Characteristics and behaviour of screen-detected ductal carcinoma in situ of the breast: comparison with symptomatic patients

Breast cancer is the most common malignancy in Singapore women. Ductal carcinoma in situ (DCIS) is the putative, non-obligate precursor of the majority of invasive breast cancers. The efficacy of the Singapore breast-screening pilot project in detecting early stage breast cancer led to the launch of a national breast-screening programme, BreastScreen Singapore (BSS), in January 2002. In this study, we compared clinicopathological and immunohistochemical characteristics, as well as clinical outcomes, between screen-detected and symptomatic DCIS. The study cohort comprised 1202 cases of DCIS diagnosed at Singapore General Hospital from 1994 to 2010. Comparison of clinicopathological parameters, immunohistochemical results of ER, PR, HER2, CK14, EGFR, and 34βE12, and clinical outcomes was carried out between the 2 groups. Amongst 1202 cases, 610 (50.7%) were screen-detected and 592 (49.3%) were symptomatic DCIS. Screen-detected cases were smaller in size (P < 0.001), of lower nuclear grade (P = 0.004), and more frequently expressed ER (P < 0.001). Luminal A phenotype was more frequently observed in screen-detected DCIS, while triple-negative and HER2 phenotypes were more common in symptomatic DCIS (P < 0.001). The basal-like phenotype was also more frequent in symptomatic DCIS (P = 0.041). Mean and median follow-up was 99.7 and 97.8 months, respectively, with a maximum follow-up of 246.0 months. More symptomatic patients developed invasive recurrences compared to screen-detected patients (P = 0.001). A trend for better disease-free survival was observed in screen-detected patients (P = 0.076). Patients who were screen-detected experienced better overall survival than those with symptomatic DCIS (P = 0.007). Our data indicate a more favourable outcome of screen-detected DCIS patients confirming the role of BSS in early identification of this curable disease.

P16 and cyclin D1 (CYD1) as prognostic markers in hypopharyngeal (HSC) and oropharyngeal squamous cell carcinoma (OSC)

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Background: In head and neck cancer (HNC), dysregulation of cell cycle proteins p16 and CYD1 are common. Variable associations of p16 over- and under- expression and CYD1 overexpression with overall survival (OS) have been described in different HNC sites. We evaluated the relationship of p16 and CYD1 expression with clinical characteristics and OS in OSC and HSC. Methods: p16 and CYD1 expression was evaluated by immunohistochemistry in 77 HSC and 103 OSC patients (pts) and recorded as p16N (0% tumor cells stained), p16L (5-69%) and p16H (≥70%), CYD1-(<10%) and CYD1+ (≥10%). OS between groups was evaluated by Kaplan-Meier method and compared by log rank test. Hazard ratio (HR) for death was estimated using multivariable Cox models. Results: Pts were predominantly Chinese (83.6% v 85.4%) with locally advanced HNC (91.4% v 92.2%). Compared to OSC, HSC pts were older (median age 67 v 61 yrs), more likely male (89.3% v 74.0%), current or ex-smokers (83.3% v 63.6%) with higher comorbidity-age combined risk score (ageCCI), less likely p16H (6.5% v 30.1%)(all p<0.001) and had similar CYD+. p16H pts were younger (median age 58 (p16H) v 65 (p16L) v 66 (p16N) yrs, p=0.002), more likely non-smoker (51.4% v 23.4% v 13% p<0.001) with lowest ageCCI (p<0.001). Clinical characteristics did not differ by CYD1 status. At median f/u of 50mths, median OS was 33 mths. Median OS was poor in HSC compared to OSC (23.9 v 72.1, p<0.001). Multivariate analysis showed associations of N2/N3 disease (HR 1.57, p=0.036), ageCCI (HR 1.22 per 1 pt increase, p<0.001), p16 (p16H: ref; p16L: HR 2.34, p=0.045; p16N: HR 2.74, p=0.013) and CYD1+ (HR 1.94, p=0.015) with death, independent of gender, smoking and site. Association of p16 with OS was seen mainly in OSC (median OS p16H: not reached (NR), p16L: 62, p16N: 22 mths, p<0.001) compared with median OS (HSC) (27 v 28 v 21, p=0.609). Similarly the association of CYD1 with OS was mainly in OSC (median OS CYD1-: NR v 23 mths, p<0.001 v HSC: 25 v 25 mths, p=0.19). Conclusions: In OSC, p16 expression correlates with OS, with p16N associated with worst OS. CYD1 has an independent association with OS. Poorer OS in HSC may be due to adverse clinical characteristics. Assessment of p16 and CYD1 status in HSC did not predict for OS.

Association of smoking status with p16 and cyclin D1 (CCND1) expression with clinical characteristics and overall survival (OS) in oropharyngeal squamous cell carcinoma (OSC)

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Background: Smoking-related head and neck cancer (HNC) is genetically different, with higher mutation rates compared with non-smokers (NS). Human papillomavirus (HPV)-positive (+) OSC has a superior prognosis independent of treatment. Among HPV+ patients (pt), current or prior smokers (CS) have poor OS compared with NS. Expression of p16, a known HPV surrogate, and CYD1, a cell cycle marker often dysregulated in HNC, was evaluated with respect to smoking status and OS. Methods: Expression of p16 and CYD1 was assessed by immunohistochemistry in 108 OSC pt treated between 1999-2009, using cutoffs of ≥70% (p16+) and ≥10% (CYD1+) stained tumor cells. Associations between expression, clinical characteristics and OS were evaluated by Kaplan-Meier method and compared by log rank test. Hazard ratio (HR) for death was estimated using Cox models. Results: 31 pt (28.7%) were p16+ and 80 pt (75.5%) were CYD1 negative(-). p16+ pt were younger (median age 57 v 66 yrs, p=0.002), more likely female (35.5% v 15.2%, p=0.035), NS (51.6% v 13.9%, p<0.001) with lower combined age-comorbidity score (ageCS) (p=0.003). CYD1+ pt were older (median 66 v 57 yrs, p=0.015), more likely CS (81.5% v 48.1%, p=0.002) with higher ageCS (p=0.018). At a median f/u of 65.7 months, median OS was 57.3 months. p16+ pt had better OS than p16- pt (median OS not reached (NR) v 22.3 mths, p<0.001). CYD1+ pt had poorer OS than CYD1- pt (median OS NR v 17.7 mths, p<0.001). On multivariable analysis p16 and CYD1 status were independently associated with OS (HR 0.412, p=0.045 and HR 4.06, p=0.011 respectively), independent of smoking status (HR 5.01, p=0.008), ageCS (HR 1.32 per 1 point increase, p<0.001) and stage. Strikingly, among NS, 5-year OS in p16+ compared with p16- pt was 100% vs 67% (p<0.001). In contrast, among CS, p16 status had no association with OS (HR 0.97, p=0.943), while CYD1 status and ageCS were independent predictors of death (HR 4.70, p=0.025 and HR 1.28, p<0.001 respectively). Conclusions: In OSC, NS with high p16 expression have excellent prognosis. Among CS, pt with fewer comorbidities and low CYD1 expression have better OS. p16 status was not prognostic in the latter group of patients.

Predicting clinical behaviour of breast phyllodes tumours: a nomogram based on histological criteria and surgical margins

AIM

To define a predictive model for clinical behaviour of breast phyllodes tumours (PT) using histological parameters and surgical margin status.

METHODS

Cases of breast PT diagnosed in the Department of Pathology Singapore General Hospital between January 1992 and December 2010 were stratified into benign, borderline and malignant grades based on a combination of histological parameters (stromal atypia, hypercellularity, mitoses, overgrowth and nature of tumour borders). Surgical margin status was assessed. Clinical follow-up and biostatistical modelling were accomplished.

RESULTS

Of 605 PT, 440 (72.7%) were benign, 111 (18.4%) borderline and 54 (8.9%) malignant. Recurrences, which were predominantly local, were documented in 80 (13.2%) women. Deaths from PT occurred in 12 (2%) women. Multivariate analysis revealed stromal atypia, overgrowth and surgical margins to be independently predictive of clinical behaviour, with mitoses achieving near significance. Stromal hypercellularity and tumour borders were not independently useful. A nomogram developed based on atypia, mitoses, overgrowth and surgical margins (AMOS criteria) could predict recurrence-free survival at 1, 3, 5 and 10 years. This nomogram was superior to a total histological score derived from adding values assigned to each of five histological parameters.

CONCLUSION

A predictive nomogram based on three histological criteria and surgical margin status can be used to calculate recurrence-free survival of an individual woman diagnosed with PT. This can be applied for patient counselling and clinical management.

Human papillomavirus infection and its possible correlation with p63 expression in cervical cancer in Japan, Mongolia, and Myanmar

Although human papillomavirus (HPV) 16 is the cause of cervical cancer in most countries including Japan, the involvement of cervical cancer with HPV types in Mongolian and Myanmar populations is largely unknown. We examined the expression of HPV in formalin-fixed and paraffin-embedded cervical tissues from 40 Japanese, 32 Mongolian, and 30 Myanmar cervical cancer patients. We performed immunohistochemistry using anti-HPV16 and anti-HPV 1, 6, 11, 16, 18 and 31 cocktail and then correlated it with the expression of Ki-67 and p63. HPV 16 was detected in 72%, 65% and 50% of Japanese, Mongolian and Myanmar cervical cancer patients, respectively, whereas 5 (13%) of the 40 patients, 8 (25%) of the 32 patients and 7 (23%) of the 30 patients in HPV 16-negative cancers were positive for other HPV types included in the cocktail, respectively. Ki-67 labeling index (LI) as well as p63 LI was significantly higher in HPV 16-positive patients than in HPV 16-negative ones in the Japanese and Mongolian samples. p63 expression was significantly associated with stage III and IV in Japan and Mongolia. These findings suggest that HPV 16 may be associated with cell proliferative activity and tumor progression, possibly depending upon the expression of p63 in the cervical cancer. In addition, immunohistochemical detection for distinguishing the type of HPV may also be useful for cervical cancer in the clinical setting.