. AIM: This study aimed to examine predictors of the hormone therapy to the outcome of recurrence-free survival (RFS) of estrogen receptor-positive (ER+) breast cancer. METHODS: In this cohort study, we followed up 219 eligible breast cancer patients with ER+ who had hormone therapy in 2017–2018. Age of patients, cancer stage, and various histopathology parameters were collected from the medical records, then we followed up with the patients within 2 years (2019–2020) to assess the RFS outcome. Bivariate analysis was conducted to assess the association between the clinicopathology parameters with RFS outcome. Multivariate analysis with logistic regression was also performed to see the dominant predictor. Mediation path analysis was also performed to determine the estimated effect of a predictor on the level of RFS and to see the visualization of the association of predictors with RFS. RESULTS: Breast cancer RFS was 91.3% within 2 years of hormone therapy. The recurrent rate was only 8.7%, which most of them (68.4%) were local. There was no association of age, lymphovascular invasion (LVI), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status with RFS. Based on the molecular subtype, the RFS was better in luminal A (p = 0.045), and also better gradually in the lower stage (p = 0.001). Multivariate analysis shows that the cancer stage was the dominant predictor of the RFS outcome (p = 0.001) with OR = 4.271 (Exp[B] = 1.937–9.417). Mediation analysis also found that there was a positively associated molecular subtype with RFS through cancer stage mediation (r = 16.7%, p = 0.006) but no statistically significant association of age, LVI, PR, and HER2 status (p > 0.005). CONCLUSION: Cancer stage is the main predictor of RFS of hormone therapy outcome. Luminal A is most also likely to have a better outcome of RFS, especially mediated by the lower stage.

Association of human breast cancer CD44-/CD24- cells with delayed distant metastasis

Tumor metastasis remains the main cause of breast cancer-related deaths, especially delayed breast cancer distant metastasis. The current study assessed the frequency of CD44^-/CD24^- breast cancer cells in 576 tissue specimens for associations with clinicopathological features and metastasis and investigated the underlying molecular mechanisms. The results indicated that higher frequency (≥19.5%) of CD44^-/CD24^- cells was associated with delayed postoperative breast cancer metastasis. Furthermore, CD44^-/CD24^-triple negative breast cancer (TNBC) cells spontaneously converted into CD44⁺/CD24^-cancer stem cells (CSCs) with properties similar to CD44⁺/CD24^-CSCs from primary human breast cancer cells and parental TNBC cells in terms of stemness marker expression, self-renewal, differentiation, tumorigenicity, and lung metastasis in vitro and in NOD/SCID mice. RNA sequencing identified several differentially expressed genes (DEGs) in newly converted CSCs and RHBDL2, one of the DEGs, expression was upregulated. More importantly, RHBDL2 silencing inhibited the YAP1/USP31/NF-κB signaling and attenuated spontaneous CD44^-/CD24^- cell conversion into CSCs and their mammosphere formation. These findings suggest that the frequency of CD44^-/CD24^- tumor cells and RHBDL2 may be valuable for prognosis of delayed breast cancer metastasis, particularly for TNBC.

Disease recurrence and oncological outcome of patients treated surgically with curative intent for estrogen receptor positive, lymph node negative breast cancer

BACKGROUND

The molecular era has identified four breast cancer subtypes. Luminal A breast cancer (LABC) is defined by estrogen-receptor positive (ER+), progesterone-receptor positive (PgR+) and human epidermal growth factor receptor-2 negative (HER2-) tumours; these cancers are the most common and carry favourable prognoses.

AIMS

To describe clinicopathologic features, oncological outcome and relapse patterns in LABC.

METHODS

Consecutive female patients diagnosed with ER/PgR+/HER2-, lymph node negative (LN-) breast cancer between 2005 and 2015 were included. Clinicopathological and recurrence data was recorded using descriptive statistics. Oncological outcome was determined using Kaplan-Meier and Cox-regression analyses.

RESULTS

Analysis was performed for 849 patients with median follow-up of 102.1 months. Mean disease-free (DFS) and overall survival (OS) were 85.8% and 91.8%. Seventy patients died during this study (8.2%), while 58 patients had recurrence; 7 had local recurrence (0.8%) and 51 had distant recurrence (DDR) (6.0%). Patients developing DDR were likely to be postmenopausal (P = 0.028), present symptomatically (P < 0.001) and have larger tumours (P < 0.001). The mean time to DDR was 65.7 months, with fatal recurrence occurring in 66.6% of patients with DDR (34/51). Systemic chemotherapy prescription did not influence DDR (P = 0.053). Age >65 (hazards ratio (HR):1.66, 95% Confidence Interval (CI):1.07-2.55, P = 0.022), presenting symptomatically (HR:2.28, 95%CI:1.21-4.29, P = 0.011) and tumour size >20 mm (HR:1.81, 95%CI:1.25-2.62, P = 0.002) predicted DFS, while age>65 (HR:2.60, 95%CI:1.49-4.53, P = 0.001) and being postmenopausal at diagnosis (HR:3.13, 95%CI:1.19-8.22, P = 0.020) predicted OS.

CONCLUSION

Our series demonstrated excellent survival outcomes for patients diagnosed with LN- LABC after almost a decade of follow-up. However, following DDR, fatal progression is often imminent.

Care for Breast Cancer Survivors

The number of cancer survivors is increasing globally. More than 15.5 million Americans in 2016 and 1.3 million Koreans in 2013 were living with cancer history. This growing population is expected to increase due to marked development of cancer treatment and early detection. Especially, breast cancer is the second most common cancer in Korean women with relatively favorable 5-year survival rate. Cancer survivors generally face various physical, psychological, and social problems including late-effect or long-term effect after cancer treatment and high risk for second primary cancer and comorbid chronic diseases such as cardiovascular disease and bone health. Breast cancer survivors also encounter wide range of health problems. To satisfy their complex needs, comprehensive supports are required. We categorized the strategy of comprehensive care for breast cancer survivors into (1) Surveillance for primary cancer, (2) Screening of second primary cancer, (3) Management of comorbid health condition, (4) Promoting healthy lifestyle behaviors, and (5) Preventive care. In the future, studies for providing best comprehensive care for breast cancer survivors are needed according to the individuals' demand.

A Case of Pulmonary Metastasis of Breast Cancer 23 Years after Surgery Accompanied with Non-Tuberculous Mycobacterium Infection

Recurrence of oestrogen receptor (ER)-positive breast cancer rarely occurs postoperatively after a long period. Breast cancer cells survive and settle in distant organs in a dormant state, a phenomenon known as "tumour dormancy." Here, we present a 66-year-old woman with recurrence of ER-positive breast cancer in the left lung 23 years after surgery accompanied with non-tuberculous mycobacterium infection (NTM). At the age of 43 years, the patient underwent a right mastectomy and adjuvant hormonotherapy to completely cure breast cancer. Twenty-three years after the operation, when the patient was 66 years old, computed tomography presented nodular shadows in the lower lobes bilaterally with bronchiectasis and ill-defined satellite tree-in-bud nodules. Mycobacterium intracellulare was detected in cultured bronchoalveolar lavage fluid obtained from the left lower lobe by bronchoscopy. Rifampicin, ethambutol, and clarithromycin were started, which resulted in shrinkage of the nodule in the right lower lobe and satellite nodules; however, the nodule in the left lower lobe increased in size gradually. Wedge resection of the left lower lobe containing the nodule by video-assisted thoracoscopic surgery was performed, which demonstrated that the nodule was adenocarcinoma in intraoperative pathological diagnosis; therefore, a left lower lobectomy and mediastinal lymph node dissection were performed. The tumour was revealed to be consistent with recurrence of previous breast cancer according to its morphology and immunohistochemical staining. Furthermore, caseous epithelioid cell granulomas existed in the periphery of the tumour. It is reported that inflammatory cytokines induce reawakening of dormant oestrogen-dependent breast cancer and, in our case, NTM infection might have stimulated the dormant tumour cells in the lower lobe.

Colorectal and gastric metastases from lobular breast cancer that resembled superficial neoplastic lesions

Breast cancer is the most common malignancy in women and has a risk of late recurrence. We report a case of metastasis to the stomach and colon 23 years after surgery, with characteristic findings. A 74-year-old woman underwent breast cancer resection at the age of 51. At the time, no additional therapy was performed despite the histological diagnosis of invasive lobular carcinoma with lymph node metastasis. Upper gastrointestinal endoscopy, which was performed as a follow-up for her chronic gastritis, revealed multiple erosions. Histology revealed diffuse proliferation of signet ring cell-like atypical cells, that were positive for cytokeratin CAM5.2 and estrogen receptor. These findings suggested metastasis from the invasive lobular breast carcinoma. Positron-emission tomography revealed sternal and vertebral metastases. Colonoscopy also performed to screen for intestinal metastasis revealed several lesions that resembled hyperplastic polyps. Although these lesions were not strongly suspected of metastasis, histology surprisingly revealed the same findings as the gastric metastasis. This case involved gastric and colorectal superficial metastases that were synchronously detected 23 years after primary treatment. We report that early-stage colorectal metastasis may resemble hyperplastic polyps, and biopsy should always be considered in patients with a history of breast cancer, regardless of years elapsed since treatment.

Toxicity of extended adjuvant endocrine with aromatase inhibitors in patients with postmenopausal breast cancer: A Systemtic review and Meta-analysis

BACKGROUND

Extended endocrine therapy (EET) with aromatase inhibitors (AIs) therapy can further reduce the risk of recurrence in breast cancer patients. But the conclusion that whether EET with AIs increases the risk of some side effects compared with nonextended endocrine therapy (NEET) is still controversial and not exhaustive.

METHODS

We searched for Randomized controlled trials (RCT) trials published in EMBASE and PubMed between March 2008 and December 2019. Studies comparing the side effects of adjuvant EET with those of NEET were included. The objective was to determine whether EET with AIs increases the risk of side effects compared with NEET.

RESULTS

Overall, 11 trials comprising 24,187 participants were identified. EET with AIs increased the risk of cardiotoxicity [odds ratio (OR) 1.19, 95 % confidence interval (CI) 1.04-1.36; P < 0.05; 438 vs 423], bone pain (OR 1.18, 95 % CI 1.02-1.36; P < 0.05; 446 vs 404), osteoporosis (OR 1.53, 95 % CI 1.35-1.72; P < 0.05; 866 vs 641), fractures (OR 1.33, 95 % CI 1.18-1.50; P < 0.05; 596 vs 438), arthralgia (OR 1.27, 95 % CI 1.19-1.36; P < 0.05; 2404 vs 2060), myalgia (OR 1.29, 95 % CI 1.16-1.43; P < 0.05; 960 vs 776), and hot flashes (OR 1.40, 95 % CI 1.15-1.69; P < 0.05; 2418 vs 2174) and was associated with opposite risk of vaginal bleeding (OR 0.74, 95 % CI 0.59-0.92; P < 0.05; 148 vs 197). However, the extended therapy did not increase the risk of hypertension (OR 1.03, 95 % CI 0.80-1.33; P = 0.80; 364 vs 353), hypercholesterolemia (OR 1.03, 95 % CI 0.91-1.16; P = 0.62; 643 vs 627), vaginal dryness (OR 1.19, 95 % CI 1.00-1.42; P = 0.05; 294 vs 257), fatigue (OR 1.20, 95 % CI 0.96-1.50; P = 0.12; 1501 vs 1462), dizziness (OR 1.04, 95 % CI 0.92-1.17; P = 0.55; 614 vs 595), headaches (OR 1.06, 95 % CI 0.95-1.18; P = 0.30; 885 vs 848), constipation (OR 0.91, 95 % CI 0.79-1.04; P = 0.15; 480 vs 522), nausea (OR 1.83, 95 % CI 0.49-6.83; P =0.37; 340 vs 325), and dyspnea (OR 0.96, 95 % CI 0.82-1.13; P = 0.64; 340 vs 351). The risk of grade ≥ 3 hot flashes increased following extended endocrine therapy (OR 2.01, 95 % CI 1.23-3.29; P < 0.05; 47 vs 23). We observed no evidence for a difference in the risk of grade ≥3 fatigue, arthralgia, myalgia, bone pain, osteoporosis, fractures, hypertension, and headache between both endocrine therapies. Secondary outcomes shows that after receive EET with AIs, patients can benefit from the control of the local recurrence, distant recurrence, contralateral breast cancer, and second cancers.

CONCLUSIONS

Compared with NEET, EET with AIs significantly increased the risk of cardiotoxicity, bone pain, osteoporosis, fractures, hot flashes, arthralgia, myalgia, and grade ≥3 hot flashes, and EET with AIs can reduced the risks of local recurrence, distant recurrence, contralateral breast cancer, and second cancers. These findings offer an important guide for clinicians and patients.

DGM-CM6: A New Model to Predict Distant Recurrence Risk in Operable Endocrine-Responsive Breast Cancer

To investigate the prognostic value of DGM-CM6 (Distant Genetic Model-Clinical variable Model 6) for endocrine-responsive breast cancer (ERBC) patients, we analyzed 752 operable breast cancer patients treated in a Taiwan cancer center from 2005 to 2014. Among them, 490 ERBC patients (identified by the PAM50 or immunohistochemistry method) were classified by DGM-CM6 into low- and high-risk groups (cutoff <33 and ≥33, respectively). Significant differences were observed between the DGM-CM6 low- and high-risk groups for 10-year distant recurrence-free survival (DRFS) in both lymph node (LN)- (P < 0.05) and LN+ patients (P < 0.05). Multivariate analysis confirmed the independent strength of DGM-CM6 for the prediction of high- vs. low- risk groups for DRFS (P < 0.0001, HR: 6.76, 95% CI, 1.8–25.42) and overall survival (P = 0.01, HR: 6.06, 95% CI:1.55–23.47), respectively. In summary, DGM-CM6 may be used to classify low- and high-risk groups for 10-year distant recurrence in both LN- and LN+ ERBC patients in the Asian population. A large scale clinical trial is warranted.

Case Report: Metastatic breast cancer to the gallbladder

Cholecystitis is one of the leading causes of emergency surgical interventions; the occurrence of metastases to the gallbladder is rare and has only been reported in the literature exceptionally. Metastatic breast cancer to the gallbladder is even less frequent; in fact, breast cancer usually metastasizes to bone, lung, lymph nodes, liver and brain. We report the case of an 83-year-old female patient with a previous history of breast surgery with axillary dissection in 1997, followed by adjuvant chemotherapy due to invasive ductal carcinoma of the left breast. The patient was admitted at the emergency department for sepsis and an episode of acute kidney failure, anuria and fever. Right-upper quadrant abdominal pain triggered by food intake and abdominal tenderness was also present, placing the diagnostic suspicion of biliary sepsis due to acute cholecystitis. The histological examination of the surgical specimen highlighted the presence of metastasis from an infiltrating ductal breast carcinoma with positive hormone receptors. We also report here the results of a review of the literature looking at articles describing cases of gallbladder metastasis from breast cancer.

Early Recurrence of Breast Cancer after the Primary Treatment: Analysis of Clinicopathological and Radiological Predictive Factors

목적

유방암 일차치료 후 조기 재발 예측에 도움이 되는 임상병리학적 인자 및 원발암의 영상 의학적 특징을 알아보고자 하였다.

대상과 방법

본원에서 2010년 1월부터 2014년 12월까지 유방 보존 수술 및 보조요법 치료 후 추적관찰을 받은 480명을 대상으로 하였다. 일차치료 완결 후 3년 이내 재발한 경우를 조기 재발으로 정의하고, 이와 관련된 임상병리학적 및 영상의학적 예측인자를 알아보기 위해 단변량 및 다변량 로지스틱 회귀분석을 시행하였다.

결과

단변량 분석에서 임상병리학적 인자 중 높은 종양 병기(p=0.021), 고등급 조직학적 분화도(p < 0.001), estrogen receptor 수용체 음성(p=0.002), Ki-67 과발현(p=0.017), 삼중음성유방 아형(p=0.019)과, 영상 소견 중 유방암의 다초점성(p < 0.001), 도플러 검사에서 테두리 혈류(p=0.012), 자기공명영상에서 테두리 조영증강(p < 0.001)이 조기 재발과 유의한 연관성을 보였다. 다변량 분석에서 원발암의 높은 종양 병기[odds ratio (이하 OR) = 3.47, 95% confidence interval (이하 CI) 1.12~10.73, p=0.031]와 도플러 검사에서 테두리 혈류 (OR = 3.32, 95% CI 1.38~8.02,p=0.008)가 조기 재발과 관련된 독립적인 예측인자였다.

결론

유방암 치료 전 도플러 검사에서 원발암의 테두리 혈류 소견은 유방암의 일차치료 후 조기 재발의 독립적인 영상의학적 예측인자이다.

Molecular imaging of bone metastases using bone targeted tracers

Molecular imaging using bone targeted tracers has been used in clinical practice for almost fifty years and still plays an essential role in the diagnosis and follow-up of bone metastases. It includes both [99mTc]bisphosphonates for bone scan and [18F]NaF for positron emission tomography/computed tomography (PET/CT) which are very sensitive to detect osteoblastic activity, but it is important to consider several aspects to increase the specificity of reported findings (such as specific tracer characteristics and mechanism of action, patient's clinical history, common metastatic patterns, changes after treatment, limitations of the technique, variations and pitfalls). This will enable useful information for clinical management being provided in the report. Furthermore, iatrogenic skeletal adverse events are common and they should also be identified, as they have impact on patient's quality of life. This review makes a brief summary of the mechanism of action of bone targeted tracers, followed by a discussion of classic patterns of bone metastasis, treatment response assessment and iatrogenic skeletal complications. The value of hybrid imaging techniques with bone targeted tracers, including single photon emission computed tomography and PET/CT is also explored. The final part summarizes new bone targeted tracers with superior imaging characteristics that are being developed, and which may further enhance the applications of radionuclide bone imaging.

Prognostic assessment of breast carcinoma submitted to neoadjuvant chemotherapy with pathological non-complete response

Background

Breast cancer with pathological non-complete response (non-pCR) after neoadjuvant chemotherapy (NAC) has a worse prognosis. Despite Neo-Bioscore has been validated as an independent prognostic model for breast cancer submitted to NAC, non-pCR carcinoma was not assessed in this setting.

Methods

This is a retrospective trial that included women with localized breast cancer who underwent NAC and had non-pCR carcinoma in surgical specimen between 01/01/2013 to 12/31/2015 with a three-year follow-up. Survival analysis was performed by Kaplan-Meier estimator and hazard ratio (HR) set by log-rank test for the primary and secondary endpoints, respectively Disease-Free Survival (DFS) and Overall Survival (OS). According to Neo-Bioscore, the proposed prognostic model named Clustered Neo-Bioscore was classified into low (0–3), low-intermediate (4–5), high-intermediate (6) and high (7) risk. The prognostic accuracy for recurrence risk was assessed by time-dependent receiver operating characteristic (time-ROC) methodology. Multivariate Cox regression assessed the menopausal status, histological grade, Ki-67, estrogen receptor, HER2, tumor subtype, pathological and clinical stages. Confidence interval at 95% (CI95%) and statistical significance at set 2-sided p-value less than 0.05 were adopted.

Results

Among the 310 women enrolled, 267 patients (86.2%) had non-pCR carcinoma presenting size T3/T4 (63.3%), node-positive axilla (74.9%), stage III (62.9%), Ki-67 ≥ 20% (71.9%) and non-luminal A (78.3%). Non-pCR carcinoma presented worse DFS-3y (HR = 3.88, CI95% = 1.18–11.95) but not OS-3y (HR = 2.73, CI95% = 0.66–11.40). Clustered Neo-Bioscore discerned the recurrence risk for non-pCR carcinoma: low (DFS-3y = 0.86; baseline), low-intermediate (DFS-3y = 0.70; HR = 2.61), high-intermediate (DFS-3y = 0.13, HR = 14.05), and high (DFS-3y = not achieved; HR = 22.19). The prognostic accuracy was similar between Clustered Neo-Bioscore and Neo-Bioscore (0.76 vs 0.78, p > 0.05). Triple-negative subtype (HR = 3.6, CI95% = 1.19–10.92) and pathological stages II (HR = 5.35, CI95% = 1.19–24.01) and III (HR = 6.56, CI95% = 1.29–33.32) were prognoses for low-intermediate risk, whereas pathological stage III (HR = 13.0, CI95% = 1.60–106.10) was prognosis for low risk.

Conclusions

Clustered Neo-Bioscore represents a novel prognostic model of non-pCR carcinoma undergoing NAC with a more simplified and appropriate score pattern in the assessment of prognostic factors.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5812-0) contains supplementary material, which is available to authorized users.

HER2-Positive Conversion in a Metastatic Liver Focus in Late Recurrent Breast Cancer

Late recurrence of estrogen receptor (ER) positive breast cancer is common. When tissues from a recurrent or metastatic focus are available, re-evaluation of ER, progesterone receptor (PgR), and human epidermal growth factor receptor 2 (HER2) status is recommended for treatment selection. This case report describes a 59-year-old woman who underwent surgery for left breast cancer, with a histopathological diagnosis of invasive ductal carcinoma (pathological stage T2N1aM0 Stage IIB, ER positive, PgR positive and HER2 negative). A health check-up 16 years after surgery revealed multiple hepatic mass lesions, and the patient was referred to our hospital for tests. Based on computed tomography, intrahepatic bile duct cancer or metastatic hepatic tumors were suspected, and a liver biopsy was performed. The histopathological diagnosis was a poorly differentiated adenocarcinoma (ER negative, PgR negative and HER2 positive), and the distinction from poorly differentiated intrahepatic bile duct cancer was difficult. Fluorodeoxyglucose (FDG)-positron emission tomography revealed FDG accumulation in the patient's bones and soft tissues, in addition to the hepatic tumors. The patterns and finding of metastasis were compatible with breast cancer recurrence, and the patient was diagnosed with postoperative recurrence of left breast cancer. Pertuzumab, trastuzumab, and docetaxel were started, and the therapeutic effect was assessed as a partial response. It was evident that in this case, the expression of hormone receptors and HER2 differed between the primary focus and the recurrence foci, and this contributed to the treatment strategy. Whenever possible, a biopsy should be performed for lesions that are suspected to be distal metastases.

Young Patients with Hormone Receptor-Positive Breast Cancer Have a Higher Long-Term Risk of Breast Cancer Specific Death

Purpose

Although it is widely accepted that hormone receptor (HR) status is associated with later post-diagnostic periods, a debate exists as to whether the association is independent of age. The aim of our study was to confirm the impact of HR status on later period breast cancer-specific death (LP-BCSD) and later period non-breast cancer-specific death (LP-non-BCSD) in different age subgroups.

Methods

Surveillance, Epidemiology, and End Results databases were utilized to identify 181,108 breast cancer patients with > 5 years survival. The cumulative incidence of LP-BCSD and LP-non-BCSD was calculated using the Gray method. The subdistribution hazard ratio (SHR) of variables was estimated via the Fine and Gray proportional hazard regression model. Subgroup analyses for LP-BCSD and LP-non-BCSD were performed according to the HR status.

Results

The risk of LP-BCSD was exceeded by that of LP-non-BCSD at > 5 years since the diagnosis, particularly in old women. The competing risk regression model indicated that hormone receptor-positive (HR+) was an independent factor for more LP-BCSD (hazard ratio, 1.54; 95% confidence interval, 1.44–1.54; p < 0.001). However, stratified analysis indicated that HR+ was only associated with more LP-BCSD in the young women subgroup. Although HR+ was associated with more LP-non-BCSD, the predictive value of HR+ for LP-non-BCSD was eliminated after adjusting for age.

Conclusions

HR+ was related to LP-BCSD in the premenopausal population. LP-BCSD should be an optimal endpoint in future trials designed to evaluate the role of extended adjuvant endocrine therapy.

Prognostic Factors of Local-Regional Recurrence in Patients with Operable Breast Cancer in Asia: A Meta-Analysis

BACKGROUND

Cause of recurrence of breast cancer is multifactorial. Also, the occurrence of breast cancer in Asian patients has some different factors from the recurrence of breast cancer in western countries.

AIM

This study aims to determine the prognostic factors of local-regional recurrence in patients with operable breast cancer in Asia.

METHODS

The authors conducted a meta-analysis of published research articles published in an online database of PubMed, ProQuest and EBSCO between January 2000 and July 2018. Pooled risk ratios (RR) were calculated using fixed and random-effect models. Data were processed by using Review Manager 5.3 (RevMan 5.3).

RESULTS

This study reviewed 879 articles. There were 11 studies conducted a systematic review then continued by meta-analysis of relevant data with total patients involved were 5,213 patients. The prognostic factors found of local-regional recurrence in patients with operable breast cancer were Nodal (N) stage with the highest risk ratio (RR = 6.35 [95% CI 3.78-10.67]) followed by HER2 positive (RR = 2.14 [95% CI 1.16-3.97]), stage of cancer (RR = 1.82 [95% CI 1.44-2.31]), tumor size (RR = 1.55 [95% CI 1.04-2.31]), tumor grade (RR = 1.43 [95% CI 1.23-1.65]), PR status (RR = 0.65 [95% CI 0.48-0.88]) and the least was ER status (RR = 0.60 [95% CI 0.39-0.91]). Homogeneity of variance was found in N stage, tumor size and tumor grade for recurrence of operable breast cancer.

CONCLUSION

This meta-analysis confirmed the correlation of N stage, HER2, stage of cancer, tumour size, tumour grade, ER and PR status with recurrence in patients with operable breast cancer in Asia.

5-Year Survival Rates and Prognostic Factors in Patients with Synchronus and Metachronus Breast Cancer from 2010 to 2015

Introduction:

Currently breast (BC) cancer is a serious medical problem in all countries of the world. Survival depends on many factors. The present study focused on 5-year survival and its related factors in patients with BC in Iran. Material and methods. The present analytical retrospective study was performed (from March 2010 until March 2015) on patients with BC followed for at least 6 months. The main variables assessed were tumor size, grade of lymph node involvement, metastasis, stage, history, human epidermal growth factor receptor expression, and tumor origin. Analysis of survival was accomplished using the Kaplan- Meier method.

Results:

Some 351 (80.2%) of the total of 438 individuals had unilateral and 87(19.8%) had bilateral cancer, 28 (35.6%) of the latter being synchronous and 56(64.4%) metachronous. Mean duration of follow-up was 47.44±28.19 months, during which 61 (17.3%) patients with unilateral and 18 with bilateral cancer eventually died. The 5-year survival rate in patients with unilateral BC was significantly higher than those with bilateral BC (Log-rank Test chi2= 3.11, p=0.032). In addition, with metachronous cases, the survival rate was 64.2% in comparison with 51.6% for synchronous BCs. Survival rate was significantly (p value =0.038) higher with metachronous than with synchronous cancers (Log-rank Test chi2=3.54, p=0.038). The highest survival rate was reported for BCs originating from lobule tissue and the lowest rate examples of interstitial tissue origin (Log-rank Test chi2=11.54, p=0.0001). Patients with earl stage lesions (M1) survived longer than with other stages (Log-rank Test chi2= 9.55, p=0.001).

Conclusion:

In this study, most women with BC had a positive family history and were married. The 5-year survival rate was lower with advanced stages of cancer. According to our findings, survival rates might improve if patients undergo screening and diagnosis is made at an early stage of the disease.

Amyloid Precursor Protein Is Associated with Aggressive Behavior in Nonluminal Breast Cancers

BACKGROUND

β-amyloid precursor protein (APP), a potential target for Alzheimer's disease treatment, has recently been shown to take part in carcinogenesis. Increased APP promotes migration, survival, and proliferation in breast cancer cell lines. We examined the clinical value of APP in breast cancers. A comprehensive examination of clinicopathological features related to APP expression in a large cohort of breast cancers and the corresponding metastatic lymph nodes was performed. APP expression and its prognostic impact in different breast cancer subtypes were examined.

RESULTS

APP was highly expressed in nonluminal breast cancers and correlated with features associated with nonluminal breast cancers (including higher grade, the presence of necrosis, and higher proliferative index, growth factor receptor, and basal marker expression). Multivariate Cox hazard analysis demonstrated that APP was an independent adverse prognostic factor of disease-free survival (DFS; hazard ratio [HR], 2.090; p = .013; 95% confidence interval [CI], 1.165-3.748) and breast cancer-specific survival (BCSS; HR, 2.631; p = .002; 95% CI, 1.408-4.915) in the nonluminal group. The independent prognostic impact was also seen in triple negative breast cancers. Interestingly, a higher expression of APP was found in nodal metastasis compared with primary tumor. Such APP upregulation was correlated with further distal metastasis and poorer outcome (DFS: log-rank, 12.848; p < .001; BCSS: log-rank, 13.947; p < .001).

CONCLUSION

Our findings provided evidence of oncogenic roles of APP in clinical breast cancers. Patients with positive APP expression, particularly those with APP upregulation in lymph node metastases, may require vigilant monitoring of their disease and more aggressive therapy.

IMPLICATIONS FOR PRACTICE

β-amyloid precursor protein (APP), a potential target for Alzheimer's disease, has recently been implicated in oncogenesis. Here, evidence of its roles in clinical breast cancers is provided. Positive APP expression was found to be an independent prognostic factor in nonluminal cancers, particularly triple negative breast cancers (TNBCs). Interestingly, a higher APP in nodal metastases was associated with distal metastases. TNBCs are heterogeneous and currently have no available target therapy. APP could have therapeutic potential and be used to define the more aggressive cases in TNBCs. Current prognostic analysis is based on primary tumor. The present data suggest that investigation of nodal metastases could provide additional prognostic value.

The Clinical Value of PELP1 for Breast Cancer: A Comparison with Multiple Cancers and Analysis in Breast Cancer Subtypes

Purpose

Proline, glutamic acid, and leucine-rich protein 1 (PELP1), a novel nuclear receptor (NR) co-regulator, is highly expressed in breast cancer. We investigated its expression in breast cancer subtypes, in comparison with other breast markers as well as cancers from different sites. Its prognostic relevance with different subtypes and other NR expression was also examined in breast cancers.

Methods

Immunohistochemical analysis was performed on totally 1,944 cancers from six different organs.

Results

PELP1 expression rate was the highest in breast cancers (70.5%) among different cancers. Compared to GATA3, mammaglobin and gross cystic disease fluid protein 15, PELP1 was less sensitive than GATA3 for luminal cancers, but was the most sensitive for non-luminal cancers. PELP1 has low expression rate (<20%) in colorectal cancers, gastric cancers and renal cell carcinomas, but higher in lung cancers (49.1%) and ovarian cancers (42.3%). In breast cancer, PELP1 expression was an independent adverse prognostic factor for non-luminal cancers (disease-free survival [DFS]: hazard ratio [HR], 1.403; p=0.012 and breast cancer specific survival [BCSS]: HR, 1.443; p=0.015). Interestingly, its expression affected the prognostication of androgen receptor (AR). AR^posPELP1^lo luminal cancer showed the best DFS (log-rank=8.563, p=0.036) while AR^negPELP1^hi non-luminal cancers showed the worst DFS (log-rank=9.536, p=0.023).

Conclusion

PELP1 is a sensitive marker for breast cancer, particularly non-luminal cases. However, its considerable expression in lung and ovarian cancers may limit its utility in differential diagnosis in some scenarios. PELP1 expression was associated with poor outcome in non-luminal cancers and modified the prognostic effects of AR, suggesting the potential significance of NR co-regulator in prognostication.

Clinicopathologic features of hormone-receptor-positive breast cancer patients with late recurrence

The number of long-term breast cancer survivors with a risk of late recurrence is increasing. Hormone-receptor-positive patients have greater risks of late recurrence. Although several studies demonstrated that extended adjuvant endocrine therapy reduces the incidence of late recurrence, it remains unclear which hormone-receptor-positive patients have greater risks of late recurrence. Hormone-receptor-positive breast cancer patients were retrospectively selected from the prospective database of primary breast cancer patients treated at Keio University Hospital from January 1989 to December 2003. Late recurrence was defined as initial recurrence after 5 years from the initial surgery. We evaluated the clinicopathologic features of breast cancer patients with late recurrence. At a median follow-up of 10.9 years (range, 5.1-23.8), 371 patients had no recurrence, 90 had early recurrence (within 5 years), and 83 had late recurrence. Multivariate analysis revealed that >4 involved lymph nodes were significant risk factors for late recurrence (P < .001), whereas 1-3 positive nodes were not. Endocrine therapy significantly reduced the incidence of late recurrence (P < .001). After menopause, adjuvant therapy with aromatase inhibitors resulted in longer disease-free survival than tamoxifen (10-year disease-free survival: 97.6% vs 89.7%, P = .0955). High nodal involvement was significantly correlated with late recurrence in hormone-receptor-positive breast cancer patients. Hormone-receptor-positive breast cancer patients who receive adjuvant endocrine therapy with tamoxifen alone might be candidates for extended endocrine therapy.

Epsin Family Member 3 and Ribosome-Related Genes Are Associated with Late Metastasis in Estrogen Receptor-Positive Breast Cancer and Long-Term Survival in Non-Small Cell Lung Cancer Using a Genome-Wide Identification and Validation Strategy

BACKGROUND

In breast cancer, gene signatures that predict the risk of metastasis after surgical tumor resection are mainly indicative of early events. The purpose of this study was to identify genes linked to metastatic recurrence more than three years after surgery.

METHODS

Affymetrix HG U133A and Plus 2.0 array datasets with information on metastasis-free, disease-free or overall survival were accessed via public repositories. Time restricted Cox regression models were used to identify genes associated with metastasis during or after the first three years post-surgery (early- and late-type genes). A sequential validation study design, with two non-adjuvantly treated discovery cohorts (n = 409) and one validation cohort (n = 169) was applied and identified genes were further evaluated in tamoxifen-treated breast cancer patients (n = 923), as well as in patients with non-small cell lung (n = 1779), colon (n = 893) and ovarian (n = 922) cancer.

RESULTS

Ten late- and 243 early-type genes were identified in adjuvantly untreated breast cancer. Adjustment to clinicopathological factors and an established proliferation-related signature markedly reduced the number of early-type genes to 16, whereas nine late-type genes still remained significant. These nine genes were associated with metastasis-free survival (MFS) also in a non-time restricted model, but not in the early period alone, stressing that their prognostic impact was primarily based on MFS more than three years after surgery. Four of the ten late-type genes, the ribosome-related factors EIF4B, RPL5, RPL3, and the tumor angiogenesis modifier EPN3 were significantly associated with MFS in the late period also in a meta-analysis of tamoxifen-treated breast cancer cohorts. In contrast, only one late-type gene (EPN3) showed consistent survival associations in more than one cohort in the other cancer types, being associated with worse outcome in two non-small cell lung cancer cohorts. No late-type gene was validated in ovarian and colon cancer.

CONCLUSIONS

Ribosome-related genes were associated with decreased risk of late metastasis in both adjuvantly untreated and tamoxifen-treated breast cancer patients. In contrast, high expression of epsin (EPN3) was associated with increased risk of late metastasis. This is of clinical relevance considering the well-understood role of epsins in tumor angiogenesis and the ongoing development of epsin antagonizing therapies.

Acute acalculous cholecystitis due to breast cancer metastasis to the cystic duct

BACKGROUND

Acute acalculous cholecystitis (AAC) is a relatively rare disorder of the gallbladder. Breast cancer recurrence more than 10 years after curative surgery is also infrequent.

CASE PRESENTATION

Here, we report a case of a 59-year-old woman who presented with right flank pain. Her medical history included a lumpectomy for cancer of the left breast 12 years prior. Laboratory tests showed a severe inflammatory reaction and mild liver function abnormalities. Ultrasonography and computed tomography revealed an enlarged gallbladder and inflammation of the surrounding tissues; however, no gallstone was present. She was diagnosed with AAC. We performed an emergency laparoscopic cholecystectomy, and histopathological examination revealed a poorly differentiated adenocarcinoma in the cystic duct. Both metastatic and primary tumor cells were positive for estrogen and progesterone receptors on immunohistochemistry. The final pathological diagnosis was acute cholecystitis due to breast cancer metastasis to the cystic duct.

CONCLUSION

Although AAC secondary to metastatic breast cancer is rare, it should be included in the differential diagnosis for abdominal pain in patients with a previous history of breast cancer.

Dynamic contrast-enhanced breast magnetic resonance imaging for the prediction of early and late recurrences in breast cancer

The aim of the study was to evaluate dynamic contrast-enhanced breast magnetic resonance imaging (DCE-MRI) features for the prediction of early and late recurrences in patients with breast cancer.Of 1030 breast cancer patients who underwent surgery at our hospital from January 2007 to July 2011, 83 recurrent breast cancer patients were enrolled in this study. We compared MRI features (background parenchymal enhancement [BPE], internal enhancement, adjacent vessel sign, whole-breast vascularity, initial enhancement pattern, kinetic curve types, and quantitative kinetic parameters) and clinico-pathologic variables (age, stage, histologic grade, nuclear grade, existence of lymphovascular invasion and extensive intraductal carcinoma component, and immunohistochemical profiles) between patients with early (≤2.5 years after surgery) and late recurrence (>2.5 years after surgery). Cox proportional hazard regression analysis was performed to evaluate independent risk factors for early and late recurrence.On breast MRI, prominent ipsilateral whole-breast vascularity was independently associated with early recurrence (hazard ratio [HR], 2.86; 95% confidence intervals [CI], 1.39-5.88) and moderate or marked BPE (HR, 2.08; 95% CI, 1.04-4.18) and rim enhancement (HR, 2.14; 95% CI, 1.00-4.59) were independently associated with late recurrence. Clinico-pathologic variables independently associated with early recurrence included negative estrogen receptor (HR, 0.53; 95% CI, 0.29-0.96), whereas T2 stage (HR, 2.08; 95% CI, 1.04-4.16) and nuclear grade III (HR, 2.54; 95% CI, 1.29-4.98) were associated with late recurrence.In DCE-MRI, prominent ipsilateral whole-breast vascularity, moderate or marked BPE, and rim enhancement could be useful for predicting recurrence timing in patients with breast cancer.

Factors that predict recurrence later than 5 years after initial treatment in operable breast cancer

BACKGROUND

Occasionally, breast cancer relapses more than 5 years after initial treatment, sometimes with highly aggressive disease in such late-recurring patients. This study investigated predictors of recurrence after more than 5 years in operable breast cancer.

METHODS

We retrospectively analyzed data from patients with recurrent breast cancer treated at Siriraj Hospital. Patients were divided into those whose relapse times were longer or shorter than 5 years. Factors that predicted late recurrence were analyzed in both the overall population and the luminal subgroup. Patterns of relapse, changes in biomarkers, and time to disease progression after first relapse were also recorded.

RESULTS

We included 300 women whose breast cancers recurred between 2005 and 2013, of whom 180 had recurrence within 5 years of diagnosis and 120 later than 5 years (median time to recurrence: 45.43 months; range: 4.4-250.3 months). Tumors larger than 2 cm, lymph node metastasis, and high nuclear grade were related with early recurrence. Estrogen receptor-positive, progesterone receptor-positive, and HER2(-) disease predicted late recurrence. Almost all late-relapsing patients with luminal tumors had high estrogen receptor (ER(+)) titers (≥50 %) and HER2(-) disease. Liver and brain were the most common early recurrence sites. Biomarkers did not significantly change by time of recurrence.

CONCLUSIONS

ER(+)/PR(+) and HER2(-) patients have higher risk of recurrence later than 5 years, especially in patients with high ER titer and low nuclear grade. Larger and node-positive tumors had higher risk of early recurrence.

FOXA1 expression affects the proliferation activity of luminal breast cancer stem cell populations

The expression of estrogen receptor is the key in most breast cancers (BC) and binding of estrogen receptor to the genome correlates to Forkhead protein (FOXA1) expression. We herein assessed the correlation between the cancer stem cell (CSC) population and FOXA1 expression in luminal BC. We established luminal BC cells derived from metastatic pleural effusion and analyzed the potency of CSC and related factors with established luminal BC cell lines. We also confirmed that mammosphere cultures have an increased aldehyde dehydrogenase‐positive population, which is one of the CSC markers, compared with adherent culture cells. Using a quantitative PCR analysis, we found that mammosphere forming cells showed a higher expression of FOXA1 and stemness‐related genes compared with adherent culture cells. Furthermore, the growth activity and colony‐forming activity of 4‐hydroxytamoxifen‐treated BC cells were inhibited in a mammosphere assay. Interestingly, 4‐hydroxytamoxifen‐resistant cells had significantly increased FOXA1 gene expression levels. Finally, we established short hairpin RNA of FOXA1 (shFOXA1) MCF‐7 cells and investigated the relationship between self‐renewal potential and FOXA1 expression. As a result, we found no significant difference in the number of mammospheres but decreased colony formation in shFOXA1 MCF‐7 cells compared with control. These results suggest that the expression of FOXA1 appears to be involved in the proliferation of immature BC cells rather than the induction of stemness‐related genes and self‐renewal potency of CSCs.

Evaluation of an Optimal Cut-Off Point for the Ki-67 Index as a Prognostic Factor in Primary Breast Cancer: A Retrospective Study

The Ki-67 index is an important biomarker for indicating the proliferation of cancer cells and is considered to be an effective prognostic factor for breast cancer. However, a standard cut-off point for the Ki-67 index has not yet been established. Therefore, the aim of this retrospective study was to determine an optimal cut-off point in order to establish it as a more accurate prognostic factor. Immunohistochemical analysis of the Ki-67 index was performed on 4329 patients with primary breast cancer from August 1987 to March 2012. Out of this sample, there were 3186 consecutive cases from September 1997 with simultaneous evaluations of ER, PgR and HER2 status. Cox's proportional hazard model was used to perform univariate and multivariate analyses of the factors related to OS. The hazard ratios (HR) and the p values were then compared to determine the optimal cut-off point for the Ki-67 index. The median Ki-67 index value was 20.5% (mean value 26.2%). The univariate analysis revealed that there was a statistically significant negative correlation with DFS and OS and the multivariate analysis revealed that the Ki-67 index value was a significant factor for DFS and OS. The top seven cut-off points were then carefully chosen based on the results of the univariate analysis using the lowest p-values and the highest HR as the main selection criteria. The multivariate analysis of the factors for OS showed that the cut-off point of 20% had the highest HR in all of the cases. However, the cutoff point of 20% was only a significant factor for OS in the Luminal/HER2- subtype. There was no correlation between the Ki-67 index value and OS in any of the other subtypes. These data indicate that the optimal cut-off point of 20% is the most effective prognostic factor for Luminal/HER2- breast cancer.

Survival time according to the year of recurrence and subtype in recurrent breast cancer

BACKGROUND

Survival for patients with recurrent breast cancer has improved over time due to the introduction of modern systemic therapy. The aim of this study was to determine the impact of subtype and the year of recurrence on the survival times of recurrent breast cancer.

METHODS

Between 1979 and 2013, 813 patients who underwent initial treatment for primary breast cancer experienced recurrence. They were divided into two groups based on the year of recurrence; before 2000 and after 2001. Survival after recurrence was compared between these groups based on following criteria; subtypes, disease free interval (DFI), and dominant recurrent site. The median follow-up period after recurrence was 4.3 years.

RESULTS

Survival improved significantly in the after 2001 group, and a significant improvement in survival was only seen in the HER2-enriched subtype. Multivariate analysis revealed that DFI, ER, HER2 status, dominant recurrent site and the Ki-67 index value were significant prognostic factors. In the HER2-enriched subtype, the year of recurrence, DFI and dominant recurrent site were significant independent factors. In the other subtypes, these factors were not correlated with survival.

CONCLUSION

Our study revealed that the survival rate of patients with only the HER2-enriched subtype significantly improved after recurrence. To prolong the survival time after recurrence of both luminal and triple negative subtypes, the development of novel targeting therapies to overcome refractory recurrent breast cancer is extremely important.

A new tumor biomarker, serum protein peak at 3,144 m/z, in patients with node-positive breast cancer

Purpose

To explore the association between the 3,144 m/z protein peak and the clinicopathological features and prognosis in breast cancer.

Methods

Using SELDI–TOF MS, we analyzed serum protein peak at 3,144 m/z in 283 patients with node-positive breast cancer, its relationship with clinicopathological features and their prognosis evaluating value of survival.

Results

3,144 m/z positive rate was higher in elderly patients (42.8 % in ≥50-year-old vs. 31.2 % in <50, P = 0.04). However, no correlation was observed between 3,144 m/z and other clinicopathological features (body mass index, menstrual status, family history, TNM, molecular subtypes, vascular invasion, neural invasion, p53 and CA15-3). However, the positive rate of 3,144 m/z was higher than that of CA15-3 (35.5 vs. 11.4 %, McNemar χ² test, p < 0.001). 3,144 m/z-negative patients (n = 177) had a better 3-year overall survival (OS) than 3,144 m/z-positive patients (n = 106) (89.8 vs. 81.2 %, P = 0.045). Younger patients (P = 0.016), postmenopausal status (P = 0.019), small tumor (P < 0.001), less positive nodes (P < 0.001), early stage (P < 0.001), favorable molecular subtype (P = 0.007), normal CA15-3 (P = 0.003) and neoadjuvant chemotherapy (P = 0.001) predicted better survival. Cox analysis showed that T3–4 (95 % CI 1.419–8.057, P = 0.006), lymph node metastasis (95 % CI 1.242–3.632, P = 0.006) and p53 mutation (95 % CI 1.088–6.378, P = 0.032) were independent adverse prognostic factors. But childbirth ≥2 (95 % CI 0.163–0.986, P = 0.046), adjuvant chemotherapy (95 % CI 0.062–0.921, P = 0.038) and adjuvant radiotherapy (95 % CI 0.148–0.928, P = 0.034) were the independent factors in reducing risk of death in breast cancer patients. Combination testing of 3,144 m/z and CA15-3 will improve the prognosis value of 3-year survival (P = 0.011); patients with CA153−/3144− were characterized by the longest survival (89.8 %) and the CA153+/3144+ patients by the shortest.

Conclusions

Serum protein peak at 3,144 m/z is a new biomarker for breast cancer diagnosis and prognosis and showed a higher positive rate than serum CA15-3. Combining 3,144 m/z and CA15-3 testing may improve prognosis of longer survival in breast cancer patients.

Prognostic significance of the progesterone receptor status in Ki67-high and -low Luminal B-like HER2-negative breast cancers

BACKGROUND

Breast cancer is a heterogeneous disease, and immunohistochemical evaluation is a surrogate marker that is widely used in clinical settings to identify the intrinsic subtypes. The definition of the Luminal B-like breast cancer was changed at the 2013 St. Gallen meeting; therefore, we investigated the clinicopathological features of the new Luminal B-like breast cancer categorized in the latest definition. We also compared the conventional PgR-high Luminal B-like breast cancer with the conventional PgR-low or -negative Luminal B-like breast cancer.

PATIENTS

We investigated 118 Luminal HER2-negative breast cancer patients who were operated in 2005-2008 at a single institution. Data on each patient's medical history were retrieved.

RESULTS

A subset of patients (14.4 %) was categorized as the new Luminal B-like due to low or negative PgR: 58.8 % were histological grade I, 65 % were T1 in tumor size, and half had node involvement. Chemotherapy was performed in half of the cases. Breast cancer-related events were more frequent for the new Luminal B-like breast cancer than for the Luminal A-like breast cancer and were less frequent than for the conventional Luminal B-like breast cancer. Based on multivariate analysis, low or negative expression of PgR and the absence of hormonal therapy were worse prognostic factors. When categorized into two groups by the PgR status, 48.1 % of the conventional Luminal B-like breast cancer was PgR-high; tumor size was smaller, and nodal involvement was less in this group. The rate of adjuvant chemotherapy of the conventional PgR-high Luminal B-like breast cancer was less than that of the conventional PgR-low or -negative Luminal B-like breast cancer. Breast cancer-related events were significantly lower in the conventional PgR-high Luminal B-like breast cancer.

CONCLUSIONS

Our results show the possibility that PgR status has some influence on the prognosis for Luminal HER2-negative breast cancers. Therefore, attention should be paid to the PgR status as well as Ki-67.

Prognostic significance of Ki-67 index value at the primary breast tumor in recurrent breast cancer

The Ki-67 index value is a prognostic factor in primary breast cancer and is a proliferation marker that also distinguishes between luminal type A and type B breast cancer. Moreover, a change in Ki-67 index values due to treatment and recurrence is considered to be important in treating breast cancer. In this study, we investigated whether the baseline Ki-67 value in the primary tumor is useful as a prognostic factor following disease recurrence. Immunohistochemical analysis of the Ki-67 index was performed on 4,701 patients with primary breast cancer from 1987 until March, 2013. Among these patients, there were 666 consecutive cases exhibiting recurrence after primary surgery. The fraction of proliferating cells was based on a count of at least 500 tumor cells in the area including the hot spot. The Ki-67 values were divided into 3 groups, namely <20, ≥20 and ≥50%. The investigated items included estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor 2 (HER2), tumor size, nodal status for the primary tumor, recurrence site (soft tissue, bone and viscera) and disease-free interval (DFI). The Cox's proportional hazard model was used to perform univariate and multivariate analyses of the factors associated with overall survival (OS) following recurrence. The median follow-up period was 65.9 months in the surviving group. The median Ki-67 value at baseline was 20% in all the cases and 27% in the recurrent cases. The Ki-67 values were low (24%) in patients with bone metastasis and significantly higher in patients with liver or brain metastasis (38 and 55%, respectively). Moreover, DFI was found to be inversely correlated with the Ki-67 values. Univariate analysis was performed to identify the prognostic factors for OS after recurrence. The significant factors included tumor size, lymph node status, ER, PgR, DFI, recurrence site and Ki-67 index value. Among these factors, a multivariate analysis identified the Ki-67 index value in the primary tumor as an independent significant factor, particularly in luminal type tumors. The Ki-67 index value in the primary tumor was a significant prognostic factor for OS after disease recurrence. It is, therefore, important to take the Ki-67 index value into consideration for the treatment and follow-up of breast cancer patients.

Umbilical metastasis derived from breast cancer: report of a case

Umbilical metastases mainly arise from malignancies of the digestive and gynecological systems, but rarely from breast cancer. A 64-year-old woman with a history of breast cancer was referred to us for investigation of a painful lesion in the umbilicus. Immunohistochemical staining of a specimen obtained by biopsy from the nodule showed umbilical metastasis of breast cancer. After a work up, she was successfully treated with a combination of surgery and endocrine therapy. We report this case to reinforce that not all periumbilical tumoral deposits are consistent.

Sternal intraosseous schwannoma mimicking breast cancer metastasis

The preoperative diagnosis of intraosseous schwannoma is challenging because of its rarity. We report a resected case of sternal intraosseous schwannnoma mimicking late recurrence of breast cancer.

A 60-year-old Japanese woman with a history of breast cancer was diagnosed as having a sternal tumor by chest computed tomography (CT) demonstrating a round, well-defined, low-density nodule measuring 3.3 × 2.8 cm, which was located almost at the center of the sternum and associated with bone lysis and erosion. [¹⁸ F]Fluorodeoxyglucose positron emission tomography (FDG-PET)/CT demonstrated FDG accumulation in the tumor, suggesting malignancy. Therefore, late isolated recurrence of breast cancer was suspected. Surgical resection was performed for both confirmation of the diagnosis and treatment.

Pathological examination revealed that the tumor was composed predominantly of spindle-shaped cells arranged in a typical palisading pattern, being compatible with schwannoma. Although the periosteum was intact, the tumor was found to have destroyed the cortex of the sternum and proceeded forward to the bone marrow. Additionally, immunohistochemical staining revealed that the lesion was diffusely and strongly positive for S-100 protein. Thus metastasis from breast cancer was ruled out on the basis of the features revealed by microscopy.