Advancing breast cancer subtyping: optimizing immunohistochemical staining classification with insights from real-world Taiwanese data

Gene expression signatures provide valuable information to guide postoperative treatment in breast cancer (BC) patients. However, genetic tests are prohibitively expensive for the majority of BC patients. Immunohistochemical staining (IHC) subtype classification system has been widely used for treatment guideline and is affordable to most BC patients. We aimed to revise immunohistochemical staining (IHC) subtyping to better match gene expression-based Prediction Analysis of Microarray 50 (PAM50) subtyping. Real world data of 372 BC patients were recruited in the Tri-Service General Hospital between Jan 2019 and Dec 2021. Clinical pathological information, blood, twelve pathological tissue slide samples, and fresh surgical tumor specimens were collected to examine IHC and PAM50. Current IHC subtyping (cIHC) tends to misclassify PAM50-based luminal A (lum A) to luminal B (lum B) by 35.81%, PAM50-lum B to PAM50-lum A by 9.09%, PAM50-Her2-enriched to lum B by 61.11%, PAM50-based Her2-enriched to lum B by 61.11%, and PAM50-based basal-like to lum B by 33.33%. We used random forest to identify estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (Her2), and Ki-67 status as the best indicators for revised IHC subtyping (rIHC4) and revised the classification rules by stratified analysis and prediction efficacy. rIHC4 increased the concordance rate for PAM50 subtypes from 68.3% to 74.7%. Both sensitivity and precision increased in most rIHC4 subtypes. Sensitivity increased from 33.3% to 87.4% in the Her2-enriched subtype; precision increased more evidently in the basal-like and lum B subtypes, from 71.4% to 83.3% and 57% to 65.1%, respectively. Our rIHC4 subtyping improved consistency with the PAM50 subtype, which could improve clinical management of BC patients without increasing medical expense.

A practical port-sharing approach for concomitant cholecystectomy with laparoscopic sleeve gastrectomy: single-center experience

Gallbladder disease is very common in obese patients. Concomitant cholecystectomy with laparoscopic sleeve gastrectomy (CC-LSG) may be necessary in such cases, and it has been proven safe when indicated. Herein, we presented an experience of our practical four-port-sharing technique for CC-LSG that can substitute the conventional trocar placement. A cohort study was conducted between January 2017 and March 2022 using a prospective database. Out of 238 patients with obesity who underwent bariatric surgery, 45 patients with gallbladder disease received CC-LSG using our four-port-sharing technique. The patients' demographic characteristics, intraoperative outcomes, and postoperative outcomes were examined. Of 45 obese patients with gallbladder disease undergoing CC-LSG, 18 patients with symptomatic cholelithiasis, 25 patients with asymptomatic cholelithiasis, and 2 patients with gallbladder polyps were identified. The mean age of these 45 patients (26 men and 19 women) was 38.3 years, and the mean body mass index was 41.8 kg/m2. There was no case of conversion to laparotomy. The mean operative time of LC and following LSG, the volume of blood loss, and hospital stay were 52.7 minutes and 95.2 minutes, 13.3 mL, and 3.8 days, respectively. No postoperative complications, including hemorrhage, bile leakage, staple leakage, pulmonary embolism, incisional hernia, and wound infection were noted. In CC-LSG, the application of our four-port-sharing technique is safe and feasible for obese patients with gallbladder diseases.

Challenge scenario: mid-gastric stenosis and gastric tube twist following laparoscopic sleeve gastrectomy

The incidence of gastric stenosis, a complication of laparoscopic sleeve gastrectomy (LSG), has been reported to range from 0.7% to 4%. Only 1.1% of stenosis develop symptoms that require endoscopic or surgical intervention. We herein report a challenging case of mid-gastric stenosis and gastric tube twist following LSG. A 38-year-old woman with an initial body mass index (BMI) of 35 kg/m2 and metabolic syndrome undergoing LSG. A week after surgery, the patients developed intermittent vomiting and eating difficulty. Gastroscopy and following diagnostic laparoscopy were performed 3 weeks after LSG, subsequently revealing unusual mid-gastric stenosis and gastric tube twist. Initial conservative treatment and endoscopic balloon dilatation were implemented but failed. The patient received laparoscopic revisional Roux-en-Y gastric bypass and recovered well. A follow-up after 2 years revealed that her BMI decreased to 22.1 kg/m2. In conclusion, post-LSG stenosis is a serious complication that requires early detection and prompt management. Prompt revisional surgery is necessary for complicated stenosis.

The Risk of Breast Cancer between Western and Mediterranean Dietary Patterns

Breast cancer is a significant public health problem globally and prevention strategies have become of great interest as its incidence rises. Exploring the connection between dietary patterns and the reduction of breast cancer risk is considered a promising approach. High levels of fiber, phytochemicals, a good antioxidant profile, and a composition of advantageous fatty acids are characteristics of healthy dietary programs such as the Mediterranean diet. This review summarized and discussed the active compounds that are considered important in preventing breast cancer, including dietary components from recent related reports. These include polyunsaturated fatty acids, fiber, phytochemicals, and alcohol. Although the exact mechanism for preventing breast cancer using these dietary factors is not well understood, the combination of all the elements in a healthy diet plays a role in reducing breast cancer risk. Considering the elevated probability of breast cancer relapse and mortality, it is crucial to investigate the correlation between a nutritious dietary pattern and breast cancer, while identifying bioactive components that have the potential to mitigate the risk of breast cancer incidence.

Invasive breast carcinoma with osteoclast-like stromal giant cells: A case report

BACKGROUND

Invasive breast carcinoma with osteoclast-like stromal giant cells (OGCs) is an extremely rare morphology of breast carcinomas. To the best of our knowledge, the most recent case report describing this rare pathology was published six years ago. The mechanism controlling the development of this unique histological formation is still unknown. Further, the prognosis of patients with OGC involvement is also controversial.

CASE SUMMARY

We report the case of a 48-year-old woman, who presented to the outpatient department with a palpable, growing, painless mass in her left breast for about one year. Sonography and mammography revealed a 26.5 mm × 18.8 mm asymmetric, lobular mass with circumscribed margin and the Breast Imaging Reporting and Data System was category 4C. Sono-guided aspiration biopsy revealed invasive ductal carcinoma. The patient underwent breast conserving surgery and was diagnosed with invasive breast carcinoma with OGCs, grade II, with intermediate grade of ductal carcinoma in situ (ER: 80%, 3+, PR: 80%, 3+, HER-2: negative, Ki 67: 30%). Adjuvant chemotherapy and post-operation radiotherapy were initiated thereafter.

CONCLUSION

As a rare morphology of breast cancer, breast carcinoma with OGC occurs most often in relatively young women, has less lymph node involvement, and its occurrence is not race-dependent.

Revisional One Anastomosis Gastric Bypass (OAGB) for Poor Response of Duodenal-Jejunal Bypass with Sleeve Gastrectomy (DJB-SG) (Video Report)

BACKGROUND

Bariatric surgery has actually focused not only on obesity but also more on the improvements or remission of the metabolic diseases. Therefore, revisional surgery is indicated for patients with poor response to the primary bariatric surgery to control weight and obesity-associated medical conditions.

METHOD

In this video report, the patient was a 27-year-old Asian female with an initial BMI of 36.5 kg/m² and poorly controlled type 2 diabetes (HbA1c: 11.9%). She underwent primary bariatric surgery of laparoscopic duodenal-jejunal bypass with sleeve gastrectomy (DJB-SG) in June 2019. She had a nadir BMI of 28.8 kg/m² (corresponding body weight of 72 kg) in June 2020. However, she regained weight (BMI: 34 kg/m²) and had a relapse of diabetes with an HbA1c of 12.0% at the time of consultation for revisional bariatric surgery (RBS) in September 2022. After a multidisciplinary team evaluation, laparoscopic procedures of one anastomosis gastric bypass (OAGB) with resizing the gastric tube, removal of duodenal-jejunal anastomosis, and lengthening of the biliopancreatic limb were performed.

RESULTS

The operative time was 186 min and blood loss was 50 ml. There were no intraoperative or postoperative complications. The patient had an uneventful postoperative course and was discharged on postoperative day 5. At the 3-month follow-up after RBS, the patient had lost 13 kg (weight dropped from 85 to 72 kg) and achieve remission of diabetes with HbA1c of 5.7%.

CONCLUSION

Laparoscopic OAGB is technically feasible and practical as a revisional procedure for poor response of DJB-SG.

The impact of frailty on breast cancer outcomes: evidence from analysis of the Nationwide Inpatient Sample, 2005-2018

The aims of the present study were to examine whether and how frailty impacts the outcomes of breast cancer. Data of women with breast cancer hospitalized during 2005 and 2018 were extracted from the US Nationwide Inpatient Sample (NIS) database. Frailty was identified using a novel algorithm, Hospital Frailty Risk Score (HFRS). Propensity-score (PS) matching was utilized to balance the baseline characteristics between frail and non-frail groups. In-hospital mortality, unfavorable discharge, prolonged length of stay (LOS), and total hospital cost were compared using univariate and multivariable logistic regression analyses. A total of 19,522 patients with metastatic (frailty n = 9,906; no frailty n = 9,716) and 135,200 with non-metastatic breast cancer (frailty n = 30,235; no frailty n = 104,965) were included. After adjustment, frailty was significantly and independently associated with higher risk for in-hospital mortality, unfavorable discharge, prolonged LOS, and greater hospital cost in both metastatic and non-metastatic diseases, in which the impacts of frailty was greater in women with non-metastatic disease. In stratified analysis, frailty had the greatest impact on in-hospital mortality among women had had non-metastatic disease and aged <50 years (aOR = 3.88; 95% CI: 1.95-7.73). In conclusion, frailty is associated with worse outcomes in women with breast cancer, and the effects are greater in non-metastatic disease and younger patients.

Comprehensive Analyses of Prognostic Values and Immune Infiltration of KDM3 Gene Family in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most commonly diagnosed malignancy globally with a pessimistic prognosis. Previous studies have demonstrated that abnormal expression of genes in the lysine-specific histone demethylase 3 (KDM3) family with epigenetic changes and dysregulation of enzymes promotes cancer progression. In this study, multiomics analyses were utilized to analyze differential expression, prognostic value, genetic alteration, protein-protein interaction, associated biological pathways and immune cell infiltration of KDM3s in patients with HCC. KDM3A-C were significantly upregulated to different extents based on pathologic and tumor grades in patients with HCC compared to normal tissue. Of note, higher KDM3A expression was associated with poor survival in HCC patients, whereas KDM3B and KDM3C were not associated with survival. Furthermore, KDM3A-B genetic alterations had significant effects on survival in patients with HCC. Analyses of the KEGG pathway and miRNAs targets of KDM3A and KDM3B in HCC may provide potential value in tumor behaviors and treatment. The differential expression of the KDM3 family has a strongly significant correlation with the infiltration of the abundance of immune cells, including B cells, CD8⁺ T cells, CD4⁺ T cells, macrophages, neutrophils, and dendritic cells in HCC. This study indicates that KDM3A may have the potential to be a promising molecular target in terms of prognostic biomarkers or therapeutic targets for HCC treatment.

A Novel IGLC2 Gene Linked With Prognosis of Triple-Negative Breast Cancer

Background

Immunoglobulin-related genes are associated with the favorable prognosis of triple-negative breast cancer (TNBC) patients. We aimed to analyze the function and prognostic value of immunoglobulin lambda constant 2 (IGLC2) in TNBC patients.

Methods

We knocked down the gene expression of IGLC2 (IGLC2-KD) in MDA-MB-231 cells to evaluate the proliferation, migration, and invasion of tumors via 3-(4,5-Dimethythiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay, wound healing, and transwell cell migration assay respectively. Relapse-free survival (RFS) and distant metastasis-free survival (DMFS) analyses were conducted using the KM plotter online tool. The GSE76275 data set was used to analyze the association of IGLC2 and clinical characteristics. A pathway enrichment analysis was conducted using the next-generation sequencing data of wild-type and IGLC2-KD MDA-MB-231 cells.

Results

The low gene expression of IGLC2 was related to unfavorable RFS, DMFS. The high expression of IGLC2 was exhibited in the basal-like immune-activated (BLIA) TNBC molecular subtype, which was immune-activated and showed excellent response to immune therapy. IGLC2 was positively correlated with programmed death-ligand 1 (PD-L1) as shown by Spearman correlation (r = 0.25, p < 0.0001). IGLC2 had a strong prognostic effect on lymph node-negative TNBC (RFS range: 0.31, q value= 8.2e-05; DMFS = 0.16, q value = 8.2e-05) but had no significance on lymph node-positive ones. The shRNA-mediated silencing of IGLC2 increased the proliferation, migration, and invasion of MDA-MB-231 cells. The results of pathway enrichment analysis showed that IGLC2 is related to the PI3K-Akt signaling pathway, MAPK signaling pathway, and extracellular matrix–receptor interaction. We confirmed that MDA-MB-231 tumor cells expressed IGLC2, subverting the traditional finding of generation by immune cells.

Conclusions

IGLC2 linked with the proliferation, migration, and invasion of MDA-MB-231 cells. A high expression of IGLC2 was related to favorable prognosis for TNBC patients. IGLC2 may serve as a biomarker for the identification of TNBC patients who can benefit the most from immune checkpoint blockade treatment.

Survival outcomes in elderly Taiwanese women according to breast cancer subtype and lymph node status: A single-center retrospective study

This study aimed to determine the rates of overall survival and recurrence-free survival among elderly Taiwanese women (>65 years old) according to breast cancer subtype and lymph node status. We identified 554 eligible patients who were >65 years old and had been treated based on international recommendations at our center between June 2005 and June 2015. Patients with the luminal A subtype had the highest rates of overall survival (90.6%) and recurrence-free survival (97.0%), while the lowest overall survival rate was observed in those with the triple-negative subtype (81.3%) and the lowest recurrence-free survival rate was observed in those with the luminal B subtype (84.0%). Multivariate Cox proportional hazard analysis, using the luminal A subtype as the reference, revealed significant differences in recurrence-free survival among luminal B patients according to lymph node status. Among elderly Taiwanese women with breast cancer, the breast cancer subtype might help predict survival outcomes. The luminal B subtype was associated with poor recurrence-free survival, and lymph node status was useful for predicting recurrence-free survival in this subset of patients.

Self-Esteem as a Predictor of Mental Adjustment in Patients with Breast Cancer

This study aimed to explore the relationship between self-esteem and mental adjustment and examine the directional effects in patients with breast cancer using path modeling. This was a cross-sectional, descriptive, and correlational study. A total of 128 patients with breast cancer were selected through convenience sampling at a medical center in northern Taiwan. They completed a basic characteristics questionnaire, the Memorial Symptom Assessment Scale short form, the Rosenberg Self-Esteem Scale, and the mini-Mental Adjustment to Cancer Scale. Descriptive statistics, regression analysis, and path analysis were used to analyze the data. The results showed that higher self-esteem was associated with better mental adjustment (β = 0.9, 95% confidence interval 0.6~1.3, p < 0.001). Age, religious beliefs, employment, cancer stage, and symptom distress were correlated with mental adjustment. Path modeling demonstrated that self-esteem, cancer stage, performance status, and symptom distress directly affected mental adjustment in patients with breast cancer. These findings suggest that health professionals should evaluate self-esteem, performance status, and symptom distress in patients with breast cancer immediately upon admission. This can facilitate early implementation of relevant nursing interventions and, consequently, improve self-esteem and symptom distress and increase mental adjustment in these patients.

Revisional Single Anastomosis Sleeve Ileal (SASI) Bypass for Failed Gastric Clipping and Proximal Jejunal Bypass (GC-PJB) (Video Report)

BACKGROUND

Bariatric surgery, the most effective strategy to manage morbid obesity, has increased rapidly in the face of expanding obese population in the twenty-first century. Hence, it is reasonable to expect a rise in the need for revisional bariatric surgery (RBS), especially due to weight recidivism.

METHOD

In this video report, the patient was a 28-year-old Asian female with an initial BMI of 42.6 kg/m² and underwent primary bariatric surgery of laparoscopic gastric clipping with proximal jejunal bypass (GC-PJB) in January 2018. She had the nadir BMI of 35.2 kg/m² in August 2019. However, she regained weight and her BMI rebounded to 43.7 kg/m² at the time of consultation for RBS in 2021. After a multidisciplinary team evaluation, laparoscopic procedures of removal of gastric clip and single anastomosis sleeve ileal (SASI) bypass with preservation of previous jejunojejunal anastomosis were performed.

RESULTS

The operative time was 216 min and blood loss was 25 ml. There were no intraoperative or postoperative complications. The patient had an uneventful postoperative course and was discharged 4 days after surgery. At the 3-month follow-up after RBS, the patient had lost 25 kg (weight dropped from 119 to 94 kg), and the corresponding BMI was 34.5 kg/m².

CONCLUSION

Laparoscopic removal of gastric clip and SASI bypass with preservation of previous jejunojejunal anastomosis is technically feasible and promising as a revisional procedure for failed GC-PJB.

Amongst Women Stratified to Receive Endocrine Therapy on the Basis of Their Tumor Estrogen and Progesterone Receptor Levels, Those with Higher Tumor Progesterone Receptor Levels Had a Better Outcome Than Those with Lower Levels of Tumor Progesterone Receptor

Simple Summary

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer death of women worldwide. Several cut-points for estrogen receptor (ER) and progesterone receptor (PgR) have been proposed as predictive effects of hormone therapy; while the cut-off values were inconsistent. The aim of our retrospective study was to propose better prognostic cut-off levels for ER and PgR, and their effects on breast cancer-specific survival (BCSS) and disease-free survival (DFS) over 5 and 10 years were evaluated in 1807 eligible patients. Subgroups were generated based on ER and PgR expression percentage and scoring from the Allred scoring system (Allred scores). After comparing the hazard ratios (event rates in each group to reference group) of BCSS and DFS using multivariate analyses, our results suggested that patients with PgR expression ≤50% or Allred score ≤5 revealed a poor prognosis and should be paid more attention during follow-up.

Abstract

Background: To realize the association between stratified expression levels of ER and PgR and long-term prognosis of breast cancer patients who received adjuvant hormone therapy, this study aimed to propose better prognostic cut-off levels for estrogen receptor (ER) and progesterone receptor (PgR). Methods: Patients who received adjuvant hormone therapy after surgical intervention were selected. The ER and PgR status and their effects on breast cancer-specific survival (BCSS) and disease-free survival (DFS) over 5 and 10 years were evaluated. Next, subgroups were generated based on ER and PgR expression percentage and Allred scores. Survival curves were constructed using the Kaplan–Meier method. Results: ER and PgR expression were significantly associated with better prognosis in 5 years, whereas only PgR expression was significantly associated during the 10-year follow-up. The optimal cut-off values for better 5-year BCSS were ER > 50%; ER Allred score > 7; PgR ≥ 1%; or PgR Allred score ≥ 3; the corresponding values for DFS were ER > 40%; ER Allred score > 6; PgR > 10%; or PgR Allred score ≥ 3. In the long-term follow-up, PgR of > 50% or Allred score of > 5 carriers revealed a better prognosis of both BCSS and DFS. Conclusion: Patients with a PgR expression > 50% or an Allred score > 5 exhibited better 10-year BCSS and DFS.

High B3GALT5 expression confers poor clinical outcome and contributes to tumor progression and metastasis in breast cancer

BACKGROUND

Existence of breast cancer stem cells (BCSCs) is implicated in disease relapse, metastasis, and resistance of treatment. β1,3-Galactosyltransferase 5 (B3GALT5) has been shown to be a pro-survival marker for BCSCs. However, little is known about the prognostic significance of B3GALT5 in breast cancer.

METHODS

Paired tissues (tumor part and adjacent non-tumor part) from a cohort of 202 women with breast cancer were used to determine the expression levels of B3GALT5 mRNA by qRT-PCR. Kaplan-Meier and multivariable Cox proportional hazard models were used to assess survival differences in terms of relapse-free survival (RFS) and overall survival (OS). Both breast cancer cells and cancer stem cells (BCSCs) were used to see the in vitro effects of knockdown or overexpression of B3GALT5 on cell migration, invasion, and epithelial-to-mesenchymal transition (EMT). A patient-derived xenograft (PDX) model was used to see the in vivo effects of knockdown of B3GALT5 in BCSCs on tumor growth and metastasis.

RESULTS

Higher expression of B3GALT5 in 202 breast cancer tissues, especially in adjacent non-tumor tissue, correlated with poor clinical outcomes including shorter OS and RFS in all patients, especially those with early stage breast cancer. In vitro studies showed B3GALT5 could enhance cell migration, invasion, mammosphere formation, and EMT. Of note, B3GALT5 upregulated the expression of β-catenin and EMT activator zinc finger E-box binding homeobox 1 (ZEB1) pathway in BCSCs. In vivo studies showed B3GALT5 expression in BCSCs is critical for not only tumor growth but also lymph node and lung metastasis in PDX mice.

CONCLUSION

Our results demonstrated the value of B3GALT5 as a prognostic marker of breast cancer, especially among the early stage patients, and its crucial roles in regulating EMT, cell migration, and stemness thereby promoting breast cancer progression.

Protective Association Between Calcium Channel Blocker Use and Breast Cancer Recurrence in Postsurgical Women: A Population-Based Case-Control Study in Taiwan

Neoadjuvant chemotherapy induces metastasis of residual breast cancers through activation of tumor-associated macrophages. Previous studies have indicated that calcium channel blockers (CCBs) exert anti-inflammatory and antimigratory effects on macrophages via attenuating Ca²⁺ entry into macrophages. However, no existing empirical research has addressed the relationship between previous CCB use and breast cancer recurrence. In this study, 4840 Taiwanese women aged ≥20 years with breast cancer who underwent breast surgery from January 1, 2007, to December 31, 2015, were enrolled. The date of cancer recurrence was defined as the index date. Logistic regression was performed to evaluate the relationship between previous CCB exposure and cancer recurrence among female patients who underwent surgery for breast cancer. After adjusting for demographic characteristics, comorbidities, and tumor-node-metastasis stage, the adjusted odds ratio (OR) for CCB exposure within 5 years before the index date in women with recurrence compared with nonrecurrent controls was 0.73 (95% confidence interval [CI], 0.53-0.97). Further analysis revealed that the adjusted OR for CCB exposure between the surgery and index dates in women with recurrence relative to nonrecurrent controls was 0.72 (95%CI, 0.66-0.95). In particular, prior CCB use was significantly associated with a lower risk (34%) of breast cancer recurrence among women 20 to 54 years old (OR, 0.66; 95%CI, 0.47-0.83). This study uncovered a protective association between previous CCB use and breast cancer recurrence.

Simple laparoscopic repair of perforated peptic ulcer without omental patch

OBJECTIVE

We evaluated the outcomes of laparoscopic repair of perforated peptic ulcers using simple closure only.

METHODS

This retrospective study included 79 patients who underwent laparoscopic repair of perforated peptic ulcers from January 2011 to February 2016. They were divided into two groups: repair with an omental patch and repair with simple closure only. All of them underwent peritoneal cavity lavage with several litres of warm normal saline. A closed suction drain system was placed for drainage of intra-abdominal abscess. Patients' age, sex, Boey score, perforation size, operation time, overall complications, and length of hospital stay were evaluated.

RESULTS

A total of 79 patients diagnosed with perforated peptic ulcers who underwent emergency laparoscopic operations were enrolled in this study. Thirty patients underwent simple closure without an omental patch (group A), and 49 patients underwent simple closure with an omental patch (group B). Between the two groups, there were no statistically significant differences in the patients' age, size of perforation, and Boey score. However, the operation time was significantly different (p < 0.05) between the groups, with the average time being 84.4 min in group A and 106.65 min in group B. There was no statistically significant difference in the complication rate or the average length of hospital stay. No patient underwent reoperation for complications.

CONCLUSION

Laparoscopic repair of a perforated peptic ulcer without an omental patch is a safe option and does not increase the morbidity and mortality rate.

Integrated omics-based pathway analyses uncover CYP epoxygenase-associated networks as theranostic targets for metastatic triple negative breast cancer

Background

Current prognostic tools and targeted therapeutic approaches have limited value for metastatic triple negative breast cancer (TNBC). Building upon current knowledge, we hypothesized that epoxyeicosatrienoic acids (EETs) and related CYP450 epoxygenases may have differential roles in breast cancer signaling, and better understanding of which may uncover potential directions for molecular stratification and personalized therapy for TNBC patients.

Methods

We analyzed the oxylipin metabolome of paired tumors and adjacent normal mammary tissues from patients with pathologically confirmed breast cancer (N = 62). We used multivariate statistical analysis to identify important metabolite contributors and to determine the predictive power of tumor tissue metabolite clustering. In vitro functional assays using a panel of breast cancer cell lines were carried out to further confirm the crucial roles of endogenous and exogenous EETs in the metastasis transformation of TNBC cells. Deregulation of associated downstream signaling networks associated with EETs/CYPs was established using transcriptomics datasets from The Cancer Genome Atlas (TCGA) and Molecular Taxonomy of Breast Cancer International Consortium (METABRIC). Comparative TNBC proteomics using the same tissue specimens subjected to oxylipin metabolomics analysis was used as validation set.

Results

Metabolite-by-metabolite comparison, tumor immunoreactivity, and gene expression analyses showed that CYP epoxygenases and arachidonic acid-epoxygenation products, EET metabolites, are strongly associated with TNBC metastasis. Notably, all the 4 EET isomers (5,6-, 8,9-, 11,12-, and 14,15-EET) was observed to profoundly drive the metastasis transformation of mesenchymal-like TNBC cells among the TNBC (basal- and mesenchymal-like), HER2-overexpressing and luminal breast cancer cell lines examined. Our pathway analysis revealed that, in hormone-positive breast cancer subtype, CYP epoxygenase overexpression is more related to immune cell-associated signaling, while EET-mediated Myc, Ras, MAPK, EGFR, HIF-1α, and NOD1/2 signaling are the molecular vulnerabilities of metastatic CYP epoxygenase-overexpressing TNBC tumors.

Conclusions

This study suggests that categorizing breast tumors according to their EET metabolite ratio classifiers and CYP epoxygenase profiles may be useful for prognostic and therapeutic assessment. Modulation of CYP epoxygenase and EET-mediated signaling networks may offer an effective approach for personalized treatment of breast cancer, and may be an effective intervention option for metastatic TNBC patients.

Electronic supplementary material

The online version of this article (10.1186/s13046-019-1187-y) contains supplementary material, which is available to authorized users.

[Clinical value of transcatheter arterial chemoembolization therapy for hepatocellular carcinoma with blood supply from right adrenal artery]

Objective: To study the clinical value of transcatheter arterial chemoembolization (TACE) therapy for hepatocellular carcinoma with blood supply from right adrenal artery. Methods: An imaging and clinical data of HCC patients with blood supply from right adrenal artery were collected from 2012 to 2016 after TACE treatment in the Second Affiliated Hospital of Chongqing Medical University and the safety and therapeutic efficacy of complete embolization therapy was analyzed retrospectively. Results: Twenty hepatocellular carcinoma patients with blood supply from right adrenal artery had received 23 times treatment. All lesions had invaded and protruded from the exogenous development of liver capsule. There were 14 cases with lesions > 5 cm in diameter. Right adrenal artery was found to be involved in the blood supply of three cases of hepatocellular carcinoma during TACE treatment for the first time. In addition, the remaining 17 cases had also received TACE treatment for the second to sixth time. The superior, middle, and inferior adrenal arteries were involved in 13, 3, and 9 cases, respectively. Twenty-four right adrenal arteries (96.0%) superselectively cannulated were successfully embolized without any serious complications. The standard method for evaluating the efficacy of liver cancer in 20 solid tumors follow-up cases showed that three cases were completely relieved, nine cases were partially relieved, two cases were stable, and six cases were progressive. The effective rate of embolization with blood supply from right adrenal artery lesions was 60.0%, and the control rate of lesion development was 70.0%. Conclusion: The right adrenal artery is mainly located in the S5-S7 segments of the liver. TACE features are obvious to ascertain its safety and effectiveness in the treatment of right adrenal artery tumors.

Ovarian metastases from gallbladder mimics primary ovarian neoplasm in young patient: a case report

Background

Gallbladder cancer is unusually seen but can result in highly mortality rate. It makes challenge to diagnose for clinicians due to present asymptomatic or non-specific clinical presentation including abdominal pain, anorexia. It usually also accompanies with cholelithiasis (incidence is 1–2%) and incidentally detected by radiologic examination such as ultrasound, computed tomography or intra-operative intervention accidentally. Gallbladder cancer results in highly fatal malignancy because it is difficult to early detect. The ovarian metastases from gallbladder mimics primary neoplasm isn’t seen before and mentioned in English literatures before.

Case presentation

A 28-year-old woman suffered from intermittently lower abdominal tenderness and nausea after meals for 3 years. The abdominal ultrasound revealed a right ovarian mass with fluid accumulation and the contrast CT of abdomen revealed a gallbladder fundus mass and liver tumor lesion located at segment 4. We arranged surgical intervention with radical cholecystectomy and debulking operation with salpingo-oophorectomy. The pathologic report revealed adenocarcinoma of gallbladder with liver, peritoneum, and right ovarian invasion. After surgical intervention, she also received adjuvant chemotherapy with Gemcitabine, Cetuximab, Cisplatin and Cyberknife.

Conclusion

The non-specific symptoms make the challenge to difference the primary malignant neoplasm. The rarely diagnosis must take in consider if the gastrointestinal tract tumours coexist with ovarian tumours.

Reduced miR-550a-3p leads to breast cancer initiation, growth, and metastasis by increasing levels of ERK1 and 2

Hyperactivation of the Ras/ERK pathway contributes to breast cancer initiation and progression, and recent evidence suggests aberrant signaling of miRNAs that regulate the Ras/ERK pathway play important roles during carcinogenesis and cancer progression. In this study, we demonstrate that miR-550a-3p expression is negatively correlated with levels of ERK1 and ERK2, two pivotal effectors in the Ras/ERK pathway. MiR-550a-3p gradually decreased during breast cancer initiation and progression and this reduction was a prognostic indicator of poorer overall survival (OS) and disease-free survival (DFS) among breast cancer patients. Our mechanistic studies demonstrated that miR-550a-3p exerts its tumor-suppressor role by directly repressing ERK1 and ERK2 protein expression, thereby suppressing the oncogenic ERK/RSK cascades, which reduced breast cancer cell viability, survival, migration, invasion, tumorigenesis, and metastasis. The inhibitory effects of miR-550a-3p were rescued by ectopic expression of ERK1 and/or ERK2. The novel connection between miR-550a-3p and ERK defines a new diagnostic and prognostic role for miR-550a-3p and highlights ERK inhibition as a candidate therapeutic target for breast cancers exhibiting hyperactivated Ras/ERK signaling.

Blunt Abdominal Trauma with Left Kidney Dropped into Lower Retroperitoneal Cavity: A Case Report and Literature Review

Blunt abdominal injury with kidney laceration is not unusually seen in high-energy traffic accident. It can present with no symptoms and yet lead to fatal complications. High-grade lacerations of kidney (American Association for the Surgery of Trauma [AAST] grade IV to V) will show up with contrast extravasation and disrupted kidney/pelvicalyceal system morphology in computed tomography (CT). However, it is rare to see kidney dislocation from retroperitoneal space because of the presence of the Gerota's fascia. We present a case of a 16-year-old boy suffering from traffic accident with blunt truncal/abdominal injury. The contrast CT of abdomen revealed that his left kidney was dislocated from the original retroperitoneal space and sagged to the lower retroperitoneal cavity. We performed emergency left nephrectomy. He recovered well and there was no complication noted after the surgical intervention. We also review the literature of kidney laceration regarding diagnosis and treatment. (Hong Kong j.emerg.med. 2016;24:176-179)

The Values of Combined and Sub-Stratified Imaging Scores with Ultrasonography and Mammography in Breast Cancer Subtypes

Background and Objectives

The Breast Imaging Reporting and Data System (BI-RADS) of Mammography (MG) and Ultrasonography (US) were equivalent to the “5-point score” and applied for combined and sub-stratified imaging assessments. This study evaluated the value of combined and sub-stratified imaging assessments with MG and US over breast cancer subtypes (BCS).

Materials and Methods

Medical records of 5,037 cases having imaging-guided core biopsy, performed from 2009 to 2012, were retrospectively reviewed. This study selected 1,995 cases (1,457 benign and 538 invasive cancer) having both MG and US before biopsy. These cases were categorized with the “5-point score” for their MG and US, and applied for combined and sub-stratified imaging assessments. Invasive cancers were classified on the basis of BCS, and correlated with combined and sub-stratified imaging assessments.

Results

These selected cases were evaluated by the “5-point score.” MG, US, and combined and sub-stratified imaging assessments all revealed statistically significant (P < 0.001) incidence of malignancy. The sensitivity was increased in the combined imaging score (99.8%), and the specificity was increased in the sub-stratified combined score (75.4%). In the sub-stratified combined imaging assessment, all BCS can be classified with higher scores (abnormality hierarchy), and luminal B subtype showed the most salient result (hierarchy: higher, 95%; lower, 5%).

Conclusions

Combined and sub-stratified imaging assessments can increase sensitivity and specificity of breast cancer diagnosis, respectively, and Luminal B subtype shows the best identification by sub-stratified combined imaging scoring.

Association of Tartrate-Resistant Acid Phosphatase-Expressed Macrophages and Metastatic Breast Cancer Progression

Infiltrating neutrophils, lymphocytes, macrophages, and cytokines constitute a state of chronic inflammation within the tumor microenvironment. Tartrate-resistant acid phosphatase 5a (TRACP5a) protein, a novel product of activated macrophage, is postulated to be a biomarker for systemic inflammatory burden in states of chronic inflammation. We aimed to investigate the clinical significance of TRACP5a expression in tumor-infiltrating macrophages and serum TRACP5a in patients with metastatic breast cancer (BC). We retrospectively analyzed the clinical data from 34 BC patients with confirmed skeletal/visceral metastasis upon or during first-line palliative treatment. Patients were stratified into 3 groups based on the therapeutic responses and follow-up disease course. The association of TRACP5a protein with other inflammatory and cancer biomarkers was assessed among the clinically distinct group of patients. Higher TRACP5a protein was significantly correlated with earlier disease progression and survival (P = 0.0045) in comparison to other inflammatory markers, CRP or IL-6. Patients with higher serum TRACP5a level and shorter survival and treatment refractoriness also had more TRACP+ tumor-infiltrating macrophages. Our data support a hypothesis that serum TRACP5a protein can potentially be a predictive and prognostic marker to evaluate disease progression and therapeutic response in BC patients with bone/visceral metastasis. The associations between overall survival and TRACP expression by macrophages require further prospective investigation.

Abstract 3018: SHIP2 plays an oncogenic role in breast cancer stem cells through JNK/vimentin activation and its phosphatase activity

Background and Objectives: Over-expression of SH2-containing-5’-inositol phosphatase-2 (SHIP2) which converts phosphatidylinositol (3,4,5)-trisphosphate [PI(3,4,5)P3] into phosphatidylinositol (3,4)-biphosphate [PI(3,4)P2] has been shown to correlate with decreased disease-free survival in breast cancer. However, its role in breast cancer stem cells (BCSCs) remains unclear.

Results: We analyzed 60 clinical breast cancer specimens and found that the percentage of SHIP2+ cells was positively correlated with that of CD24-CD44+ cells. Among 20 estrogen receptor (ER)-negative samples, 17 had greater SHIP2 expression in CD24-CD44+ subpopulation than the remaining subpopulation. Examination of mouse xenografts derived from primary human breast cancer specimens revealed that SHIP2 protein and its tyrosine 1135 phosphorylation were significantly higher in BCSCs, identified as CD24-CD44+ or ALDH+, than non-BCSCs. SHIP2 silencing or inhibitor of SHIP2 phosphatase significantly decreased mammosphere-forming efficiency, percentage of ALDH+ subpopulation in vitro and tumorigenicity of BCSCs in vivo. SHIP2 shRNA knockdown and SHIP2 phosphatase inhibitor suppressed p-AktSer473 levels. Addition of PI(3,4)P2 could partially rescue Akt phosphorylation and ALDH+ subpopulation in SHIP2-overexpressing AS-B634 cells treated with SHIP2 phosphatase inhibitor. Whereas, PI(3,4)P2 failed to reverse the effects of SHIP2-silencing on Akt activation and ALDH+ subpopulation. Futhermore, over-expression of SHIP2 enhanced the expression of epithelial-mesenchymal transition markers including vimentin (VIM), which was mainly expressed in ER-negative breast cancer cells with higher level in mammospheres than monolayer culture. Ablation of c-Jun N-terminal kinase 1 (JNK1), JNK2 or VIM hampered the increases of both ALDH+ population and tumorigenicity induced by SHIP2 over-expression. BCSCs displayed greater expression of phospho-JNK than non-BCSCs. Futhermore, silencing of JNK suppressed the upregulation of VIM by SHIP2 in breast cancer.

Conclusion: Our study is the first to demonstrate that SHIP2 is crucial for maintaining the properties of BCSCs. Within ER-negative breast cancer, there was a significant correlation of greater expression of SHIP2 in BCSCs than non-BCSCs. We documented a novel functional role of SHIP2 in enhancing mammosphere formation and ALDH+ subpopulation in vitro, promoting tumorigenicity in vivo and inducing the expression of EMT markers including VIM. The upregulation of VIM was mediated by JNK activation. Furthermore, the phosphatase activity of SHIP2 also contributed to its role in BCSCs. In summary, our study has uncovered an oncogenic role of SHIP2 in promoting BCSC features and its underlying molecular mechanisms, providing the impetus for the design of novel BCSC-directed therapeutics by targeting SHIP2.

Citation Format: Chiung-Hui Fu, Ruey-Jen Lin, John Yu, Wen-Wei Chang, Guo-Shiou Liao, Wen-Ying Chang, Ling-Ming Tseng, Yi-Fang Tsai, Jyh-Cherng Yu, Alice L. Yu. SHIP2 plays an oncogenic role in breast cancer stem cells through JNK/vimentin activation and its phosphatase activity. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3018. doi:10.1158/1538-7445.AM2014-3018

The prognostic significance of RUNX2 and miR-10a/10b and their inter-relationship in breast cancer

Background

The major cancer related mortality is caused by metastasis and invasion. It is important to identify genes regulating metastasis and invasion in order to curtail metastatic spread of cancer cells.

Methods

This study investigated the association between RUNX2 and miR-10a/miR-10b and the risk of breast cancer relapse. Expression levels of RUNX2 and miR-10a/b in108 pairs of tumor and non-tumor tissue of breast cancer were assayed by quantitative PCR analysis and evaluated for their prognostic implications.

Results

The median expression levels of RUNX2 and miR-10b in tumor tissue normalized using adjacent non-tumor tissue were significantly higher in relapsed patients than in relapse-free patients. Higher expression of these three genes were significantly correlated with the hazard ratio for breast cancer recurrence (RUNX2: 3.02, 95% CI = 1.50 ~ 6.07; miR-10a: 2.31, 95% CI = 1.00 ~ 5.32; miR-10b: 3.96, 95% CI = 1.21 ~ 12.98). The joint effect of higher expression of all three genes was associated with a hazard ratio of 12.37 (95% CI = 1.62 ~ 94.55) for relapse. In a breast cancer cell line, RUNX2 silencing reduced the expression of miR-10a/b and also impaired cell motility, while RUNX2 overexpression elicited opposite effects.

Conclusions

These findings indicate that higher expression of RUNX2 and miR-10a/b was associated with adverse outcome of breast cancer. Expression levels of RUNX2 and miR-10a/b individually or jointly are potential prognostic factors for predicting breast cancer recurrence. Data from in vitro studies support the notion that RUNX2 promoted cell motility by upregulating miR-10a/b.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-014-0257-3) contains supplementary material, which is available to authorized users.

The prognostic value of lymph node status among breast cancer subtypes

BACKGROUND

Breast cancer subtypes (BCSs) are predictive of responses to specific therapies and of prognostic value for clinical outcomes. This study aimed to evaluate the relative 5-year overall survival (OS) and recurrence-free survival rates (RFS) based on lymph node (LN) status among BCSs.

METHODS

Medical records of 1,399 breast cancer patients treated from 2006 to 2011 were retrospectively reviewed. Pathologic findings, type of treatment, and OS and RFS were evaluated for 5 molecular subtypes.

RESULTS

Luminal A cancers accounted for 40.9% of the total, luminal B 21.5%, luminal human epidermal growth factor receptor 2 (HER2) 24.8%, HER2 6.9%, and triple negative 5.9%, of which 30% (n = 395) were LN positive. Analysis of patient characteristics showed significant differences among BCSs in age, tumor size, LN status, chemotherapy, and endocrine therapy. Adjustments for age and tumor size revealed significant differences in OS according to the nodal status in luminal A, luminal B, and luminal HER2 subtypes, and with RFS in the luminal B and luminal HER2 subtypes.

CONCLUSION

LN status in BCS presents an important prognostic factor of OS and RFS.

Malignant phyllodes tumors display mesenchymal stem cell features and aldehyde dehydrogenase/disialoganglioside identify their tumor stem cells

Introduction

Although breast phyllodes tumors are rare, there is no effective therapy other than surgery. Little is known about their tumor biology. A malignant phyllodes tumor contains heterologous stromal elements, and can transform into rhabdomyosarcoma, liposarcoma and osteosarcoma. These versatile properties prompted us to explore their possible relationship to mesenchymal stem cells (MSCs) and to search for the presence of cancer stem cells (CSCs) in phyllodes tumors.

Methods

Paraffin sections of malignant phyllodes tumors were examined for various markers by immunohistochemical staining. Xenografts of human primary phyllodes tumors were established by injecting freshly isolated tumor cells into the mammary fat pad of non-obese diabetic-severe combined immunodeficient (NOD-SCID) mice. To search for CSCs, xenografted tumor cells were sorted into various subpopulations by flow cytometry and examined for their in vitro mammosphere forming capacity, in vivo tumorigenicity in NOD-SCID mice and their ability to undergo differentiation.

Results

Immunohistochemical analysis revealed the expression of the following 10 markers: CD44, CD29, CD106, CD166, CD105, CD90, disialoganglioside (GD2), CD117, Aldehyde dehydrogenase 1 (ALDH), and Oct-4, and 7 clinically relevant markers (CD10, CD34, p53, p63, Ki-67, Bcl-2, vimentin, and Globo H) in all 51 malignant phyllodes tumors examined, albeit to different extents. Four xenografts were successfully established from human primary phyllodes tumors. In vitro, ALDH⁺ cells sorted from xenografts displayed approximately 10-fold greater mammosphere-forming capacity than ALDH^- cells. GD2⁺ cells showed a 3.9-fold greater capacity than GD2^- cells. ALDH⁺/GD2⁺cells displayed 12.8-fold greater mammosphere forming ability than ALDH^-/GD2^- cells. In vivo, the tumor-initiating frequency of ALDH⁺/GD2⁺ cells were up to 33-fold higher than that of ALDH⁺ cells, with as few as 50 ALDH⁺/GD2⁺ cells being sufficient for engraftment. Moreover, we provided the first evidence for the induction of ALDH⁺/GD2⁺ cells to differentiate into neural cells of various lineages, along with the observation of neural differentiation in clinical specimens and xenografts of malignant phyllodes tumors. ALDH⁺ or ALDH⁺/GD2⁺ cells could also be induced to differentiate into adipocytes, osteocytes or chondrocytes.

Conclusions

Our findings revealed that malignant phyllodes tumors possessed many characteristics of MSC, and their CSCs were enriched in ALDH⁺ and ALDH⁺/GD2⁺ subpopulations.

Acute appendicitis with superior mesenteric vein septic thrombophlebitis

Septic thrombophlebitis of the superior mesenteric vein (SMV) is rarely caused by acute appendicitis. The clinical symptoms of SMV thrombophlebitis are varied and atypical, so the diagnosis is commonly delayed, resulting in a reported mortality rate of 30%-50%. We report a case of SMV septic thrombophlebitis caused by acute appendicitis in which the patient was successfully treated with surgical intervention, appropriate antibiotics, and anticoagulation therapy. A follow-up abdominal computed tomography scan after 3 months of treatment showed that the SMV thrombosis had been resolved.

Current surgical approach to Paget's disease

BACKGROUND

Paget's disease constitutes between 1% and 3% of all breast malignancies, which makes defining standard surgical therapy difficult. We sought to identify preoperative factors that would select patients for successful breast conservation.

METHODS

Fifty-one patients with Paget's disease underwent surgical therapy between October 1998 and January 2010. Clinical presentation of Paget's disease, preoperative imaging, pathologic tumor characteristics, as well as surgical, radiation, and adjuvant therapies were reviewed.

RESULTS

Thirty-seven percent underwent breast conservation whereas 63% underwent mastectomy. Twelve patients presented with a palpable mass, and all were treated with mastectomy. Twenty-two patients underwent a mammogram, identifying extensive abnormality requiring mastectomy. Magnetic resonance imaging added to surgical planning in 52% of patients who participated in the study. None of our patients had a local/regional recurrence at 29 months of follow-up evaluation.

CONCLUSIONS

Paget's disease of the breast can be treated with breast conservation in a properly selected subset of patients. Successful breast conservation was achieved in patients without a palpable finding, a benign mammogram, and a normal magnetic resonance imaging scan.

Transection of the esophagus is optional in the Modified Sugiura procedure

BACKGROUND/AIMS

Esophageal transection in the Modified Sugiura procedure is advocated by some authors, but considered unnecessary by others. We compared the effectiveness of the Modified Sugiura procedure to our simplified Sugiura procedure that omits esophageal transection for the emergency treatment of bleeding esophagogastric varices.

METHODOLOGY

From January 1999 to September 2004 we treated 51 patients with cirrhosis of the liver and bleeding esophagogastric varices. All patients had failed management with emergency endoscopy treatment or balloon tamponade with vasopressin infusion. The patients were randomly divided into two groups and underwent the Modified Sugiura procedure with or without esophageal transections.

RESULTS

There were no significant differences in age, gender, cause of cirrhosis, or Child-Pugh classification between the two groups. The preoperative hemoglobin levels, preoperative and intraoperative transfusion volume, mortality, morbidity, and days of hospitalization showed no significant differences between the groups. The operative time was shorter with the simplified Sugiura procedure. The 1-3 year survival rates and the rebleeding rates did not differ significantly between the two groups.

CONCLUSION

Both treatments are effective emergency procedures for bleeding esophagogastric varices. Our simplified Sugiura procedure is an effective treatment for bleeding esophagogastric varices and requires a shorter operating time than the Modified Sugiura procedure.

Radiofrequency ablation after transarterial embolization as therapy for patients with unresectable hepatocellular carcinoma

PURPOSE

To evaluate the usefulness of transcatheter arterial embolization (TAE) followed by radiofrequency ablation (RFA) as combined treatment for unresectable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Thirty-six consecutive patients (cirrhosis, Child-Pugh class A or B) with solitary or oligonodular HCC were treated (41 lesions; mean size, 58.9 mm; range, 30-120 mm). RFA was performed after one TAE treatment. Local efficacy was evaluated with multiphasic computed tomography (CT) performed an average of two months after RFA and once during later follow-up.

RESULTS

The mean follow-up period was 16 months (range, 2-45 months). Technical success (namely, complete tumor devascularization during the arterial phase) was achieved for 59% of lesions at the first CT evaluation and for 46% at the second evaluation. Among prognostic factors included in the analysis, only lesion diameter (< 50 mm versus > or = 50 mm) was statistically significant in terms of predicting local success (Fisher's exact test: 85% versus 43% at first CT, p<0.01; 70% versus 36% during follow-up, p=0.05). There were no major periprocedural complications. Kaplan-Meier analysis showed survival rates of 84% at 12 months and 57% at 24 months.

CONCLUSIONS

Combined therapy--TAE then RFA--for unresectable HCC lesions in patients with cirrhosis produces a relatively high complete local response rate compared with TAE or RFA alone. Our results, considered with those from other case series, may help design prospective, randomized clinical trials to test combination therapy versus single-modality therapy in terms of risks and benefits.

Knot formation in the feeding jejunostomy tube: A case report and review of the literature

Jejunostomy feeding tubes provide surgeons with an excellent method for providing nutritional support, but there are several complications associated with a tube jejunostomy, including complications resulting from placement of the tube, mechanical problems related to the location or function and development of focally thickened small-bowel folds. A 76-year old man who presented with multiple medical diseases was admitted to our hospital due to aspiration pneumonia with acute respiratory failure and septic shock. He underwent exploratory laparotomy with feeding jejunostomy using a 14-French nasogastric tube for nutritional support. However, occlusion of the feeding tube was found 30 d after operation, and a rare complication of knot formation in the tube occurred after a new tube was replaced. On the following day, the tube was removed and replaced with a similar tube, which was placed into the jejunum for only 15 cm. The patient’s feedings were maintained smoothly for two months. Knot formation in the feeding tube seems to be very rare. To our knowledge, this is the third case in the literature review. Its incidence is probably related to the length of the tube inserted into the lumen.