Subtyping of triple-negative breast cancers: its prognostication and implications in diagnosis of breast origin

BACKGROUND

Triple-negative breast cancer (TNBC) subtyping by gene profiling has provided valuable clinical information. Here, we aimed to evaluate the relevance of TNBC subtyping using immunohistochemistry (IHC), which could be a more clinically practical approach, for prognostication and applications in patient management.

METHODS

A total of 123 TNBC cases were classified using androgen receptor (AR), CD8, Forkhead box C1 protein (FOXC1), and doublecortin-like kinase 1 (DCLK1) into luminal androgen receptor (LAR), basal-like immunosuppressive (BLIS), mesenchymal-like (MES), and immunomodulatory (IM) subtypes. The IM cases were further divided into the IM-excluded and IM-inflamed categories by CD8 spatial distribution. Their clinicopathological and biomarker profiles and prognoses were evaluated.

RESULTS

LAR (28.6%) and MES (11.2%) were the most and least frequent subtypes. The IHC-TNBC subtypes demonstrated distinct clinicopathological features and biomarker profiles, corresponding to the reported features in gene profiling studies. IM-inflamed subtype had the best outcome, while BLIS had a significantly poorer survival. Differential breast-specific marker expressions were found. Trichorhinophalangeal syndrome type 1 (TRPS1) was more sensitive for IM-inflamed and BLIS, GATA-binding protein 3 (GATA3) for IM-excluded and MES, and gross cystic disease fluid protein 15 (GCDFP15) for LAR subtypes.

CONCLUSIONS

Our findings demonstrated the feasibility of IHC surrogates to stratify TNBC subtypes with distinct features and prognoses. The IM subtype can be refined by its CD8 spatial pattern. Breast-specific marker expression varied among the subtypes. Marker selection should be tailored accordingly.

TRPS1 is a promising marker for all subtypes of breast cancer

AIMS

Trichorhinophalangeal syndrome-1 (TRPS1) has been proposed as a novel breast marker with equally high expression in breast cancer (BC) subtypes, making it a useful diagnostic tool. Here, its expression was evaluated alongside other commonly used markers [GATA3, GCDFP15, mammaglobin (MGB) and SOX10] in a large cohort of BCs (n = 1852) and their corresponding nodal metastases. Its usefulness as a diagnostic tool and its correlation with clinicopathological features were assessed.

METHODS AND RESULTS

TRPS1 was expressed at 75.8% overall in the BC cohort, with at least 58% expression among BC subtypes. It was less sensitive than GATA3 for luminal and HER2-overexpressing (HER2-OE) cancers (luminal A: 82 versus 97%; luminal B: 80 versus 95%; HER2-OE: 62 versus 76%), but it was the most sensitive for TNBC (60 versus ≤ 41%). It showed a stable expression in nodal metastases (primary tumour 76 versus nodal metastasis 78%), unlike a reduced nodal expression for GATA3 (86 versus 77%). TRPS1 outperformed GATA3 in detecting non-luminal cancers when paired with other breast markers. TRPS1 and GCDFP15 was the most sensitive combination in TNBC detection, with a 76% detection rate. For TRPS1-negative and GCDFP15-negative TNBCs, SOX10 was more sensitive than GATA3 (29 versus 24%).

CONCLUSIONS

TRPS1 is a highly sensitive marker for all breast cancer subtypes, outperforming GATA3 in non-luminal cancers and displaying the highest sensitivity for TNBC detection when combined with GCDFP15. It is a valuable addition to the breast marker panel for accurate identification of BC.

Imaging manifestations of IgG4-related disease

IgG4-related disease is a multisystem immune-mediated disorder associated with lesions manifesting an IgG4-rich plasma cell infiltrate and often raised serum IgG4 concentrations. The disease can mimic neoplastic, infective, and inflammatory processes due to features such as development of masses or organ enlargement. Prompt consideration of this diagnosis is essential to avoid unnecessary investigations and offer appropriate treatments, which can include steroids and other immunosuppressive agents. Although histology is typically diagnostic, imaging is critical to assess disease burden, determine biopsy targets, and evaluate response to treatment. Characteristic imaging features can also point towards the diagnosis in the absence of biopsy. This review highlights these features, as well as more atypical findings, grouped by organ or system. Differential diagnoses are emphasised. The full spectrum of imaging methods is discussed. Whole-body imaging with integrated 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT) has an evolving role in the detection of multi-organ involvement and subsequent follow-up.

Comprehensive characterization of HER2-low breast cancers: implications in prognosis and treatment

BACKGROUND

HER2-low cancers are heterogeneous with different degrees of HER2 expression and hormone receptor (HR) status. Currently, its analysis is mostly focused on the standard clinic-pathologic features or common biomarkers expression, without considering the heterogeneity within the category. A further characterization and understanding of this cancer subgroup will facilitate its management.

METHODS

A large cohort of HER2-negative cancers (N = 1464) was included. The HER2-low (N = 412) and HER2-zero cancers (N = 1052) were compared and correlated with a comprehensive panel of clinico-pathologic features and biomarker expression according to different HER2 expressions and HR statuses. The prognostic values of these features in HER2-low cancers were also evaluated.

FINDINGS

The characteristics of HER2-low breast cancers, as compared to HER2-zero, varied with the HR status. HER2-low luminal cancers were associated with younger age, larger tumor, high pAKT and high HLA expression. Among TNBCs, opposite trends in age and tumor size were found. Additionally, HER2-low TNBC showed less necrosis, higher pN, lower c-kit and CK14 than HER2-zero cancers. Nonetheless, regardless of HR status, HER2-low status was associated with increased COX2 and AR expression, implicated in the biology of HER2-low cancers. HER2-low cancers showed high expression of HLAs in tumors and PD-L1 in immune cells. In particular, the co-expression of HLAs was found to be associated with better survival in HER2-low cancers.

INTERPRETATION

This study revealed further characteristic of HER2-low breast cancers as compared to HER2-zero cancers, provided further insights into its prognostication and therapeutic strategies.

FUNDING

Health and Medical Research Fund (08190586), Cheng Yue Pui Charity Foundation and CUHK direct grant.

OUP accepted manuscript

Background

PD-L1 has been used as a biomarker to select patients for treatment of PD-1/PD-L1 inhibitors.

Materials and Methods

In this study, we assessed the clinicopathological features of breast cancers that are associated with PD-L1 expression, as well as its relationship with other immune components and its prognostic significance.

Results

Totally 1752 cases were included in this cohort. PD-L1 expression in tumor-infiltrating immune cells (PD-L1-IC) expression and in tumor cells (PD-L1-TC) expression were identified in 34.2% and 10.1% of cases, respectively, and they showed a positive correlation with higher tumor grade, morphological apocrine features, presence of necrosis, and higher stromal tumor-infiltrating lymphocytes (sTIL). PD-L1-IC and PD-L1-TC expression correlated positively with each other, and both of them were negatively associated with estrogen receptor and progesterone receptor and positively associated with Ki67, HER2, EGFR, p63, and p-cadherin. In survival analysis, PD-L1-IC expression was associated with better disease-free survival (DFS) and breast cancer-specific survival (BCSS) in HER2-overexpressed (HER2-OE) cancers and high–grade luminal B cancers. In triple–negative breast cancers (TNBC) and HER2–OE cancers, compared with sTIL low PD-L1-IC negative cases, sTIL high cases showed significantly better DFS independent of PD-L1-IC status. sTIL low PD-L1-IC positive cases also demonstrated a better DFS in HER2–OE cancers. In high–grade luminal B cancers, sTIL high PD-L1-IC positive cases showed the best BCSS.

Conclusion

The data suggested that the combining analysis of sTIL and PD-L1-IC expression refined the prognostication of breast cancer subtypes. Cases with high TIL and PD-LI-IC expression appear to be more immune active.

Combined SOX10 GATA3 is most sensitive in detecting primary and metastatic breast cancers: a comparative study of breast markers in multiple tumors

PURPOSE

For invasive breast cancer (IBC), high SOX10 expression was reported particularly in TNBC. This raised the possibility that SOX10 may complement other breast markers for determining cancers of breast origin.

METHODS

Here, we compared the expression of SOX10 with other breast markers (GATA3, mammaglobin and GCDFP15) and their combined expression in a large cohort of IBC together with nodal metastases. We have also evaluated the expression of GATA3 and SOX10 in a wide spectrum of non-breast carcinomas to assess their value as breast specific markers.

RESULTS

Compared with other markers, SOX10 showed lower overall sensitivity (6.5%), but higher sensitivity in TNBC (31.4%) than other breast markers including GATA3 (29.7% for TNBC). Its expression demonstrated the highest concordance between the paired IBC and nodal metastases (96.4%, κ = 0.663) among all the breast markers. More importantly, SOX10 identified many GATA3-negative TNBC, thus the SOX10/GATA3 combination was the most sensitive marker combination for IBC (86.6%). For non-breast carcinoma, a high SOX10/GATA3 expression rate was found in melanoma (77.9%, predominately expressed SOX10), urothelial carcinoma (82.0%, predominately expressed GATA3) and salivary gland tumors (69.4%). Other carcinomas, including cancers from lungs, showed very low expression for the marker combination.

CONCLUSIONS

The data suggested that SOX10/GATA3 combination can be used for differentiating metastases of breast and multiple non-breast origins. However, the differentiation with melanoma and urothelial tumors required more careful histologic examination, thorough clinical information and additional site-specific IHC markers. For salivary gland tumors, the overlapping tumor types with IBC renders the differentiation difficult.

Interactions between head motion and coil sensitivity in accelerated fMRI

BACKGROUND

Parallel imaging is widely adopted to accelerate functional MRI (fMRI) data acquisition, through various strategies that involve multi-channel receiver coils. However, the non-uniform spatial sensitivity of multi-channel receiver coils may introduce unwanted artifacts when head motion occurs during the few-minute long fMRI scans. Although prospective correction provides a promising solution for alleviating the head motion artifacts in fMRI, the relative position of the fixed multi-channel receiver coils moves in the moving reference frame, potentially resulting in artifactual signal.

NEW METHOD

We used numerical simulations to investigate this effect on fMRI using two parallel imaging schemes: sensitivity encoding (SENSE) and generalized autocalibrating partially parallel acquisitions (GRAPPA) with acceleration factors 2 and 4, towards characterizing the regime over which parallel-imaging fMRI with prospective motion correction will benefit from updating coil sensitivities to reflect relative positional change between the head and the receiver coil. Moreover, six subjects were scanned with acceleration factors 2 and 4 while performing a simple finger-tapping task with and without overt head motion.

RESULTS

Updating coil sensitivities showed significant positive impact on standard deviation and activation maps in presence of overt head motion compared to that obtained with no overt head motion.

COMPARISON WITH EXISTING METHODS

The parallel imaging fMRI with updated coil sensitivity maps were compared to that with the coil sensitivity maps acquired at the reference position.

CONCLUSIONS

Head motion in relation to a fixed multi-channel coil can adversely affect the quality of parallel imaging fMRI data; and updating coil sensitivity map can mitigate this effect.

Improved blood pressure, nitric oxide and asymmetric dimethylarginine are independent after bariatric surgery

Background

Obesity is associated with hypertension, but the exact mechanism is not fully understood. Bariatric surgery significantly decreases weight and blood pressure (BP). Low plasma nitric oxide (NO) and raised asymmetric dimethylarginine (ADMA), an endogenous inhibitor of NO, concentrations are associated with both obesity and hypertension. Correlations between the changes in these parameters were studied after bariatric surgery.

Methods

Weight, BP, plasma ADMA and NO were measured in 29 obese patients (24 female, 5 male) before and six weeks after bariatric surgery.

Results

Patients were 39.2 ± 1.2 (mean ± SEM) years old and weighed 126 ± 3 kg. Six weeks after the surgery, patients had lost 10 ± 0.7 kg ( P < 0.0001) and mean arterial pressure (MAP) decreased by 11 ± 1.0 mmHg ( P < 0.0001). The plasma ADMA concentration decreased by 24 ± 2% from 5 ± 0.4 to 4.0 ± 0.3 μmol/L ( P < 0.0001). The plasma total nitrite concentration increased by 15 ± 1% from 51.4 ± 2.6 to 60 ± 3 μmol/L ( P < 0.0001). The correlation between the decrease of ADMA and increase of NO subsequent to weight loss was significant ( P < 0.0001). However, MAP was not correlated to the changes in ADMA or NO.

Conclusions

After bariatric surgery, beneficial changes in BP, NO and ADMA occur, but our findings suggest that these BP changes are independent of changes in the NO–ADMA axis. Other causes for the changes in BP should therefore be considered.

Magnetoencephalographic study of vibrotactile evoked transient and steady-state responses in human somatosensory cortex

Somatosensory responses to vibrotactile stimulation applied to the index fingertip were recorded with whole-head MEG in eleven healthy young adult participants. Stimulus trains were produced by a pneumatically driven membrane oscillating at 22 Hz for a trial duration of 1 s, separated by interstimulus intervals (ISIs) of 0.5, 1.0, 3.0, and 7.0 s. Data analysis was performed in two frequency bands. Transient onset responses in the lower frequency band (<20 Hz) contained a clearly expressed P50 component. The higher frequency band (18-30 Hz) revealed a gamma-band response (GBR) within the first 200 ms followed by rhythmic activity at the stimulus frequency that continued throughout the stimulus duration, known as the steady-state response (SSR). Dipoles associated with the transient responses and SSRs were localized in two distinct regions within the primary somatosensory cortex (SI), with transient responses located on average 3 mm more medial and inferior than the SSRs. The transient and GBR peak amplitudes increased with ISI, whereas the SSR amplitude showed no ISI dependence. These results may reflect functionally and spatially distinct neural populations. Further investigations are required to assess the implications of these findings for probing the somatosensory system using other functional neuroimaging methods such as fMRI.

Assessing linear time-invariance in human primary somatosensory cortex with BOLD fMRI using vibrotactile stimuli

The assumption of linear time-invariance (LTI) in the human primary somatosensory cortex (SI) is assessed for fMRI signals generated by variable-duration vibrotactile stimuli. Predictions based on time-shifted summation (TSS) of responses to 2 s stimuli overestimate observed BOLD signal amplitudes in response to longer-duration stimuli, in agreement with previous findings in other primary sensory cortices. To interpret these results, we undertook an alternative approach for LTI assessment by characterizing BOLD signals using two biophysical models. The first model assumes that the input stimulus envelope is proportional to neural activity. The second assumes that neural activity exhibits both transient and steady-state components, consistent with extensive electrophysiological data, and fits the experimental data better. Although nonlinearity remains evident for short stimulus durations, the latter model shows that the TSS procedure to assess LTI overestimates the BOLD signal because the temporal characteristics of neural activity have not been considered adequately. Further research to investigate the BOLD response to time-varying neural activity is required.

Nonparenchymal cells from regenerating rat liver generate interleukin-1alpha and -1beta: a mechanism of negative regulation of hepatocyte proliferation

Following experimental partial hepatectomy of 70% in the rat, there is a semisynchronized surge of hepatocyte proliferation that ceases after 48 to 72 hours. Little is known about the determinants governing the termination of the proliferative phase, although transforming growth factor (TGF) beta has been implicated as an important inhibitor of hepatocyte replication in this model. We previously reported an additional non-TGF-beta inhibitor in medium conditioned by nonparenchymal cells isolated from regenerating liver (CM-NPC-Reg) between 24 and 48 hours after partial hepatectomy, but it was not found in medium conditioned by nonparenchymal cells from unoperated control liver. CM-NPC-Reg suppressed replicative DNA synthesis of primary rat hepatocytes in response to hepatocyte growth factor (HGF), epidermal growth factor (EGF), or TGF-alpha as assessed by 3H-thymidine incorporation. We now present evidence that interleukin (IL)-1 is the major inhibitor of hepatocyte DNA synthesis present in CM-NPC-Reg. IL-1 receptor antagonist abrogated the inhibition, as did antibodies to rat IL-1alpha and -beta; a combination of both antibodies was required, implicating both IL-1alpha and IL-1beta as active constituents in CM-NPC-Reg. To investigate in vivo changes in IL-1 expression, we assessed expression of IL-1alpha messenger RNA (mRNA) in whole rat liver following partial hepatectomy; mRNA was down-regulated at 10 hours in the pre-replicative phase of liver regeneration and up-regulated at 24 hours and 48 hours when proliferation is waning. Rat hepatocytes isolated from liver 24 hours after partial hepatectomy showed increased sensitivity to the inhibitory action of IL-1. Exogenous IL-1beta, administered parenterally to a group of rats at 0 and 12 hours after partial hepatectomy significantly reduced the incorporation of the thymidine analogue, bromodeoxyuridine (BrdU), into hepatocytes at 18 hours. These data indicate that nonparenchymal cells isolated from regenerating rat liver elaborate IL-1, and support the hypothesis that IL-1 plays a role suppressing hepatocyte proliferation and terminating the surge of DNA synthesis induced after partial hepatectomy.

Functional modulation of the human flexion and crossed extension reflexes by body position

The effects of body position on the electrically evoked flexion (FR) and crossed extension reflexes (CER) were investigated in humans. The FR area in the ipsilateral tibialis anterior muscle was significantly smaller during sitting than supported stance by 36% (P < 0.01). In contrast, the excitability of extensor muscles on both sides was enhanced in standing. For instance, twice as many subjects manifested a response in the ipsilateral vastus lateralis (VL) and the contralateral VL and/or soleus muscles (i.e. the CER) in standing than sitting. The FR and CER modulation observed seems to be dictated by the difference in functional demand between sitting and supported stance.

Prevalence of antibody to human T-cell lymphotropic virus type I/II in people of Caribbean origin in Toronto

OBJECTIVE

To estimate the prevalence of antibody to human T-cell lymphotropic virus type I/II (anti-HTLV-I/II) in people from an HTLV-I/II-endemic area (the Caribbean) living in a nonendemic region (Canada).

DESIGN

Cross-sectional household survey.

SETTING

Households in Toronto in 1989.

PARTICIPANTS

A modified quota sampling method was used to recruit subjects of Caribbean origin as well as other Canadians. Of 2900 people invited to participate in the study 1323, 743 of Caribbean origin, were interviewed about their background and possible exposure to HTLV-I/II.

MAIN OUTCOME MEASURES

Blood samples were analysed for anti-HTLV-I/II by means of an enzyme-linked immunoassay, the result being confirmed by the Western blot technique and radioimmunoprecipitation assay. The samples were also analysed for antibody to human immunodeficiency virus (anti-HIV) and hepatitis B surface antigen (HBsAg) and for surrogate markers of non-A, non-B hepatitis.

RESULTS

A total of 853 blood samples (64.5%) were analysed, 483 (56.6%) from subjects of Caribbean origin. The proportion of subjects who agreed to give a blood sample was similar for the Caribbean and non-Caribbean strata. Eleven subjects, all of Caribbean origin (2.3% of the Caribbean stratum), were confirmed to be positive for anti-HTLV-I/II. There were no significant differences between the antibody-positive and antibody-negative subjects with respect to sex, age, racial origin or residence in the Caribbean for at least 22 years. All anti-HTLV-I/II-positive subjects were negative for anti-HIV and HBsAg, and four (36.4%) were positive for antibody to HBsAg and to hepatitis B core antigen.

CONCLUSIONS

Except for origin, an association between antibody positivity and other factors could not be demonstrated. The findings suggest that blood donor screening might include place of origin in addition to the usual lifestyle or behavioural factors. However, the need to ensure safety of transfusion must be balanced against the need for participation of all groups in the blood transfusion program.

The role of continuous ambulatory peritoneal dialysis in end-stage renal failure due to multiple myeloma

A study in 10 patients (eight male, two female; mean age 61.9 +/- 10.7 years) suffering from multiple myeloma (MM) and end-stage renal failure (ESRF) is detailed. Continuous ambulatory peritoneal dialysis (CAPD) was the preferred mode of chronic dialysis in all the patients. Survival after diagnosis was 32.2 +/- 23.9 months. Survival after starting dialysis was 24.6 +/- 20.6 months. All patients on CAPD were adequately dialyzed and in good fluid control. Peritonitis was the main problem on CAPD (one episode per 5.6 patient-months). The majority of peritonitis episodes responded to intraperitoneal antibiotic therapy. One patient with Staphylococcus aureus peritonitis, septicemia, and neutropenia secondary to chemotherapy, died. Recommendations for prophylaxis and treatment of peritonitis are given. Three patients were transferred to hemodialysis. The use of subclavian vein catheters during hemodialysis was associated with a high incidence of gram-positive septicemia. Alkylating agent-based chemotherapy resulted in hematological responses in five patients. Survival after diagnosis in those responders was 47.4 +/- 25.6 months, compared with 17.0 +/- 7.2 months in the nonresponders (P less than 0.05). All responders subsequently relapsed. Four patients died with progressive myeloma. Bone marrow suppression resulted in a high blood transfusion requirement, neutropenia, and thrombocytopenia associated with bleeding into the gastrointestinal tract and central nervous system. Uremic myeloma patients can be adequately dialyzed using CAPD. Those patients who do not have an initial hematological response have a poor prognosis.

Bacterial peritonitis following esophageal injection sclerotherapy for variceal hemorrhage

Patients presenting with ascites and upper gastrointestinal hemorrhage were studied prospectively. Five patients presenting with acute variceal hemorrhage were found not to have pre-existing spontaneous bacterial peritonitis on initial paracentesis. However, three of these five developed findings compatible with bacterial peritonitis after sclerotherapy. Although the number of cases is small, our results support the monitoring of ascitic fluid after sclerotherapy.