Abstract P4-02-04: Using ultrasound findings to predict high tumor-infiltrating lymphocytes in triple negative breast cancer

Purpose Previous clinical data showed that high tumor-infiltrating lymphocytes (TILs) indicated a good prognosis in triple negative breast cancer (TNBC) and suggested that TNBC with TILs responded well to immunotherapy. Breast ultrasound is a safe inspection method without any radiation exposure. Therefore, we investigated whether ultrasound findings can predict high TILs in TNBC.

Patients and Methods The TNBC patients who underwent surgery at Mitsui Memorial Hospital, Tokyo, Japan, from 2009 to 2015, including those who underwent neo adjuvant chemotherapy (NAC), were selected for this study. The pre-treatment ultrasound findings were used retrospectively, and we compared the shape, margin, homogeneity of internal echoes, posterior features, and growth pattern of the lesions. Regarding shape, we classified the ultrasound findings as “round”, “oval”, “lobulated”, “irregular”, and “other” in accordance with The Japan Associations of Breast and Thyroid Sonology. Similarly, we classified the margins as "circumscribed" or "well-defined and smooth", "well-defined and rough", "indistinct" and "obscure". We used “homogeneous” and “heterogeneous” internal echoes. In terms of posterior features, we used the “accentuation”, “not changing”, “attenuating” and “shadowing” categories. By referring to previous report, we classified four types of growth patterns, i.e., "growing along the mammary ducts", "expansive growth pattern", "irregularly shaped mass with retracting surrounding tissue" and "other". Two pathologists evaluated stromal TILs, which were located between the cancer nests, by surgical specimens or needle biopsies of those who underwent NAC. Then the TILs were classified into four groups: “absent”, “weak”, “moderate”, and “dense”. “Absent” indicated that there were no lymphocytes in the stroma. “Weak”, “moderate” and “dense” indicated that lymphocytes occupied about 1–40%, 40–75% and 75%–100% area in the stroma, respectively. We analyzed ultrasound findings and TILs with the χ -square test.

Results A total of 97 lesions and 95 female TNBC patients were validated. The median age was 62 years old (range, 32–88 years). Of the total, 37 patients underwent NAC. The degree of “absent” TILs was 5 lesions, “weak” was 58, “moderate” was 22, and “dense” was 12 lesions. In the ultrasound findings, the shape categories “round,” “oval,” and “lobulated” were more "dense" TILs (n=12, 100%) than others (n=47, 55.3%) (p = 0.002). The "circumscribed" and "well-defined and rough" margins were found to be more “dense” TILs (n=11, 91.7%) than the other TILs (n=49, 57.6%) (p=0.020). “Accentuating” posterior echoes were more “dense” and “moderate” TILs (n=23, 67.6%) than “weak” and “absent” TILs (n=25, 39.7%) (p=0.009). The lesions with expansively growing pattern showed higher rate “dense” and “moderate” TILs (n=20, 58.8%) than “weak” and “absent” TILs (n=20, 31.7%) (p=0.010). There were no significant differences in internal echoes.

Conclusion We determined that ultrasound findings of round, oval or lobulated shape, accentuating posterior echoes and expansively growing pattern could predict the presence of high TILs. Thus, the safe, low-cost, and radiation-free ultrasound examination was recommended for predicting high TILs and prognosis.

Citation Format: Inagaki M, Ota D, Tsuji M, Kobayashi Y, Mori M, Fukuuchi A. Using ultrasound findings to predict high tumor-infiltrating lymphocytes in triple negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-02-04.

A case of malignant fibrous histiocytoma after breast conserving therapy for breast cancer

A 45-year-old woman with malignant fibrous histiocytoma (MFH) of the breast following breast conserving therapy (BCT) is described. She noticed a lump in her left breast 52 months after BCT for breast cancer. The lump was excised and nodular fasciitis was initially diagnosed. However, the tumor recurred locally 4 times in the next 18 months. MFH was finally diagnosed. This case is considered to be radiation-induced sarcoma. The risk of radiation-induced sarcoma after BCT seems to be very low, however careful follow-up is necessary.

[Thyroid biopsy in the auto-immune thyroid diseases]

There are three types of thyroid biopsy, fine needle biopsy, large needle biopsy and open biopsy. The aim of thyroid biopsy is not the diagnosis of auto-immune thyroid diseases itself, but the differential diagnosis of coexisting nodular goiter. Though fine needle aspiration biopsy cytology(FNABC) is a safe and valuable method, there is a limit. Large needle biopsy has small part for thyroid field. In case of malignant lymphoma or anaplastic carcinoma, the open biopsy is recommended. By using ultrasonic guide technique, the accuracy of ABC has come to high. Immunohistochemical method or molecular biological technique are now available.

[Management of severe pain after extended maxillectomy in a patient with carcinoma of the maxillary sinus]

We treated a 65 year-old man with severe facial pain after extended maxillectomy due to carcinoma of maxillar sinus. He had been suffering from pain at rest, on mastication, or at treatment of surgical wound. Various kinds of analgesics had been tried, but his pain did not disappear. At 17 weeks after the operation, he came to our pain clinic. Because his pain was thought to be due to reflex sympathetic dystrophy (RSD), stellate ganglion blocks (SGB) were performed. After 5 administrations of SGB, pain was reduced markedly but the pain at treatment of wound persisted. We thought that persistent pain would need trigeminal nerve block. Then Gasserian ganglion block was performed directly through an open wound after the operation. After the Gasserian ganglion block, the pain was diminished remarkably. He could tolerate procedures for facial prosthesis. Pain control after the operation in this patient was very efficient to improve his quality of life. Serum concentrations of catecholamines, serotonin and substance P were measured. The levels of norepinephrine and serotonin are related to the mechanism of pain as seen in this patient.

[A case of spasticity following spinal cord injury improved by epidural spinal cord stimulation]

Epidural spinal cord stimulation was performed in a patient complaining of spasticity with intractable pain after operation of metastatic spinal tumor. The end of the electrode was positioned along a line extending down the 11th vertebral body. Following confirmation of satisfactory effects during 10 days of trial stimulation, the electrode was permanently implanted. Excellent pain relief (80%) and significant relaxation of spasticity resulted in a medication free period with improved daily activities. Although the treatment of this case resulted in clinical success, the problem concerning the payment of the transmitter remained. We hope that the health insurance system will extend its indications to cover medical fees for the transmitter.

Duodenal gastrinomas, duodenotomy, and duodenal exploration in the surgical management of Zollinger-Ellison syndrome

Studies have shown that the duodenum is a more common site (30-40%) of primary gastrinomas than previously reported. These tumors are often occult to conventional exploration, and their detection requires duodenotomy and meticulous evaluation of the mucosa by eversion and direct palpation. Furthermore, tumors as small as 1 to 2 mm may be associated with lymph node metastases. Seven patients with duodenal gastrinomas treated during a 2-year period are reported. Four had sporadic Zollinger-Ellison syndrome (ZES), and three had multiple endocrine neoplasia type I (MEN-I) syndrome. All seven patients had malignant duodenal gastrinomas as proved by metastatic lymph nodes and in one case a large liver metastasis as well. Local excision of the tumor, lymph node excisions, and in one case liver lobectomy resulted in eugastrinemia in the 4 with sporadic ZES. Two of the three with MEN-I were also eugastrinemic after similar procedures, with the addition of distal pancreatectomy. Duodenotomy is considered an essential procedure in sporadic ZES patients when no pancreatic tumor is found and in all MEN-I/ZES patients, regardless of the pancreatic findings. Regional lymph node excisions are essential when a duodenal tumor has been found.

Mechanisms of somatostatin action in RINm5F cells in culture: Preliminary evidence for possible altered G protein function

Octreotide (SMS), a somatostatin analogue, is an established antigrowth peptide, but it does not effectively inhibit the growth of insulinoma cells. In order to study the mechanisms that underlie this apparent lack of an antiproliferative effect on insulinoma tumor cells we established the rat insulinoma cell line, RINm5F, in culture. Cells in culture were tested by incubation in media with and without SMS. To study tritiated [3H]-thymidine incorporation into extracted DNA (TTID), 2 muCi/well of 3H was added for 24 hr, and cells were harvested and assayed for TTID (cpm/microgram DNA). Insulin (IRI) and intracellular cAMP (cAMPi) were measured by RIA. To study the effects of SMS on insulin secretion, conditioned media were sampled after 24 hr. To study the effects of cAMPi, conditioned medium was used to extract cAMPi following incubation with SMS for 15 min. Increasing concentrations of SMS had no significant effect on TTID in the presence of 1% FBS. Trypan blue exclusion tests showed > 90% viable cells throughout all stages of these experiments. There were no significant differences in cell numbers and protein content in the presence of SMS. There was a significant decrease in the secretion of insulin and intracellular cAMP levels in response to 50 nM SMS. However, SMS significantly inhibited TTID in RINm5F cells following a 4-hr pretreatment with pertussis toxin (PT) (23553 +/- 1747 vs 20635 [cpm/microgram DNA] +/- 1983 [SEM], P < 0.01). We conclude that the inhibition of insulin secretion by SMS is associated with an attenuation of cAMP formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of gastrinomas by immunohistochemistry and in situ hybridization histochemistry

Gastrinomas from 25 patients were examined by immunohistochemistry (IHC) and in situ hybridization histochemistry (ISH). Most patients (84%) presented with the Zollinger-Ellison syndrome. Six had multiple endocrine neoplasia type I (MEN-I). Twelve patients (48%) had duodenal primaries and 11 of 12 of these had metastases to regional lymph nodes and/or liver in spite of the small sizes of the primary tumors (mean size of 0.9 cm). Five patients had pancreatic gastrinomas and eight patients had metastatic tumor in regional lymph nodes or liver at surgery but a primary was not found. IHC and ISH analyses showed that all cases were positive for gastrin protein and 24 of 25 (96%) expressed gastrin mRNA that was easily detected in formalin-fixed, paraffin-embedded tissue sections. Both benign and malignant tumors expressed alpha subunit of human chorionic gonadotropin protein (alpha-HCG). However, only malignant gastrinomas (29%) expressed adrenocorticotropic hormone protein or proopiomelanocortin (POMC) mRNA. ISH and Northern hybridization analysis revealed that chromogranin A mRNA was the most common member of the chromogranin/secretogranin (Cg/Sg) family which was expressed in both benign and malignant gastrinomas. These results indicate that duodenal gastrinomas are common in both sporadic and MEN-1-associated cases, and small duodenal primaries may be associated with extensive regional lymph node and liver metastases. Expression of ACTH/POMC protein and mRNA was consistently associated only with malignant gastrinomas while gastrin protein, gastrin mRNA and Cgs/Sgs mRNAs were readily detected in both benign and malignant gastrinomas.

Differentiated thyroid carcinoma in children and adolescents

From 1936 to 1990, 89 children and adolescents (72 girls and 17 boys) were treated for differentiated thyroid carcinoma at the University of Michigan Medical Center; 58 of these patients were first reported in 1971. Thirty (34%) patients had previously received external irradiation to the head and neck, although only 1 (3%) patient of the last 33 patients seen had this history. Patients first presenting from 1971 to 1990 had less advanced disease than those seen earlier. Also, during this time period, the rate of initial palpable cervical adenopathy fell from 63% to 36%, local infiltration of primary cancer from 31% to 6%, and initial pulmonary metastases from 19% to 6%. The incidence of cervical nodal metastases has remained 88% for 54 years. Papillary or the follicular variant of papillary carcinoma was found in 93% of all patients. Seventy-nine (89%) patients had total or completion total thyroidectomy. Surgical management of lymphatic metastases varied from regional excision of nodes to radical neck dissection. The overall rate of permanent accidental recurrent laryngeal nerve palsy and hypoparathyroidism was 4.5%, although neither has occurred in a child or adolescent undergoing surgery at the center in the past 25 years. The most recent 33 patients had a low rate of local/regional persistence or recurrence. Cervical nodal persistence occurred in 21%; there were no thyroid recurrences. Eighty-two percent of patients received 131I. The long-term mortality rate was 2.2%. We continue to advocate total thyroidectomy, cervical lymph node dissection, and postoperative 131I therapy as the most conservative treatment regimen for children with differentiated thyroid carcinoma.

Mid-mediastinal parathyroid lesions: preoperative localization and surgical approach in two cases

Although hyperfunctioning mediastinal parathyroid lesions that require median sternotomy or thoracotomy for removal are occasionally present, the majority are located in the anterior mediastinum closely associated with the thymus. Only eight cases of ectopic hyperfunctioning parathyroid tumors in the middle mediastinum have been reported. We experienced two cases of either persistent or recurrent hyperparathyroidism in which abnormal parathyroid tissue was located in the aorticopulmonary window. One of the patients had a parathyroid adenoma and the other had metastatic lesions of parathyroid carcinoma. In both cases, thallium scanning proved useful in identifying the lesions while computed tomography scan was effective for mediastinal three-dimensional localization. In one case, single photon emission computed tomography imaging with thallium proved beneficial for both identification and localization of the middle mediastinal lesion. The surgical approach used in both cases was different. In one case, left thoracotomy was performed, after which the ligamentum arteriosum was divided, and an adenoma anterior to the left main bronchus and posterior to the left pulmonary artery removed. In the other case, two metastatic tumors of parathyroid carcinoma anterior to the right main bronchus and posterior to the right pulmonary artery were resected through a median sternotomy and opening of the pericardium.

Pseudogout associated with primary hyperparathyroidism: management in the immediate postoperative period for prevention of acute pseudogout attack

Three cases of pseudogout associated with primary hyperparathyroidism are reported. Preoperative radiological studies revealed association of pseudogout. Considering the frequent development of acute pseudogout attack following parathyroidectomy, prevention of a sudden decrease in the serum calcium concentration was attempted using calcium supplement therapy starting on the first postoperative day in all three cases. Serum calcium slowly decreased to the normal range, and the postoperative courses were uneventful. From these experiences, we advocate that calcium supplement therapy is worth trying for the prevention of acute pseudogout attack following parathyroidectomy.