Ductal carcinoma in situ of the breast: the importance of morphologic and molecular interactions.

Ductal carcinoma in situ (DCIS) of the breast is a lesion characterized by significant heterogeneity, in terms of morphology, immunohistochemical staining, molecular signatures, and clinical expression. For some patients, surgical excision provides adequate treatment, but a subset of patients will experience recurrence of DCIS or progression to invasive ductal carcinoma (IDC). Recent years have seen extensive research aimed at identifying the molecular events that characterize the transition from normal epithelium to DCIS and IDC. Tumor epithelial cells, myoepithelial cells, and stromal cells undergo alterations in gene expression, which are most important in the early stages of breast carcinogenesis. Epigenetic modifications, such as DNA methylation, together with microRNA alterations, play a major role in these genetic events. In addition, tumor proliferation and invasion is facilitated by the lesional microenvironment, which includes stromal fibroblasts and macrophages that secrete growth factors and angiogenesis-promoting substances. Characterization of DCIS on a molecular level may better account for the heterogeneity of these lesions and how this manifests as differences in patient outcome and response to therapy. Molecular assays originally developed for assessing likelihood of recurrence in IDC are recently being applied to DCIS, with promising results. In the future, the classification of DCIS will likely incorporate molecular findings along with histologic and immunohistochemical features, allowing for personalized prognostic information and therapeutic options for patients with DCIS. This review summarizes current data regarding the molecular characterization of DCIS and discusses the potential clinical relevance

A Distinct Pattern of Beclin-1 Staining Helps Distinguish Sessile Serrated Adenomas

Autophagy, a lysosomal degradation system, has both cell survival and cell death-promoting capabilities, and its versatility is exploited in many pathologic entities. In neoplastic processes, autophagy has been demonstrated to contribute to both tumor suppression and tumorigenesis in a relatively tumor-specific fashion. Beclin-1 is a protein involved in the formation of the autophagosome, the core unit of autophagy, and serves as one of the general markers for this process. Previous studies have shown Beclin-1 overexpression in both pre-neoplastic and invasive colon carcinoma but weak to absent expression in normal colonic mucosa. Serrated polyps (SPs) of the colon represent morphologically and molecularly unique precursor lesions in the serrated adenoma-carcinoma pathway. The pathophysiology of the serrated pathway and its natural progression is of great interest. The specific role of autophagy in SPs is not fully described. We evaluated SPs and autophagy using Beclin-1 protein, a general autophagy marker, to aid in the assessment of autophagy along the serrated pathway. Difference in Beclin-1 staining may represent variation in autophagy among polyp subtypes, exposing biological and possible clinically useful properties

A New Frontier in Breast Cancer Management: Oncotype DX

Diagnosing and prognosticating breast cancer has traditionally relied upon histomorphologic analysis and immunohistochemistry. With the recent advent of multigene molecular assays, traditional methods are being augmented with molecular biomarkers. Implementation of the Oncotype DX assay has led to a change in treatment of patients with early stage, estrogen positive cancer. Oncotype DX uses the expression of 21 genes at the mRNA level to determine a 10 year recurrence risk in node negative and 5 year recurrence risk in node positive cancer. 16 malignancy markers related to estrogen, HER2, cell proliferation, and invasion potential are compared with 5 reference genes and run through a proprietary algorithm to provide a recurrence score of either low, intermediate, or high risk. Using the results of this assay provides an opportunity for personalized treatment based on unique malignancy markers. Oncotype DX allows patients with low recurrence risk to be spared the adverse effects of chemotherapy, while ensuring that high risk patients are treated systemically. For the first time, the most recent treatment guidelines specify the use of Oncotype DX for the management of breast cancer

The Value of Intraoperative Examination of Axillary Sentinel Nodes in Carcinoma of the Breast.

Abstract Axillary sentinel lymph node biopsy (SLNB) has become the standard of care for T1-2, N-0, M-0 carcinoma of the breast. However, the accuracy of frozen section in the intra-operative examination of sentinel nodes (SN) remains controversial. The senior author has championed the use of the intraoperative examination of SN by frozen section ex-amination from the inception of its use, and we present our experience with frozen section examination of SN, confirming that this technique is both practical and highly accurate. Materials & Methods: Between 2000 and 2007, 236 SLNB procedures were performed that were read as “fro-zen section negative.” SN were identified by 1% lymphazurin blue dye only. The identification of SN in these 236 women was 100%. Each SN specimen was prosected by the senior author; a dedicated surgical pathology technician prepared the frozen sections. Nodes were dissected from the specimen individually and cut at 2.5 to 3.0 mm. intervals. Each of these sections was then cut at three levels. The frozen sections were read by the attending pathologist assigned to frozen sections for that day, not by a dedicated breast pathologist. During the period of the study, 14 different attending pathologists read the slides, with 6 pathologists each reading more than 20 cases. Others read from 1 to14 cases. Results: In this group of 236 cases, 11 patients had positive nodes on subsequent examination of the H&E slides; thus, the false negative rate of intraoperative frozen section was 4.7%, i.e., the frozen section was read as negative but the paraffin sections were posi-tive for metastasis. Therefore, the sensitivity of the negative frozen section was \u3e95%. Nine of the 11 false positives were micrometastases, less than 2 mm diameter, one was considered a macrometastasis, with two areas in one node measuring 2.0 and 2.1 mm each, and one was a sub-micrometastasis. The following variables were compared for significance: Pathologist, nuclear grade, histologic grade, margins, lymphovascular invasion, tumor type (ductal vs lobular), ER & PR values. The only significant variables were lymphovascular invasion (p=.019) and presence of in situ ductal carcinoma (p=.001). Only one of the false negatives was a purely lobular carcinoma (1/11). Discussion: Our data confirm the high accuracy of intraoperative examination of SN, \u3e95%, even without a dedicated breast pathologist reviewing the sections. The missed metastases are likely to be micrometastases, and the likelihood of missing a macrometastasis is \u3c1%. In patients with large primary tumors, presence of in situ ductal carcinoma or if lymphovascular invasion is associated with the tumor, special care should be taken to review these cases more thoroughly since these characteristics of tumors seem to make them more likely than others to have micrometastases to the axillary nodes over-looked

Complete resolution of gastric amyloidosis after autologous stem cell transplantation.

A 48-year-old female with multiple myeloma (MM) and amyloidosis presented with massive upper gastrointestinal (GI) bleeding one week after autologous stem cell transplantation (autologous-SCT). Esophagogastroduodenoscopy (EGD) demonstrated necrotic, purple, pigmented, friable lesions throughout the stomach (Figure 1a), along with a bleeding ulcer in the cardia (Figure 1b, Video 1) which was successfully treated with epinephrine (1:10,000) injections. Biopsies demonstrated nodular amyloid deposition (Figures 2) which was Congo red positive. The patient had no further hematemesis and was discharged home 4 days later. Ten months after autologous-SCT, EGD revealed a normal stomach (Figure 3, Video 2) with no histologic evidence of amyloid

Solitary fibrous tumor of the breast.

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MCM2 and chromogranin are markers of serrated polyp progression

Objectives: Using immunohistochemistry for MCMs and CGA: Examine the proliferative compartment of SPs Assess neuroendocrine cell population in SPs Goal: Identify potential trends in the proliferative and the neuroendocrine cell compartments in SP progression compared to the background normal mucos

The significance of GATA3 expression in breast cancer: a 10-year follow-up study.

GATA3 is a transcription factor closely associated with estrogen receptor alpha in breast carcinoma, with a potential prognostic utility. This study investigated the immunohistochemical expression of GATA3 in estrogen receptor alpha-positive and estrogen receptor alpha-negative breast carcinomas. One hundred sixty-six cases of invasive breast carcinomas with 10-year follow-up information were analyzed. Positive GATA3 and estrogen receptor alpha cases were defined as greater than 20% of cells staining. Time to cancer recurrence and time to death were analyzed with survival methods. Of 166 patients, 40 were estrogen receptor alpha negative and 121 estrogen receptor alpha positive. Thirty-eight (23%) recurrences and 51 (31%) deaths were observed. In final multivariable analyses, GATA3-positive tumors had about two thirds the recurrence risk of GATA3-negative tumors (hazard ratio = 0.65, P = .395) and comparable mortality risk (hazard ratio = 0.86, P = .730). In prespecified subgroup analyses, the protective effect of GATA3 expression was most pronounced among estrogen receptor alpha-positive patients who received tamoxifen (hazard ratio = 0.57 for recurrence and 0.68 for death). We found no statistically significant differences in recurrence or survival rates between GATA3-positive and GATA3-negative tumors. However, there was a suggestion of a modest-to-strong protective effect of GATA3 expression among estrogen receptor alpha-positive patients receiving hormone therapy

Sex hormone-dependent tRNA halves enhance cell proliferation in breast and prostate cancers.

Sex hormones and their receptors play critical roles in the development and progression of the breast and prostate cancers. Here we report that a novel type of transfer RNA (tRNA)-derived small RNA, termed Sex HOrmone-dependent TRNA-derived RNAs (SHOT-RNAs), are specifically and abundantly expressed in estrogen receptor (ER)-positive breast cancer and androgen receptor (AR)-positive prostate cancer cell lines. SHOT-RNAs are not abundantly present in ER(-) breast cancer, AR(-) prostate cancer, or other examined cancer cell lines from other tissues. ER-dependent accumulation of SHOT-RNAs is not limited to a cell culture system, but it also occurs in luminal-type breast cancer patient tissues. SHOT-RNAs are produced from aminoacylated mature tRNAs by angiogenin-mediated anticodon cleavage, which is promoted by sex hormones and their receptors. Resultant 5\u27- and 3\u27-SHOT-RNAs, corresponding to 5\u27- and 3\u27-tRNA halves, bear a cyclic phosphate (cP) and an amino acid at the 3\u27-end, respectively. By devising a cP-RNA-seq method that is able to exclusively amplify and sequence cP-containing RNAs, we identified the complete repertoire of 5\u27-SHOT-RNAs. Furthermore, 5\u27-SHOT-RNA, but not 3\u27-SHOT-RNA, has significant functional involvement in cell proliferation. These results have unveiled a novel tRNA-engaged pathway in tumorigenesis of hormone-dependent cancers and implicate SHOT-RNAs as potential candidates for biomarkers and therapeutic targets

TP53 mutations detected in circulating tumor cells present in the blood of metastatic triple negative breast cancer patients.

INTRODUCTION: Circulating tumor cells (CTCs) are tumor cells shed from either primary tumors or its metastases that circulate in the peripheral blood of patients with metastatic cancers. The molecular characterization of the CTCs is critical to identifying the key drivers of cancer metastasis and devising therapeutic approaches. However, the molecular characterization of CTCs is difficult to achieve because their isolation is a major technological challenge. METHODS: CTCs from two triple negative breast cancer patients were enriched using CellSearch and single cells selected by DEPArray™. A TP53 R110 fs*13 mutation identified by next generation sequencing in the breast and chest skin biopsies of both patients was studied in single CTCs. RESULTS: From 6 single CTC isolated from one patient, 1 CTC had TP53 R110 delC, 1 CTC showed the TP53 R110 delG mutation, and the remaining 4 single CTCs showed the wild type p53 sequence; a pool of 14 CTCs isolated from the same patient also showed TP53 R110 delC mutation. In the tumor breast tissue of this patient, only the TP53 R110 delG mutation was detected. In the second patient a TP53 R110 delC mutation was detected in the chest wall skin biopsy; from the peripheral blood of this patient, 5 single CTC and 6 clusters of 2 to 6 CTCs were isolated; 3 of the 5 single CTCs showed the TP53 R110 delC mutation and 2 CTCs showed the wild type TP53 allele; from the clusters, 5 showed the TP53 R110 delC mutation, and 1 cluster the wild type TP53 allele. Single white blood cells isolated as controls from both patients only showed the wild type TP53 allele. CONCLUSIONS: We are able to isolate uncontaminated CTCs and achieve single cell molecular analysis. Our studies showed the presence of different CTC sub-clones in patients with metastatic breast cancer. Some CTCs had the same TP53 mutation as their matching tumor samples although others showed either a different TP53 mutation or the wild type allele. Our results indicate that CTCs could represent a non-invasive source of cancer cells from which to determine genetic markers of the disease progression and potential therapeutic targets