Relationship Between Breast Density, Breast Cancer Subtypes, and Prognosis.

BACKGROUND: In the United States, Europe, and Asia, a consensus has been reached that there is a higher risk of breast cancer in high density breasts. However, there are some contrary reports that suggest the absence of an association between breast composition and breast cancer subtype; thus, there is conflicting evidence. The purpose of this study was to investigate trends in the incidence of breast cancer subtypes according to breast composition and analyze the survival rates in Japanese women. PATIENTS AND METHODS: Between 2007 and 2008, 1258 Japanese patients with invasive breast cancer who underwent mammography and obtained a pathological diagnosis in our institution were included in the study. We compared cancer subtypes with breast composition types (dense and non-dense breast), and classified them based on initial mammography findings. Information on 5- and 10-year survival rates was collected by chart review for patients with dense and nondense breasts. Statistical analysis was performed using the Pearson's chi-square test for breast composition and cancer subtype. The effect of breast composition on mortality was examined using a multivariate Cox proportional hazards model, and adjusted hazard ratios were calculated. RESULTS: No significant difference was found between breast cancer subtype and breast composition (P = .08). Five-year (log-rank test, P = .09) and 10-year (log-rank test, P = .31) survival rates were not significantly different between breast composition types. CONCLUSION: There was no significant association between breast composition and cancer subtypes. There was also no significant difference in the prognosis between patients with and without dense breasts.

A case of systemic sarcoidosis with mesangial proliferative glomerulonephritis showing predominant deposition of IgG in the mesangial region.

A 37-year-old African-British man was referred to our hospital for detailed examination because of persistent fever, swelling and pain in both ankle joints, and blurred vision for two months. Inguinal lymph node biopsy showed a large number of epithelioid granulomas without necrosis. Granulomatous anterior uveitis, nephropathy, high serum angiotensin-converting enzyme activity, and high serum-soluble interleukin-2 receptor were observed, and the diagnosis of systemic sarcoidosis was made. His serum creatinine was 1.4 mg/dL and hematuria, leukocyturia, and urine protein were also seen. The renal biopsy finding was mesangial proliferative glomerulonephritis, with no findings of granuloma formation or tubular interstitial nephritis. Immunofluorescence staining showed deposition of IgG, C3, and C1q in the mesangial region. IgG3 was dominant in subclass staining. There was no monoclonality on kappa and lambda staining. Electron microscopy showed predominant deposition in the mesangial region with some subepithelial and endothelial deposition. His hematuria and leukocyturia disappeared with steroid therapy, suggesting sarcoidosis-related nephropathy. A case of systemic sarcoidosis with mesangial proliferative glomerulonephritis showing predominant deposition of IgG in the mesangial region is presented. No cases of such histological findings have been reported so far, and it is necessary to analyze further cases to clarify the pathogenic significance of the renal biopsy findings observed in this case.

Clonal evidence for the development of neuroblastoma with extensive copy-neutral loss of heterozygosity arising in a mature teratoma.

Mature teratomas are usually benign tumors that rarely undergo malignant transformation. We report an advanced neuroblastoma arising in a mature teratoma of the ovary. Whole-exome sequencing identified extensive copy-neutral loss of heterozygosity (LOH) in both neuroblastoma and teratoma elements, suggesting that the neuroblastoma evolved from the teratoma. In addition, several truncating germline heterozygous variants in tumor suppressor genes, including RBL2 and FBXW12, became homozygous as a result of LOH. Collectively, we speculate that extensive LOH in teratoma cells may force heterozygous germline variants to become homozygous, which, in turn, may contribute to the development of neuroblastoma with the acquisition of additional chromosomal changes.

Long-Term Oncologic Safety of Nipple-Sparing Mastectomy With Immediate Reconstruction.

BACKGROUND: We assessed the long-term oncologic safety of nipple-sparing mastectomy (NSM) compared to skin-sparing mastectomy (SSM) for primary breast cancer patients with immediate reconstruction. PATIENTS AND METHODS: Data of stage 0-III primary breast cancer patients undergoing NSM (n = 190) or SSM (n = 729) from June 2006 to December 2012 were retrospectively collected. Nipple-tumor distance (NTD) was measured on pretreatment mammography, magnetic resonance imaging, or ultrasonography findings. NSM patients with NTD < 1 cm were excluded. Locoregional recurrence (LRR) rates were compared between groups. Disease-free survival (DFS) and overall survival (OS) according to surgical procedure were assessed. RESULTS: The median (range) follow-up period for NSM and SSM was 71 (10-131) months and 79 (9-140) months, respectively. LRR developed in 11 patients with invasive ductal carcinoma (5.8%) for NSM and 44 (42 in patients with invasive ductal carcinoma and 2 in patients with ductal carcinoma-in-situ) (6.0%) for SSM. Hormone receptor and HER2 status were not associated with LRR in either group. DFS and OS rates did not differ between groups (DFS: 89.3% for NSM, 89.3% for SSM, P = .87; OS: 98.4% for NSM, 94.5% for SSM, P = .43). CONCLUSION: NSM with immediate reconstruction was as safe as SSM for primary breast cancer with respect to prognosis and local control, regardless of the presence of invasive carcinoma or breast cancer subtype.

Accuracy of morphologic change measurements by ultrasound in predicting pathological response to neoadjuvant chemotherapy in triple-negative and HER2-positive breast cancer.

BACKGROUND: Neoadjuvant chemotherapy (NAC) is standard therapy in triple-negative breast cancer (TNBC) and HER2-positive breast cancer (HER2 + ve BC). There are concerns about the accurate imaging modalities to measure residual tumor during or after NAC. Up to now no standard imaging method for monitoring the efficacy of NAC has been established, and few reports showed ultrasonographic change. We aimed to assess the echogenicity in ultrasonography (US) as the predictive marker of pathological complete response (pCR) for not only TNBC, but also HER2 + ve BC. Furthermore, we also investigated the change in depth (D) and width (W) of the tumor as the predictive value of pCR. METHODS: We retrospectively reviewed a consecutive 59 patients with TNBC and 41 patients with HER2 + ve BC who received NAC. In all of 100 patients, echogenicity, D and W of the tumor were measured before (pre-NAC) and after NAC (post-NAC). The tumor echogenicity was measured at representative region of interest (ROI), and calculated as the relative comparative assessment with fat echogenicity (ROI ratio). RESULTS: pCR was significantly associated with higher post-NAC ROI ratio in TNBC (p = 0.010), while there was no association in HER2 + ve BC (p = 0.885). pCR was significantly associated with smaller sizes of post-NAC D and W in TNBC (p = 0.001, 0.003), while no trend was observed in HER2 + ve BC (p = 0.259, 0.435). The area under the curve (AUC) for post-NAC ROI ratio and D were 0.701, 0.755, respectively. Combined with them, AUC became higher up to 0.762. CONCLUSION: TNBC and HER2 + ve BC showed different morphologic features of residual disease. Echogenicity and tumor size after NAC were both useful to predict pCR for TNBC, but not HER2 + ve BC. In future, radiological imaging needs to be analyzed in terms of breast cancer subtypes.

Comparison of endoscopic band ligation devices used for colonic diverticular bleeding: in vivo animal study.

BACKGROUND AND AIM: Endoscopic band ligation (EBL), used for the treatment of colonic diverticular bleeding, has a lower rebleeding rate than endoscopic clipping. However, different devices are used in Japan and the Western countries; no animal studies have been conducted to elucidate the safety of such devices. We compared two EBL devices, the first used in Japan and the second used in Western countries. METHODS AND RESULTS: The Japanese and Western EBL devices were compared by assessing the EBL safety at 40 sites in an animal model with a normal colon that is anatomically similar to the human colon. Macroscopic and pathological examinations were performed to evaluate the layer ligated by the band and the presence of perforation. The findings on day 1 and day 7 after EBL were compared. The ligated layer was the muscularis propria at 39 sites; the layer was not evaluated at one site where the band was unintentionally removed during the endoscopic procedure. Pathologically, there was no perforation at any of the assessed sites. There was no statistical difference in any of the pathological variables between the two devices or between days 1 and 7 after EBL. The total procedure time was significantly shorter with the Western EBL device. CONCLUSIONS: In this animal study, both evaluated devices were safe for EBL, without differences in the macroscopic and pathological variables after EBL. Ligation of the muscularis propria layer did not result in perforation.

Hepatocellular adenoma, approximately half and predominantly inflammatory subtype, in 38 Japanese patients with several differences in age, gender, and clinical background factors from Western populations.

AIM: Hepatocellular adenoma (HCA) has a lower prevalence in Japan than in Western countries and HCA subtypes have been reported for only a few Japanese patients. We analyzed HCA subtype data 38 patients from 23 hospitals in Japan in order to examine character and difference between Western countries. METHODS: To confirm HCA and to analyze subtypes, we performed immunohistochemical examinations. RESULTS: Thirty-eight cases were found to have HCA without cirrhosis. The male/female ratio was 18/20. Ages ranged from 15 to 79 (average, 43.2) years. Male and elder patients are not rare, furthermore, most of elder patients are male. Glycogen storage disease, past history of medicament use, hepatitis B virus surface antigen-positivity, antihepatitis C virus -positivity, diabetes mellitus, obesity, lipid metabolism disorder and alcoholism were present in of 6, 8, 1, 1, 6, 6, 4, and 6 cases, respectively. As to HCA subtypes, HNF1alpha-inactivated HCA, beta-catenin activated HCA (b-HCA), inflammatory HCA (IHCA) and unclassified HCA (U-HCA) accounted for nine (23.7%), four (10.5%), 17 (44.7%) and eight (21.1%) cases, respectively. Two cases showed coexistence of HCA and hepatocellular carcinoma (HCC) at surgery, and another had HCC which had been detected 23 years after HCA diagnosis. The HCA subtype of one of the former cases was U-HCA, while the remaining two had b-HCA and U-HCA. CONCLUSIONS: In Japanese HCA cases, the proportions of U-HCA, male and elder cases were slightly higher than in Western countries, and most of elder patients were male. IHCA was however common regardless of race, and was assumed to be the predominant subtype of HCA.

Evaluation of Axillary Lymph Nodes in Breast Cancer Patients with Atopic Dermatitis.

This study assessed the diagnostic accuracy of ultrasound in detecting axillary lymph node metastases in women with breast cancer and atopic dermatitis. We retrospectively reviewed the records of 91 breast cancer patients with a history of atopic dermatitis and compared the dimensions of the lymph nodes on ultrasonographic images of women with and without lymph node metastases diagnosed using histology. Using a major-axis length of ≥5 mm, a short-axis length of ≥5 mm and a cortical thickness of ≥2.3 mm as the criteria for diagnosing axillary lymph node metastases, the specificity was 12.7%, 41.3% and 58.7%, respectively. The low specificity of the ultrasound criteria makes ultrasound unsuitable for diagnosing axillary lymph nodes metastases in breast cancer patients with atopic dermatitis.

Rapidly Growing Papillary Well-Differentiated Adenocarcinoma in a Patient With a Helicobacter pylori-Naive Gastric Mucosa.

Although undifferentiated adenocarcinomas and fundic gland-type carcinomas are known as Helicobacter pylori-naive gastric carcinomas, well-differentiated gastric phenotype adenocarcinomas with papillary growth are rare. We encountered a case of a rapidly growing pedunculated well-differentiated adenocarcinoma in a patient with a H. pylori-naive gastric mucosa. The tumor had characteristics of a gastric phenotype (pepsinogen I and H and K-adenosine triphosphatase staining negative; diffusely positive for both mucin-5AC [MUC-5AC] and MUC-6; and MUC-2, common acute lymphocytic leukemia antigen 10 [CD-10], and p53 negative) and treated with endoscopic mucosal resection. We report our case along with a relevant literature review.

Lower response to trastuzumab emtansine in metastatic breast cancer patients with human epidermal growth factor receptor 2 immunohistochemistry score of 2 and fluorescence in situ hybridization positive compared with immunohistochemistry score of 3: a retrospective study.

Tumor human epidermal growth factor receptor 2 (HER2) status is defined by either protein expression using immunohistochemistry (IHC) or gene amplification using fluorescence in situ hybridization (FISH). Approximately 20% of HER2-positive breast cancer is HER2 IHC 2+/FISH-positive. Unlike trastuzumab, it has not been studied whether the response to trastuzumab emtansine (T-DM1) differs according to HER2-positive status. We retrospectively identified and reviewed medical records of all patients with HER2-positive advanced breast cancer (ABC) who received T-DM1 in our hospital from October 2013 to December 2016. We compared the objective response rate (ORR) and progression-free survival (PFS) between patients in the HER2 IHC 3+ group and those in the HER2 IHC 2+/FISH-positive group. A total of 39 patients (IHC 3+: n = 32; IHC 2+/FISH-positive: n = 7) were analyzed. Nineteen (48.7%), 13 (33.3%), and 29 (74.4%) patients had received at least one prior chemotherapy, more than three lines of chemotherapy, and prior pertuzumab for ABC, respectively. ORR was significantly higher in the IHC 3+ group than in the IHC 2+/FISH-positive group (53.3% vs. 0%, P = 0.024). Median PFS was 7.9 months in the IHC 3+ group versus 3.9 months in the IHC 2+/FISH-positive group (hazard ratio 0.68; 95% confidence interval 0.28-1.69, P = 0.408). Among the HER2-positive ABC patients treated with T-DM1, ORR was significantly worse in HER2 IHC 2+/FISH-positive than in HER2 IHC 3+ patients. Median PFS tended to be shorter in patients with HER2 IHC 2+/FISH-positive.

A Novel Technique of Endoscopic Vein Harvesting With Preserved Perivascular Tissue.

The no-touch saphenous vein harvesting technique is considered to be the ideal procedure to achieve the best quality of vein, whereas the endoscopic vein harvesting (EVH) technique is considered to be ideal for decreasing wound complications. We developed a new technique of EVH with perivascular tissue preservation. This procedure was performed by dissecting the immediate anterior and posterior perivascular connective tissues of the saphenous vein followed by cutting approximately 1 cm laterally from the saphenous vein with the use of a harvester (MAQUET Getinge Group, Getinge AB, Göteborg, Sweden). Histopathological examination revealed preserved perivascular tissue and intimal folding.

Colonic clear cell adenocarcinoma with enteroblastic differentiation.

Adenocarcinoma with enteroblastic differentiation (ACED) has high malignant potential. It is known as clear-cell adenocarcinoma, which is a special type of adenocarcinomas characterized by primitive intestine-like structures. Although ACED is often encountered in the stomach, it is very rare in the colon and has not been sufficiently reported. ACED has also not been described in the WHO and Japanese Colonic Carcinoma Classification. ACED has biological characteristics of easy metastasis and a poor prognosis than these of tubular adenocarcinoma. Therefore, all cases of colonic ACED that have been reported previously required either surgery or chemotherapy. We describe a case of flat-elevated-type and 15 mm in size colonic ACED that was successfully treated with endoscopic submucosal dissection. We report our case along with a relevant literature review.

Endoscopic papillectomy for an ampullary neuroendocrine tumor.

Ampullary neuroendocrine tumors (NETs) are extremely rare, have a high rate of transmural invasion and lymph node metastasis, and are generally recommended for surgery. In contrast, endoscopic papillectomy (EP) for ampullary NET, a low-grade type within the submucosal layer, is feasible and useful to avoid surgery. However, EP for ampullary NET is controversial, there are no consensus guidelines, and international recommendations are lacking. We present the case of a 60-year-old man with an ampullary NET who was successfully treated with EP via a hexagonal snare. Prior to EP, endoscopic ultrasonography, magnetic resonance cholangiopancreatography, and intraductal ultrasonography in endoscopic retrograde cholangiopancreatography were performed to assess for ductal infiltration of the NET. The specimen revealed a low-grade NET measuring 1.0 × 0.8 × 0.7 cm without venous or lymphatic infiltration, which was negative for horizontal and vertical margins. No recurrence was observed over a 12-month follow-up.

The rare case of elevated signet ring cell gastric carcinoma with Helicobacter pylori-naïve mucosa.

Patients with Helicobacter pylori-naive mucosa may develop a pale, depressed signet ring cell gastric carcinoma or elevated gastric phenotype carcinoma. Almost all signet ring cell carcinomas are of the flat or depressed type, and elevated lesions are rare. We experienced a case of elevated signet ring cell carcinoma with Helicobacter pylori-naïve mucosa. Although the lesion needed to be differentiated from nonepithelial tumor, we diagnosed early and treated with endoscopic submucosal dissection. We report our case along with the relevant literature review.

CT Findings of Upper Urinary Tract Lesions in IgG4-Related Disease: Comparison With Urothelial Carcinoma.

OBJECTIVE. IgG4-related disease is characterized by extensive infiltration of IgG4-positive plasma cells and fibrosis in various organs. The objective of this study is to investigate CT findings of IgG4-related lesions involving the upper urinary tract and compare them with those of urothelial carcinomas. MATERIALS AND METHODS. This study reviewed pretreatment CT images of 13 consecutive patients with IgG4-related disease with upper urinary tract lesions and 80 consecutive patients with urothelial carcinomas. The findings assessed were laterality, location, growth pattern, margins, internal structure, presence of calcification and lipid component, enhancement pattern, and extraurinary findings. RESULTS. Bilaterality (p < 0.0001), an extramural growth pattern (p < 0.0001), a greater number of affected segments (p = 0.04), and a gradual dynamic enhancement pattern (p < 0.001) were significantly more frequent in patients with IgG4-related disease. With regard to extraurinary findings, paraaortic fat stranding (p = 0.03), presacral fat stranding (p < 0.001), fat stranding of the pelvic walls (p < 0.001), and aortic involvement (p < 0.001) were seen more frequently in patients with IgG4-related disease; on the other hand, there was no statistically significant difference in terms of frequency of pancreatic involvement. Hydronephrosis and renal involvement were seen more frequently in patients with urothelial carcinoma, although the difference was not statistically significant. CONCLUSION. CT findings suggestive of IgG4-related upper urinary tract lesions in comparison with urothelial carcinoma are bilateral and have a longer urinary tract involvement and exhibit an extramural growth pattern, ill-defined margins, a gradual enhancement pattern, aortic involvement, and fat stranding in the paraaortic, presacral, or pelvic wall areas.

MR Imaging of Mushroom-like Skin Adnexal Tumors in the Scalp: A Report of Two Cases.

Few studies had been published regarding imaging findings of skin adnexal tumors. We experienced two giant cases of them with a characteristic mushroom-like growth pattern. MRI showed a circumscribed mushroom-like shaped mass extruding from the subcutaneous tissue with microcystic lesions. Although differentiation between benignancy and malignancy may be difficult by radiological examinations, MRI may be helpful to identify its origin and differentiate soft tissue tumors with skin adnexal tumors in having these imaging findings.

Predictive and prognostic value of stromal tumour-infiltrating lymphocytes before and after neoadjuvant therapy in triple negative and HER2-positive breast cancer.

AIM: Lymphocyte predominant breast cancer (BC) is associated with higher pathological complete response (pCR) rate after neoadjuvant therapy (NAT) and favorable outcome in triple negative breast cancer (TNBC) and HER2+ BC. The predictive and prognostic impact of stromal tumour-infiltrating lymphocytes (TILs) after NAT and the change of TILs before (pre-) and after (post-) NAT are not well studied. We aimed to assess the predictive and prognostic value of pre- and post-NAT TILs, as well as their pharmacodynamics modulation and their change for TNBC and HER2+ BC. MATERIALS AND METHODS: Two-hundred and nine consecutive patients (n = 80 TNBC, n = 129 HER2+ BC) who received NAT between 2001 and 2009 in a single institution were included. We evaluated the association between pre-NAT TILs and pCR, and the association between pre- and post-NAT TILs, as well as their immunodynamics change with relapse-free survival (RFS) for patients with residual disease (RD). RESULTS: Low pre-NAT TILs compared to int/high were significantly associated with lower pCR rate (TNBC: 4.0% vs 43.6%; HER2+ BC: 26.0% vs 51.9%). The median follow-up period was 98 months. In TNBC with RD, low pre-NAT TILs showed significant association with shorter RFS (HR = 3.844 [1.190-12.421], p = 0.024) in multivariate analysis. Low post-NAT TILs showed borderline significant association with shorter RFS (HR = 2.836 [0.951-8.457], p = 0.061). The change in TILs was not associated with RFS. In HER2+ BC, low pre-NAT TILs were not associated with RFS. CONCLUSION: In TN and HER2+ BCs, low pre-NAT TILs tumours had a low likelihood of achieving pCR. In TNBC with RD, both low pre- and post-NAT TILs were associated with shorter RFS. These results suggest that TILs information should be taken into account when additional therapies may be given in the post-neoadjuvant setting.

Recurrent YAP1-MAML2 and YAP1-NUTM1 fusions in poroma and porocarcinoma.

Poroma is a benign skin tumor exhibiting terminal sweat gland duct differentiation. The present study aimed to explore the potential role of gene fusions in the tumorigenesis of poromas. RNA sequencing and reverse transcription PCR identified highly recurrent YAP1-MAML2 and YAP1-NUTM1 fusions in poromas (92/104 lesions, 88.5%) and their rare malignant counterpart, porocarcinomas (7/11 lesions, 63.6%). A WWTR1-NUTM1 fusion was identified in a single lesion of poroma. Fluorescent in-situ hybridization confirmed genomic rearrangements involving these genetic loci. Immunohistochemical staining could readily identify the YAP1 fusion products as nuclear expression of the N-terminal portion of YAP1 with a lack of the C-terminal portion. YAP1 and WWTR1, also known as YAP and TAZ, respectively, encode paralogous transcriptional activators of TEAD, which are negatively regulated by the Hippo signaling pathway. The YAP1 and WWTR1 fusions strongly transactivated a TEAD reporter and promoted anchorage-independent growth, confirming their tumorigenic roles. Our results demonstrate the frequent presence of transforming YAP1 fusions in poromas and porocarcinomas and suggest YAP1/TEAD-dependent transcription as a candidate therapeutic target against porocarcinoma.

The Loss of Lymph Node Metastases After Neoadjuvant Chemotherapy in Patients With Cytology-proven Axillary Node-positive Primary Breast Cancer.

BACKGROUND: Axillary lymph node (LN) dissection after neoadjuvant chemotherapy (NAC) still remains a standard treatment of initially LN-positive primary breast cancer because of the difficulty of assessment of LN status. The aim of this study was to assess the LN status after NAC in initially LN-positive primary breast cancer patients who were assessed as clinically LN-negative after NAC (ycN0) and identify factors associated with loss of LN metastasis. PATIENTS AND METHODS: The study cohort comprised 279 patients with cytology-proven LN-positivity before NAC. LN status was assessed by ultrasonography. Regional recurrence-free survival and overall survival according to pathologic LN after NAC (ypN) status were assessed in patients with ycN0. RESULTS: Of the 279 patients, 179 patients (64.2%) had ycN0. High nuclear grade, estrogen receptor-negative (ER-), and human epidermal growth factor receptor 2-positive (HER2+), were significant predictors of ycN0/ypN0 (P < .001, .007, and .046, respectively). Metastases persisted in 1 or 2 LNs for 5 (20.0%) of 25 patients with ER-/HER2+ and for 4 (21.1%) of 19 patients with ER-/HER2-, and in 3 or more LNs for 0 (0%) of 25 patients with ER-/HER2+ and for 1 (5.3%) of 19 patients with ER-/HER2-. Patients with ER+ tumors had more numerous residual LN metastases than those with ER- tumors (P < .001). Among patients with ycN0, ypN status was not associated with regional recurrence-free survival or overall survival. CONCLUSIONS: Three or more residual LN metastases were rare in patients with ER- tumors if assessed as ycN0 by ultrasonography. Prospective studies are needed to confirm the prognostic impact of not performing axillary lymph node dissection in such patients.