Luminal A and luminal B (HER2 negative) subtypes of breast cancer consist of a mixture of tumors with different genotype

A deep learning based holistic diagnosis system for immunohistochemistry interpretation and molecular subtyping

BACKGROUND

Breast cancer in different molecular subtypes, which is determined by the overexpression rates of human epidermal growth factor receptor 2 (HER2), estrogen receptor (ER), progesterone receptor (PR), and Ki67, exhibit distinct symptom characteristics and sensitivity to different treatment. The immunohistochemical method, one of the most common detecting tools for tumour markers, is heavily relied on artificial judgment and in clinical practice, with an inherent limitation in interpreting stability and operating efficiency. Here, a holistic intelligent breast tumour diagnosis system has been developed for tumour-markeromic analysis, combining the automatic interpretation and clinical suggestion.

METHODS

The holistic intelligent breast tumour diagnosis system included two main modules. The interpreting modules were constructed based on convolutional neural network, for comprehensively extracting and analyzing the multi-features of immunostaining. Referring to the clinical classification criteria, the interpreting results were encoded in a low-dimensional feature representation in the subtyping module, to efficiently output a holistic detecting result of the critical tumour-markeromic with diagnosis suggestions on molecular subtypes.

RESULTS

The overexpression rates of HER2, ER, PR, and Ki67, as well as an effective determination of molecular subtypes were successfully obtained by this diagnosis system, with an average sensitivity of 97.6 % and an average specificity of 96.1 %, among those, the sensitivity and specificity for interpreting HER2 were up to 99.8 % and 96.9 %.

CONCLUSION

The holistic intelligent breast tumour diagnosis system shows improved performance in the interpretation of immunohistochemical images over pathologist-level, which can be expected to overcome the limitations of conventional manual interpretation in efficiency, precision, and repeatability.

Clinical characteristics of breast cancer patients admitted to academic surgical wards in Tehran, Iran: an analytical cross-sectional study

BACKGROUND

Breast cancer (BC) is the most commonly diagnosed cancer and the leading cause of cancer death among women. Knowledge of the clinical characteristics of BC in a population may be informative for disease prediction or diagnosis and for developing screening and diagnostic guidelines. This study aimed to evaluate the clinical characteristics of female patients with BC who were admitted to academic surgical wards in Tehran, Iran.

METHODS

In this cross-sectional study, demographic information and clinical characteristics of Iranian females with BC who had undergone breast surgery from 2017-2021 in four academic Breast Surgery Units were extracted from medical files and recorded via a pre-designed checklist.

RESULTS

A total of 1476 patients with a mean age of 48.03 (± 11.46) years were enrolled. Among them, 10.4% were aged less than 35. In younger patients, Triple-negative and Her2-enriched subtypes of BC were significantly higher compared to older ones. Overall, 85.7% of tumors were invasive ductal carcinoma, 43.3% were grade 2, 41.4% were located in the UOQ, and 65.2% had presented with mass palpation. The mean pathologic tumor size was 28.94 mm, and the most common subtype was luminal B.

CONCLUSIONS

Many characteristics of breast cancer in this study were similar to other countries and previous studies in Iran. However, a higher proportion of young BC compared with Western countries, and even with older studies in Iran, suggest a trend toward lower age for BC in recent years. These results indicate the need for preventive measures and screening in Iranian women at a younger age.

The impact of microRNAs on the resistance of breast cancer subtypes to chemotherapy

Breast cancer (BC) formation is primarily influenced by genetics, epigenetics and environmental factors. Aberrant Genetics and epigenetics leads to a condition known as heterogeneity. The heterogeneity of BC can be divided into several subtypes. Among the epigenetic factors, microRNAs (miRNAs) have been shown to play a crucial role in the development and progression of malignancies. These small non-coding RNAs regulate gene expression through a variety of mechanisms, resulting in either mRNA degradation or translation repression. As miRNAs directly control many proteins, genetic anomalies affect tumor metastasis, apoptosis, proliferation, and cell transportation. Consequently, miRNA dysregulations contribute not only in cancer development but also in invasiveness, proliferation rate and more importantly, drug response. Findings mostly indicate subtype-specified identical miRNA profile in BC. Among the BC subtypes, TNBC, HER2 + and luminal are the most resistant to therapy, respectively. Therapy resistance is greatly associated with miRNA expression profile. Hence, concentration of miRNA is the first marker of its role in chemotherapy response. Overexpressed miRNAs may disrupt drug efflux transporters and decrease the drug accumulation in cell. While down-regulated miRNAs which mediate drug resistance processes are mostly correlated with poor treatment response. Moreover, other mechanisms in which miRNAs play crucial roles in chemoresistance such as cell receptor mediations, dysregulation by environmental factors, DNA defects, etc. Recently, several miRNA-based treatments have shown promising results in cancer treatment. Inhibition of up-regulated miRNAs is one of these therapeutic approaches whilst transfecting cell with down-regulated miRNAs also show promising results. Moreover, drug-resistance could also be determined while in the pre-treatment phase via expression levels of miRNAs. Therefore, miRNAs provide intriguing insights and challenges in overcoming chemoresistance. In this article, we have discussed how miRNAs regulate breast cancer subtypes-specific chemoresistance.

Stromal Tumor-Infiltrating Lymphocytes Associated with Immunohistopathology and Molecular Subtypes of Breast Cancer in Vietnam

OBJECTIVE

Breast cancer is a heterogeneous disease with varied symptoms and pathogenesis, as well as variable prognosis and therapeutic outcomes. Stromal tumor-infiltrating lymphocytes, one of the tumor microenvironment factors, has been recognized as an important immunological biomarker that reflected the antitumor immune response in breast cancer.

METHODS

We analyzed 207 invasive breast cancer patients who had lumpectomy or mastectomy and have not received any pre-operative treatment. Clinicopathological characteristics, immunohistochemistry characteristics, molecular subtypes classification and stromal TILs evaluation were investigated.

RESULT

Stromal TILs correlated with well-established prognostic markers. Tumor grade showed significantly higher sTILs percentages in high-grade tumors than in low-grade tumors (p<0.001). There was a statistically significant association between intermediate and high levels of sTILs and a high Ki-67 index (p< 0.001). ER/PR negative was significantly related to high sTILs. Mean sTILs score was significantly higher in TNBC (40.1±31.6%) compared to others, statistically significant (p<0.001). In HER2-negative breast cancer, sTILs were significantly associated with histologic grade, ER status, PR status, and Ki67 index.

CONCLUSION

sTILs played an important role, associated with unfavorable factors in breast cancer. Our findings support the use of stromal sTILs to identify a more aggressive phenotype of tumors.

The Utility of Quantitative Parameters of Shear-Wave Elastography to Predict Prognostic Histologic Features of Breast Cancer

ABSTRACT

In this study, we aimed to investigate the correlation of stiffness values of shear-wave elastography (SWE) and histopathological prognostic factors in patients with breast cancer. Between January 2021 and June 2022, SWE images of 138 core-biopsy proven breast cancer lesions from 132 patients were retrospectively reviewed. Histopathogic prognostic factors, including tumor size, histologic grade, histologic type, hormone receptor positivity, human epidermal growth factor receptor (HER2) status, immunohistochemical subtype and Ki-67 index were documented. Elasticity values including mean and maximum elasticity ( Emean and Emax ) and lesion-to-fat ratio ( Eratio ) were recorded. The association between histopathological prognostic factors and elasticity values were assessed using Mann-Whitney U and Kruskal-Wallis test, and multiple linear regression analysis. Tumor size, histological grade, and Ki-67 index were significantly associated with the Eratio ( P < 0.05). Larger tumor size and higher Ki-67 index also showed significantly higher Emean and Emax values ( P < 0.05). However, hormone receptor positivity, HER2 status, and immunohistochemical subtype were not significantly associated with elasticity values ( P > 0.05). Multivariate logistic regression analysis revealed that tumor size was significantly associated with Emean , Emax , and Eratio values ( P < 0.05). A high Ki-67 index was also significantly associated with high Eratio values. Larger tumor size and higher Ki-67 index are independently associated with high Eratio values. Preoperative SWE may improve the performance of conventional ultrasound in predicting prognosis and treatment planning.

DNA aneuploidy identifies a subset of Luminal subtype breast carcinoma patients with worse clinical outcome

AIM

In breast carcinoma (BC), the relationship between the ploidy pattern and molecular subtyping is still unknown. We aim to investigate the prognostic impact of DNA ploidy within molecular subtypes of a large cohort of BC patients.

METHODS

The series involved 520 BC patients with no neoadjuvant therapy and a median follow-up of 115.5 months. Immunohistochemical assessment of hormonal receptors, ERBB2 (HER2) status and Ki67 proliferative activity was the basis of the surrogate molecular subtyping. Ploidy was evaluated by DNA flow cytometry in fresh/frozen tumour samples. Kaplan-Meier (K-M) survival estimation was used for prognostic statistical analysis.

RESULTS

Luminal A subtype had the lowest prevalence of disease recurrences (23.6 %) and deaths from disease (18.3 %), while Luminal B (42.2 %/37.9 %), Triple-negative (46.4 %/40.6 %), and HER2-positive (55.9 %/50.0 %) subtypes had the highest. The Triple-positive subtype shows an intermediate/low frequency of adverse events (29.4 % of disease recurrences and 17.6 % of deaths from disease). Luminal A tumours were mostly diploid (55.3 %), while Triple-negative and HER2-positive tumours showed a high incidence of aneuploidy (82.6 % and 88.2 %, respectively). Luminal B and Triple-positive tumours had an intermediate percentage of aneuploidy (63.8 % and 70.6 %, respectively). K-M survival curves showed that DNA aneuploidy is significantly associated with shorter disease-free survival and overall survival in Luminal A and Luminal B molecular subtypes.

CONCLUSION

DNA aneuploidy identifies a subset of Luminal BC patients with worse clinical outcome, potentially eligible for more aggressive adjuvant therapy.

Prolonged endocrine therapy in the management of hormone receptor-positive early-stage breast cancer: What is the appropriate duration?

AIM

The clinical benefits associated with 5 years of endocrine therapy in the treatment of hormone receptor-positive, early-stage breast cancer (ESBC) have been well-substantiated. However, numerous studies have reported on the results of extended (i.e., >5 years) endocrine therapy to further effectuate a clinical benefit, with varying outcomes. Hence, the purpose of this study is to review these prolonged investigations and endeavor to clarify their corresponding treatment implications.

METHODS

We reviewed the study findings from several randomized controlled trials and meta-analyses, which incorporated clinical outcomes from pre-and postmenopausal, hormone receptor-positive, ESBC patients.

RESULTS

Hormone receptor-positive, ESBC patients treated with 5 years of endocrine therapy, who are node-negative with tumors <2 cm, will unlikely benefit from five additional years of treatment. Conversely, in women with larger tumors and node-positive disease, 7-8 total years of endocrine therapy may be indicated. Ultimately, clinicians should also consider the attendant side effects from endocrine therapy, namely bone fractures, namely cardiovascular symptoms, and vasomotor symptoms, when considering the appropriate treatment regimen.

CONCLUSIONS

While increased duration of endocrine therapy may selectively accord significant clinical benefits, prior to determining the patient's treatment interval, physicians should also assess the cumulative side effects from endocrine therapy when endeavoring to maintain treatment compliance and bolster quality of life.

DDX43 mRNA expression and protein levels in relation to clinicopathological profile of breast cancer

BACKGROUND

Breast cancer (BC) is the most often diagnosed cancer in women globally. Cancer cells appear to rely heavily on RNA helicases. DDX43 is one of DEAD- box RNA helicase family members. But, the relationship between clinicopathological, prognostic significance in different BC subtypes and DDX43 expression remains unclear. Therefore, the purpose of this study was to assess the clinicopathological significance of DDX43 protein and mRNA expression in different BC subtypes.

MATERIALS AND METHODS

A total of 80 females newly diagnosed with BC and 20 control females that were age-matched were recruited for this study. DDX43 protein levels were measured by ELISA technique. We used a real-time polymerase chain reaction quantification (real-time PCR) to measure the levels of DDX43 mRNA expression. Levels of DDX43 protein and mRNA expression within BC patients had been compared to those of control subjects and correlated with clinicopathological data.

RESULTS

The mean normalized serum levels of DDX43 protein were slightly higher in control than in both benign and malignant groups, but this result was non-significant. The mean normalized level of DDX43 mRNA expression was higher in the control than in both benign and malignant cases, although the results were not statistically significant and marginally significant, respectively. Moreover, the mean normalized level of DDX43 mRNA expression was significantly higher in benign than in malignant cases. In malignant cases, low DDX43 protein expression was linked to higher nuclear grade and invasive duct carcinoma (IDC), whereas high mRNA expression was linked to the aggressive types of breast cancer such as TNBC, higher tumor and nuclear grades.

CONCLUSION

This study explored the potential of using blood DDX43 mRNA expression or protein levels, or both in clinical settings as a marker of disease progression in human breast cancer. DDX43 mRNA expression proposes a less invasive method for discriminating benign from malignant BC.

Prediction of Molecular Subtypes Using Superb Microvascular Imaging and Shear Wave Elastography in Invasive Breast Carcinomas

RATIONALE AND OBJECTIVES

To investigate the efficacy of the advanced imaging methods, superb microvascular imaging (SMI) and shear wave elastography (SWE) in predicting molecular subtypes in invasive breast carcinomas.

MATERIALS AND METHODS

A total of 210 biopsy-proven breast carcinomas in 200 patients who underwent ultrasound (US) imaging with SMI and SWE were included in this study. Quantitative analyses were performed using mean elasticity (E_mean) score by SWE and vascular index (VI) by SMI. For qualitative assessment of microvascularity, first, lesions were graded according to Adler's classification in four types. Then, a new morphological model was used to classify the microvascular architecture into six patterns: type one, no signal; type two, penetrant; type three, rim-like; type four, dot-like/linear/regional; type five, wheel-like and type six, irregular signals. The correlation between these variables and molecular subtypes, nuclear grade, the Ki-67 levels and axillary status was investigated.

RESULTS

The average VI and E_mean values were relatively higher in non-luminal subtypes (VI, p = 0.002; E_mean, p > 0.05). The two microvascularisation models were significantly able to differentiate the molecular subtypes according to the Kruskal Wallis test (p < 0.05). Rim-like, penetrant and regional patterns were primarily observed in luminal subtypes. The dominant pattern in non-luminal subtypes was wheel-like pattern. VI, E_mean, Adler's classification and morphological vascularisation model were not significantly correlated with the nuclear grade, Ki-67 index or axillary status.

CONCLUSION

The proposed microvascular categorization model may be more valuable in predicting molecular subtypes of breast carcinomas compared to VI and E_mean and may contribute to the management of breast carcinomas as a non-invasive variable.

Gene expression profile analysis to discover molecular signatures for early diagnosis and therapies of triple-negative breast cancer

Triple-negative breast cancer (TNBC) is one of the most lethal subtypes of breast cancer (BC), and it accounts for approximately 10%-20% of all invasive BCs diagnosed worldwide. The survival rate of TNBC in stages III and IV is very low, and a large number of patients are diagnosed in these stages. Therefore, the purpose of this study was to identify TNBC-causing molecular signatures and anti-TNBC drug agents for early diagnosis and therapies. Five microarray datasets that contained 304 TNBC and 109 control samples were collected from the Gene Expression Omnibus (GEO) database, and RNA-Seq data with 116 tumor and 124 normal samples were collected from TCGA database to identify differentially expressed genes (DEGs) between TNBC and control samples. A total of 64 DEGs were identified, of which 29 were upregulated and 35 were downregulated, by using the statistical limma R-package. Among them, seven key genes (KGs) were commonly selected from microarray and RNA-Seq data based on the high degree of connectivity through PPI (protein-protein interaction) and module analysis. Out of these seven KGs, six KGs (TOP2A, BIRC5, AURKB, ACTB, ASPM, and BUB1B) were upregulated and one (EGFR) was downregulated. We also investigated their differential expression patterns with different subtypes and progression stages of BC by the independent datasets of RNA-seq profiles from UALCAN database, which indicated that they may be potential biomarkers for early diagnosis. Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses with the proposed DEGs were performed using the online Enrichr database to investigate the pathogenetic processes of TNBC highlighting KGs. Then, we performed gene regulatory network analysis and identified three transcriptional (SOX2, E2F4, and KDM5B) and three post-transcriptional (hsa-mir-1-3p, hsa-mir-124-3p, and hsa-mir-34a-5p) regulators of KGs. Finally, we proposed five KG-guided repurposable drug molecules (imatinib, regorafenib, pazopanib, teniposide, and dexrazoxane) for TNBC through network pharmacology and molecular docking analyses. These drug molecules also showed significant binding performance with some cancer-related PTM-sites (phosphorylation, succinylation, and ubiquitination) of top-ranked four key proteins (EGFR, AURKB, BIRC5, and TOP2A). Therefore, the findings of this computational study may play a vital role in early diagnosis and therapies against TNBC by wet-lab validation.

Differential Cytotoxicity of Curcumin-Loaded Micelles on Human Tumor and Stromal Cells

Although curcumin in the form of nanoparticles has been demonstrated as a potential anti-tumor compound, the impact of curcumin and nanocurcumin in vitro on normal cells and in vivo in animal models is largely unknown. This study evaluated the toxicity of curcumin-loaded micelles in vitro and in vivo on several tumor cell lines, primary stromal cells, and zebrafish embryos. Breast tumor cell line (MCF7) and stromal cells (human umbilical cord vein endothelial cells, human fibroblasts, and human umbilical cord-derived mesenchymal stem cells) were used in this study. A zebrafish embryotoxicity (FET) assay was conducted following the Organisation for Economic Co-operation and Development (OECD) Test 236. Compared to free curcumin, curcumin PM showed higher cytotoxicity to MCF7 cells in both monolayer culture and multicellular tumor spheroids. The curcumin-loaded micelles efficiently penetrated the MCF7 spheroids and induced apoptosis. The nanocurcumin reduced the viability and disturbed the function of stromal cells by suppressing cell migration and tube formation. The micelles demonstrated toxicity to the development of zebrafish embryos. Curcumin-loaded micelles demonstrated toxicity to both tumor and normal primary stromal cells and zebrafish embryos, indicating that the use of nanocurcumin in cancer treatment should be carefully investigated and controlled.

Immunohistochemical Features of Breast Cancer Seen in Women in Kinshasa, Democratic Republic of the Congo: A Six-Year Retrospective Study

Introduction

The molecular classification of breast cancer (BC) based on gene expression and then protein profile has made it possible to distinguish different molecular subtypes. The objective of this study was to describe immunohistochemical features of BC infiltrating women at the Nganda Hospital Center in Kinshasa, Democratic Republic of the Congo (DRC).

Methods

A retrospective study from 2014 to 2019 involved 190 patients with invasive BC who were enrolled at the Nganda Hospital Center. The tumors were analyzed histologically and classified after an immunohistochemical study into subtypes: luminal A, luminal B, HER2-overexpressed, and triple-negative. A chi-square test was performed to assess the relationship between age, histological grade, and these subtypes.

Results

The luminal A subtype (44.74%) was the most common, followed by luminal B (40.53%), triple-negative (10.53%), and HER2-overexpressed (4.20%). The mean age of the patients at diagnosis was 48.27 years. Of all cases, 94.21% were ductal, 2.63% were mucinous, and 2.11% were lobular. They were classified as grade I in 68.82% of the cases, grade II in 28.42% of the cases, and grade III in 3.16% of the cases. There was a significant association between histological grade and breast cancer subtypes (p < 0.0001), but no correlation was found with age (p = 0.467).

Conclusion

In our BC patients, the luminal A was predominant, while HER2-overexpressed was the least found. A strong association was noted between histological grade and molecular subtypes. These results should allow for important clinical and policy implications for BC control in the DRC.

Oral Contraceptive Use and Breast Cancer Risk According to Molecular Subtypes Status: A Systematic Review and Meta-Analysis of Case-Control Studies

We conducted a systematic review and meta-analysis to investigate the effect of oral contraceptives (OCs) on risk of breast cancer (BrCa) by status of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). We searched the MEDLINE (PubMed), Embase and the Cochrane Library database and bibliographies of pertinent articles published up to 2020. Therein, we identified nineteen eligible case-control studies which provided data by breast cancer subtypes: ER-positive (ER+), ER-negative (ER−), HER2-positive (HER2+) and Triplet-negative (TN). Summary risk estimates (pooled OR [pOR]) and 95% confidence intervals (CIs) were calculated using fixed/random effects models. The summary meta-analysis showed that over-use of OCs led to significant increased risk of TNBrCa (OR = 1.37, 95% CI; 1.13 to 1.67, p = 0.002), as well as of ER−BrCa (OR = 1.20, 95% CI: 1.03 to 1.40, p = 0.019). There was also a significant reduction in the risk of ER+BrCa (OR = O.92, 95% CI: 0.86 to 0.99, p = 0.026,) and a slight reduction in the risk of HER2+BrCa (OR = 0.95, 95% CI; 0.79 to 1.14, p = 0.561) after taking OCs. Meta-analysis indicated that OC use has different impacts on risk of breast cancer subtypes defined by receptor status. The identified differences between individual subtypes of breast cancer may reflect different mechanisms of carcinogenesis.

Primary neuroendocrine carcinomas of the breast and neuroendocrine differentiated breast cancers: Relationship between histopathological and radiological features

PURPOSE

The aim of this study wasto investigate whole-breast imaging findings (mammography, ultrasonography (US), magnetic resonance imaging (MRI),clinical, and histopathological findings of primary neuroendocrine carcinomas of the breast (NEC) and neuroendocrine differentiated breast cancers (NEBC).

METHODS

Patients withadiagnosis of breast cancer with histopathological neuroendocrine features between the years 2010 and 2021 were retrospectively screened.The lesions were divided into two main groups depending on staining with neuroendocrine markers (synaptophysin and chromogranin A). Those showing focal staining were categorized as NEBC while those with diffuse staining as NEC.The mammography, US, and MRI of the lesionswere reviewed in consensus by two breast radiologists in order to assess imaging featuresretrospectively according to the Breast Imaging Reporting and Data System (BI-RADS) 5th lexicon.The findings were compared with breast cancers without neuroendocrine features (BC-WNE) which were randomly selected from the same database.

RESULTS

A total of 105 lesions [NEBC (n = 44), NEC(n = 11), BC-WNE (n = 50)] were evaluated.Patients with neuroendocrine tumors were older (p < 0.001) than those with BC-WNE. Compared with BC-WNE tumors, radiological findings typical of malignancy such as irregular shape [NEBC (7/20); NEC(3/7) vs BC-WNE (35/43); p < 0.001], spiculation [NEBC (2/20); NEC(0/7) vs BC-WNE (21/43); p < 0.001], architectural distortion [(NEBC (3/24); NEC(0/9) vs BC-WNE (31/50); p < 0.001)], calcification [(NEBC (6/24), NEC(0/9) vs BC-WNE (n = 27/50); p = 0.001)] on mamography, non-parallel orientation to skin [(NEBC (n = 17/29), NEC(n = 4/9), BC-WNE (n = 35/42); p = 0.008)], acoustic shadowing [(NEBC (n = 12/29), NEC(1/9), BC-WNE (n = 29/42); p = 0.009)], axillary lymphadenopathy [(NEBC(n = 3/30), NEC(n = 1/9), BC-WNE (21/50); p < 0.001)]on US were less common features of the neuroendocrine carcinomas of breast. Aside from shape features, there was no significant difference in contrast pattern (p = 0.866), kinetic curve (p = 0.454) and diffusion restriction (p = 0.242) on MRI.

CONCLUSION

Characteristic malignant imaging features, including irregular shape, spiculated margins, suspicious calcifications, and posterior acoustic shadowing, are uncommon in neuroendocrine carcinomas of breast. These carcinomas tend to show more benign imaging features when compared with BC-WNE.

Assessment of Breast Cancer Immunohistochemical Properties with Demographics and Pathological Features; A Retrospective Study

Background: Breast cancer is considered the most common malignant disease in the female population. It is known as an emerging epidemy with a great burden on women's health, which can be associated with poor outcomes. Some factors including histological type, immunohistochemistry (IHC), tumor grade, and tumor size can have effects on breast cancer. Objectives: This study aimed at assessing the effects of mentioned factors on IHC type of breast cancer. Methods: This retrospective cross-sectional study was conducted on 142 patients, who were referred to one of the referral centers for breast cancer in Mashhad. Information including age, histological type, familial history, menopause status, tumor grade, tumor size, and IHC properties was collected from the patient’s medical records. Allred score was used for reporting hormonal status. The data were analyzed by version 26 of SPSS software. Results: The mean age of patient was 50.2 ± 12.7. The frequency of luminal A and luminal B type was calculated as 29.7 and 18.9%, respectively. In addition, triple-negative IHC type has a prevalence of 24.3% and HER2 had a prevalence of 27%. There were no significant differences between age (P = 0.34), familial history (P = 0.42), menopause (P = 0.36), histological type (invasive: P = 0.11, in situ: P = 0.45), and IHC properties. However, tumor diameter (P = 0.0001) and tumor grading (P = 0.002) had significant association with IHC properties. Conclusions: Factors including tumor size and pathological grade can have effects on the gene expression properties of breast cancers. Luminal IHC type A is more common in breast cancer and is associated with better outcomes. However, age, histological type, familial history, and menopause status had no effects on the IHC properties of breast cancer.

Metastatic hormone receptor-positive breast cancer in CDK 4/6 era: An outcome audit

Background

The treatment landscape of metastatic hormone receptor (HR) positive breast cancer has been changed in recent years. Availability of CDK 4/6 inhibitor and other hormone therapy has changed the treatment algorithm for these patient, we retrospectively analyzed our metastatic HR positive breast cancer patients.

Materials and Methods

In this study, we retrospectively analyzed the case records of hr positive metastatic breast cancer patient treated at department of medical oncology from October 2016 to September 2018. Demographical characteristics, site of metastasis, objective response and clinical benefit response and toxicity profile were analyzed.

Results

We treated a total of 178 patients of MBC with HT at our center during the study period. One hundred fifty-two patients received HT alone (control group) and 26 patients received HT and CDK 4/6 inhibitor (study group). The median age of patients was 56 and 58 years in the control group and study group. The ORR was 41.7 versus 57.9 (95% CI [1.01-2.56]), and the CBR was 66.1% versus 78.9%; (CI [1.18-3.56]) (P < 0.05) of the patients in control and study groups, respectively.

Conclusions

Among patients with HR-positive, advanced breast cancer, hormone therapy is efficacious addition of CDK 4/6 inhibitor improve the efficacy with tolerable side effects.

The structures of E. coli NfsA bound to the antibiotic nitrofurantoin; to 1,4-benzoquinone and to FMN

NfsA is a dimeric flavoprotein that catalyses the reduction in nitroaromatics and quinones by NADPH. This reduction is required for the activity of nitrofuran antibiotics. The crystal structure of free Escherichia coli NfsA and several homologues have been determined previously, but there is no structure of the enzyme with ligands. We present here crystal structures of oxidised E. coli NfsA in the presence of several ligands, including the antibiotic nitrofurantoin. Nitrofurantoin binds with the furan ring, rather than the nitro group that is reduced, near the N5 of the FMN. Molecular dynamics simulations show that this orientation is only favourable in the oxidised enzyme, while potentiometry suggests that little semiquinone is formed in the free protein. This suggests that the reduction occurs by direct hydride transfer from FMNH⁻ to nitrofurantoin bound in the reverse orientation to that in the crystal structure. We present a model of nitrofurantoin bound to reduced NfsA in a viable hydride transfer orientation. The substrate 1,4-benzoquinone and the product hydroquinone are positioned close to the FMN N5 in the respective crystal structures with NfsA, suitable for reaction, but are mobile within the active site. The structure with a second FMN, bound as a ligand, shows that a mobile loop in the free protein forms a phosphate-binding pocket. NfsA is specific for NADPH and a similar conformational change, forming a phosphate-binding pocket, is likely to also occur with the natural cofactor.

Current State of Breast Cancer Diagnosis, Treatment, and Theranostics

Breast cancer is one of the leading causes of cancer-related morbidity and mortality in women worldwide. Early diagnosis and effective treatment of all types of cancers are crucial for a positive prognosis. Patients with small tumor sizes at the time of their diagnosis have a significantly higher survival rate and a significantly reduced probability of the cancer being fatal. Therefore, many novel technologies are being developed for early detection of primary tumors, as well as distant metastases and recurrent disease, for effective breast cancer management. Theranostics has emerged as a new paradigm for the simultaneous diagnosis, imaging, and treatment of cancers. It has the potential to provide timely and improved patient care via personalized therapy. In nanotheranostics, cell-specific targeting moieties, imaging agents, and therapeutic agents can be embedded within a single formulation for effective treatment. In this review, we will highlight the different diagnosis techniques and treatment strategies for breast cancer management and explore recent advances in breast cancer theranostics. Our main focus will be to summarize recent trends and technologies in breast cancer diagnosis and treatment as reported in recent research papers and patents and discuss future perspectives for effective breast cancer therapy.

Expression of CCL2/CCR2 signaling proteins in breast carcinoma cells is associated with invasive progression

Ductal carcinoma in situ (DCIS) is the most common type of pre-invasive breast cancer diagnosed in women. Because the majority of DCIS cases are unlikely to progress to invasive breast cancer, many women are over-treated for DCIS. By understanding the molecular basis of early stage breast cancer progression, we may identify better prognostic factors and design treatments tailored specifically to the predicted outcome of DCIS. Chemokines are small soluble molecules with complex roles in inflammation and cancer progression. Previously, we demonstrated that CCL2/CCR2 chemokine signaling in breast cancer cell lines regulated growth and invasion through p42/44MAPK and SMAD3 dependent mechanisms. Here, we sought to determine the clinical and functional relevance of CCL2/CCR2 signaling proteins to DCIS progression. Through immunostaining analysis of DCIS and IDC tissues, we show that expression of CCL2, CCR2, phospho-SMAD3 and phospho-p42/44MAPK correlate with IDC. Using PDX models and an immortalized hDCIS.01 breast epithelial cell line, we show that breast epithelial cells with high CCR2 and high CCL2 levels form invasive breast lesions that express phospho-SMAD3 and phospho-p42/44MAPK. These studies demonstrate that increased CCL2/CCR2 signaling in breast tissues is associated with DCIS progression, and could be a signature to predict the likelihood of DCIS progression to IDC.

Real-world data of fulvestrant as first-line treatment of postmenopausal women with estrogen receptor-positive metastatic breast cancer

Goals of endocrine therapy for advanced breast cancer (ABC) include prolonging survival rates, maintaining the quality of life, and delaying the initiation of chemotherapy. We evaluated the effectiveness of fulvestrant as first-line in patients with estrogen receptor (ER)-positive ABC with relapse during or after adjuvant anti-estrogenic therapy in real-world settings. Retrospective, observational study involving 171 postmenopausal women with ER-positive ABC who received fulvestrant as first-line between January 2011 and May 2018 in Spanish hospitals. With a median follow-up of 31.4 months, the progression-free survival (PFS) with fulvestrant was 14.6 months. No differences were seen in the visceral metastatic (14.3 months) versus non-visceral (14.6 months) metastatic subgroup for PFS. Overall response rate and clinical benefit rate were 35.2% and 82.8%. Overall survival was 43.1 months. The duration of the clinical benefit was 19.2 months. Patients with ECOG performance status 0 at the start of treatment showed a significant greater clinical benefit rate and overall survival than with ECOG 1–2. Results in real-world settings are in concordance with randomized clinical trials. Fulvestrant continues to demonstrate clinical benefits in real-world settings and appears be well tolerated as first-line for the treatment of postmenopausal women with ER-positive ABC.

Breast cancers, mammary stem cells, and cancer stem cells, characteristics, and hypotheses

The cellular heterogeneity of breast cancers still represents a major therapeutic challenge. The latest genomic studies have classified breast cancers in distinct clusters to inform the therapeutic approaches and predict clinical outcomes. The mammary epithelium is composed of luminal and basal cells, and this seemingly hierarchical organization is dependent on various stem cells and progenitors populating the mammary gland. Some cancer cells are conceptually similar to the stem cells as they can self-renew and generate bulk populations of nontumorigenic cells. Two models have been proposed to explain the cell of origin of breast cancer and involve either the reprogramming of differentiated mammary cells or the dysregulation of mammary stem cells or progenitors. Both hypotheses are not exclusive and imply the accumulation of independent mutational events. Cancer stem cells have been isolated from breast tumors and implicated in the development, metastasis, and recurrence of breast cancers. Recent advances in single-cell sequencing help deciphering the clonal evolution within each breast tumor. Still, few clinical trials have been focused on these specific cancer cell populations.

Genomic Signatures in Luminal Breast Cancer

Background

Breast cancer is a very heterogeneous disease and luminal breast carcinomas represent the hormone receptor-positive tumors among all breast cancer subtypes. In this context, multigene signatures were developed to gain further prognostic and predictive information beyond clinical parameters and traditional immunohistochemical markers.

Summary

For early breast cancer patients these molecular tools can guide clinicians to decide on the extension of endocrine therapy to avoid over- and undertreatment by adjuvant chemotherapy. Beside the predictive and prognostic value, a few genomic tests are also able to provide intrinsic subtype classification. In this review, we compare the most frequently used and commercially available molecular tests (OncotypeDX®, MammaPrint®, Prosigna®, EndoPredict®, and Breast Cancer Index^SM). Moreover, we discuss the clinical utility of molecular profiling for advanced breast cancer of the luminal subtype.

Key Messages

Multigene assays can help to de-escalate systemic therapy in early-stage breast cancer. Only the Oncotype DX® and MammaPrint®test are validated by entirely prospective and randomized phase 3 trials. More clinical evidence is needed to support the use of genomic tests in node-positive disease. Recent developments in high-throughput sequencing technology will provide further insights to understand the heterogeneity of luminal breast cancers in early-stage and metastatic disease.

Biomarker phenotyping drives clinical management in axillary sentinel node: A retrospective study on women with primary breast cancer in 2002

The current study examined if cancer biomarker phenotyping could predict the clinical/pathological status of axillary nodes in women with primary breast cancer. Primary breast cancers from 2002 were analyzed for tumor size, estrogen receptor (ER), progesterone receptor (PgR), Ki-67MIB expression and Her2/neu amplification. Relationships between the clinical and pathological status of the axilla and the biological subtypes classification were analyzed using univariate, multivariate and regression tree analysis. A total of 65% of women with axillary nodes clinically involved had complete axillary node dissection (ALND) while 705 women with clinically negative axillary underwent sentinel lymph node biopsy (SLNB), 18.5% of the latter had at least one pathologically SLNB involved node. Multivariate analysis revealed that the Luminal A subtype was significantly associated (OR 0.62; P<10^-9) with clinical negative axilla while HER2pos/not Luminal was associated with clinical positivity (OR 1.71; P<0.01). No significant association between biological subtypes and SLNB status was demonstrated. Regression tree analysis revealed that subgroups with significantly different probability of SLNB status were separated according to tumor size and PgR values. In conclusion, the current study demonstrated that biomarker breast cancer phenotyping is significantly associated with clinical status of axillary nodes but not with pathological involvement of nodes at SLNB. Regression tree analysis could represent a valid attempt to individualize some patients subgroups candidate to different surgical axilla approaches.

Optimal acquisition time to discriminate between breast cancer subtypes with contrast-enhanced cone-beam CT

PURPOSE

To identify the optimal acquisition time to best discriminate between benign and malignant breast lesions on contrast-enhanced cone beam CT (CE-CBCT) and evaluate the potential of CE-CBCT to differentiate between breast cancer subtypes.

MATERIAL AND METHOD

A total of 98 women with a mean age of 49±10 (SD) years (range: 29-77 years) with 100 BI-RADS 4 or 5 breast lesions were prospectively included. CE-CBCT images were obtained at 1- and 2-min after intravenous administration of iodinated contrast material. Contrast enhancement of breast lesions on CE-CBCT were evaluated and compared between different subtypes. Cut-off values for best discriminating between benign and malignant breast lesions with CE-CBCT were obtained from receiver operating characteristic curves.

RESULTS

Malignant breast lesions showed greater enhancement than benign ones at 1-min (67.28±39.79 [SD] HU vs. 42.27±40.31 [SD] HU, respectively; P=0.007) and 2-min (70.93±38.05 [SD] HU vs. 48.94±41.83 [SD] HU, respectively; P=0.016) after intravenous administration of contrast material. At 1-min after intravenous administration of contrast material, an optimal cut-off value of 54.43 HU was found to best discriminate between malignant and benign breast lesions (AUC=0.681; 95%CI: 0.558-0.805; P=0.006) yielding 69.0% sensitivity (95%CI: 56.9-79.5%) and 69.2% specificity (95% CI: 48.2-85.7%). At 2-min, an optimal cut-off value of 72.65 HU was found to best discriminate between malignant and benign breast lesions (AUC=0.654; 95%CI: 0.535-0.774; P=0.020) yielding 50.7% sensitivity (95%CI: 38.6-62.8%) and 80.8% specificity (95%CI: 60.6-93.4%). CE-CBCT helped differentiate between immunohistochemical subtypes of breast lesions with lowest enhancement for triple negative lesions. No differences in enhancement were found among histopathological subtypes lesions at 1-min (P=0.478) and 2-min (P=0.625).

CONCLUSION

CE-CBCT helps discriminate between malignant and benign breast lesions, with best capabilities obtained at 1-min after intravenous administration of contrast material. For malignant lesions, quantitative analysis of enhancement on CE-CBCT helps differentiate between immunohistochemical subtypes.

Dichotomic effects of clinically used drugs on tumor growth, bone remodeling and pain management

Improvements in the survival of breast cancer patients have led to the emergence of bone health and pain management as key aspects of patient’s quality of life. Here, we used a female rat MRMT-1 model of breast cancer-induced bone pain to compare the effects of three drugs used clinically morphine, nabilone and zoledronate on tumor progression, bone remodeling and pain relief. We found that chronic morphine reduced the mechanical hypersensitivity induced by the proliferation of the luminal B aggressive breast cancer cells in the tumor-bearing femur and prevented spinal neuronal and astrocyte activation. Using MTT cell viability assay and MRI coupled to ¹⁸FDG PET imaging followed by ex vivo 3D µCT, we further demonstrated that morphine did not directly exert tumor growth promoting or inhibiting effects on MRMT-1 cancer cells but induced detrimental effects on bone healing by disturbing the balance between bone formation and breakdown. In sharp contrast, both the FDA-approved bisphosphonate zoledronate and the synthetic cannabinoid nabilone prescribed as antiemetics to patients receiving chemotherapy were effective in limiting the osteolytic bone destruction, thus preserving the bone architecture. The protective effect of nabilone on bone metabolism was further accompanied by a direct inhibition of tumor growth. As opposed to zoledronate, nabilone was however not able to manage bone tumor-induced pain and reactive gliosis. Altogether, our results revealed that morphine, nabilone and zoledronate exert disparate effects on tumor growth, bone metabolism and pain control. These findings also support the use of nabilone as an adjuvant therapy for bone metastases.

Conventional US and 2-D Shear Wave Elastography of Virtual Touch Tissue Imaging Quantification: Correlation with Immunohistochemical Subtypes of Breast Cancer

Our study aimed to investigate the correlation of the imaging features obtained using conventional ultrasound (US) and elastography (conventional strain elastography of elasticity imaging [EI], virtual touch tissue imaging [VTI] and 2-D shear wave elastography [2-D-SWE] of virtual touch tissue imaging quantification [VTIQ]) with the clinicopathologic features and immunohistochemical (IHC) subtypes of breast cancer. The sample consisted of images from 202 patients with 206 breast lesions that were confirmed as breast cancers. Lesions with HER2 overexpression (luminal B HER2+ or HER2+) had higher mean shear wave velocity (SWV) values than the others. Older patients, lower histologic grade, no lymphovascular invasion and no lymph node metastasis were associated with luminal A (p < 0.001). There were significant differences in SWV values, histologic grade and lymph node status among the different pathologic types. This association may allow the use of 2-D-SWE in the pre-operative prediction of tumor characteristics and biologic activity, which may determine the prognosis in a non-invasive manner.

Luminal B is the Most Common Intrinsic Molecular Subtypes of Invasive Ductal Breast Carcinoma Patients in East Kalimantan, Indonesia

Objective:

Breast carcinoma has no longer been considered as a single and standalone disease. Its subtypes have been known to vary in terms of risk factors, natural histories, and responses to therapies. In particular, intrinsic molecular subtypes based on St. Gallen International Expert Consensus 2013 have classified breast carcinoma into luminal A, luminal B, HER2+, and triple-negative, depending on the expression of ER, PgR, HER2, and Ki-67. Research on intrinsic molecular subtypes of breast carcinoma in Indonesia, however, are rarely conducted, which then triggers the intention to conduct this study.

Methods:

In this work, a retrospective study was conducted on 92 formalin-fixed paraffin-embedded samples of invasive ductal breast carcinoma patients. These samples were from patients at Abdul Wahab Sjahranie County General Hospital Samarinda, East Kalimantan, Indonesia, in 2016. Next, immunohistochemical staining using anti-ER, PgR, HER2, and Ki-67 antibodies was applied to classify intrinsic molecular subtypes. Then, an association between clinical and immunohistochemical factors with intrinsic molecular subtypes of breast carcinoma were analyzed using Chi-square test.

Results:

Looking at results of the retrospective study, luminal B was discovered as the most common intrinsic molecular subtypes of breast carcinoma (42.39%) in East Kalimantan, Indonesia. The next ranks of breast carcinoma subtypes in the region included HER2+ (39.13%), triple-negative (10.87%), and luminal A (7.61%). In fact, there was a significant association between age (p = 0.019) with intrinsic molecular subtypes of breast carcinoma.

Conclusion:

The study found luminal B as the most common intrinsic molecular subtypes of Indonesian breast carcinoma in the region under investigation. In the future, the higher positivity rate of luminal B in breast carcinoma patients compared to prior studies would require further investigations.

Elevated preoperative serum levels of collagen I carboxyterminal telopeptide predict better outcome in early-stage luminal-B-like (HER2-negative) and triple-negative subtypes of breast cancer

Type 1 collagen is an important part of the extracellular matrix and changes in its metabolism and distribution are essential in breast cancer induction and progression. Serum concentrations of type 1 collagen synthesis (aminoterminal propeptide (PINP)) and degradation markers (carboxyterminal telopeptide (ICTP)) have previously been studied in early and metastatic breast cancer, but no data are available on specific breast cancer subtypes. We assayed 662 preoperative serum samples for PINP and ICTP and 109 postoperative serum samples for ICTP. The results were linked to prospectively collected clinical data and the cases were divided into breast cancer subtypes for survival analyses. The concentrations of both pre- and postoperative ICTP serum levels increased linearly from ductal in situ carcinoma to stage I-II tumors, stage III tumors, and finally to those with concomitant primary metastases (preoperative ICTP, p = 0.009; postoperative ICTP, p = 0.016). High-preoperative ICTP levels were associated with better breast cancer-specific survival in connection with luminal-B-like (HER2-negative) tumors (p = 0.017), which was confirmed in Cox regression analysis (relative risk = 3.127; 95% confidence interval = 1.081-9.049, p = 0.035), when T-class (relative risk = 4.049; 95% confidence interval = 1.263-12.981; p = 0.019) and nodal status (relative risk = 3.896; 95% confidence interval = 1.088-13.959; p = 0.037) were included in the analysis. In patients with triple-negative breast cancer, a high-preoperative ICTP level was a significant predictor of local relapse-free survival in univariate (p = 0.0020) and multivariate analyses (relative risk = 13.04; 95% confidence interval = 1.354-125.5; p = 0.026; for T-class, relative risk = 2.128 and 95% confidence interval = 0.297-15.23; p = 0.452; for N-class, relative risk = 0.332 and 95% confidence interval = 0.033-3.307; p = 0.347). A preoperatively elevated serum ICTP level appears to be an important marker of better prognosis in triple-negative breast cancer and luminal-B-like (HER2-negative) subtypes.

Blood-based protein biomarkers in breast cancer

Breast cancer (BCa) is a significant healthcare problem on women worldwide. Thus, early detection is very important to reduce mortality. Furthermore, better BCa prognosis could improve selection of patients eligible for adjuvant therapy. New markers for early diagnosis, accurate prognosis and prediction of response to treatment are necessary to improve BCa care. The present review summarizes important aspects of the potential usefulness of modern technologies, strategies, and scientific findings in proteomic research for discovery of breast cancer-associated blood-based protein biomarkers in the clinic.

KLP-PI: a new prognostic index for luminal B HER-2-negative breast cancer

Luminal B HER-2-negative (LBHN) subtype is one of the major subtypes of breast cancer according to different features, clinical behaviors, and treatment response. The LBHN subtype shows a poor prognosis and is insensitive to endocrine therapy. Our work aim is to investigate the prognostic factor in the LBHN subgroup and, meanwhile, try to obtain an optimal prognostic index (PI) contrapose LBHN subgroup which helps to guide chemotherapy. A total of 515 female LBNH patients who underwent diagnosis and surgery at our hospitals from August 2008 to August 2018 were enrolled. Clinical-pathological information was obtained and immunohistochemistry result was available. From these cases, a 30% Ki-67 LI was employed to divide LBHN into two groups with low and high levels; high Ki-67 LI was associated with GIII tumor grade (P < 0.001), positive axillary lymph nodes (ALN) status (P = 0.018) and negative PR status (P = 0.016), and also seemed to be related to T2-T3 tumor size (P = 0.058). High Ki-67 level (HR = 3.30; P < 0.011), positive ALN (HR = 7.29; P < 0.001) and PR negative (HR = 2.63; P = 0.034) significantly associated with poor 5-year DFS in multivariate Cox's proportional hazard regression model. A novel prognosis prediction model (KLP-PI), based on Ki-67 LI, ALN and PR status, showed a better discriminatory ability compared with traditional Nottingham prognostic index targeted to LBHN breast cancer. Our study highlights that high Ki-67 LI, positive ALN and negative PR status were associated with poor outcome in LBHN patients, and composed by these prognostic factors, KLP-PI improves the prognostic assessment using the Nottingham Prognostic Index when aiming at LBHN subtype.

Prognostic Value of Lymphangiogenesis Determinants in Luminal and Non-luminal Breast Carcinomas

Background:

Breast carcinomas (BCs) are sub-classified according to the molecular characteristics into luminal and non-luminal subtypes that clinically show different biological behavior, treatment and prognosis. BCs spread primarily through lymphatic vessels using cascade processes of lymphagiogenesis in which VEGF-C plays an important role during lymph node metastasis. Prognostic value of VEGF-C in luminal and non-luminal BC is still unclear and has not been studied thoroughly to clarify and define prognosis and therapeutic monitoring.

Aim:

To define the prognostic value of lymphangiogenesis on survival rates of luminal and non-luminal subtypes BC.

Materials and Methods:

This study applied prospective cohort design, using 130 patients of invasive duct carcinoma of the breast, stage I-IIIA, from Sardjito General Hospital, Indonesia and subsequent longitudinal follow-up. Immunohistochemical staining was carried out using anti-ER, -PR, -Her-2, VEGF-C, VEGFR-3 and D2-40 antibodies. The related clinicopathologic characteristics of BC patients and lymphangiogenesis determinants, including VEGF-C expression, were statistically analyzed.

Results:

In non-luminal BC subtypes, VEGF-C expression (HR=0.04; 95% CI=0.01-0.41), lymph node metastasis (HR=0.14; 95% CI=0.04-0.55) and stage (HR=0.30; 95% CI= 0.02-0.76) were determined as independent prognostic factors on survival rates. However, the lymphangiogenesis determinants were not associated with the survival rates of luminal BC subtypes.

Conclusion:

This study suggested that lymphangiogenesis affects survival rates of non-Luminal subtype rather than the luminal subtypes of BC.

Predicting the molecular subtype of breast cancer based on mammography and ultrasound findings

AIM

To determine the correlation between mammography and ultrasound features of breast cancer with molecular subtypes and to calculate the predictive value of these features.

MATERIALS AND METHOD

This is a prospective study of consecutive patients with breast cancer presenting between January 2016 and July 2017, who underwent mammography and/or ultrasound of breast and excision of the breast mass. Patients with contralateral breast mass, metastases, h/o prior cancer treatment, and other malignancies were excluded. On mammography, the presence or absence of microcalcification was noted. On ultrasound examination size, margins, microcalcification, posterior acoustic features, vascularity, and axillary nodes were assessed. Margins were categorized into circumscribed and non-circumscribed. Posterior acoustic features were classified into four categories: shadowing, enhancement, mixed, and no changes. Vascularity was assessed based on Adler's index into grades 0, 1, 2, and 3. Grades 0 and 1 were considered low and 2 and 3 were high.

RESULTS

Tumors with non-circumscribed margins and posterior acoustic shadowing were likely to be luminal A or B subtype of breast cancer [odds ratio (OR) 5.78; 95% confidence interval (CI) 3.68-9.80; P < 0.0001]. Tumors with non-circumscribed margins, posterior acoustic shadowing, and high vascularity were more likely to be luminal B subtype (OR 2.88; 95% CI 2-4.14; P- <0.0001). Tumors with microcalcification and posterior mixed acoustic pattern were strongly associated to be HER2-positive (OR 5.48; 95% CI 3.06-9.80; P < 0.0001). Tumors with circumscribed margins and posterior acoustic enhancement were highly suggestive of triple-negative breast cancer (OR 7.06; 95% CI 4.64-10.73; P < 0.0001).

CONCLUSION

Microcalcification detected on mammography and certain ultrasound features such as circumscribed or non-circumscribed margins, posterior acoustic features, and vascularity are strongly correlated in predicting the molecular subtypes of breast cancer, and thus may further expand the role of conventional breast imaging.

The prognostic value of quantitative analysis of CCL5 and collagen IV in luminal B (HER2-) subtype breast cancer by quantum-dot-based molecular imaging

Objective

Breast cancer is the most common malignancy and one of the main causes of death in women. Luminal B (HER2−) breast cancer subtype has been proposed since the 2011 St Gallon consensus. The hormone receptor status in this type of breast cancer is positive; thus, endocrine therapy was performed in all cases, but the treatment was not satisfactory, and a significant number of cases received very little benefit from chemotherapy. Furthermore, there is no effective treatment target for this subtype. Luminal B (HER2−) breast cancer subtype has been proposed since the 2011 St Gallon consensus. Therefore, the study of the key molecules in the microenvironment of breast cancer can help to reveal the biological characteristics.

Patients and methods

Luminal B (HER2−) breast cancer is a subtype with higher heterogeneity and poorer prognosis than luminal A. It is known that the development of cancer cells is an active process, and this process needs microenvironment cytokines, including chemokine (C–C motif) ligand 5 (CCL5) and collagen IV. Therefore, CCL5 and collagen IV were imaged and detected by quantum dot, and the CCL5/collagen IV ratio was calculated to investigate the prognostic value of the CCL5/collagen IV ratio in luminal B (HER2−).

Results

Quantitative determination showed a statistically significant negative correlation between CCL5 and collagen IV. The 5-year disease-free survival (5-DFS) of the high and low CCL5/collagen IV ratio subgroups was significantly different. The CCL5/collagen IV ratio had a greater prognostic value for 5-DFS. The CCL5/collagen IV ratio was an independent prognostic indicator.

Conclusion

Our findings revealed the effective integration of tumor CCL5 and collagen IV, and a new method for predicting the prognosis of luminal B (HER2−) has been developed.

Where youth matters-clinicopathologic characteristics and emerging trends in treatment and outcomes in young Irish women with breast cancer

BACKGROUND

Young women with breast cancer (YWBC) represent 7-12% of breast cancer diagnoses and ostensibly have more biologically aggressive subtypes with higher relapse and mortality rates. We studied the clinical and pathological characteristics in YWBC and examined how outcomes and treatment have evolved.

METHODS

YWBC were identified from pathology databases at two tertiary centers. Patients were divided into two cohorts: those diagnosed from 2000 to 2005 (C1) and from 2006 to 2015 (C2). Data were retrieved from clinical, radiology, and histology databases. Statistical analysis was performed using R® (V3.2.0).

RESULTS

We identified 345 patients. Median age was 36 years (23-39 years). Mastectomy was performed in 232 patients (67.2%) and axillary lymph node clearance (ALNC) in 207 patients (60% [C1 82.7 vs. C2: 49.4%, p < 0.001]). One hundred-seventy patients (49%) were ER + HER2-, 88 (25.5%) were HER2+, and 58 (16.8%) were triple negative. Eighty patients (23.2%) received neoadjuvant therapy. Pathological complete response rates were statistically similar between C1 and C2 [C1 1 (0.9%) vs C2 16 (6.8%) p = 0.1]. Distant relapse occurred in 59 (19%) patients. There was a higher relapse rate (RR) in C1 [27 (32.1%) vs. 32 (15.7%), p < 0.002). HER2+ and ER+ HER2- patients in C1 had higher RRs than C2. Median overall survival in patients with metastatic disease was 29 months (range 2-119 months).

CONCLUSION

Locally advanced disease was more prevalent in YWBC. Mastectomy and ALNC rates were high and most received multimodal treatment. The extent of axillary surgery declined over time. Outcomes were unchanged in triple negative patients. These remain a priority for research.

Steroid metabolism in breast cancer: Where are we and what are we missing?

It is well-known that breast cancer is hormone-dependent and that steroid hormones exert their mitogenic effects by binding to estrogen, progesterone and androgen receptors. Vital to our understanding and treatment of this malignancy, is the local metabolism of steroid hormones in breast cancer tissue. This review summarises our current knowledge on steroid producing pathways in the adrenal, ovary and breast, while focussing on the availability of specific circulating hormone precursors and steroidogenic enzymes involved in the local synthesis and metabolism of steroid hormones in the breast. Consequently, we highlight alternate pathways that may be instrumental in the etiology of breast cancer.

The challenges of modeling hormone receptor-positive breast cancer in mice

Estrogen receptor-positive (ER+) tumors account for 70-80% of all breast cancer (BC) cases and are characterized by estrogen dependency for their growth. Endocrine therapies using estrogen receptor antagonists or aromatase inhibitors represent a key component of the standard of care for these tumors. The occurrence of de novo or acquired resistance to estrogen withdrawal represents an important clinical problem, impacting on patient survival. In addition, despite an initially favorable outcome, a part of ER+ BC patients present with disease recurrence locally or at distant sites years or even decades after apparent remission. In vivo models that closely mimic human disease are urgently needed to study the biology of these tumors, investigate the molecular mechanisms underlying endocrine resistance and identify patients at risk of recurrence. Despite the similarities in the overall hormonal regulation of mammary gland development between mice and humans, the majority of the mammary carcinomas occurring in genetically engineered mouse models (GEMMs) are ER negative and most xenograft models are based on few ER+ cancer cell lines. We recently showed that the microenvironment is critical for ER+ cancer cells and discuss in this review the potential of intraductal xenograft model for basic and preclinical research.

Collagen analysis by second-harmonic generation microscopy predicts outcome of luminal breast cancer

Second-harmonic generation microscopy represents an important tool to evaluate extracellular matrix collagen structure, which undergoes changes during cancer progression. Thus, it is potentially relevant to assess breast cancer development. We propose the use of second-harmonic generation images of tumor stroma selected on hematoxylin and eosin–stained slides to evaluate the prognostic value of collagen fibers analyses in peri and intratumoral areas in patients diagnosed with invasive ductal breast carcinoma. Quantitative analyses of collagen parameters were performed using ImageJ software. These parameters presented significantly higher values in peri than in intratumoral areas. Higher intratumoral collagen uniformity was associated with high pathological stages and with the presence of axillary lymph node metastasis. In patients with immunohistochemistry-based luminal subtype, higher intratumoral collagen uniformity and quantity were independently associated with poorer relapse-free and overall survival, respectively. A multivariate response recursive partitioning model determined 12.857 and 11.894 as the best cut-offs for intratumoral collagen quantity and uniformity, respectively. These values have shown high sensitivity and specificity to differentiate distinct outcomes. Values of intratumoral collagen quantity and uniformity exceeding the cut-offs were strongly associated with poorer relapse-free and overall survival. Our findings support a promising prognostic value of quantitative evaluation of intratumoral collagen by second-harmonic generation imaging mainly in the luminal subtype breast cancer.

Contrast Enhancement on Cone-Beam Breast-CT for Discrimination of Breast Cancer Immunohistochemical Subtypes

PURPOSE: To evaluate whether contrast enhancement on cone-beam breast-CT (CBBCT) could aid in discrimination of breast cancer subtypes and receptor status. METHODS: This study included female patients age >40 years with malignant breast lesions identified on contrast-enhanced CBBCT. Contrast enhancement of malignant breast lesions was standardized to breast fat tissue contrast enhancement. All breast lesions were approved via image-guided biopsy or surgery. Immunohistochemical staining was conducted for expression of estrogen (ER), progesterone (PR), human epidermal growth factor receptor-2 (HER2) and Ki-67 index. Contrast enhancement of breast lesions was correlated with immunohistochemical breast cancer subtypes (Luminal A, Luminal B, HER2 positive, triple negative), receptor status and Ki-67 expression. RESULTS: Highest contrast enhancement was seen for Luminal A lesions (93.6 HU) compared to Luminal B lesions (47.6 HU, P = .002), HER2 positive lesions (83.5 HU, P = .359) and triple negative lesions (45.3 HU, P = .005). Contrast enhancement of HER2 positive lesions was higher than Luminal B lesions (P = .044) and triple negative lesions (P = .039). No significant difference was evident between Luminal B and triple negative lesions (P = .439). Lesions with high Ki-67 index showed lower contrast enhancement than those with low Ki-67 index (P = .0043). ER, PR and HER2 positive lesions demonstrated higher contrast enhancement than their receptor negative counterparts, although differences did not reach statistical significance (P = .1714; P = .3603; P = .2166). CONCLUSIONS: Contrast enhancement of malignant breast lesions on CBBCT correlates with immunohistochemical subtype and proliferative potential. Thereby, CBBCT might aid in selecting individualized treatment strategies for breast cancer patients based on pre-operative imaging.

Assessment of Ki67 expression for breast cancer subtype classification and prognosis in the Nurses' Health Study

PURPOSE

Ki67 is a proliferation marker commonly assessed by immunohistochemistry in breast cancer, and it has been proposed as a clinical marker for subtype classification, prognosis, and prediction of therapeutic response. However, the clinical utility of Ki67 is limited by the lack of consensus on the optimal cut point for each application.

METHODS

We assessed Ki67 by immunohistochemistry using Definiens digital image analysis (DIA) in 2653 cases of incident invasive breast cancer diagnosed in the Nurses' Health Study from 1976 to 2006. Ki67 was scored as continuous percentage of positive tumor cells, and dichotomized at various cut points. Multivariable hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox regression models for distant recurrence, breast cancer-specific mortality and overall mortality in relation to luminal subtypes defined with various Ki67 cut points, adjusting for breast cancer prognostic factors, clinico-pathologic features and treatment.

RESULTS

DIA was highly correlated with manual scoring of Ki67 (Spearman correlation ρ = 0.86). Mean Ki67 score was higher in grade-defined luminal B (12.6%), HER2-enriched (17.9%) and basal-like (20.6%) subtypes compared to luminal A (8.9%). In multivariable-adjusted models, luminal B tumors had higher breast cancer-specific mortality compared to luminal A cancer classified using various cut points for Ki67 positivity including the 14% cut point routinely reported in the literature (HR 1.38, 95% CI 1.11-1.72, p = 0.004). There was no significant difference in clinical outcomes for ER- tumors according to Ki67 positivity defined at various cut points.

CONCLUSIONS

Assessment of Ki67 in breast tumors by DIA was a robust and quantitative method. Results from this large prospective cohort study provide support for the clinical relevance of using Ki67 at the 14% cut point for luminal subtype classification and breast cancer prognosis.

Molecular Subtypes of Breast Cancers from Myanmar Women: A Study of 91 Cases at Two Pathology Centers

Background: Breast cancer is the most common cancer in Myanmar women. Revealing the hormonal receptor status, human epidermal growth factor receptor 2 (HER2) and Ki-67 expression is useful for estimating patient prognosis as well as determination of treatment strategy. However, immunohistochemical features and classification of molecular subtypes in breast cancers from Myanmar remain unknown. Methods: The clinicopathological features of 91 breast cancers from Myanmar women were examined. Immunohistochemistry was performed on tissue specimens with antibodies to estrogen receptor (ER), progesterone receptor (PgR), HER2, Ki-67, cytokeratin (CK)5/6 and CK14. Immunohistochemistry-based molecular subtyping was conducted. Results: Breast cancers in Myanmar women were relatively large, high grade with frequent metastatic lymph nodes. Of the 91 patients, tumors with ER positive, PgR positive, and HER2 positive were 57.1%, 37.4%, and 28.6%, respectively. The most prevalent subtype was luminal B (HER2-) (39.6%), followed by HER2 (22.0%), triple negative (TN)-basal-like (12.1%), luminal A (11.0%), TN-null (8.8%) and luminal B (HER2+) (6.6%). The mean Ki-67 expression of 91 cases was 33.9% (33.9% ± 19.2%) and the median was 28% (range; 4%-90%). The mean Ki-67 expression of luminal A, luminal B, HER2 and TN-basal-like/ null was 7%, 30%, 40%, and 57%/43%, respectively. A higher Ki-67 expression significantly correlated with a higher grade, larger size and higher stage of malignancy. Conclusions: We, for the first time, investigated the histopathological features of breast cancers from Myanmar women. Myanmar breast cancers appeared to be aggressive in nature, as evidenced by high frequency of poor-prognosis subtypes with high level of Ki-67 expression.

Do Histopathological Features and Microcalcification Affect the Elasticity of Breast Cancer?

OBJECTIVES

The aim of this study was to evaluate any association between histological grade, molecular subtypes of breast cancer, and strain elastography, and to investigate whether microcalcification affects the stiffness of tumor in breast cancers with the same histological grade.

METHODS

Between April 2015 and March 2016, 94 lesions of 94 patients with the diagnosis of invasive ductal carcinoma were included in the study. Strain elastography was performed on all patients before biopsy. Histological grades (Grades 1, 2, and 3), molecular subtypes (luminal A, luminal B, Her-2, and basal-like), and strain ratio (SR) were compared. In the same histological grades, patients were divided into two groups according to the presence of microcalcifications, and the groups were compared with each other.

RESULTS

Compared with Grades 1 (20.5) and 2 (23.7), Grade 3 (11.7) showed lower SR values (Grade 3-2, P = .01; Grade 3-1, P = .2). The groups with microcalcification had slightly higher SR in all histological grades, but not of statistical significance. In molecular subtypes, luminal A and B demonstrated higher SR, whereas HER2 and basal-like had lower SR (P > .05 for all group comparisons).

CONCLUSIONS

Grade 3 invasive ductal carcinomas are different from other grades with lower SR values. The presence of microcalcifications and molecular subtypes do not affect elasticity like a high histological grade does.

Prognostic Value of Clinicopathological Factors for Indonesian Breast Carcinomas of Different Molecular Subtypes

Background:

Breast carcinoma (BC) is a heterogeneous disease due to its different molecular profiles i.e. luminal (luminal A and luminal B) and non-luminal (HER2 positive and triple negative) subtypes. Prognostic value of clinicopathological factors of Indonesian BC of different molecular subtypes has never been reported previously. This study aims to elaborate prognostic impacts on Indonesian BCs focusing on separate molecular subtypes.

Methods:

A hundred and fifty cases of invasive BC, stage I-IIIA, in Sardjito Hospital, Indonesia, were stained using anti ER, PR, HER2 and Ki-67 antibodies. Survival and prognostic values were statistically analyzed.

Results:

Compared to the luminal subtypes, the non-luminal subtypes demonstrated higher proportions of intermediate-to-high grade, stage IIIA, positive lymph node infiltration and mortality. The triple negative subtype was typically intermediate-to-high grade, stage IIIA and with a high relative death risk. Luminal A lesions were characteristically low grade, stage I-II and less likely to cause death.

Conclusion:

In non-luminal BC, staging and lymph node metastasis are independent prognostic factors for survival in HER2 positive and triple negative subtypes, respectively. In luminal BC, clinicopathological factors demonstrated no influence on survival. This study suggests that staging and lymph node metastasis are correlated with survival in non-luminal Indonesian BCs.

Squamous cell carcinoma of the breast in the United States: incidence, demographics, tumor characteristics, and survival

PURPOSE

Squamous cell carcinoma of breast accounts for less than 0.1% of all breast cancers. The purpose of this study is to describe the epidemiology and survival of this rare malignancy.

METHODS

Data were extracted from the National Cancer Institute's Surveillance, Epidemiology and End Results Registry to identify women diagnosed with squamous cell carcinoma of breast between 1998 and 2013. SEER*Stat 8.3.1 was used to calculate age-adjusted incidence, age-wise distribution, and annual percentage change in incidence. Kaplan-Meier curves were plotted for survival analysis. Univariate and multivariate Cox proportional hazard regression model was used to determine predictors of survival.

RESULTS

A total of 445 cases of squamous cell carcinoma of breast were diagnosed during the study period. The median age of diagnosis was 67 years. The overall age-adjusted incidence between 1998 and 2013 was 0.62 per 1,000,000 per year, and the incidence has been on a decline. Approximately half of the tumors were poorly differentiated. Stage II was the most common stage at presentation. Majority of the cases were negative for expression of estrogen and progesterone receptor. One-third of the cases underwent breast conservation surgery while more than half of the cases underwent mastectomy (unilateral or bilateral). Approximately one-third of cases received radiation treatment. The 1-year and 5-year cause-specific survival was 81.6 and 63.5%, respectively. Excluding patient with metastasis or unknown stage at presentation, in multivariate Cox proportional hazard model, older age at diagnosis and higher tumor stage (T3 or T4) or nodal stage at presentation were significant predictors of poor survival.

CONCLUSIONS

Our study describes the unique characteristics of squamous cell carcinoma of breast and demonstrates that it is an aggressive tumor with a poor survival. Older age and higher tumor or nodal stages at presentation were independent predictors of poor survival for loco-regional stages.

The role of ultrasonographic findings to predict molecular subtype, histologic grade, and hormone receptor status of breast cancer

PURPOSE

The correlation between imaging findings and pathologic characteristics of tumors may provide information for diagnosis and treatment of cancer. The aim of this study is to determine whether ultrasound features of breast cancer are associated with molecular subtype, histologic grade, and hormone receptor status, as well as assess the predictive value of these features.

METHODS

A total of 201 consecutive invasive breast cancer patients were reviewed from the database according to the Breast Imaging and Reporting Data System (BI-RADS). Tumor margins were classified as circumscribed and noncircumscribed. Noncircumscribed group was divided into indistinct, spiculated, angular, and microlobulated. The posterior acoustic features were divided into four categories: shadowing, enhancement, no change, and mixed pattern.

RESULTS

Tumors with posterior shadowing were more likely to be of nontriple negative subtype (odds ratio [OR], 7.42; 95% CI, 2.10-24.99; P = 0.002), low histologic grade (grade 1 or 2 vs. grade 3: OR, 2.42; 95% CI, 1.34-4.35; P = 0.003) and having at least one positive receptor (OR, 3.36; 95% CI, 1.55-7.26; P = 0.002). Tumors with circumscribed margins were more often triple-negative subtype (OR, 6.72; 95% CI, 2.56-17.65; P < 0.001), high grade (grade 3 vs. grade 1 or 2: OR, 5.42; 95% CI, 2.66-11.00; P < 0.001) and hormone receptor negative (OR, 4.87; 95% CI, 2.37-9.99; P < 0.001).

CONCLUSION

Sonographic features are strongly associated with molecular subtype, histologic grade, and hormone receptor status of the tumor. These findings may separate triple-negative breast cancer from other molecular subtypes.

Novel insight into triple-negative breast cancers, the emerging role of angiogenesis, and antiangiogenic therapy

Triple-negative breast cancer (TNBC) is a heterogeneous group of tumours characterised by lack of expression of oestrogen-, progesterone- and human epidermal growth factor receptors. TNBC, which represents approximately 15% of all mammary tumours, has a poor prognosis because of an aggressive behaviour and the lack of specific treatment. Accordingly, TNBC has become a major focus of research into breast cancer and is now classified into several molecular subtypes, each with a different prognosis. Pathological angiogenesis occurs at a late stage in the proliferation of TNBC and is associated with invasion and metastasis; there is an association with metabolic syndrome. Semaphorins are a versatile family of proteins with multiple roles in angiogenesis, tumour growth and metastasis and may represent a clinically useful focus for therapeutic targeting in this type of breast cancer. Another important field of investigation into the control of pathological angiogenesis is related to the expression of noncoding RNA (ncRNA) – these molecules can be considered as a therapeutic target or as a biomarker. Several molecular agents for intervening in the activity of different signalling pathways are being explored in TNBC, but none has so far proved effective in clinical trials and the disease continues to pose a defining challenge for clinical management as well as innovative cancer research.

Nuclear and extranuclear-initiated estrogen receptor signaling crosstalk and endocrine resistance in breast cancer

Estrogens regulate function of reproductive and non-reproductive tissues in healthy and diseased states including breast cancer. They mainly work through estrogen receptor alpha (ERα) and/or estrogen receptor beta (ERβ). There are various ERα targeting agents that have been used for treatment of ER (+) breast tumors. The impact of direct nuclear activity of ER is very well characterized in ER (+) breast cancers and development and progression of endocrine resistance. Recent studies also suggested important roles for extranuclear-initiated ERα pathways, which would decrease the potency and efficiency of ERα targeting agents. In this mini-review, we will discuss the role of nuclear and extra-nuclear ER signaling and how they relate to therapy resistance in breast cancer.