Clinicopathological prognostic characteristics and long‑term outcomes of patients with breast cancer and collagen disorder in comparison to those without collagen disorder

Collagen disorders are chronic autoimmune diseases with a complex clinical course; however, the risk of breast cancer in patients with collagen disorders remains unclear. The present study aimed to investigate long-term outcomes in women with breast cancer and collagen disorders. A total of 25 patients with breast cancer and collagen disorders who were treated between January 2004 and December 2011 were included. The clinicopathological factors, treatment, recurrence-free survival (RFS) and overall survival (OS) were reviewed. The mean age was 56.4±12.6 years, and 14, eight and three patients had cancer of clinical stages I, II and III, respectively. Regarding comorbid collagen disorders, 11 patients had rheumatoid arthritis, four had systemic lupus erythematosus, four had polymyositis/dermatomyositis, two had mixed connective tissue disease, two had Sjogren's syndrome, one had scleroderma and one had adult-onset Still's disease. The expression statuses of hormone receptors (HR) and human epidermal growth factor receptor 2 (HER2) were HR(+), HER2(+) and HR(-)HER2(-) in 20 (80.0%), four (16.0%) and four (16.0%) patients, respectively. A total of 22 (84.0%) patients received steroids or immunosuppressive drugs for collagen disorders. The collagen disorder group had a higher mean Ki-67 labeling index than the control group (41.1 vs. 20.8%; P=0.007). After median observation periods of 103 and 114 months, the RFS and OS rates were lower in the collagen group than in the control group (64.5 and 80.7% vs. 85.3 and 94.3%, respectively; P<0.01). Patients with breast cancer and collagen disorders had relatively high Ki-67 expression, and relatively low RFS and OS rates. Thorough follow-up is necessary for patients with breast cancer who also have collagen disorders and high Ki-67 values.

First Impressions: Setting the Stage for Better Relationships

Background:

There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction.

Methods:

This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence.

Results:

Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15.

Conclusion:

The authors’ risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan

BACKGROUND

There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction.

METHODS

This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence.

RESULTS

Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15.

CONCLUSION

The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Vimentin-positive invasive breast carcinoma of no special type: A breast carcinoma with lethal biological characteristics

Vimentin is a stable mesenchymal immunohistochemical marker and is widely recognized as a major marker of mesenchymal tumors. The purpose of the present study was to investigate if the vimentin expression status might serve as a significant predictor of outcomes in patients with invasive breast carcinoma of no special type (IBC-NST) and to investigate, by comprehensive RNA sequencing analyses, the mechanisms involved in the heightened malignant potential of vimentin-positive IBC-NSTs. This study, conducted using the data of 855 patients with IBC-NST, clearly identified vimentin expression status as a very important independent biological parameter for accurately predicting the outcomes in patients with IBC-NST. RNA sequence analyses clearly demonstrated significant upregulation of coding RNAs known to be closely associated with cell proliferation or cellular senescence, and significant downregulation of coding RNAs known to be closely associated with transmembrane transport in vimentin-positive IBC-NSTs. We conclude that vimentin-positive IBC-NSTs show heightened malignant biological characteristics, possibly attributable to the upregulation of RNAs closely associated with proliferative activity and cellular senescence, and downregulation of RNAs closely associated with transmembrane transport in IBC-NSTs.

Tumor budding and fibrotic focus-proposed grading system for tumor budding in invasive carcinoma no special type of the breast

Tumor budding grade is a very useful histological prognostic indicator for colorectal cancer patients. Recently, it has been also reported as a significant prognostic indicator in invasive breast carcinoma patients. Our group and others have previously reported that the presence of a fibrotic focus in the tumor is a very useful histological finding for accurately predicting the prognosis in patients with invasive carcinoma of no special type (ICNST) of the breast. The purpose of the present study was to investigate whether a grading system incorporating tumor budding in a fibrotic focus is superior to the conventional grading system for tumor budding to accurately predict outcomes in patients with ICNST. According to our new grading system, we classified the tumors into grade I (164 cases), grade II (581 cases), and grade III (110 cases), and the results clearly demonstrated the significant superiority of the new grading system over that of conventional tumor budding alone for accurately predicting outcomes in patients with ICNST. Our findings strongly suggest that tumor cells and tumor-stromal cells interaction play very important roles in tumor progression rather than tumor cells alone.

Superdrainage Using the Cephalic Vein Due to Unsuitable Internal Thoracic Vein for Microvascular Anastomosis in Esophageal Reconstruction Using Pedicled Jejunum

The progress and popularization of microvascular surgical techniques may improve the outcomes of esophageal reconstruction using non-gastric tube (GT) grafts. A pedicled jejunum (PJ) with microvascular anastomoses is frequently selected as a reconstructed conduit for esophageal reconstruction when the GT is unavailable, and the internal thoracic (IT) vein is frequently selected as a recipient blood vessel for microvascular anastomosis. However, the IT vein may be inadequate for microvascular anastomosis because of its absence or underdevelopment. Since it is difficult to preoperatively predict such rare cases, it becomes necessary to urgently and rapidly prepare an alternative blood vessel. Herein, we present surgical procedures for superdrainage using the cephalic vein (CeV). Due the superficial nature of the CeV, it is both easy to identify and collect sufficient length. Thus, the CeV is very useful as an urgent substitute blood vessel when the IT vein is unavailable for microvascular anastomosis in esophageal reconstruction.

[Clinical Outcomes of Five Cases of Occult Breast Cancer in Which the Primary Site Was Not Detected in the Breast-by-Breast MRI]

Occult breast cancer is rare in practice. We studied the clinical outcomes of 5 occult breast cancers, including 2 with Luminal and 3 with non-Luminal subtypes, for which the primary site was not detected in the breast-by-breast MRI. The percentage of occult breast cancers that we encountered at our hospital was 0.11%. The mean age was 54 years. The Ki-67 labeling index value was 30% or higher for all the patients except one. Four patients were administered neoadjuvant chemotherapy and all but one patient received non-mastectomy and axillary dissection plus radiotherapy. We observed recurrent cases in one example each of the Luminal and HER2 subtypes, and both patients were less than 40 years old. The estimates of the probability of 5 year recurrence-free survival and 5 year overall survival were 40.0% and 66.7%, respectively. One recurrence case was a patient negative for ER and positive for HER2 wherein a breast cancer lesion appeared in the breast during post-treatment follow-up. Intrabreast relapse, which is itself rare in occult breast cancer, was observed 4 years postoperatively after standard treatment. Although there was no deviation according to subtype rate, the Ki-67 labeling index value was high and the prognosis was poor in our 5 cases.

Hydrosurgical debridement as an approach to wound healing: an animal thermal burn model

OBJECTIVE

This study investigates the advantages of hydrosurgical debridement compared with surgical debridement.

METHOD

Thermal skin burns were created on the backs of male Wistar rats. Surgical debridement was used to treat one wound and hydrosurgical debridement (Versajet Hydrosurgery System, Smith&Nephew, UK) used to treat the second wound. Debridement time, blood loss volume, time-to-heal and histologic changes in the wound areas were compared.

RESULTS

A total of 23 rats were used in the study. Debridement time and time-to-heal were significantly shorter with hydrosurgical debridement than with surgical debridement (p<0.01 and p<0.05, respectively). Blood loss volume was significantly less with hydrosurgical debridement (p<0.01), and the wound surface area was significantly smaller on days two (p<0.01), four (p<0.05) and seven (p<0.05). Dense inflammatory cell infiltration into dermal muscle was deeper after surgical debridement (p=0.017). Reactive fibrotic tissue at the wound surface was significantly thinner (p<0.001) and the vascular endothelial cell count was significantly higher (p<0.001) after hydrosurgical debridement.

CONCLUSION

The hydrosurgical system used appears to provide for minimally invasive debridement that can be performed in a relatively short period of time. Use of the device appears to minimise injury to healthy tissue and ameliorate inflammation, which in turn promotes early wound healing and reduces scar contracture. Hydrosurgical debridement appears to cause less damage to normal tissues. Furthermore, it is easier and requires less time.

In vivo analysis of skin microcirculation and the role of nitric oxide during vibration

Studies in healthy volunteers and patients with renal failure have shown that vibration, applied with a frequency of 47 Hz and a vibrational intensity of 600 mVpp, increases microcirculation of blood in the skin. This controlled, in vivo, experimental study was conducted to further evaluate the effect of vibration on skin microcirculation and to ascertain whether administration of a nitric oxide (NO) synthase inhibitor (NG-nitro-L-arginine methyl ester [L-NAME]) diminishes the effect of vibration on skin blood flow. Using a mouse microcirculatory model, 12 animals were prepared for study (six in the control and six in the experimental group). In the experimental group, vibrations were applied horizontally for 15 minutes. The control group received no vibration. Venular blood flow was measured using intravital videomicroscopy at baseline and at 0, 5, and 15 minutes after the application of vibration. Vibration significantly increased the blood flow at 5 and 15 minutes after application (P = 0.002 and P = 0.046, respectively). Differences between the control and experimental group also were statistically significant (P = 0.0017 and P = 0.046, respectively). In the second study, all animals (seven in each group) received an intraperitoneal injection of NO synthase inhibitor L-NAME before vibration application. When NO synthase inhibitor L-NAME was administered, the increase in blood flow in the vibration group was minimal after 5 and 10 minutes, and nonexistent after 15 minutes. No significant differences between the control and experimental group were observed. Because NO synthase inhibitor L-NAME inhibits NO production in vivo, these findings imply the involvement of NO in the observed blood flow increase during vibration. Future clinical trials to establish evidence as to the beneficial effects of vibration are warranted.

Determinants of wound healing in bone marrow-impregnated collagen matrix treatment: impact of microcirculatory response to surgical debridement

Although previous reports have suggested the efficacy of autologous bone marrow-impregnated collagen matrix experimentally and clinically, we occasionally encounter difficult wounds that fail to respond to the treatment. The current study retrospectively investigated the factors that affect clinical outcomes based on the hypothesis that periwound microcirculation may play a significant role. Fifty-three patients with chronic wounds received surgical debridement, followed by application of an autologous bone marrow-impregnated collagen matrix. The periwound transcutaneous oxygen tension (TcPO(2)) was evaluated (n=39). The patients were retrospectively divided into successful and unsuccessful subgroups. Successful treatment was defined as wound closure by spontaneous healing or skin graft. The TcPO(2) of the unsuccessful subgroup significantly decreased after debridement while that of the successful subgroup increased. Among various parameters, the TcPO(2) at 4 days after debridement showed the strongest association with the success of the treatment. As reference data, we collected the information of the patients (n=22) who received standard wound care, and they showed the same trend wherein the TcPO(2) of the unsuccessful subgroup markedly decreased after debridement. Reactivity of the wound microcirculation to increased wound perfusion in response to the surgical debridement might be a key determinant for successful wound healing.

Versatility of the Limberg flap and the V-Y flap (based on a distal perforator) for covering sacral ulcers

Our simple criteria for selection of two efficient flaps achieves consistently good results for most sacral ulcers. One hundred and ten patients had their sacral ulcers reconstructed with the Limberg flap (n = 48) or the distal-perforator-based V-Y (DPVY) flap (n = 62). The criteria for selection were based on pinching of the donor skin to estimate the feasibility of the Limberg flap. Overall, 101/110 (92%) of the flaps healed primarily, 43/48 (90%) in the Limberg flap group, and 58/62 (94%) in the DPVY flap group. The advantages of reconstruction using our two flaps include simple and consistent design of, and procedure for, both flaps, wide excursion of the DPVY flap, and consistency of the surgeons' skill because they used only two flaps.

Effect of vibration on skin blood flow in an in vivo microcirculatory model

The effect of vibration on skin microcirculation was studied to investigate the possibility of clinical use of vibration to prevent and treat pressure ulcers. Vibrations at a vibrational intensity of 600, 800, or 1,000 mVpp with a fixed frequency of 47 Hz were applied horizontally to the ear of male hairless mice (n = 6 for each group) under inhalation anesthesia. The control group (n = 6) received no vibrations. Venular blood flow was measured by an intravital videomicroscope at the baseline and at 0, 5, and 15 min after the application of vibrations. A significant increase was observed in the 600 mVpp group 5 and 15 min after vibration in comparison to the control group (P = 0.002 and P = 0.046, respectively). We also detected increased blood flow in the 800 mVpp group (P = 0.028) and the 1,000 mVpp group (P = 0.012) 5 min after vibration; however, these increases attenuated after 15 min. These results indicate that direct skin vibration at a frequency of 47 Hz improves skin blood flow. The present study gives further support to the role of vibration on a short-term increase in skin blood flow.

Structural impairments in optic nerve of diabetic rats ameliorated with the aldose reductase inhibitor

Structural impairments of optic nerve fibers in the streptozotocin-induced diabetic rat were investigated using morphometric analysis. The effect of aldose reductase inhibitor (ARI) on abnormalities in myelinated nerve fibers was also evaluated. Three months after the induction of diabetes, loss of body weight and significantly elevated levels of serum glucose were observed. Light microscopic examination revealed that the mean size of the optic nerve in the diabetic rat remained unchanged. Electron microscopic morphometry showed the significantly smaller cross-sectional size of axons and myelin but no change of myelinated fiber number. Reductions of myelinated fiber size was especially remarkable in the larger fibers. ARI treatment improved structural abnormalities without any changes in body weight and blood glucose level. Reduction of axon size and myelin/axon ratio was completely inhibited by ARI treatment. These findings suggest that structural impairment may contribute to the abnormalities of psychophysical and electrophysiological measurements detected in diabetes. Moreover, ARI treatment, which can improve the polyol metabolism, may have a beneficial effect on optic nerve impairment in diabetes.