Computational pathology in the identification of HER2-low breast cancer: Opportunities and challenges

For the past 2 decades, pathologists have been accustomed to reporting the HER2 status of breast cancer as either positive or negative, based on HER2 IHC. Today, however, there is a clinical imperative to employ a 3-tier approach to interpreting HER2 IHC that can also identify tumours categorised as HER2-low. Meeting this need for a finer degree of discrimination may be challenging, and in this article, we consider the potential for the integration of computational approaches to support pathologists in achieving accurate and reproducible HER2 IHC scoring as well as outlining some of the practicalities involved.

Need for Staging Investigations in Newly Diagnosed Breast Cancer: Establishing Local Guidelines for Radiological Staging in Bahrain

Objective

Staging workup and detection of distant metastases is important in newly diagnosed breast cancer in order to make treatment decisions and establish the prognosis. There is wide variation in current recommendations for staging investigations in breast cancer. Routine staging is performed for all patients in Bahrain because of lack of consistent guidelines. Optimization of the criteria for staging is important for identification of metastases, while minimizing harm and costs. The aim of this study was to evaluate factors associated with distant metastases in newly diagnosed patients with breast cancer, in order to establish local guidelines for proper selection of patients for systemic staging.

Materials and Methods

Patients with newly diagnosed breast cancer at Salmaniya Medical Complex in Bahrain who underwent staging investigations between January 2016 and December 2022 were identified from a pathology database. Patients with previous history of cancer, synchronous tumors, bilateral breast cancer and ductal carcinoma in situ were excluded. Clinical, radiological and pathological data were retrospectively analyzed.

Results

A total of 593 patients underwent staging computed tomography and bone scans or a PET scan. Distant metastases were identified in 20.7% of cases. M1 disease was significantly associated with multifocality/multicentricity, high grade tumors, hormone receptor-negative cancers, high Ki67 index, advanced tumor stage, node-positive disease, triple-negative breast cancer, use of PET scans and those who underwent neoadjuvant chemotherapy. Age was not associated with identification of distant metastases.

Conclusion

The prevalence of distant metastases in this population of newly diagnosed patients with breast cancer was higher than previously reported. Routine staging of all patients at presentation was not indicated, especially for asymptomatic patients with early breast cancer. This study identified certain groups of patients with a higher risk of distant metastasis, in whom metastatic workup should be performed. These findings may allow for the development of a local guideline that addresses the question of which breast cancer patients need staging investigations for distant metastases.

Melanocyte colonization and pigmentation of breast carcinoma: A case report

Pigmented mammary Paget disease is a rare variant of mammary Paget disease that is often clinically misdiagnosed as a melanocytic lesion of the skin or nipple-areolar complex. Careful morphological assessment, along with the performance of adequate immunohistochemical stains, will help in achieving the right diagnosis and avoiding misdiagnosis of the entity as malignant melanoma. We report a rare case of pigmented mammary Paget disease with concomitant colonization of the underlying invasive ductal carcinoma by melanocytes mimicking melanoma.

Transition Metal Oxide-Decorated MXenes as Drugless Nanoarchitectonics for Enriched Nanocatalytic Chemodynamic Treatment

Despite their unique characteristics, 2D MXenes with sole photothermal conversion ability are required to explore their superfluous abilities in biomedicine. The small-molecule-based chemotherapeutics suffer from various shortcomings of time-consuming and expensiveness concerning theoretical and performance (preclinical/clinical) checks. This study demonstrates the fabrication of Ti3C2 MXene nanosheets (TC-MX NSs) and subsequent decoration with transition metal oxides, that is, copper oxide (Cu2O/MX, CO-MX NCs) as drugless nanoarchitectonics for synergistic photothermal (PTT)-chemodynamic therapeutic (CDT) efficacies. Initially, the monolayer/few-layered TC-MX NSs are prepared using the chemical etching-assisted ultrasonic exfoliation method and then deposited with Cu2O nanoconstructs using the in situ reduction method. Further, the photothermal ablation under near-infrared (NIR)-II laser irradiation shows PTT effects of CO-MX NCs. The deposited Cu2O on TC-MX NSs facilitates the release of copper (Cu+) ions in the acidic microenvironment intracellularly for Fenton-like reaction-assisted CDT effects and enriched PTT effects synergistically. Mechanistically, these deadly free radicals intracellularly imbalance the glutathione (GSH) levels and result in mitochondrial dysfunction, inducing apoptosis of 4T1 cells. Finally, the in vivo investigations in BALB/c mice confirm the substantial ablation of breast carcinoma. Together, these findings demonstrate the potential synergistic PTT-CDT effects of the designed CO-MX NCs as drugless nanoarchitectonics against breast carcinoma.

Breast Metastasis: An Unusual Cause of Malignant Breast Lesion

Teaching point: Although rare, an intra-mammary metastasis from extramammary cancer should be considered in a patient with an oncological history.

High HER2 Intratumoral Heterogeneity Is a Predictive Factor for Poor Prognosis in Early-Stage and Locally Advanced HER2-Positive Breast Cancer

PURPOSE

Breast cancer tumors frequently have intratumoral heterogeneity (ITH). Tumors with high ITH cause therapeutic resistance and have human epidermal growth factor receptor 2 (HER2) heterogeneity in response to HER2-targeted therapies. This study aimed to investigate whether high HER2 heterogeneity levels were clinically related to a poor prognosis for HER2-targeted adjuvant therapy resistance in primary breast cancers.

METHODS

This study included patients with primary breast cancer (n = 251) treated with adjuvant HER2-targeted therapies. HER2 heterogeneity was manifested by the shape of HER2 fluorescence in situ hybridization amplification (FISH) distributed histograms with the HER2 gene copy number within a tumor sample. Each tumor was classified into a biphasic grade graph (high heterogeneity [HH]) group or a monophasic grade graph (low heterogeneity [LH]) group based on heterogeneity. Both groups were evaluated for disease-free survival (DFS) and overall survival (OS) for a median of ten years of annual follow-up.

RESULTS

Of 251 patients with HER2-positive breast cancer, 46 (18.3%) and 205 (81.7%) were classified into the HH and LH groups, respectively. The HH group had more distant metastases and a poorer prognosis than the LH group (DFS: p < 0.001 (HH:63% vs. LH:91% at 10 years) and for the OS: p = 0.012 (HH:78% vs. LH:95% at 10 years).

CONCLUSIONS

High HER2 heterogeneity is a poor prognostic factor in patients with HER2-positive breast cancer. A novel approach to heterogeneity, which is manifested by the shape of HER2 FISH distributions, might be clinically useful in the prognosis prediction of patients after HER2 adjuvant therapy.

Efficacy of Peripheral Nerve Stimulator Guided Pectoral Nerve Block-1 and Serratus Anterior Plane Block for Post-operative Analgesia in Modified Radical Mastectomy: A Randomized Controlled Study

BACKGROUND

Breast carcinoma is one of the most common cancers in present-day women worldwide, hence surgical intervention for the same is inevitable. General anesthesia being the preferred technique, the selection of appropriate postoperative pain management is a major concern in which superficial fascial plane chest wall blocks play a pivotal role. We aimed to prove the efficacy of peripheral nerve stimulator-guided pectoral nerve-1 (PEC 1) block and serratus anterior plane (SAP) block for postoperative analgesia in modified radical mastectomy.

METHODS

This prospective randomized controlled clinical study comprised 60 females undergoing modified radical mastectomy and was randomly allocated to two groups. Group A patients received general anesthesia while, in addition to general anesthesia, group B patients received PEC 1 and SAP blocks. Postoperatively the active and passive visual analog score (VAS), duration of analgesia, cumulative requirement of rescue analgesics in the first 24 hours and associated perioperative complications were noted. All quantitative data were analyzed by student t-test and qualitative data by chi-square test using MedCalc software 12.5.

RESULTS

VAS score for first 24 hours in group B was lower at rest, on pressure over the surgical site as well as on movements compared with the patients in group A with the p-value being < 0.0001 at all time intervals. Time for receiving first rescue analgesia was shorter (1.25±0.56hour vs 20.05±7.78hour, p<0.001) with the significantly higher requirement of cumulative doses of tramadol in the first 24 hours in patients belonging to group A (233.33±47.95mg vs 110±31.62 mg, p<0.001).

CONCLUSION

PEC 1 and SAP blocks given under peripheral nerve stimulator guidance have a high success rate and are reliable in providing adequate postoperative analgesia for patients undergoing modified radical mastectomy.

The Relationship Between Breast Density and Breast Cancer Surgical Outcomes: A Systematic Review

This study aims to investigate the relationship between mammographic breast density and the surgical outcomes of breast cancer. PubMed, SCOPUS, Web of Science, Science Direct, and the Wiley Library were systematically searched for relevant literature. Rayyan QRCI was employed throughout this comprehensive process. Our results included ten studies with a total of 5017 women diagnosed with breast cancer. The follow-up duration ranged from 1 year to 15.1 years. Eight out of the twelve included studies reported that low mammographic breast density was significantly associated with no local recurrence, metachronous contralateral breast cancer, and fewer challenges in the preoperative and intraoperative phases. On the other hand, four studies reported that mammographic breast density is not linked to disease recurrence, survival, re-excision, or an incomplete clinical and pathological response. There is a significant association between low mammographic breast density and reduced challenges in the preoperative and intraoperative phases, as well as no local recurrence and fewer mastectomy cases. However, the link between mammographic breast density and disease recurrence, survival, re-excision, and incomplete clinical and pathological response is less clear, with some studies reporting no significant association. The findings suggest that mammographic breast density may play a role in certain aspects of breast cancer outcomes, but further research is needed to fully understand its impact.

Management and risk of upgrade of atypical ductal hyperplasia in the breast: A population-based retrospective cohort study

BACKGROUND

International guidelines recommend open surgery for atypical ductal hyperplasia (ADH) in the breast due to risk of underestimating malignant disease. Considering the ongoing randomized trials of active surveillance of low-risk ductal carcinoma in situ (DCIS), it seems reasonable to define a low-risk group of women with ADH where a conservative approach is appropriate. The aim here was to evaluate the management and risk for upgrade of lesions diagnosed as ADH in percutaneous breast biopsies in two Swedish hospitals.

METHODS

All women with a screen-detected or symptomatic breast lesion breast imaging-reporting and data system (BI-RADS) 2-4 and a percutaneous biopsy showing ADH between 2013 and 2022 at Sundsvall Hospital and Umeå University Hospital were included. Information regarding imaging, histopathology, clinical features, and management was retrieved from medical records. Odds ratio (OR) and 95% confidence intervals (CI) for upgrade to malignant diagnosis after surgery were calculated by logistic regression analysis.

RESULTS

Altogether, 101 women were included with a mean age 56.1 (range 36-93) years. Most women were selected from the national mammography screening program due to microcalcifications. Biopsies were performed with vacuum-assisted biopsy (60.4%) or core-needle biopsy (39.6%). Forty-eight women (47.5%) underwent surgery, of which 11 were upgraded to DCIS, and 7 to invasive breast cancer (upgrade rate 37.5%). Among the 53 women managed conservatively (median follow-up 74 months), one woman (1.9%) developed subsequent ipsilateral DCIS. The combined upgrade rate was 18.8%. No clinical variable statistically significantly correlating to risk of upgrade was identified.

CONCLUSIONS

The upgrade rate of 37.5% in women undergoing surgery compared to an estimated 5-year risk of ipsilateral malignancy at 1.9% in women managed conservatively indicate that non-surgical management of select women with ADH is feasible. Research should focus on defining reproducible criteria differentiating high-risk from low-risk ADH.

exerts oncostatic effects in rodent and in vitro models of breast carcinoma

Introduction: Based on extensive data from oncology research, the use of phytochemicals or plant-based nutraceuticals is considered an innovative tool for cancer management. This research aimed to analyze the oncostatic properties of Salvia officinalis L. [Lamiaceae; Salviae officinalis herba] using animal and in vitro models of breast carcinoma (BC). Methods: The effects of dietary administered S. officinalis in two concentrations (0.1%/SAL 0.1/and 1%/SAL 1/) were assessed in both syngeneic 4T1 mouse and chemically induced rat models of BC. The histopathological and molecular evaluations of rodent carcinoma specimens were performed after the autopsy. Besides, numerous in vitro analyses using two human cancer cell lines were performed. Results and Conclusion: The dominant metabolites found in S. officinalis propylene glycol extract (SPGE) were representatives of phenolics, specifically rosmarinic, protocatechuic, and salicylic acids. Furthermore, the occurrence of triterpenoids ursolic and oleanolic acid was proved in SPGE. In a mouse model, a non-significant tumor volume decrease after S. officinalis treatment was associated with a significant reduction in the mitotic activity index of 4T1 tumors by 37.5% (SAL 0.1) and 31.5% (SAL 1) vs. controls (set as a blank group with not applied salvia in the diet). In addition, salvia at higher doses significantly decreased necrosis/whole tumor area ratio by 46% when compared to control tumor samples. In a rat chemoprevention study, S. officinalis at a higher dose significantly lengthened the latency of tumors by 8.5 days and significantly improved the high/low-grade carcinomas ratio vs. controls in both doses. Analyses of the mechanisms of anticancer activities of S. officinalis included well-validated prognostic, predictive, and diagnostic biomarkers that are applied in both oncology practice and preclinical investigation. Our assessment in vivo revealed numerous significant changes after a comparison of treated vs. untreated cancer cells. In this regard, we found an overexpression in caspase-3, an increased Bax/Bcl-2 ratio, and a decrease in MDA, ALDH1, and EpCam expression. In addition, salvia reduced TGF-β serum levels in rats (decrease in IL-6 and TNF-α levels were with borderline significance). Evaluation of epigenetic modifications in rat cancer specimens in vivo revealed a decline in the lysine methylations of H3K4m3 and an increase in lysine acetylation in H4K16ac levels in treated groups. Salvia decreased the relative levels of oncogenic miR21 and tumor-suppressive miR145 (miR210, miR22, miR34a, and miR155 were not significantly altered). The methylation of ATM and PTEN promoters was decreased after S. officinalis treatment (PITX2, RASSF1, and TIMP3 promoters were not altered). Analyzing plasma metabolomics profile in tumor-bearing rats, we found reduced levels of ketoacids derived from BCAAs after salvia treatment. In vitro analyses revealed significant anti-cancer effects of SPGE extract in MCF-7 and MDA-MB-231 cell lines (cytotoxicity, caspase-3/-7, Bcl-2, Annexin V/PI, cell cycle, BrdU, and mitochondrial membrane potential). Our study demonstrates the significant chemopreventive and treatment effects of salvia haulm using animal or in vitro BC models.

Phase II Trial Assessing the Repeatability and Tumor Uptake of [68Ga]Ga-HER2 Single-Domain Antibody PET/CT in Patients with Breast Carcinoma

Human epidermal growth factor receptor 2 (HER2) status is used for decision-making in breast carcinoma treatment. The status is obtained through immunohistochemistry or in situ hybridization. These two methods have the disadvantage of necessitating tissue sampling, which is prone to error due to tumor heterogeneity or interobserver variability. Whole-body imaging might be a solution to map HER2 expression throughout the body. Methods: Twenty patients with locally advanced or metastatic breast carcinoma (5 HER2-positive and 15 HER2-negative patients) were included in this phase II trial to assess the repeatability of uptake quantification and the extended safety of the [68Ga]Ga-NOTA-anti-HER2 single-domain antibody (sdAb). The tracer was injected, followed by a PET/CT scan at 90 min. Within 8 d, the procedure was repeated. Blood samples were taken for antidrug antibody (ADA) assessment and liquid biopsies. On available tissues, immunohistochemistry, in situ hybridization, and mass spectrometry were performed to determine the correlation of HER2 status with uptake values measured on PET. If relevant preexisting [18F]FDG PET/CT images were available (performed as standard of care), a comparison was made. Results: With a repeatability coefficient of 21.8%, this imaging technique was repeatable. No clear correlation between PET/CT uptake values and pathology could be established, as even patients with low levels of HER2 expression showed moderate to high uptake. Comparison with [18F]FDG PET/CT in 16 patients demonstrated that in 7 patients, [68Ga]Ga-NOTA-anti-HER2 shows interlesional heterogeneity within the same patient, and [18F]FDG uptake did not show the same heterogeneous uptake in all patients. In some patients, the extent of disease was clearer with the [68Ga]Ga-NOTA-anti-HER2-sdAb. Sixteen adverse events were reported but all without a clear relationship to the tracer. Three patients with preexisting ADAs did not show adverse reactions. No new ADAs developed. Conclusion: [68Ga]Ga-NOTA-anti-HER2-sdAb PET/CT imaging shows similar repeatability to [18F]FDG. It is safe for clinical use. There is tracer uptake in cancer lesions, even in patients previously determined to be HER2-low or -negative. The tracer shows potential in the assessment of interlesional heterogeneity of HER2 expression. In a subset of patients, [68Ga]Ga-NOTA-anti-HER2-sdAb uptake was seen in lesions with no or low [18F]FDG uptake. These findings support further clinical development of [68Ga]Ga-NOTA-anti-HER2-sdAb as a PET/CT tracer in breast cancer patients.

A Case Report of Zosteriform Cutaneous Metastases from Breast Carcinoma

We described a 58-year-old female diagnosed with zosteriform cutaneous metastases from breast carcinoma. She was initially diagnosed with herpes zoster. Correct diagnosis was obtained after pathological biopsy. Various forms of cutaneous metastases have various forms, which require careful discrimination by dermatologists to reduce the rate of misdiagnosis.

A New Synthesized Dicarboxylated Oxy-Heparin Efficiently Attenuates Tumor Growth and Metastasis

Heparanase (Hpa1) is expressed by tumor cells and cells of the tumor microenvironment and functions to remodel the extracellular matrix (ECM) and regulate the bioavailability of ECM-bound factors that support tumor growth. Heparanase expression is upregulated in human carcinomas, sarcomas, and hematological malignancies, correlating with increased tumor metastasis, vascular density, and shorter postoperative survival of cancer patients, and encouraging the development of heparanase inhibitors as anti-cancer drugs. Among these are heparin/HS mimetics, the only heparanase-inhibiting compounds that are being evaluated in clinical trials. We have synthesized dicarboxylated oxy-heparins (DCoxHs) containing three carboxylate groups per split residue (DC-Hep). The resulting lead compound (termed XII) was upscaled, characterized, and examined for its effectiveness in tumor models. Potent anti-tumorigenic effects were obtained in models of pancreatic carcinoma, breast cancer, mesothelioma, and myeloma, yielding tumor growth inhibition (TGI) values ranging from 21 to 70% and extending the survival time of the mice. Of particular significance was the inhibition of spontaneous metastasis in an orthotopic model of breast carcinoma following resection of the primary tumor. It appears that apart from inhibition of heparanase enzymatic activity, compound XII reduces the levels of heparanase protein and inhibits its cellular uptake and activation. Heparanase-dependent and -independent effects of XII are being investigated. Collectively, our pre-clinical studies with compound XII strongly justify its examination in cancer patients.

Diagnostic Utility of Fine-Needle Aspiration Cytology (FNAC) and Frozen Section Against Histopathology in Evaluating Benign and Malignant Breast Lesions

INTRODUCTION

Breast lesions, particularly lumps, pose concerns for females, varying between benign and malignant conditions. Accurate differentiation solely through clinical assessment is challenging, necessitating a definitive diagnostic strategy. Fine-needle aspiration cytology (FNAC) is integral in the "triple approach" to breast evaluation, offering simplicity, reliability, and cost-effectiveness. However, FNAC has limitations, occasionally failing to yield definitive diagnoses due to inherent constraints. Contrarily, frozen-section analysis, a long-standing intraoperative diagnostic method, plays a crucial role in swift diagnosis during surgeries. Despite technological advancements, frozen sections serve specific diagnostic purposes, confirming carcinoma when FNAC is inconclusive and evaluating resected margins. However, freezing artifacts may affect tissue assessment, emphasizing the continued reliance on histopathology for guiding treatment decisions.

OBJECTIVES

This study was conducted at KVG Medical College and Hospital, Sullia, Karnataka, India. It aimed to analyze the morphological characteristics of benign and malignant breast lesions using FNAC, frozen section, and histopathology and evaluate the sensitivity, specificity, and predictive values of FNAC and frozen section against histopathology as the reference standard.

METHODS

A cross-sectional investigation was carried out at a tertiary care hospital's Department of Pathology, on 60 female patients who presented with palpable breast masses over a span of two and a half years. FNAC was conducted, and the observations were classified into five categories as per the International Academy of Cytology guidelines. In addition, intraoperative frozen-section analysis was undertaken. A comparative analysis was conducted between the FNAC and intraoperative frozen-section findings, juxtaposed with the subsequent histopathological diagnoses.

RESULTS

FNAC revealed 51.7% malignant, 45% benign, and 3.3% inadequate cases; the frozen-section analysis indicated 51.6% malignant, 45% benign, and 3.3% deferred cases; histopathology showed 53.3% malignant, 45% benign, and 1.6% borderline cases. FNAC demonstrated 93.9% sensitivity, 100% specificity, 100% positive predictive value (PPV), 93.1% negative predictive value (NPV), and 96.7% accuracy. The frozen-section analysis exhibited 96.9% sensitivity, 100% specificity, 100% PPV, 96.4% NPV, and 98.3% accuracy.

CONCLUSION

Intraoperative frozen-section analysis displays superior diagnostic utility compared to preoperative FNAC. However, histopathology remains the definitive gold standard. Integrating all three diagnostic modalities is crucial for precise diagnosis and effective patient management.

Breast cancer's hidden partner: meningoencephalitis as a paraneoplastic revelation: a rare presentation of invasive ductal carcinoma of breast: a case report

Introduction and importance

Paraneoplastic neurologic syndromes encompass a group of neurologic disorders arising from pathological processes unrelated to metastasis, metabolic disturbances, infections, coagulopathy, or treatment-related side effects. These syndromes can affect various regions of the nervous system, resulting in diverse clinical manifestations.

Case presentation

The authors present a rare case of anti-amphiphysin-associated meningoencephalitis in a South Asian Pakistani woman. Initially, the patient was managed for suspected infectious meningitis, but empirical treatment failed to yield improvement. Subsequent investigations unveiled a paraneoplastic syndrome secondary to breast cancer.

Discussion

Diagnosing these clinical entities is challenging due to their multifaceted presentations, often leading to delayed identification, increased patient suffering, economic burdens, and preventable complications.

Conclusion

Anti-amphiphysin-associated meningoencephalitis is a rare manifestation of paraneoplastic syndromes. It is crucial to raise awareness among healthcare professionals about the diverse presentations of paraneoplastic syndromes.

Prognostic value of glucose transporter proteins-1 (GLUT1) in breast carcinoma

Several studies have reported increased glucose transporters (GLUT) expression in different cancer types, including breast cancer. The primary purpose of this study is to examine GLUT1 immunoexpression in breast cancer patients in Saudi Arabia and to determine its significance. The study examined the association between GLUT1 immunophenotype and the clinicopathological characteristics in breast cancer. GLUT1 expression was analyzed in retrospectively collected tissue samples (n = 578) from breast cancer patients using immunohistochemistry. A total of 311 (54%) of the cases expressed GLUT1 cytoplasmic immunohistochemical staining. In univariate analysis, we found a significant association between GLUT1 expression and high-grade tumors (p < 0.0001). Positive estrogen and progesterone receptor results predicted lower GLUT1 immunoexpression (p < 0.0001 for both). Vascular invasion showed a significant association with GLUT1 immunoexpression (p = 0.045). Our findings support that GLUT1 immunohistochemistry can be used as a marker to determine the grade and hormonal receptor status in breast cancer.

Infiltrative Optic Neuropathy in Advanced Breast Carcinoma

Infiltrative optic neuropathy is a condition characterized by the invasion of tumor cells into the optic nerve. Breast carcinoma can metastasize to various organs, most commonly the bones, lungs, and liver, and rarely involves the orbit. Orbital involvement may result in debilitating visual impairment and blindness. We report a case of infiltrative optic neuropathy secondary to advanced breast carcinoma. A 39-year-old woman with stage 4 breast carcinoma presented with sudden-onset blurred vision in her right eye for one week. It was associated with a localized scotoma in the visual field. She was previously diagnosed with secondary metastases involving the liver and bone and is currently undergoing treatment with chemotherapy and radiotherapy. Visual acuity in the right eye was 6/7.5, with a positive relative afferent pupillary defect and an inferonasal field defect. The extraocular muscle movement was full, with no significant proptosis. Both anterior segments were unremarkable. Fundoscopy showed a normal optic disc in both eyes, with no optic disc swelling. A computed tomography (CT) scan of the brain and orbit revealed secondary metastases in the dura and right orbital apex. Magnetic resonance imaging (MRI) of the brain revealed right infiltrative optic neuropathy. The patient received whole-brain radiotherapy (WBRT), followed by 12 cycles of chemotherapy. On follow-up, the patient was stable; however, her vision in the right eye deteriorated from 6/7.5 to perception of light. In conclusion, orbital metastasis should be the leading diagnostic consideration when the affected patient has a history of cancer. Early detection, coupled with prompt treatment, can help patients achieve better visual outcomes and, whenever possible, preserve their vision.

The overexpression of cyclin D1 is a positive prognostic factor in advanced-stage breast carcinoma cases

OBJECTIVE

Cyclin D1 (CDDN1) is a protein required for mitotic cell cycle progression through the G1 phase, as well as a regulatory component of the cyclin-dependent kinases CDK4 and CDK6. In this study, we wanted to evaluate the relationship between CDDN1 expression and clinicopathological features in breast cancer (BC) cases and whether CDDN1 could be used as a prognostic biomarker for BC cases.

METHODS

A total of 70 cases, 30 cases each with limited and advanced-stage BC, and as the control group, 10 healthy breast tissue, without a cancer diagnosis, with examined for benign reasons (mammoplasty, breast reduction surgery, etc.) were included in this study. The pathological specimens from the cases were stained, immunohistochemically, and categorized as a "low" (L) group or a "high" (H) group for CDDN1 expression. The cases' clinicopathological features and survival rates were evaluated statistically, within a 95% of confidence interval, p<0.05, retrospectively.

RESULTS

The median follow-up period of the cases was 48.00 (range, 6-150) months. CDDN1 expression was significantly higher in advanced-stage BC cases than in normal breast tissue and limited-stage BC cases. The median overall survival (OS) was 96 months (CI 95%: 67.74-117.59) in the H-CDDN1 group, compared to the L-CDDN1 group not reached, but there was no relation (p>0.05). CDDN1 overexpression was more prominent in low-grade advanced BC cases (p=0.004). The median OS of advanced-stage BC cases with Grade 1 was significantly longer than those with other grades (p=0.04).

CONCLUSION

Our results suggest that CDDN1 expression can be used as a potentially appropriate positive prognostic biomarker for advanced-stage BC cases.

Lobular Carcinoma of the Breast: A Comprehensive Review with Translational Insights

The second most common breast carcinoma, invasive lobular carcinoma, accounts for approximately 15% of tumors of breast origin. Its incidence has increased in recent times due in part to hormone replacement therapy and improvement in diagnostic modalities. Although believed to arise from the same cell type as their ductal counterpart, invasive lobular carcinomas (ILCs) are a distinct entity with different regulating genetic pathways, characteristic histologies, and different biology. The features most unique to lobular carcinomas include loss of E-Cadherin leading to discohesion and formation of a characteristic single file pattern on histology. Because most of these tumors exhibit estrogen receptor positivity and Her2 neu negativity, endocrine therapy has predominated to treat these tumors. However novel treatments like CDK4/6 inhibitors have shown importance and antibody drug conjugates may be instrumental considering newer categories of Her 2 Low breast tumors. In this narrative review, we explore multiple pathological aspects and translational features of this unique entity. In addition, due to advancement in technologies like spatial transcriptomics and other hi-plex technologies, we have tried to enlist upon the characteristics of the tumor microenvironment and the latest associated findings to better understand the new prospective therapeutic options in the current era of personalized treatment.

Value of Molybdenum Target X-Ray and High-Frequency Color Doppler Flow Imaging in Early Diagnosis of Breast Carcinoma: A Comparative Analysis

Background

Breast carcinoma (BC) threatens the physical and mental health of women worldwide, and early diagnosis is important for improving patient outcomes and ensuring successful treatment.

Purpose

This research mainly aims to compare and analyze the value of molybdenum target X-ray and high-frequency color Doppler flow imaging (CDFI) in the early diagnosis of BC.

Methods

First, 102 patients with suspected early-stage BC (ESBC) admitted to Henan Provincial People's Hospital were examined by molybdenum target X-ray and CDFI. Based on the pathological findings, the diagnostic efficiency data of the two diagnostic modalities such as positive detection rate (PDR), positive predictive value (PPV), negative predictive value (NPV), sensitivity (SEN), specificity (SPE), and accuracy (ACC), as well as imaging information like masses, microcalcifications (MCs), axillary lymph node (LN) metastases, and blood flow signal or vascular sign abnormalities were analyzed.

Results

CDFI contributed to higher PDR, PRV, NPV, SEN, and ACC than molybdenum target X-ray in ESBC diagnosis, but similar SPE. The combined diagnosis of molybdenum target X-ray plus CDFI contributed to even higher PDR, PRV, NPV, SEN, and ACC than molybdenum target X-ray alone and higher ACC than CDFI. Imaging inspection revealed that the number of cases of masses, axillary LN metastases, and abnormalities in blood flow signals or vascular signs detected by CDFI was significantly higher than that by molybdenum target X-ray, while the number of MCs was significantly lower.

Conclusion

Molybdenum target X-ray plus CDFI is more effective in the diagnosis of ESBC and plays a complementary role in imaging examination, which can synergistically improve the diagnostic ACC of ESBC and is worthy of clinical promotion.

Cbl induced ubiquitination of HER2 mediate immune escape from HER2-targeted CAR-T

Breast cancer (BC) with high HER2 expression has higher recurrence rate and worse prognosis, and its immunotherapy is promising. Based on the high expression of HER2, develop Chimeric Antigen Receptor T-cell (CAR-T) and PDL-1 immunotherapy, and study the molecular pathways of related immune cells and recurrence. HER2-CAR-T cells were constructed using retroviruses, and their specific recognition and immune effects on HER2+ BC cells were verified by in vivo and in vitro experiments. PDL-1 was used as adjuvant immunotherapy, knocking down PDL-1 in tumor cells or dendritic cells, or depleted macrophages to study immune pathways. The negative regulation of HER2 by cbl was determined by IP, ubiquitination experiments, and segmented plasmids, elucidating the molecular mechanism of HER2+ BC recurrence after immunotherapy. HER2-CAR-T specifically recognizes HER2-positive tumor cells and inhibits tumor growth in vivo and in vitro, and anti-PDL1 treatment enhances the therapeutic effect of HER2-CAR-T on tumors. HER2-CART therapy eradicated solid tumors after PDL1 knockdown in dendritic cells. Immunotherapy of relapsed tumors lost HER2 expression by upregulating cbl. HER2-CAR-T shows specific recognition of HER2+ cells and can mediate immune response therapy with the cooperation of PDL-1.

A Review of the Advancements in Targeted Therapies for Breast Cancer

Breast cancer, the second-most common and lethal disease in women, poses a severe danger to global health. Breast cancer rates continue to climb despite advances in medical technology. Predictions indicate that by 2040, there will be more than three million new cases yearly. Targeted medicines have experienced a profound transformation in treating breast cancer, allowing for individualized strategies that lessen side effects and improve patient outcomes. This thorough analysis gives a rigorous investigation of current developments in breast cancer-targeted treatments. It carefully examines several subtypes, including hormone receptor-positive (HR+), HER2-positive (HER2+), and triple-negative breast cancer (TNBC), recognizing the illness' fundamental variety. It offers specialized treatment plans catered to each subtype's particular traits. The review also examines how precise genetic abnormalities like BRCA1/2 and PIK3CA mutations and molecular profiling facilitate therapy selection. Monoclonal antibodies and small molecule inhibitors are some of the targeted medicines examined in the study. It explains how each of these treatments works and supports its findings with data from clinical trials. It also considers potential new medications and addresses persistent problems, such as resistance mechanisms, chances for combining therapies, and cutting-edge patient classification techniques. This study seeks to give healthcare professionals, researchers, and patients a thorough overview of the recent advancements in breast cancer-targeted therapy by drawing on the opinions of top authorities in the area. The coordinated effort aims to create customized, efficient therapies, eventually bolstering the battle against this powerful illness.

Metastatic primary breast neuroendocrine neoplasms: a case series

BACKGROUND

Breast neuroendocrine neoplasms represent a rare subtype of breast cancer which have not been well studied or characterised, particularly in the metastatic setting.

AIM

To present clinicopathological characteristics, treatment and outcomes of a series of patients with metastatic neuroendocrine carcinoma of the breast and review the current literature.

METHODS

We performed a retrospective review to identify and describe patients with metastatic neuroendocrine carcinoma of the breast at our centre between 2011 and 2021. Medical records, pathology and imaging results were examined to evaluate the clinical and histopathological features as well as the treatment pathways and prognosis of these patients.

RESULTS

We present a series of seven female patients with metastatic neuroendocrine carcinoma of the breast, as defined by the World Health Organization classification, over a period of 10 years (2011-2021) from a single centre. Median age at diagnosis was 48 years (range 39-63). Six of seven tissue samples expressed synaptophysin and chromogranin and were also oestrogen and progesterone receptor positive; median Ki-67 index was 50% (range 20-90%). All seven patients had demonstrated avidity on 18 F-FDG PET imaging, and the six who underwent 68 Ga-DOTATATE PET all had significant avidity. Treatment modalities and sequencing varied, but all patients received chemotherapy during their disease course. Six patients received three or more lines of treatment. Median overall survival was 31.8 months (range 3.7-108.6). Median progression-free survival (PFS) with first-line therapy for metastatic disease was 5.8 months (range 1.8-37.8).

CONCLUSIONS

This series shows the use of multiple modalities in treating this disease, with different sequencing in different patients. Despite multiple modalities used in the first-line setting, first-line PFS remains short. Larger series and further molecular characterisation are required to aid clinicians in managing this condition and to guide optimal treatment sequencing to improve outcomes in this rare patient group.

Treatment of Epiphyseal Metastasis to the Proximal Humerus Secondary to Breast Carcinoma: A Case Report

Metastasis to the bone is a known risk of breast cancer, with the humerus being the most common upper extremity site of metastases, with most lesions located at the humeral diaphysis. We present a unique case of proximal humeral metastasis involving the epiphysis secondary to primary invasive ductal carcinoma in a middle-aged Caucasian female. It is important to have a high degree of suspicion for metastasis when musculoskeletal pain occurs in breast cancer patients, as it may be masked by common, degenerative conditions about the shoulder girdle. When humeral metastases involve the epiphysis, treatment options are complicated by its location, which jeopardizes the integrity of articular cartilage and the function of the shoulder girdle. External beam irradiation provides pain control in a non-invasive manner, sans surgical risks. Surgical intervention will vary depending on the characteristics of the bony lesion, but the use of endoprosthetics has emerged as the most effective option for restoring range of motion and pain control with acceptable rates of implant survival.

Androgen Receptor Expression in ER and PR Negative Breast Cancer-A Study from a Tertiary Hospital in Northern India

Sumeet SidhuObjectives  Breast cancer is the leading cause of cancer-related deaths in women. Estrogen (ER) and progesterone receptor (PR) status and Her2 overexpression are major determinants in therapeutic decision making. Triple-negative breast cancers (TNBCs) have limited treatment options. Androgen receptor (AR) expression opens up therapeutic avenues for these patients. The aim of this article was to study the immunohistochemical expression of ARs in ER and PR Negative breast carcinomas and to correlate AR expression with various clinical, histopathological, and other immunohistochemical parameters. Materials and Methods  It is a cross-sectional study including 105 ER and PR Negative cases of breast carcinoma. Clinical parameters, histopathology, and immunohistochemical expression of AR, Her2, and Ki67 were analyzed in all cases. Results  AR expression was observed in 63.8% of ER and PR Negative breast cancers. In this group, AR expression was strongly associated with Her2 co-expression (89.2%) as compared to TNBCs (45.8%); p -value = 0.0002. Significant correlation was also observed between AR expression and tumor necrosis ( p -value = 0.034) and postmenopausal status ( p  = 0.007). Conclusion  Our study shows that significant proportion of ER and PR Negative breast carcinomas (ER- PR- Her2+ and TNBCs) show AR expression. We strongly recommend routine evaluation of all hormone receptor-negative breast carcinomas for AR status by immunohistochemistry.

Comparison of Mast Cell Density and Prognostic Factors in Invasive Breast Carcinoma: A Single-Centre Study in Malaysia

Background

Mast cells influence tumour growth, neo-angiogenesis and the propensity for metastasis by contributing to innate and adaptive immune responses in the tumour microenvironment. The number of mast cells has increased in various malignant tumours and their abundance has been associated with either a favourable or unfavourable prognosis. This study investigated the significant difference in stromal mast cell density among multiple prognostic factor groups in invasive breast carcinoma.

Methods

CD117 (c-KIT) antibodies were used to stain 160 formalin-fixed and paraffin-embedded invasive breast carcinoma tissues to demonstrate the presence of mast cells. Then the labelled mast cells were counted in 10 fields at 400× magnification and the mean value was used to represent the mast cell density.

Results

The demographic distribution revealed that most patients were 40 years old or older (92.5%) and of Malay ethnicity (66.3%). With regard to prognostic factors, the most prevalent subtype was invasive carcinoma of no special type (80.6%), followed by tumour grade 3 (41.3%), T2 tumour size (63.1%), N0 lymph node stage (51.3%), presence of lymphovascular invasion (59.4%), positive oestrogen (64.4%) and progesterone receptors (53.1%), and negative human epidermal growth factor receptor 2 (HER2) expression (75.0%). However, there was no significant difference in stromal mast cell density among the different demographic and prognostic factor groups in invasive breast carcinoma.

Conclusion

The findings from this study suggest that stromal mast cells do not play a significant role in preventing or promoting tumour growth in invasive breast carcinoma.

Metastatic Mammary Carcinoma Presenting as a Large Cystic Axillary Mass: A Report of an Unusual Case

The differential diagnosis of cystic axillary masses is broad and includes intranodal lesions. Cystic metastatic tumor deposits are rare, and have been reported in a few tumor types, most commonly in the head and neck region, but rarely described with metastatic mammary carcinoma. We report a case of a 61-year-old female who presented with a large right axillary mass. Imaging studies revealed a cystic axillary mass and ipsilateral breast mass. She was managed with breast conservation surgery and axillary dissection for invasive ductal carcinoma, no special type, Nottingham grade 2 (21 mm). One of nine lymph nodes contained a cystic nodal deposit (52 mm), which resembled a benign inclusion cyst. Oncotype DX recurrence score for the primary tumor was low (8), conferring a low risk of disease recurrence despite the large size of the nodal metastatic deposit. A cystic pattern of metastatic mammary carcinoma is rare and important to recognize for accurate staging and management decisions.

FilGAP, a GAP for Rac1, down-regulates invadopodia formation in breast cancer cells

Invadopodia are protrusive structures that mediate the extracellular matrix (ECM) degradation required for tumor invasion and metastasis. Rho small GTPases regulate invadopodia formation, but the molecular mechanisms of how Rho small GTPase activities are regulated at the invadopodia remain unclear. Here we have identified FilGAP, a GTPase-activating protein (GAP) for Rac1, as a negative regulator of invadopodia formation in tumor cells. Depletion of FilGAP in breast cancer cells increased ECM degradation and conversely, overexpression of FilGAP decreased it. FilGAP depletion promoted the formation of invadopodia with ECM degradation. In addition, FilGAP depletion and Rac1 overexpression increased the emergence of invadopodia induced by epidermal growth factor, whereas FilGAP overexpression suppressed it. Overexpression of GAP-deficient FilGAP mutant enhanced invadopodia emergence as well as FilGAP depletion. The pleckstrin-homology (PH) domain of FilGAP binds phosphatidylinositol 3,4-bisphosphate [PI(3,4)P2], which is distributed on membranes of the invadopodia. FilGAP localized to invadopodia in breast cancer cells on the ECM, but FilGAP mutant lacking PI(3,4)P2-binding showed low localization. Similarly, the decrease of PI(3,4)P2 production reduced the FilGAP localization. Our results suggest that FilGAP localizes to invadopodia through its PH domain binding to PI(3,4)P2 and down-regulates invadopodia formation by inactivating Rac1, inhibiting ECM degradation in invasive tumor cells.Key words: invadopodia, breast carcinoma, Rac1, FilGAP, PI(3,4)P2.

Potential of Dietary HDAC2i in Breast Cancer Patients Receiving PD-1/PD-L1 Inhibitors

Breast cancer (BC) is a lethal malignancy with high morbidity and mortality but lacks effective treatments thus far. Despite the introduction of immune checkpoint inhibitors (ICIs) (including PD-1/PD-L1 inhibitors), durable and optimal clinical benefits still remain elusive for a considerable number of BC patients. To break through such a dilemma, novel ICI-based combination therapy has been explored for enhancing the therapeutic effect. Recent evidence has just pointed out that the HDAC2 inhibitor (HDAC2i), which has been proven to exhibit an anti-cancer effect, can act as a sensitizer for ICIs therapy. Simultaneously, dietary intervention, as a crucial supportive therapy, has been reported to provide ingredients containing HDAC2 inhibitory activity. Thus, the novel integration of dietary intervention with ICIs therapy may offer promising possibilities for improving treatment outcomes. In this study, we first conducted the differential expression and prognostic analyses of HDAC2 and BC patients using the GENT2 and Kaplan-Meier plotter platform. Then, we summarized the potential diet candidates for such an integrated therapeutic strategy. This article not only provides a whole new therapeutic strategy for an HDAC2i-containing diet combined with PD-1/PD-L1 inhibitors for BC treatment, but also aims to ignite enthusiasm for exploring this field.

FTO-mediated epigenetic upregulation of LINC01559 confers cell resistance to docetaxel in breast carcinoma by suppressing miR-1343-3p

This study was to explore the regulatory effect of long non-coding RNA LINC01559 on Docetaxel resistance in breast carcinoma (BCa) and its underlying mechanism. In the present study, we found that LINC01559 expression was elevated and LINC01559 overexpression facilitated docetaxel resistance in BCa cells. Moreover, it was revealed that the upregulation of LINC01559 in BCa cells was induced by FTO-mediated demethylation in an m6A-YTHDF2-dependent manner. Additionally, Dual-luciferase reporter assay confirmed the binding ability between LINC01559 and miR-1343-3p, and Pearson correlation analysis showed a negative correlation between them. Particularly, miR-1343-3p inhibition partly abolished the suppression on docetaxel resistance in BCa cells caused by LINC01559 knockdown. To sum up, FTO-mediated epigenetic upregulation of LINC01559 promoted cell resistance to Docetaxel in BCa by negatively regulating miR-1343-3p.

Metastatic osseous disease of unknown primary origin: a case report and review of literature

Cancer of unknown primary (CUP) is a heterogeneous group of metastatic tumors in the absence of a clinically identifiable site. We describe the case of a 66-year-old female with an extensive history of non-specific imaging concerning for malignancy who did not undergo further workup and in whom a diagnosis of CUP was made. The patient initially presented to her specialist with concern of right leg pain. Imaging at that time was concerning for a progressive malignant process. Given this, the patient was referred urgently for surgery. Final surgical pathology and breast prognostic panel were consistent with metastatic breast carcinoma at that time. Follow-up imaging performed 1-week postoperatively did not show suspicious findings in either breast, further supporting a diagnosis of CUP. To this end, we highlight the importance of follow-up imaging but recognize the challenges facing healthcare professionals in navigating the ethical principles of nonmalificience and beneficence in diagnostic workup.

Detecting Human Epidermal Growth Factor Receptor 2 (HER2) Amplification: Proof of Concept of an Alternative Approach

BACKGROUND

There are multiple genes that are co-amplified along with human epidermal growth factor receptor 2 (HER2) in chromosome 17. GRB7 and PGAP3 are two such genes. We hypothesize that the protein products of these genes may serve as immunohistochemistry (IHC) markers for detecting HER2 amplification in breast cancer.

METHODS

Tissue sections from one hundred and thirty-five primary breast carcinoma cases were subjected to immunohistochemical staining for antibodies against HER2, GRB7, and PGAP3 and graded on a scale of 1 to 3. Both membranous staining and cytoplasmic staining were assessed for GRB7 and PGAP3. For equivocal HER2 IHC positivity, fluorescent in situ hybridization was performed to get the final HER2 status.

RESULTS

IHC staining for GRB7 and PGAP 3 was a moderate to strong predictor for HER2 status (area under the curve (AUC) of 0.768, 0.868,0.754, and 0.790 for GRB7 membranous staining, GRB7 cytoplasmic staining, PGAP3 membranous staining, and PGAP3 cytoplasmic staining respectively). A combination of GRB7 cytoplasmic and PGAP3 membranous staining resulted in an AUC of 0.905 (95% CI 0.855-0.954), while a combination of GRB7 and PGAP3 cytoplasmic staining resulted in an AUC of 0.902 (95% CI 0.851-0.953).

CONCLUSION

The point estimates for the AUC of GRB7 and combined GRB7 and PGAP3 in predicting the AUC suggest a strong predictive ability of these markers to predict HER2. With further refinement in technique, cytoplasmic staining and membranous IHC staining for GRB7 and PGAP3 have potential to serve as surrogate markers for HER2 status. The strategy of using protein products of co-amplified genes of HER2 is likely to be successful in technical validation.

Clinicopathological Features and Prognosis of Gastrointestinal Metastases From Breast Carcinoma: A Clinicopathological Study of 22 Patients

Background. Breast carcinoma is the most common malignancy in women. Gastrointestinal metastasis is rarely found or diagnosed in patients with breast cancer. Methods. Clinicopathological features, treatment options, and prognosis were evaluated retrospectively for 22 patients with gastrointestinal metastases of breast carcinoma in Chinese women. Results. Presenting symptoms were non-specific: anorexia (21/22), epigastric pain (10/22), and vomiting (8/22), and 2 patients (2/22) presented with nonfatal hemorrhage. The first sites of metastases were skeleton (9/22), stomach (7/22), colorectal (7/22), lung (3/22), peritoneal (3/22), and liver (1/22). ER, PR, GATA binding protein 3 (GATA3), gross cystic disease fluid protein-15 (GCDFP-15), and keratin 7 can effectively confirm the diagnosis, especially in the case of keratin 20 negativity. Histology showed mainly ductal breast carcinoma (n = 11) was the predominant source of gastrointestinal metastases in this study, and lobular breast cancer (n = 9) accounted for a considerable proportion. The disease control rate to systemic therapy was 81% (17 of 21 treated patients), and the objective response rate was 10% (2 of 21 treated patients). Median overall survival was 71.5 months (range, 22-226 months), median survival for distant metastases was 23.5 months (range, 2-119 months) and the median survival for the time of gastrointestinal metastases diagnosis was 6 months (range, 2-73 months). Conclusions. Performing the endoscopy with biopsy was crucial for patients with any subtle gastrointestinal symptoms and a history of breast cancer. It is important to distinguish primary gastrointestinal carcinoma from breast metastatic carcinoma in order to select the optimal initial treatment and avoid unnecessary surgery.

The Enigma of Mammaglobin: Redefining the Biomarker Paradigm in Breast Carcinoma

The continuous evolution of cancer biology has led to the discovery of mammaglobin, a potential novel biomarker for breast carcinoma. This review aims to unravel the enigmatic aspects of mammaglobin and elucidate its potential role in redefining the paradigm of breast carcinoma biomarkers. We will thoroughly examine its expression in tumoral and peritumoral tissues and its circulating levels in the blood, thereby providing insights into its possible function in cancer progression and metastasis. Furthermore, the potential application of mammaglobin as a non-invasive diagnostic tool and a target for personalized treatment strategies will be discussed. Given the increasing incidence of breast carcinoma worldwide, the exploration of novel biomarkers such as mammaglobin is crucial in advancing our diagnostic capabilities and treatment modalities, ultimately contributing to improved patient outcomes.

The Prediction Analysis of Microarray 50 (PAM50) Gene Expression Classifier Utilized in Indeterminate-Risk Breast Cancer Patients in Hungary: A Consecutive 5-Year Experience

BACKGROUND

Breast cancer has been categorized into molecular subtypes using immunohistochemical staining (IHC) and fluorescence in situ hybridization (FISH) since the early 2000s. However, recent research suggests that gene expression testing, specifically Prosigna® Prediction Analysis of Microarray 50 (PAM50), provides more accurate classification methods. In this retrospective study, we compared the results of IHC/FISH and PAM50 testing. We also examined the impact of various PAM50 parameters on overall survival (OS) and progression-free survival (PFS).

RESULTS

We analyzed 42 unilateral breast cancer samples, with 18 classified as luminal A, 10 as luminal B, 8 as Human epidermal growth factor receptor 2 (HER2)-positive, and 6 as basal-like using PAM50. Interestingly, 17 out of the 42 samples (40.47%) showed discordant results between histopathological assessment and the PAM50 classifier. While routine IHC/FISH resulted in classification differences for a quarter to a third of samples within each subtype, all basal-like tumors were misclassified. Hormone receptor-positive tumors (hazard rate: 8.7803; p = 0.0085) and patients who had higher 10-year recurrence risk scores (hazard rate: 1.0539; p = 0.0201) had shorter OS and PFS.

CONCLUSIONS

Our study supports the existing understanding of molecular subtypes in breast cancer and emphasizes the overlap between clinical characteristics and molecular subtyping. These findings underscore the value of gene expression profiling, such as PAM50, in improving treatment decisions for breast cancer patients.

KIF20A is a Prognostic Marker for Female Patients with Estrogen Receptor-Positive Breast Cancer and Receiving Tamoxifen as Adjuvant Endocrine Therapy

Purpose

Our aim was to verify whether KIF20A has the potential to serve as a prognostic marker for female patients with estrogen receptor (ER)-positive breast cancer (BC) and treated with tamoxifen (TAM).

Patients and Methods

Online tools were used to investigate the potential correlation between KIF20A gene expression and survival of patients with ER-positive BC and TAM treatment. Furthermore, immunohistochemistry (IHC) was conducted to assess the expression levels of KIF20A in patients included from our center. The prognostic value of KIF20A for disease-free survival (DFS) and overall survival (OS) was further evaluated using Cox regression analysis.

Results

According to the results obtained from online tools, it was found that patients with low KIF20A expression exhibited significantly better survival outcomes in terms of relapse-free survival (RFS), distant metastasis-free survival (DMFS), and OS compared to those with high KIF20A expression (P < 0.001, P < 0.001, and P = 0.008, respectively). Additionally, significantly lower gene expression of KIF20A was found in patients who responded to TAM than in those who did not respond to TAM (P < 0.001). We further included 203 patients with adjuvant TAM therapy, and IHC for KIF20A was performed on sections from paraffin-embedded blocks. Patients with low KIF20A expression had significantly better DFS and OS (P = 0.001 and 0.002, respectively, log rank test), and the expression of KIF20A was identified as an independent factor for predicting both DFS and OS (P = 0.001 and 0.008, respectively).

Conclusion

KIF20A expression is an independent prognostic factor for survival in patients with ER-positive BC who received adjuvant TAM therapy. In clinical practice, IHC evaluation of KIF20A expression in surgical samples before administering tamoxifen may assist in predicting the treatment outcomes of these patients.

Artificial Intelligence-Aided Diagnosis of Breast Cancer Lymph Node Metastasis on Histologic Slides in a Digital Workflow

Identifying lymph node (LN) metastasis in invasive breast carcinoma can be tedious and time-consuming. We investigated an artificial intelligence (AI) algorithm to detect LN metastasis by screening hematoxylin and eosin (H&E) slides in a clinical digital workflow. The study included 2 sentinel LN (SLN) cohorts (a validation cohort with 234 SLNs and a consensus cohort with 102 SLNs) and 1 nonsentinel LN cohort (258 LNs enriched with lobular carcinoma and postneoadjuvant therapy cases). All H&E slides were scanned into whole slide images in a clinical digital workflow, and whole slide images were automatically batch-analyzed using the Visiopharm Integrator System (VIS) metastasis AI algorithm. For the SLN validation cohort, the VIS metastasis AI algorithm detected all 46 metastases, including 19 macrometastases, 26 micrometastases, and 1 with isolated tumor cells with a sensitivity of 100%, specificity of 41.5%, positive predictive value of 29.5%, and negative predictive value (NPV) of 100%. The false positivity was caused by histiocytes (52.7%), crushed lymphocytes (18.2%), and others (29.1%), which were readily recognized during pathologists' reviews. For the SLN consensus cohort, 3 pathologists examined all VIS AI annotated H&E slides and cytokeratin immunohistochemistry slides with similar average concordance rates (99% for both modalities). However, the average time consumed by pathologists using VIS AI annotated slides was significantly less than using immunohistochemistry slides (0.6 vs 1.0 minutes, P = .0377). For the nonsentinel LN cohort, the AI algorithm detected all 81 metastases, including 23 from lobular carcinoma and 31 from postneoadjuvant chemotherapy cases, with a sensitivity of 100%, specificity of 78.5%, positive predictive value of 68.1%, and NPV of 100%. The VIS AI algorithm showed perfect sensitivity and NPV in detecting LN metastasis and less time consumed, suggesting its potential utility as a screening modality in routine clinical digital pathology workflow to improve efficiency.

Dynamic contrast-enhanced magnetic resonance imaging features and apparent diffusion coefficient value of HER2-positive/HR-negative breast carcinoma

Background

According to hormone receptor (HR) status, human epidermal growth factor 2 positive (HER2+) breast carcinoma can be divided into HR- and HR+, with different treatment and prognosis. We analyzed the dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) findings, apparent diffusion coefficient (ADC) value and the combination of DCE-MRI and ADC value of HER2+/HR- breast carcinoma.

Methods

Totally 259 cases (96 HR-, 163 HR+) of pathologically verified HER2+ breast carcinoma were collected. Patients underwent DCE-MRI and diffusion weighted imaging (DWI). The morphological characteristics, internal enhancement characteristics, early enhancement rate (EER), and time-signal intensity curves (TIC) were recorded, and ADC values were measured. The relationship between each feature and HER2+/HR- breast cancer was analyzed. Area under the cures (AUC) was used to compare diagnostic performance of DCE-MRI, ADC value and the combination of DCE-MRI and ADC value.

Results

HER2+/HR- breast cancer presented as non-mass enhancement (NME), mass with NME, whereas HER2+/HR+ breast cancer presented as mass (P<0.001). HR- cases showed a round or oval shape with circumscribed margins, whereas HR+ cases showed an irregular mass with irregular or spiculated margins (P=0.001, P=0.028). The size of the mass, the internal enhancement characteristics, EER, and TIC did not differ significantly between the two HER2+ breast carcinomas. The ADC values for HR- and HR+ breast cancers were [1.2 (1.14, 1.33)] ×10-3 mm2/s and [1.0 (0.89, 1.11)] ×10-3 mm2/s, respectively, which were statistically significant (Z=-9.119, P<0.001). The ADC value can be used for diagnosing HER2+/HR- breast carcinoma, with the threshold value of 1.095×10-3 mm2/s [negative predictive value (NPV) of 89.8%, sensitivity of 86.5% and specificity of 70.6%]. The AUCs of ADC value, DCE-MRI, and DCE-MRI combined with ADC value were 0.839, 0.689 and 0.860, respectively. AUC of the DCE-MRI combined with ADC value was significantly higher than DCE-MRI alone (P<0.0001).

Conclusions

The diagnostic performance of the DCE-MRI combined with ADC value was good in diagnosing HER2+/HR- breast cancers. MRI is an effective tool in diagnosing HER2+/HR- breast carcinoma, which will help select the clinical treatment plan and determine the prognosis.

Primary Gastric Signet Ring Cell Carcinoma or Metastatic Lobular Carcinoma With Signet Ring Cells: A Diagnostic Challenge

Histologically, cells having vacuolated cytoplasm rich in mucin and pushing the nucleus to the periphery are indicative of signet ring cell carcinoma. This condition often affects the digestive system. On the other hand, it is a very uncommon subtype of invasive lobular breast carcinoma, with a higher probability (more than invasive breast carcinoma of no special type {IBC-NST}) to migrate to the stomach, spleen, urinary tract, and uterus. As with other metastatic carcinomas of breast origin, metastatic signet ring cell carcinoma of the breast is often treated with systemic therapies such as chemotherapy or hormonal therapy. However, surgical resection and eventual perioperative chemotherapy are usually recommended in case of primary gastric ring cell carcinomas that are non-metastatic. As a result, misdiagnosis might result in unneeded gastrectomy and chemotherapy, which would result in considerable mortality and morbidity. We report a case of mammary lobular carcinoma with signet ring cells metastatic to the stomach, a variant rarely described and challenging to distinguish from primary gastric signet ring carcinoma.

Analysis of the PARP1, ADP-Ribosylation, and TRIP12 Triad With Markers of Patient Outcome in Human Breast Cancer

PARP inhibitors (PARPi) are increasingly used in breast cancer therapy, including high-grade triple-negative breast cancer (TNBC) treatment. Varying treatment responses and PARPi resistance with relapse currently pose limitations to the efficacy of PARPi therapy. The pathobiological reasons why individual patients respond differently to PARPi are poorly understood. In this study, we analyzed expression of PARP1, the main target of PARPi, in normal breast tissue, breast cancer, and its precursor lesions using human breast cancer tissue microarrays covering a total of 824 patients, including more than 100 TNBC cases. In parallel, we analyzed nuclear adenosine diphosphate (ADP)-ribosylation as a marker of PARP1 activity and TRIP12, an antagonist of PARPi-induced PARP1 trapping. Although we found PARP1 expression to be generally increased in invasive breast cancer, PARP1 protein levels and nuclear ADP-ribosylation were lower in higher tumor grade and TNBC samples than non-TNBCs. Cancers with low levels of PARP1 and low levels of nuclear ADP-ribosylation were associated with significantly reduced overall survival. This effect was even more pronounced in cases with high levels of TRIP12. These results indicate that PARP1-dependent DNA repair capacity may be compromised in aggressive breast cancers, potentially fueling enhanced accumulation of mutations. Moreover, the results revealed a subset of breast cancers with low PARP1, low nuclear ADP-ribosylation, and high TRIP12 levels, which may compromise their response to PARPi, suggesting a combination of markers for PARP1 abundance, enzymatic activity, and trapping capabilities might aid patient stratification for PARPi therapy.

Incidence, Clinicopathologic Features, HER2 Fluorescence In Situ Hybridization Profile, and Oncotype DX Results of Human Epidermal Growth Factor Receptor 2-Low Breast Cancers: Experience From a Single Academic Center

Human epidermal growth factor receptor 2 (HER2)-low breast cancer, defined by an immunohistochemical (IHC) score of 1+ or 2+ with negative in situ hybridization, is emerging as a predictive marker for the use of the antibody-drug conjugate. To understand how this category differs from HER2-zero cases, we investigated clinicopathological characteristics and HER2 fluorescence in situ hybridization results in a large cohort of 1309 continuous HER2-negative invasive breast carcinomas from 2018 to 2021 evaluated by the Food and Drug Administration-approved HER2 IHC test. Additionally, we compared Oncotype DX recurrence scores and HER2 mRNA expression between HER-low and HER2-zero cases in a separate cohort of 438 estrogen receptor-positive (ER+) early-stage breast carcinoma cases from 2014 to 2016. Based on the cohort from 2018 to 2021, the incidence of HER2-low breast cancers was approximately 54%. HER2-low cases had less frequent grade 3 morphology, less frequent triple-negative results, ER and progesterone receptor negativity, and a higher mean HER2 copy number and HER2/CEP17 ratio than HER2-zero cases (P < .0001). Among ER+ cases, HER2-low cases showed significantly less frequent Nottingham grade 3 tumors. In the cohort from 2014 to 2016, HER2-low cases showed significantly higher ER+ percentages, fewer progesterone receptor-negative cases, lower Oncotype DX recurrence scores, and higher HER2 mRNA expression scores than HER2-zero cases. In summary, this is the first study, to our knowledge, using a large cohort of continuous cases evaluated by the Food and Drug Administration-approved HER2 IHC companion diagnostic test for HER2-low expression and HER2 fluorescence in situ hybridization profile in a real-world setting. Although HER2-low cases showed a higher HER2 copy number, ratio, and mRNA level than HER2-zero cases statistically, such small differences are unlikely to be biologically or clinically meaningful. However, our study suggests that HER2-low/ER+ early-stage breast carcinoma may represent a less aggressive group of breast carcinoma, given its association with a lower Nottingham grade and Oncotype DX recurrence score.

Implications of inflammatory cell death-related IFNG and co-expressed RNAs (AC006369.1 and CCR7) in breast carcinoma prognosis, and anti-tumor immunity

Objective: Interferon-γ (IFN-γ) encoded by IFNG gene is a pleiotropic molecule linked with inflammatory cell death mechanisms. This work aimed to determine and characterize IFNG and co-expressed genes, and to define their implications in breast carcinoma (BRCA). Methods: Transcriptome profiles of BRCA were retrospectively acquired from public datasets. Combination of differential expression analysis with WGCNA was conducted for selecting IFNG-co-expressed genes. A prognostic signature was generated through Cox regression approaches. The tumor microenvironment populations were inferred utilizing CIBERSORT. Epigenetic and epitranscriptomic mechanisms were also probed. Results: IFNG was overexpressed in BRCA, and connected with prolonged overall survival and recurrence-free survival. Two IFNG-co-expressed RNAs (AC006369.1, and CCR7) constituted a prognostic model that acted as an independent risk factor. The nomogram composed of the model, TNM, stage, and new event owned the satisfying efficacy in BRCA prognostication. IFNG, AC006369.1, and CCR7 were closely linked with the tumor microenvironment components (e.g., macrophages, CD4/CD8 T cells, NK cells), and immune checkpoints (notably PD1/PD-L1). Somatic mutation frequencies were 6%, and 3% for CCR7, and IFNG, and high amplification potentially resulted in their overexpression in BRCA. Hypomethylated cg05224770 and cg07388018 were connected with IFNG and CCR7 upregulation, respectively. Additionally, transcription factors, RNA-binding proteins, and non-coding RNAs possibly regulated IFNG and co-expressed genes at the transcriptional and post-transcriptional levels. Conclusion: Collectively, our work identifies IFNG and co-expressed genes as prognostic markers for BRCA, and as possible therapeutic targets for improving the efficacy of immunotherapy.

Abemaciclib, Palbociclib, and Ribociclib in Real-World Data: A Direct Comparison of First-Line Treatment for Endocrine-Receptor-Positive Metastatic Breast Cancer

By the end of 2020, there were more than 8 million women alive who had received a breast cancer diagnosis in the previous 5 years, making it the most prevalent neoplasia in the world. About 70% of breast-cancer cases present positivity for estrogen and/or progesterone receptors and a lack of HER-2 overexpression. Endocrine therapy has traditionally been the standard of care for ER-positive and HER-2-negative metastatic breast cancer. In the last 8 years, the advent of CDK4/6 inhibitors has shown that adding them to endocrine therapy doubles PFS. As a result, this combination has become the gold standard in this setting. Three CDK4/6 inhibitors have been approved by the EMA and the FDA: abemaciclib, palbociclib, and ribociclib. They all have the same indications, and it is at each physician's discretion to choose one or the other. The aim of our study was to perform a comparative efficacy analysis of the three CDK4/6i using real-world data. We selected patients diagnosed with endocrine-receptor-positive and HER2-negative breast cancer who were treated with all three CDK4/6i as first-line therapy at a reference center. After 42 months of retrospective follow up, abemaciclib was associated with a significant benefit in terms of progression-free survival in endocrine-resistant patients and in the population without visceral involvement. In our real-world cohort, we found no other statistically significant differences among the three CDK4/6 inhibitors.

TRPS1 outperforms GATA3 in pleural effusions with metastatic breast carcinoma versus mesothelioma

INTRODUCTION

In evaluating malignant pleural fluid cytology, metastatic adenocarcinomas and mesotheliomas are often differential diagnoses. GATA binding protein 3 (GATA3) has historically been used to confirm metastatic breast carcinomas; however, GATA3 has low specificity if mesothelioma is included in differential diagnoses. Trichorhinophalangeal syndrome type 1 (TRPS1) protein is expressed in all types of breast carcinomas, with reported high specificity and sensitivity. We investigated the performance of TRPS1 immunohistochemistry (IHC) and compared it to GATA3 in pleural fluids diagnosed with metastatic breast carcinoma and mesothelioma.

METHODS

Thirty-six consecutive ThinPrep pleural fluids and 4 pleural fine needle aspirations (FNAs) with diagnoses of metastatic breast carcinoma (21) and mesothelioma (19) were retrieved, and IHC with TRPS1 and GATA3 was performed on all. Immunoreactivity scores for TRPS1 were calculated by multiplying percentage of immunoreactive cells by staining intensity. Immunoreactivity scores were negative if 0 or 1, low positive if 2, intermediate positive if 3 or 4, or high positive if 6 or 9. Nuclear immunoreactivity of ≥10% with at least moderate intensity was judged GATA3 positive.

RESULTS

GATA3 showed immunoreactivity in all metastatic breast carcinomas and 84% of mesotheliomas. TRPS1 was immunoreactive in all breast carcinoma cases (18 with a score of 9 and 3 with a score of 6). TRPS1 showed low positivity in 5% of mesothelioma cases with all other cases being negative.

CONCLUSION

When cytomorphologic differential diagnoses of mesothelioma exist, TRPS1 is a more specific marker than GATA3 for confirmation of metastatic breast carcinoma in pleural fluid cytology.

Breast Sarcomas-How Different Are They from Breast Carcinomas? Clinical, Pathological, Imaging and Treatment Insights

Breast sarcoma (BS) is a very rare and poorly studied condition. This has led to a lack of studies with a high level of evidence and to low efficacy of current clinical management protocols. Here we present our experience in treating this disease in the form of a retrospective case series study including discussion of clinical, imaging, and pathological features and treatment. We also compare the main clinical and biological features of six cases of BS (phyllodes tumors were excluded) with a cohort of 184 patients with unilateral breast carcinoma (BC) from a previous study performed at our institution. Patients with BS were diagnosed at a younger age, presented no evidence of lymph node invasion or distant metastases, had no multiple or bilateral lesions, and underwent a shorter length of hospital stay versus the breast carcinoma group. Where recommended, adjuvant chemotherapy consisted of an anthracycline-containing regimen, and adjuvant external radiotherapy was delivered in doses of 50 Gy. The comparison data obtained from our BS cases and the ones with BC revealed differences in diagnosis and treatment. A correct pathological diagnosis of breast sarcoma is essential for the right therapeutic approach. We still have more to learn about this entity, but our case series could add value to existing knowledge in a meta-analysis study.

MRI Features of Primary Breast Lymphoma in Patient with Breast Carcinoma for Differential Diagnosis

Teaching point: Homogeneous internal enhancement and washout pattern on DCE-MRI and a low ADC value on DWI in women with breast carcinoma help distinguish primary breast lymphoma from bilateral synchronous breast carcinoma.

Challenges and Considerations in Identifying the Origin of Peritoneal Carcinomatosis: A Case Report

Invasive lobular cancer (ILC) of the breast is the second most common type of invasive breast cancer. Clinical determination of the growth pattern of ILC of the breast is difficult. Furthermore, the ILC of the breast has a unique metastatic pattern that involves gastrointestinal and peritoneal sites. Our patient was initially misdiagnosed with left ovarian cancer based on the findings of positron emission tomography and computed tomography. Herein, we report a case of ILC of the breast presenting as peritoneal carcinomatosis. The ESMO Clinical Practice Guidelines for cancers of unknown primary sites were used in the diagnosis of the carcinoma of unknown primary origin. Image-guided biopsy and immunohistochemical staining are also useful in the diagnosis of these cancer types.