Characterization of BCL-X L , MCL-1, and BAX Protein Expression in Response to Neoadjuvant Chemotherapy in Breast Cancer.

The use of chemotherapy has improved the overall treatment of breast cancer, which is frequently administered in the form of neoadjuvant chemotherapy (NAC). Apoptosis is an established cell stress response to NAC in preclinical models; however, there is limited understanding of its role in clinical cancer, specifically, its contribution to favorable pathologic responses in breast cancer therapy. Here, we aimed to characterize the change in protein expression of 3 apoptosis-associated biomarkers, namely, BCL-X L , MCL-1, and BAX in breast cancer in response to NAC. For this, we utilized a set of 68 matched invasive breast cancer FFPE samples that were collected before (pre) and after (post) the exposure to NAC therapy that were characterized by incomplete pathologic response. Immunohistochemistry (IHC) analysis suggested that most of the samples show a decrease in the protein expression of all 3 markers following exposure to NAC as 90%, 69%, and 76% of the matched samples exhibited a decrease in expression for BCL-X L , MCL-1, and BAX, respectively. The median H-score of BCL-X L post-NAC was 150/300 compared with 225/300 pre-NAC ( P value <0.0001). The median H-score of MCL-1 declined from 200 pre-NAC to 160 post-NAC ( P value <0.0001). The median H-score of BAX protein expression decreased from 260 pre-NAC to 190 post-NAC ( P value <0.0001). There was no statistically significant association between the expression of these markers and stage, grade, and hormone receptor profiling (luminal status). Collectively, our data indicate that the expression of apoptosis regulatory proteins changes following exposure to NAC in breast cancer tissue, developing a partial pathologic response.

PD-L1 Expression in Colorectal Carcinoma: A Comparison of 3 Scoring Methods in a Cohort of Jordanian Patients.

Anti-programmed death-ligand 1 (PD-L1) treatments can improve colorectal carcinoma (CRC) survival; however, there is still controversy regarding the relationship between PD-L1 expression and the outcome of immunotherapeutic treatment and survival. The discrepancies are partly caused by the lack of a unified scoring system. This retrospective, cross-sectional study evaluated PD-L1 by immunohistochemistry in 127 CRC cases and compared the 3 scoring systems used to assess PD-L1: Tumor Percentage Score (TPS), Combined Positive Score (CPS), and immune cell (IC) score. Correlations were calculated using the χ 2 test. Kaplan-Meier curves with the Log-rank test were used to measure the contribution of PD-L1 expression to survival. PD-L1-positive rate were 29.9%, 57.5%, and 55.9% based on TPS, CPS, and IC score, respectively. TPS showed a better correlation with the clinicopathologic features being significantly higher with young age, T4, and adenocarcinomas (compared with mucinous/signet ring). TPS also showed an increasing trend with higher grade, lymph node stage, and male sex, although these variables were not significantly associated with PD-L1 expression. There was no correlation between PD-L1 expression and mismatch repair protein status in the 3 scoring methods. The probability of survival was higher for PD-L1-negative cases in the first 60 months after surgery if scored by the TPS method ( P =0.058). Future efforts correlating PD-L1 status with response to treatment are needed to decide on the best scoring method to be used for making therapy decisions.

Idiopathic granulomatous mastitis: clinical, histopathological, and radiological characteristics and management approaches.

Idiopathic Granulomatous Mastitis (IGM) is an infrequent, benign breast disease that primarily affects women during their childbearing years and can be mistaken for breast cancer. This study aimed to review the clinical, radiological, and histopathological findings of patients with IGM in addition to management and outcome. Retrospective cross-sectional study of biopsy-confirmed IGM at an academic medical center and a private hospital in Amman, Jordan. Fifty-four patients were included, with a mean age of 37.0 ± 9.04 years, mostly presenting with a breast lump (n = 52, 96.3%) and breast pain (n = 45 patients, 84.9%). Approximately half of the patients (51.9%) were parous, and 50% had breastfed for an average duration of 30.37 ± 22.38 months. Most of the patients had either solitary or multiple abscesses on breast ultrasound. Histopathological analysis (n = 35) showed mostly either moderate inflammation (n = 16, 45.7%) or severe inflammation (n = 14, 40%). Two-thirds of the patients underwent surgical interventions at the time of diagnosis, mostly incision and drainage (n = 16, 29%) or surgical excision (n = 7, 13%), and no mastectomies were performed. The most common medical treatment included a combination of antibiotics, corticosteroids, and methotrexate (n = 21, 38.8%). After follow-up, 31 patients remained in remission, 3 experienced relapses, and 3 had a chronic course. The use of corticosteroids was significantly associated with remission (p = 0.035). The presentation and demographics of IGM patients in Jordan were consistent with the existing literature. Prospective research is needed to explore different treatment options and disease outcomes.

Investigating the genetic profile of familial atypical cystic fibrosis patients (DeltaF508-CFTR) with neonatal biliary atresia.

Biliary atresia (BA) is a progressive inflammatory process of the biliary tree resulting in biliary obstruction. No single known genetic or environmental factor has been established to cause BA. Cystic fibrosis (CF) is a rare cause of neonatal cholestasis, and it has never been described in familial BA cases. Here, we investigate two siblings of first-degree consanguineous parents presenting with neonatal BA. Shortly after the Kasai operation, the proband developed severe respiratory symptoms attributable to a missed CF diagnosis. This was discovered after re-investigating the family history, which revealed a first-degree cousin with CF who did not manifest BA. Afterwards, we identified a pathogenic variant (DeltaF508) in CFTR in both BA-affected siblings along with their cousin. This intrigued us to study the molecular etiology behind the familial BA presentations, which exclusively contributed to BA-pathogenesis in BA-CF-affected siblings and not in their CF-only affected cousin. We applied a multistep approach to investigate the variant profile of both siblings' and their cousin's exomes. We curated the genes whose variants were shared by the BA-CF siblings but absent or heterozygous in their CF-only-affected cousin. Consequently, we identified three candidate genes (SNAPC4, UCK1, and ZHX2) besides CFTR. We propose that these genes act cumulatively or individually in inducing BA-pathogenesis-either by aggravating the biliary damage in the context of CF or increasing the susceptibility of BA as a separate CF-comorbidity. To our knowledge, this is the first report of DeltaF508 in CFTR with familial neonatal BA cases.

Potential Composite Digenic Contribution of NPC1 and NOD2 Leading to Atypical Lethal Niemann-Pick Type C with Initial Crohn's Disease-like Presentation: Genotype-Phenotype Correlation Study.

Niemann-Pick disease type C (NPC) is an autosomal recessive neurovisceral disease characterized by progressive neurodegeneration with variable involvement of multisystemic abnormalities. Crohn's disease (CD) is an inflammatory bowel disease (IBD) with a multifactorial etiology influenced by variants in NOD2. Here, we investigated a patient with plausible multisystemic overlapping manifestations of both NPC and CD. Her initial hospitalization was due to a prolonged fever and non-bloody diarrhea. A few months later, she presented with recurrent skin tags and anal fissures. Later, her neurological and pulmonary systems progressively deteriorated, leading to her death at the age of three and a half years. Differential diagnosis of her disease encompassed a battery of clinical testing and genetic investigations. The patient's clinical diagnosis was inconclusive. Specifically, the histopathological findings were directed towards an IBD disease. Nevertheless, the diagnosis of IBD was not consistent with the patient's subsequent neurological and pulmonary deterioration. Consequently, we utilized a genetic analysis approach to guide the diagnosis of this vague condition. Our phenotype-genotype association attempts led to the identification of candidate disease-causing variants in both NOD2 and NPC1. In this study, we propose a potential composite digenic impact of these two genes as the underlying molecular etiology. This work lays the foundation for future functional and mechanistic studies to unravel the digenic role of NOD2 and NPC1.

The Expression of the Senescence-Associated Biomarker Lamin B1 in Human Breast Cancer.

Senescence is a major response to cancer chemotherapy and has been linked to unfavorable therapy outcomes. Lamin B1 is a component of the nuclear lamina that plays a pivotal role in chromatin stability. Downregulation of lamin B1 represents an established biomarker for cellular senescence. However, the protein expression level of lamin B1 in malignant tissue, particularly of the breast, has not been previously described. In this work, we investigated lamin B1 protein expression in normal breast epithelium, malignant breast tissue (including adjacent non-malignant tissue) and in malignant tissue exposed to neoadjuvant chemotherapy (NAC) using immunohistochemistry (IHC) in three patient groups (n = 15, n = 87, and n = 43, respectively). Our results indicate that lamin B1 mean positive expression was 93% in normal breast epithelium and 88% in malignant breast cells, but significantly decreased (mean: 55%, p < 0.001) in malignant breast tissue after exposure to NAC, suggestive of senescence induction. No significant association between lamin B1 expression and other clinicopathological characteristics or survival of breast cancer patients was recorded. To our knowledge, this is the first report that established the baseline protein expression level of lamin B1 in normal and malignant breast tissue, and its reduction following exposure to chemotherapy. In conclusion, lamin B1 downregulation can be used reliably as a component of multiple biomarker batteries to identify therapy-induced senescence (TIS) in clinical cancer.

PD-L1 expression in breast invasive ductal carcinoma with incomplete pathological response to neoadjuvant chemotherapy.

OBJECTIVES: To investigate the expression of programmed death-ligand 1 (PD-L1) in breast cancer in association with incomplete pathological response (PR) to neoadjuvant chemotherapy (NAC). METHODS: PD-L1 expression was evaluated using immunohistochemistry in post-operative, post-NAC samples of 60 patients (n = 60) diagnosed with breast invasive ductal carcinoma with incomplete PR to NAC, including 31 matched pre-NAC and post-NAC samples (n = 31). PD-L1 protein expression was assessed using three scoring approaches, including the tumor proportion score (TPS), the immune cell score (ICS), and the combined tumor and immune cell score (combined positive score, CPS) with a 1% cut-off. RESULTS: In the post-operative, post-NAC samples (n = 60), positive expression rate of PD-L1 was observed in 18.3% (11/60) of cases by TPS, 31.7% (19/60) by ICS, and 25% (15/60) by CPS. In matched samples, positive expression rate of PD-L1 was observed in 19.3% (6/31) of patients by TPS, 51.6% (16/31) by ICS, and 19.3% (6/31) by CPS in pre-NAC specimens, while it was observed in 22.6% (7/31) of matched post-NAC samples by TPS, 22.6% (7/31) by ICS, and 19.3% (6/31) by CPS. In the matched samples, there was a significant decrease in PD-L1 immunoexpression using ICS in post-NAC specimens (McNemar's, p = 0.020), while no significant differences were found using TPS and CPS between pre- and post-NAC samples (p = 1.000, p = 0.617; respectively). PD-L1 immunoexpression determined by TPS or CPS was only significantly associated with ER status (p = 0.022, p = 0.021; respectively), but not with other clinicopathological variables. We could not establish a correlation between PD-L1 expression and the overall survival rate (p > 0.05). There were no significant differences in the tumor infiltrating lymphocytes count between the paired pre- and post-NAC samples (t = 0.581, p = 0.563 or Wilcoxon's Signed Rank test; z = -0.625, p = 0.529). CONCLUSION: Our findings indicate that PD-L1 protein expression in infiltrating immune cells was significantly reduced in breast tumors that developed incomplete PR following the exposure to NAC.

Mast Cell Numbers in Primary Eosinophilic Colitis are Significantly Higher than in Secondary Tissue Eosinophilia and Normal Control: a Possible Link to Pathogenesis.

BACKGROUND: Primary Eosinophilic Colitis (PEC) is one of the rare eosinophilic gastrointestinal diseases with a poorly understood pathogenesis. Eosinophilic esophagitis (EE) is the most common and best-understood disease in this category. Activated mast cells (MCs) have a role to play in the tissue damage in EE. It is not known if PEC shares this mechanism. OBJECTIVE: This cross-sectional study aimed to investigate the number of MCs in PEC and to compare them with cases of secondary colonic tissue eosinophilia (TE) and normal colon. METHODS: The study included 19 PEC cases, 47 cases of secondary tissue eosinophilia and 50 normal colon tissues. Histopathological slides of all cases were reviewed to confirm the diagnosis and count the number of eosinophils. Glass slides for all cases were stained for C-kit (CD117) to highlight and count the MCs. RESULTS: The mean number of the MCs in normal controls was 9.7 MCs per HPF (SD= 4.6). The mean number of MCs in the PEC cases was 26.5 (SD=7.1) which was significantly higher than the normal counts (p-value <0.000). The mean number of MCs in the secondary TE group was 18.0 (SD=7.1), which was significantly higher than normal controls; p-value <0.000. Comparing MC counts in PEC and secondary TE also revealed a significant difference with a p-value of < 0.000. CONCLUSION: MCs in PEC are significantly higher than those in secondary TE and normal controls. This suggests the role of the MCs in the pathogenesis of Primary Eosinophilic Colitis.

Expression of Senescence and Apoptosis Biomarkers in Synchronous Bilateral Breast Cancer: A Case Report.

BACKGROUND: Synchronous bilateral breast cancer (SBBC) provides a special condition where two independent breast tumors are exposed to cancer pharmacotherapy within a uniform pharmacokinetic milieu. Both senescence and apoptosis are established responses to therapy; however, they have potentially variable contributions to the overall outcome of treatment, which are yet to be determined. METHODS: In this report, we describe the clinicopathological picture of two SBBC cases that received standard anticancer treatment and assess their expression profile of several molecular hallmarks of senescence and apoptosis. RESULTS: Our analysis identified that synchronous tumors have variable expression profiles of both senescence- and apoptosis-associated biomarkers, despite comparable pathological responses to neoadjuvant chemotherapy and current survival rates. CONCLUSIONS: Our results highlight the variable expression of senescence- and apoptosis-associated markers in breast tumors (despite the shared somatic genetic background) and invites a large-scale assessment of both senescence and apoptosis in breast cancer tissue in vivo and their contribution to the pathological response and overall survival.

Pancreatic Rheumatoid Granulomas: A Case Report of a Rare Complication of Rheumatoid Arthritis.

Cutaneous granulomas presenting as skin nodules are the most common extra-articular manifestations of rheumatoid arthritis (RA). Granulomas are defined as a form of chronic inflammatory response characterized by aggregation of activated histiocytes. Visceral granulomas are a rare complication of long-standing RA and have been described twice in the literature. We report a case of a 55-year-old woman with a 15-year history of RA. The patient presented with epigastric pain and weight loss. Imaging studies showed a large soft tissue mass in the head of the pancreas, which was suspected to be malignant. A Whipple procedure was performed, and histological examination revealed multiple non-caseating granulomas with central liquefaction and neutrophilic infiltrate. Ziehl-Neelsen stain for acid-fast bacilli and tuberculosis polymerase chain reaction were negative. The patients' granulomas were diagnosed as rheumatoid granulomas. Five years after diagnosis, the patient is doing well and has no complications.

Expression of therapy-induced senescence markers in breast cancer samples upon incomplete response to neoadjuvant chemotherapy.

Senescence is a cell stress response induced by replicative, oxidative, oncogenic, and genotoxic stresses. Tumor cells undergo senescence in response to several cancer therapeutics in vitro (Therapy-Induced Senescence, TIS), including agents utilized as neoadjuvant chemotherapy (NAC) in the treatment of invasive breast cancer. TIS has been proposed to contribute to adverse therapy outcomes including relapse. However, there is limited evidence on the induction of senescence in response to NAC in clinical cancer and its contribution to disease outcomes. In this work, the expression of three senescence-associated markers (p21CIP1, H3K9Me3 (histone H3 lysine 9 trimethylation), and Lamin B1) was investigated in breast cancer samples that developed partial or incomplete pathological response to NAC (n=37). Accordingly, 40.54% of all samples showed marker expression consistent with a senescence-like phenotype, while the remainders were either negative or inconclusive for senescence (2.70 and 56.8%, respectively). Moreover, analysis of core-needle biopsies revealed minimal changes in p21CIP1 and H3K9Me3, but significant changes in Lamin B1 expression levels following NAC, highlighting a more predictive role of Lamin B1 in senescence detection. However, our analysis did not establish an association between TIS and cancer relapse as only three patients (8.1%) with a senescence-like profile developed short-term recurrent disease. Our analysis indicates that identification of TIS in tumor samples requires large-scale transcriptomic and protein marker analyses and extended clinical follow-up. Better understanding of in vivo senescence should elucidate its contribution to therapy outcomes and pave the way for the utilization of senolytic approaches as potential adjuvant cancer therapy.

Eosinophil counts in colonic tissue eosinophilia: Investigating specificity and sensitivity of cutoff points and comparing two counting methods.

BACKGROUND/AIMS: The aim of this study was to investigate the specificity and sensitivity of eosinophil cutoff points defining the colonic tissue eosinophilia (TE) and compare the yield of reporting the highest count versus the mean of five high-power fields (HPFs). MATERIALS AND METHODS: One hundred and seventy-one cases of colonic TE, including 22 primary eosinophilic colitis (PEC) cases, were compared to one hundred and twenty-one normal controls in the University of Jordan. The highest eosinophil count (EC) and the mean of five HPFs were recorded. The receiver operating characteristic curve (ROC) analysis was used to find the cutoff point with the best sensitivity and specificity. RESULTS: There was no significant advantage of counting five fields over counting the most densely populated HPF. Using 30 eosinophils per HPF achieved 80% sensitivity and 65% specificity. This point is close to the mean in normal controls plus one standard deviation (SD) (29 per HPF). However, there was overlap between normal counts and TE, using 30 as a cutoff point resulted in 35% false-positive rate. There was no reliable cutoff point to differentiate PEC from secondary TE. CONCLUSION: We recommend reporting the highest EC in colonic biopsies and using 30 as a cutoff point, bearing in mind the overlap with normal and correlating with the clinical team to not treat asymptomatic patients. Clinicopathological correlation is essential to separate PEC from secondary TE.

Accuracy of Frozen-Section Diagnosis of Brain Tumors: An 11-Year Experience from a Tertiary Care Center.

AIM: To analyze the frozen section (FS) diagnostic accuracy in correlation with the final diagnosis of brain tumors. MATERIAL AND METHODS: This retrospective study comprised all brain tumor cases with FS diagnosis and permanent section diagnosis in Jordan University Hospital from July 1, 2007 to December 31, 2017. Data were obtained by reviewing slides and reports from the histopathology archives. Statistical Package for the Social Science (SPSS) software v20 was used for analysis. RESULTS: A total of 179 cases with frozen section and permanent section diagnoses were analyzed. Eighty-four (47%) patients were males and 95 (53%) females.The ages ranged from 1 to 85 years. Diagnostic accuracy of FS was 88.8%. Discrepancy was noted in 20 cases. Of the discrepancies, misclassification of tumor type was the most common category (12 cases, 60%), followed by grading mismatch (7 cases, 35%) and misdiagnosis of tumor versus non-tumor conditions (1 case, 5%). Patient age and gender were not significantly associated with the discrepancy between FS and final diagnosis. CONCLUSION: Our results were comparable to international reports. However, more emphasis on diagnostic cytology in intraoperative consultation is required as an effective adjunct to frozen section to overcome limitations.

Demographic features of patients with colorectal carcinoma based on 14 years of experience at Jordan University Hospital.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer worldwide. In the West, the incidence has stabilized or decreased. There are only occasional published studies that describe the epidemiology of CRC and its changing trends in Jordan and other Middle Eastern countries. OBJECTIVES: Describe the epidemiological features of CRC, predict future trends and compare the results with those from other Arab and Middle Eastern countries and the West. DESIGN: Retrospective epidemiologic study. SETTING: Tertiary center, teaching hospital. PATIENTS AND METHODS: A retrospective study covering 14 years (2003 to 2016). All cases of CRC were retrieved from the computerized system. Demographic data were recorded and analyzed using Mathematica 11.2 and IBM SPSS version 23 software. Mathematical grey forecasting models were used to predict future trends. MAIN OUTCOME MEASURES: Number of cases and accumulated average over time, percentages of demographic variables and results of mathematical forecasting models. SAMPLE SIZE: 970. RESULTS: The male-to-female ratio was 1.5:1 and 97.4% were adenocarcinomas. The accumulated mean number of diagnosed cases doubled from 44.8 between 2003 and 2007 to 82.9 from 2008 to 2016. The accumulated annual average increased beginning in 2008. The forecasting models predicted a further increase in CRC. The mean age was 60.5 years and the median 62.0. Half of the cases presented at an advanced stage (TNM stage III or IV). CONCLUSION: CRC is increasing and is expected to increase further. Better health care planning that includes education and screening is needed to reverse these rising trends and to improve early detection. LIMITATIONS: Single institution study. CONFLICT OF INTEREST: None.

The rising trend in papillary thyroid carcinoma. True increase or over diagnosis?

OBJECTIVES: To assess the changes in parameters of thyroid carcinoma, particularly papillary type, in the era of widespread use of sensitive diagnostic methods. We aim to investigate whether the increased frequency of thyroid cancer is true or resulted from over diagnosis. Methods: We conducted a retrospective study of 313 cases of thyroid carcinoma diagnosed at Jordan University Hospital and King Hussein Cancer Center from 2007-2015. Papillary carcinoma accounted for 290 (92.7%) of all cases. Cases were sub classified according to demographic features, histological type, size, stage, and other variables. For comparison of data, cases were subdivided into 2 study periods: Group I included patients diagnosed in the period 2007-2010, and Group II in the period 2011-2015. Results: The frequency of thyroid carcinoma has increased across the study period. Papillary carcinoma was the major type accounting for this increase. Papillary micro carcinomas ≤1cm accounted for 34.8% of cases of PTC. Most cases (52.4%) of papillary thyroid carcinoma (PTC) were localized stage tumors. Group II of the study witnessed a more than doubled number of cases of PTC compared to group I, with increased frequency of tumors of all sizes as well as tumors of both localized and regional stages. Conclusions: Our observed trend cannot be totally explained by over diagnosis and increased diagnostic scrutiny. This increase could be of true nature and cannot be explained by single cause.

Epidemiologic characteristics of gastric malignancies among Jordan University Hospital patients.

OBJECTIVES: To discover the epidemiologic distribution of gastric malignancies among Jordan University Hospital patients and to compare this distribution with the neighboring Arab countries. Methods: Retrospective study covering the period between  January 2006, and May 2016, in Jordan University Hospital, Amman, Jordan. All cases were retrieved from the computer system and analyzed using IBM SPSS version 23 software.  Results: One hundred and sixty-five cases were analyzed. Male-to-female ratio was 1.2:1. The mean age was 58.6 with 32.1% of patients aged 50 or younger. Primary adenocarcinoma was the most common tumor, half of which were diffuse type, followed by carcinoid tumors (15.2 %), lymphomas (10.3%), and gastrointestinal stromal tumors (8.5%). Proximally located tumors accounted for 15.4%. Helicobacter pylori were present in approximately half of the cases and 34.6% of cases contained intestinal metaplasia.  Conclusion: Jordan is a low-risk area for gastric cancer, but carcinoma occurs at a young age and is associated with gastritis, Helicobacter pylori infection, and intestinal metaplasia in a large proportion of cases. Better strategic health planning and early detection is needed, especially in young patients suffering from gastritis.