Long-term follow-up of nipple-sparing mastectomy without radiotherapy: a single center study at a Japanese institution.

Recent reports have suggested that nipple-sparing mastectomy (NSM) is a potential alternative to mastectomy (MT). The aim of our study was to investigate the oncological and technical outcomes of NSM compared with MT using long-term follow-up data. A total of 932 patients between April 1985 and March 2004 were enrolled in our study. Among them, 788 patients received NSM, whereas 144 patients received the routine mastectomy. The median follow-up time was 78 months. No significant difference in the probability of local recurrence between the NSM cohort and the MT cohort was found (8.2 vs. 7.6 %, p = 0.81). The rate of nipple-areola complex (NAC) relapse was low (3.7 %), and all of the nipple and/or areola recurrence cases were treated with NAC removal. Furthermore, nipple and/or areola recurrence was associated with a significantly better prognosis than that of skin flap recurrences and local lymph node recurrences. For the 21-year disease-free survival and the 21-year overall survival, no significant difference between the NSM and MT cohorts was observed. There was no occurrence of nipple necrosis in our trial. This was the first study to investigate the long-term follow-up of NSM in a large Japanese population. We reported the NSM could be performed without nipple necrosis and is oncologically as safe as mastectomy without radiotherapy. Therefore, we suggest that NSM without radiotherapy is a potential alternative to mastectomy for breast cancer patients for both outcome and aesthetic benefits.

[Three cases effectively treated with S-1 therapy for liver metastasis of breast cancer in long term].

We experienced 3 cases of anti-cancer drug-resistant recurrent breast cancer with liver metastasis showing significant improvement by S-1. Almost all patients maintained the full dose through the whole course of treatment, and the drug showed good tolerability. Furthermore, long-term therapeutic efficacy(more than 2 years)and QOL have been maintained for all patients. We concluded that S-1 is not only effective as a therapeutic agent, but is safe and maintains QOL.

[Nineteen years postoperatively, anastrozole, UFT and cyclophosphamide combination therapy remained effective against recurrent hormone responsive breast cancer with intraabdominal lymphnode, pleural, skin and bone metastases in old age following sixteen-year tamoxifen treatment - a case report].

We report an 89-year-old patient with recurrent hormone-responsive breast cancer who presented with pleural, skin and bone metastases. Nineteen years previously, she had undergone a mastectomy and then for 16 years received adjuvant hormone therapy. The patient was orally administered a combination therapy of anastrozole, UFT and cyclophosphamide. A remarkable response was seen after 5 months, and no side effects were observed. The patient became well and the treatment was continued without relapse at 8 months. Oral anti-cancer treatments in combination with hormone therapy appear to have few side effects and might be an effective treatment option for recurrent breast cancer patients.

[Doxifluridine, medroxyprogesterone acetate and cyclophosphamide (DMpC) combination therapy is effective against recurrent triple negative breast cancer--a case report].

We report a postmenopausal recurrent breast cancer patient with triple negative disease who presented with right recurrent nerve palsy. Nine years previously, she had undergone a mastectomy. FDG-PET scan revealed neck lymph node metastases from the breast cancer. The recurrent nerve palsy was thus considered to have been caused by the lymph node metastases. The patient was orally administered DMpC (doxifluridine, medroxyprogesterone acetate and cyclophosphamide) combination therapy. This resulted in a remarkable response after five months, with the recurrent nerve palsy completely disappearing at six months. No side effects from the treatment were observed. The patient was well and the treatment was being continued without relapse at nine months. Oral anti-cancer treatments such as DMpC appear to have few side effects and might be an effective treatment option for recurrent breast cancer patients with triple negative disease.

Calcitonin receptor gene and breast cancer: quantitative analysis with laser capture microdissection.

There is a growing body of evidence indicating that calcitonin (CT) and its receptor (CTR) is involved in cell growth, differentiation and tissue development. Using laser capture microdissection (LCM) and real-time reverse transcription polymerase chain reactions (RT-PCR), we have investigated CTR mRNA expression in 60 primary breast cancers, including 14 pairs of matched cancers and unaffected ductal epithelia from the same patients. Our results demonstrate that CTR mRNA was constantly expressed in normal ductal epithelium and in breast cancer. In the 14 cases where matched samples were available, a decrease in CTR mRNA expression was found in 9 breast cancers (64.3%), an increased CTR expression in 2 cases (14.3%) and no significant change in 3 cases (21.4%). In 60 cases of primary breast cancers, decreased CTR expression was found in 44 (73.3%), increased CTR expression was detected in 10 cases (16.7%) and no change was observed in 6 cases (10%). Decreased CTR expression was found more often in cases with lymph node metastasis (p = 0.0498) and lymphatic invasion (p = 0.0179). Also there was a decreased CTR expression in cases with an extensive intraductal component (p = 0.0543) and a high nuclear grade (p = 0.1934), although this was not statistically significant. Overall, we conclude that CTR mRNA was constantly expressed in unaffected ductal epithelium, whereas decreased CTR mRNA expression was frequently found in breast cancers, particularly in cases with lymph node metastasis and lymphatic invasion. These results suggest that CTR might be of great potential significance in breast cancer progression.

Magnetic resonance axillography for preoperative diagnosis of the axillopectoral muscle (Langer's axillary arch): a case report.

The axillary arch of Langer is the most common muscular variation in the axilla. Recognition of anatomic variations is important for surgeons to perform safe axillary surgery. We describe a case of a woman with breast cancer, in whom sentinel lymph node biopsy was successfully performed and the presence of this anomaly preoperatively diagnosed by magnetic resonance axillography.

Anastrozole-induced remission of diaphragmatic paralysis from metastatic breast cancer treated with multiple prior therapies.

We describe a woman with metastatic breast cancer treated with multiple rounds of prior cytotoxic and endocrine therapies, who presented with ipsilateral diaphragmatic paralysis. The use of anastrozole, a highly selective nonsteroidal aromatase inhibitor (1 mg daily), successfully induced remission of metastatic tumors in our patient, who is partially recovering from diaphragmatic paralysis.

Prognostic value of Bcl-2 in invasive breast cancer receiving chemotherapy and endocrine therapy.

Apoptosis induced by anticancer agents is a mechanism of treatment activity, overexpression of antiapoptotic genes could produce drug resistant tumors. We have demonstrated that the susceptibility of Bcl-2-negative tumors to a series of anticancer drugs was significantly higher than that of Bcl-2-positive tumors. The purpose of this study was to examine if negative Bcl-2 expression has treatment benefit in breast cancer patients received chemotherapy and endocrine treatment. A cohort of 147 Japanese women with invasive ductal carcinoma was studied. All the patients received postoperative adjuvant therapy consisting of combination chemotherapy with cyclophosphamide, epirubicin, and fluorouracil, and tamoxifen therapy. The expression of Bcl-2, estrogen receptor (ER) and MIB-1 was evaluated in breast cancer surgical specimens. Bcl-2 immunostaining was inversely correlated with increasing histologic grade (p=0.0095) and MIB-1 (p=0.0128). Furthermore, a positive correlation between Bcl-2 and ER was observed (p<0.0001). Unexpectedly, survival curves determined by the Kaplan-Meier method and univariate analysis demonstrated that Bcl-2-positivity was associated with favorable prognosis (p=0.0430). Cox proportional hazard model demonstrated that positive Bcl-2 expression still has favorable survival (p=0.0242) after consideration of other prognostic factors. Our results imply that Bcl-2 is a significant favorable prognostic factor for breast cancer with chemotherapy and endocrine therapy.

Loss of cell cohesion in breast cytology as a characteristic of neuroendocrine carcinoma.

OBJECTIVE: To characterize a specific group of breast cancers displaying a scattered single cell pattern in cytology and correlate it with histologic and immunohistochemical findings. STUDY DESIGN: Of 135 consecutive malignant breast cytologic specimens, 12 cases were selected for their scattered single cell pattern on aspiration cytology. Immunohistochemical staining for neuroendocrine markers and prognostic parameters was performed on paraffin sections of corresponding primary breast carcinomas. RESULTS: In the smears of the 12 cases, highly cellular neoplastic cells with a single cell pattern were observed predominantly. The tumor cells had relatively wide, granular cytoplasm and a low to moderate nuclear/cytoplasmic ratio. Histologically, they were arranged mainly in relatively large, solid nests and occasionally contained a tubular pattern with small amounts of stromal tissue. Five of the 12 cases demonstrated neuroendocrine differentiation with a positive immunoreaction for chromogranin A and synaptophysin. Except for the small mean size of the tumors (P < .01), no significant differences were identified among the prognostic parameters, including a nodal status, estrogen receptor status, growth fraction by Ki-67 or immunoreactivity for c-erbB-2, as compared with the other 123 cases. CONCLUSION: Loss of cell cohesion in breast cytology is a good morphologic marker for identifying neuroendocrine breast carcinoma.

BRCA1 in non-inherited breast carcinomas (Review).

Breast cancer occurs in hereditary and sporadic form. Breast cancer susceptibility gene (BRCA1) is known to be responsible for hereditary breast cancer. BRCA1 mutations are rare in sporadic cancers, but loss of BRCA1 resulting from reduced expression or incorrect subcellular localization is postulated to be important in non-familial breast cancers. More than 300 germline mutations have been identified so far in patients with familial breast and/or ovarian cancer, however, only a few somatic mutations have been identified in sporadic breast cancer. The decreased expression of BRCA1 in sporadic breast cancer is thought to be caused by other mechanisms, such as CpG methylation. BRCA1 expression may play an important role in the pathogenesis and prognosis of sporadic breast carcinoma.

Two-hit inactivation of FHIT by loss of heterozygosity and hypermethylation in breast cancer.

PURPOSE: The FHIT gene, which spans the FRA3B fragile site at chromosome 3p14.2, is a candidate tumor suppressor gene in breast carcinomas. In this study, we would like to delineate more precisely its role in breast tumorigenesis. EXPERIMENTAL DESIGN: To confirm the tumorigenic role of FHIT, 46 sporadic invasive ductal carcinomas of the breast were tested for the "two hits" required to inactivate this gene. Microsatellite loss of heterozygosity (LOH) was considered as the first hit. To examine the possibility that hypermethylation serves as the second hit for FHIT inactivation, methylation of 5'-CpG islands of FHIT was analyzed by methylation-specific PCR. RESULTS: LOH was detected in 8 of 40 informative tumors, and hypermethylation was observed in 22 of 46 (48%) cases. Aberrant FHIT protein expression was found in 31 of 46 (67%) cases examined. All seven tumors showing both LOH and hypermethylation showed complete loss of Fhit protein expression. In addition, a significant positive association was found between the existence of LOH and 5'-CpG island hypermethylation (P = 0.04), which was consistent with the two-hit model. CONCLUSIONS: To our knowledge, this study provides the first evidence that biallelic inactivation of FHIT by LOH and hypermethylation leads to the complete inactivation of FHIT gene in patients with breast cancer. Silencing of the FHIT gene by promoter hypermethylation occurs in primary breast carcinomas, especially those with LOH. These findings support a role for this tumor suppressor gene in sporadic breast tumorigenesis.

Chromosome 3p and breast cancer.

Solid tumors in humans are now believed to develop through a multistep process that activates oncogenes and inactivates tumor suppressor genes. Loss of heterozygosity at chromosomes 3p25, 3p22-24, 3p21.3, 3p21.2-21.3, 3p14.2, 3p14.3, and 3p12 has been reported in breast cancers. Retinoid acid receptor beta2 (3p24), thyroid hormone receptor beta1 (3p24.3), Ras association domain family 1A (3p21.3), and the fragile histidine triad gene (3p14.2) have been considered as tumor suppressor genes (TSGs) for breast cancers. Epigenetic change may play an important role for the inactivation of these TSGs. Screens for promoter hypermethylation may be able to identify other TSGs in chromosome 3p. Alternatively, use of an "epigenetic modifier" may enhance the response to another type of agent for breast cancer.

Thymidine phosphorylase and breast carcinoma.

Thymidine phosphorylase (TP), also known as platelet-derived endothelial-cell growth factor (PD-ECGF), is an enzyme that catalyzes the reversible dephosphorylation of thymidine, deoxyguridine and their analogs. TP also has angiogenic properties, although the precise mechanism by which it promotes angiogenesis is not known. TP expression is elevated in many solid tumors including ductal carcinoma in situ and invasive carcinoma of the breast. This has led to intensive study to ascertain whether TP is a biological marker in breast carcinoma; however, the clinical work has produced conflicting results. Some studies have suggested that TP is angiogenic in breast carcinoma, however, we and others have found that TP has little effect on tumor angiogenesis of invasive breast carcinoma. However, increasingly clinical results suggest that TP could represent an interesting marker that could respond to pyrimidine analogues. Widespread application of TP in prognostic testing would require greater uniformity in scoring techniques and determination of the cut-off levels which could distinguish individuals at high and low risk of cancer recurrence and death.

Correlation of prostate-specific antigen promoter polymorphisms with clinicopathological characteristics in breast cancer.

We have identified two novel polymorphisms in the prostate-specific antigen (PSA) gene promoter regions, the A-AA allele and G-A allele. Furthermore, we have found that A-AA occurred frequently in tumors with higher PSA expressions. We hypothesize that allelic differences may be associated with different phenotypes of breast cancer. To test this hypothesis, we assayed the PSA genotype for 101 breast cancer cases. We also performed immunostaining analysis for estrogen receptor, p53, MIB-1 and c-erbB-2 on all the tumors. At the time of diagnosis, the A-AA allele occurred more frequently in the tumors characterized by small tumor size, good to moderate differentiation, p53-negativity and low tumor proliferation activity. Our results suggest that the presence of the A-AA allele at the PSA promoter region is associated with less aggressive forms of breast cancer and could be looked on as a favorable prognostic factor.

MR-axillography oriented surgical sampling for assessment of nodal status in the selection of patients with breast cancer for axillary lymph nodes dissection.

BACKGROUND: We have reported that magnetic resonance axillography (MR-axillography) is the best method for assessing lymph node size and representing the relation of the lymph node to normal anatomy. METHODS: The four largest nodes on MR-axillography were sampled in 62 consecutive patients with breast cancer undergoing axillary clearance. Axillary clearance yielded a mean of 17.0 (range 5-28) nodes. RESULTS: A method of preliminary sampling of four nodes in the axilla oriented by MR-axillography was assessed in all cases, 22 of whom were histologically node positive. Based on the sampled nodes, lymph node metastases were detected in 20 of 22 (91%) of the node-positive patients. Based on the sampled nodes, of the 19 patients with macrometastatic nodes, lymph node metastases were detected in all 19 (100%), but only in 1 of the 3 (33%) patients with only one micrometastatic node. CONCLUSIONS: This experience indicates that sampling the four largest nodes by MR-axillography orientation accurately identifies patients with macrometaststic nodes. This result may be comparable to that of surgical sampling performed by the most skilled surgeons.

The Fragile Histidine Triad gene and breast cancer.

The Fragile Histidine Triad (FHIT) Gene, encompassing the FRA3B fragile site at chromosome 3p14.2, is a tumor suppressor gene involved in different tumor types. Abnormalities of the FHIT locus were found in many established cancer cell lines and tumors including breast cancer. In sporadic breast cancer, loss of heterozygosity within the FHIT gene has been observed at different frequencies and has been correlated with tumor progression. Aberrant FHIT transcripts have been reported in breast cancer. Furthermore, Fhit protein loss is correlated with prognosis. We summarized the research advances of FHIT genetic, epigenetic change and aberrant Fhit protein expression in breast cancer. Fhit protein may be a novel prognostic factor for breast cancer. FHIT gene therapy may potentially be clinically useful for treatment of breast cancer, suggesting further research involving FHIT introduction should be performed in breast cancer.

Prognostic value of thymidine phosphorylase expression in breast carcinoma.

Thymidine phosphorylase (TP), also known as platelet-derived endothelial cell growth factor (PD-ECGF), is an enzyme that catalyzes the reversible dephosphorylation of thymidine, deoxyuridine and their analogs. TP has also angiogenic properties, although the precise mechanism by which it promotes angiogenesis is not known. We examined TP expression using immunohistochemistry (654-1 Mab) in 182 invasive breast carcinomas (67 N0 and 115 N1/2; median follow-up 78 months [range, 3-177]; 51 patients treated with adjuvant systemic cyclophosphamide, methotrexate and 5-fluorouracil [CMF] chemotherapy and 82 with tamoxifen). High TP expression was found in 142 cases (78%) and correlated with lower histologic grade and low p53 expression. No correlation was found between TP expression and vascular density. TP-positive tumors had a significant increase in both disease-free survival (DFS; p = 0.0025) and overall survival (OS; p = 0.0070) in the total cohort of patients and in the subgroups of node-positive patients and patients treated with CMF adjuvant therapy; no significant difference in either DFS or OS was observed in patients without CMF treatment. Our findings suggest that TP has little effect on tumor angiogenesis of breast carcinoma, whereas it could represent an interesting marker that could predict response to CMF chemotherapy.

Loss of Msh2 is not associated with FHIT deletion in breast carcinomas.

The FHIT gene is a candidate tumor suppressor gene that has been implicated in the development and progression of breast carcinoma. Recent studies have suggested that Fhit inactivation can be a consequence of defects in mismatch repair proteins, particularly Msh2. Fifty-three breast carcinomas were evaluated for Fhit and Msh2 expression by immunohistochemical staining. The same breast carcinomas were examined for allelic loss at three loci within or near FHIT by PCR-based microsatellite analysis. Seventeen of the 53 breast cancer cases were positive for Fhit protein, and 10 of the 43 informative cases showed FHIT loci deletion. Twenty-five of the 53 (47%) cases showed loss of Msh2 expression. No relationship between Msh2 protein loss and FHIT locus alteration or Fhit protein loss could be observed. Our results suggest that this mismatch repair protein may play little role in maintaining the integrity of the common fragile locus with the FHIT gene.

5-aza-2'-deoxycytidine induces retinoic acid receptor beta 2 demethylation, cell cycle arrest and growth inhibition in breast carcinoma cells.

Like all cancers, breast cancer is considered to result in part from the accumulation of multiple genetic alterations leading to oncogene overexpression and tumor suppressor loss. More recently, CpG island hypermethylation is known to be associated with gene silencing in cancer, and these silenced genes can be reactivated by 5-aza-2'-deoxycytidine (5-Aza-CdR). Retionoic acid receptor beta 2 gene is a tumor suppressor gene and the chemopreventive effects of retinoids are due to induction of RAR beta 2. In this study, the effect of 5-Aza-CdR RAR beta 2 restoration was investigated in the MRK-nu-1 human female breast cancer cell line. Changes of the RAR beta 2 methylation status were assessed by methylation-specific PCR. Reverse transcription PCR was used to evaluate RARb beta 2 restoration. Cell cycling and growth inhibition were studied using flow cytometric analysis of DNA content and CellTiter 96 AQueous non-radioactive cell proliferation assay, respectively. 5-Aza-CdR treatment resulted in complete demethylation of the RAR beta 2 gene. RAR beta 2 restoration was accompanied by cell cycle arrest (increase in the G0/G1- and decrease in the S- and G2/M-phases) and time-dependent growth inhibition. In conclusion, RAR beta 2 can be activated in vitro by 5-Aza-CdR, which may be one of the mechanisms for the tumor cell growth inhibition by 5-Aza-CdR.

Correlation between BRCA1 expression and apoptosis-related biological parameters in sporadic breast carcinomas.

BRCA1 is a tumor suppressor gene that is responsible for hereditary breast and ovarian cancer syndrome. Increased evidence suggests that BRCA1 protein is involved in mammary carcinogenesis in sporadic and hereditary forms. Recent experimental results suggest that BRCA1 plays a role in the regulation of apoptosis. In order to test whether the analysis of human tumors would provide data supporting this hypothesis in sporadic breast carcinomas, we have investigated the relationship between BRCA1 and apoptosis-related genes. Immunohistochemical analysis was performed to determine BRCA1 and the apoptosis-related proteins bcl-2, Bax and p53 in paraffin-embedded tissues of 156 sporadic invasive ductal carcinomas. BRCA1 expression was positively-correlated with Bcl-2 expression (p = 0.0008), but no relationship between BRCA1 expression and Bax or p53 expression could be established. In addition, loss of BRCA1 expression was also related to poor tumor differentiation and lymph node metastasis. Our study shows that bcl-2 might be one of the target genes involved in the oncogenesis related to BRCA1. Loss of BRCA1 may contribute to tumor development in breast carcinomas, which may be independent of the p53 tumor suppressor.