Elucidating the Role of MicroRNA-18a in Propelling a Hybrid Epithelial-Mesenchymal Phenotype and Driving Malignant Progression in ER-Negative Breast Cancer.

Epigenetic alterations that lead to differential expression of microRNAs (miRNAs/miR) are known to regulate tumour cell states, epithelial-mesenchymal transition (EMT) and the progression to metastasis in breast cancer. This study explores the key contribution of miRNA-18a in mediating a hybrid E/M cell state that is pivotal to the malignant transformation and tumour progression in the aggressive ER-negative subtype of breast cancer. The expression status and associated effects of miR-18a were evaluated in patient-derived breast tumour samples in combination with gene expression data from public datasets, and further validated in in vitro and in vivo breast cancer model systems. The clinical relevance of the study findings was corroborated against human breast tumour specimens (n = 446 patients). The down-regulated expression of miR-18a observed in ER-negative tumours was found to drive the enrichment of hybrid epithelial/mesenchymal (E/M) cells with luminal attributes, enhanced traits of migration, stemness, drug-resistance and immunosuppression. Further analysis of the miR-18a targets highlighted possible hypoxia-inducible factor 1-alpha (HIF-1α)-mediated signalling in these tumours. This is a foremost report that validates the dual role of miR-18a in breast cancer that is subtype-specific based on hormone receptor expression. The study also features a novel association of low miR-18a levels and subsequent enrichment of hybrid E/M cells, increased migration and stemness in a subgroup of ER-negative tumours that may be attributed to HIF-1α mediated signalling. The results highlight the possibility of stratifying the ER-negative disease into clinically relevant groups by analysing miRNA signatures.

Estimation of ALU Repetitive Elements in Plasma as a Cost-Effective Liquid Biopsy Tool for Disease Prognosis in Breast Cancer.

BACKGROUND: Liquid biopsy is widely recognized as an efficient diagnostic method in oncology for disease detection and monitoring. Though the examination of circulating tumor cells (CTC) is mostly implemented for the assessment of genomic aberrations, the need of complex methodologies for their detection has impeded its acceptance in low-resource settings. We evaluated cell-free DNA (cfDNA) as a liquid biopsy tool and investigated its utility in breast cancer patients. METHODS: Total cell-free DNA was extracted from the plasma of breast cancer patients (n = 167) with a median follow-up of more than 5 years, at various stages of the disease. Quantitative PCR was performed to estimate the copy numbers of two fractions of ALU repetitive elements (ALU 115 and ALU 247), and DNA integrity (DI) was calculated as the ratio of ALU 247/115. Mutations in TP53 and PIK3CA in the cfDNA were estimated by next-gen sequencing (NGS) in a subset of samples. Associations of the levels of both the ALU fragments with various clinico-pathological factors and disease-free survival at various stages were examined. Nomogram models were constructed with clinical variables and ALU 247 levels to predict disease-free survival and the best performing model was evaluated by decision curve analysis. RESULTS: DI and ALU 247 levels were significantly lower (p < 0.0001) in the post-operative plasma when compared to their pre-surgery levels. DI and ALU 247 were found to be significantly higher in patients with metastasis (p < 0.05). Patients with higher levels of ALU 247 in their post-operative plasma had significant poor disease-free survival (p = 0.005). Higher levels of ALU 247 in the circulation also correlated with low tumor-infiltrating lymphocytes (TIL) within their primary tumors in the ER-negative breast cancer subtype (p = 0.01). Cox proportional hazard analysis confirmed ALU 247 as an independent variable of disease-free survival both in univariate and multivariate analysis [HR 1.3 (95% CI 1.047 to 1.613, p = 0.017)]. The nomogram model showed that the addition of ALU 247 with other variables significantly improved (C-index 0.823) the predictive ability of the model. CONCLUSION: Our results confirm the utility of cfDNA as an evolving liquid biopsy tool for molecular analysis. Evaluation of larger fragments of cfDNA estimated through ALU 247 can provide vital information concurrent with the pathological process of disease evolution in breast cancer and warrants expansion to other cancer types.

An androgen receptor regulated gene score is associated with epithelial to mesenchymal transition features in triple negative breast cancers.

BACKGROUND: Androgen receptor (AR) is considered a marker of better prognosis in hormone receptor positive breast cancers (BC), however, its role in triple negative breast cancer (TNBC) is controversial. This may be attributed to intrinsic molecular differences or scoring methods for AR positivity. We derived AR regulated gene score and examined its utility in BC subtypes. METHODS: AR regulated genes were derived by applying a bioinformatic pipeline on publicly available microarray data sets of AR+ BC cell lines and gene score was calculated as average expression of six AR regulated genes. Tumors were divided into AR high and low based on gene score and associations with clinical parameters, circulating androgens, survival and epithelial to mesenchymal transition (EMT) markers were examined, further evaluated in invitro models and public datasets. RESULTS: 53% (133/249) tumors were classified as AR gene score high and were associated with significantly better clinical parameters, disease-free survival (86.13 vs 72.69 months, log rank p = 0.032) when compared to AR low tumors. 36% of TNBC (N = 66) were AR gene score high with higher expression of EMT markers (p = 0.024) and had high intratumoral levels of 5α-reductase, enzyme involved in intracrine androgen metabolism. In MDA-MB-453 treated with dihydrotestosterone, SLUG expression increased, E-cadherin decreased with increase in migration and these changes were reversed with bicalutamide. Similar results were obtained in public datasets. CONCLUSION: Deciphering the role of AR in BC is difficult based on AR protein levels alone. Our results support the context dependent function of AR in driving better prognosis in ER positive tumors and EMT features in TNBC tumors.

Giant Bilateral Adrenal Myelolipoma: Case Report.

Adrenal myelolipomas are nonfunctional tumors that are usually asymptomatic; however, they have been known to coexist with other endocrine disorders, such as Cushing's syndrome, congenital adrenal hyperplasia (CAH), Conn's syndrome, and pheochromocytoma. We report a case of a 49-year-old man with hypertension and diabetes mellitus who complained of chronic abdominal pain, vomiting, and early satiety. Preoperative contrast-enhanced computerized tomography (CECT) was performed, and adrenal myelolipoma was considered, lab investigations revealed a nonfunctional tumor. CECT also revealed bilateral renal cortical cyst, right renal calculi, and hepatic cyst. A left open cortical sparing adrenalectomy was performed, pathological examination confirmed the diagnosis, and a radiological surveillance was planned for the right tumor. Four years following this, the patient came back with a similar presentation. Right adrenalectomy was performed after preoperative workup, and subsequently steroid replacement therapy was initiated. We suggest adequate follow-up of a patient presenting with adrenal myelolipoma and to explore the possibility of establishing a syndromic diagnosis such as autosomal dominant polycystic kidney disease (ADPKD).

Adding bit of esthetics with science modification of batwing mastopexy for breast conservation in a young patient with giant fibroadenoma breast.

A 19-year-old girl presented with a lump in her right breast and with a history of surgery for the similar complaint 3 years back. Ultrasound was suggestive of benign solitary lesion of size 16 cm × 10 cm. Core biopsy was suggestive of phyllodes tumor, and the histopathology report of previous surgery was also suggestive of phyllodes tumor. Wide excision of the tumor and reconstruction was done with batwing mastopexy and with a slight modification of the described technique so that to avoid contralateral reduction mammoplasty in a young unmarried girl. Postoperative histopathology was suggestive of fibroadenoma measuring 15 cm × 8 cm with all margins free of tumor, and it is probably one of the biggest fibroadenomas reported so far. On follow-up, no significant disparity noted between the appearances of both breasts.

Histological Surprises in Benign Cytologies after Lymph Node Biopsy-Surgeon's Knife Improving Patient Care.

Lymphadenopathy can be due to multitude of causes. Owing to the high prevalence of infectious diseases in India, and malignancy being a life threatening cause for lymphadenopathy; accurate diagnosis is important in preventing delay or misdiagnosis and in improving patient care, thereby increasing longevity with quality. Fine needle aspiration cytology (FNAC) is the first line investigation commonly done. Should the doctor be contented with the benign FNAC or is a lymph node biopsy needed in this age? The aims of this study are the following: (1) to study the spectral pattern of lymph node biopsies done in a surgical oncology unit of tertiary care centre, (2) to assess the yield of malignant cases from lymph node biopsy and (3) to compare the reliability of benign FNAC with lymph node biopsy. Cross-sectional study of 114 cases that underwent lymph node biopsy during the year 2014, at the Surgical Oncology Department of St. John's Medical College Hospital, Bangalore. Lymph node biopsies were done in the outpatient department (OPD) under local anaesthesia or in the operation theatre under local anaesthesia/monitored anaesthesia care based on the clinical condition of the patient. Regional lymph node dissections, central node biopsy, patients with known case of malignancy were excluded. Specimen sent for histopathological study and immunohistochemistry (IHC) done when needed. 58.8% were males among study population, age ranging from 15 to 80 years, 57% cervical and 29.8% axillary lymph node biopsies done. Sixty-seven percent (67%) of biopsies done in OPD. Thirty-three percent (33%) of biopsies in the operation theatre among which 60.5% under local anaesthesia only. 35.1% cases were reactive hyperplasia, 24.6% lymphomas with non-Hodgkin's lymphoma being the commonest, 13.2% metastatic disease with adenocarcinoma being the commonest. 72.7% of the supraclavicular nodes were malignant. 47.4% of subjects had prior FNAC of the lymph node. Twenty-five percent (25%) of the reactive hyperplasia's on FNAC (p < 0.0001), 33.3% of inadequate FNAC (p = 0.003) and 75% of atypical cells in FNAC turned to be malignant on lymph node biopsy with a discordance rate of 20.3%. Lymph node size didn't correlate with neoplasm. In our study, benign cytologies were malignant on biopsy and statistically significant. Lymph node biopsies are reliable in detecting malignancy and subtyping of the disease. In the presence of strong clinical suspicion, lymph node biopsy is essential even when the FNAC is promisingly benign in a country with limited resources. Lymph node biopsy can be safely done in OPD under local anaesthesia at a lower cost, resulting in a reliable diagnosis thereby improving patient care.

Feasibility of Axillary Reverse Mapping and Clinicopathological Features Predicting ARM Node Metastasis in Breast Cancer-a Pilot Study.

The axillary reverse mapping (ARM) technique has been described as an attempt to map and preserve the upper extremity lymphatic drainage during axillary lymph node dissection (ALND) and/or SLNB. This technique is based on the hypothesis that the lymphatic pathway from the upper extremity is not involved by metastasis from primary breast cancer. The ARM node/s however, has been found, in various studies, to be involved with metastatic foci in patients with extensive axillary lymph node metastases. Therefore, the oncological safety of this procedure has not yet been determined. In this pilot study, we assessed the ARM node intraoperatively for various parameters and compared it to final HPR, to try and determine the oncologic safety of preserving the ARM node. Seventy-two breast cancer patients were screened for this prospective pilot study which was planned to recruit 20 patients. The study was initiated on May 2014, 20 patients were recruited till July 2015. Eligibility criterion was as follows: patients requiring primary axillary lymph node dissection based on a clinically positive axilla. Forty-five patients were ineligible because they had either received neoadjuvant chemotherapy or underwent previous axillary surgery or axillary radiation (exclusion criteria). Seven patients refused to give consent. ARM node identification rate was 75%. The most common location of the ARM node was lateral to the latissimus dorsi pedicle (42.10%), none of them being malignant. None of the oval or firm nodes were malignant. Tumor deposits were identified in 13%. Fine-needle aspiration cytology (FNAC) had 100% specificity, 94.4% negative predictive value, 100% positive predictive value, and 50% sensitivity. ARM is feasible using blue dye alone, with an acceptable identification rate. Location, consistency, and intraoperative FNAC of the ARM node, put together, may be reliable parameters to predict involvement of the ARM node with metastasis.

Pattern of External Breast Prosthesis Use by Post Mastectomy Breast Cancer Patients in India: Descriptive Study from Tertiary Care Centre.

In India, Breast cancer is now the most common cancer in urban and 2nd most common in rural areas [1]. The incidence is rising, more younger women are getting affected and due to increase in survival rates there is an increase in the total number of women suffering from breast Cancer. So far there are no studies evaluating the pattern of breast prosthesis use in Indian scenario. The aim of this study is to address the patterns of external breast prosthesis used in India and view of Indian women on such prosthesis after mastectomy for breast cancer. This was a descriptive longitudinal study. In this study we interviewed (telephonic) 63 people, after three years of completing treatment under The Department of Surgical Oncology, St. Johns medical college, Bangalore. Among the study group, 27 members (40 %) were using various prosthesis, rest 36 women were not using any type of prosthesis. Among the users of prosthesis, silicon prosthesis was used by 6 women, padded cups by 8 women, cloth or cotton by 12 women and 1 woman used other type of prosthesis. Most women use simple items like cloth and cotton (44 %). Next most commonly used prosthesis are padded cups(). Only 22 % of women were found using silicon prosthesis in this study. Most of the well educated patients used external prosthesis either in the form of silicon prosthesis or padded cups. Most of women below age of 50 used external breast prosthesis. Use of prosthesis was more in urban compared to rural population (48 % vs 25 %). Prosthesis users worried more about the body image than women not using prosthesis. 25 % of women using prosthesis had body image issues where as only 5 % of non prosthesis users had such problems. Prosthesis users need improvement in terms of comfort, size, shape and affordability. Most common reasons for not using prosthesis are age, lack of motivation and awareness. Less than half of the women included in this study used external prosthesis after mastectomy for breast cancer. Most of the women are used home made prosthesis like cloth and cotton (44.4 %). Education, age and urban status are the strong factors which influences use of prosthesis. Prosthesis users are those who are more concerned about their body image. There is a palpable need to develop better prosthesis at affordable price.

Ultrasonic shears versus electrocautery in axillary dissection for breast cancer-a randomized controlled trial.

Theoretical advantages of use of Ultrasonic shears include less tissue damage and better sealing of lymphatic vessels. This may play a role in reducing prolonged drainage following axillary dissection for breast cancer. We conducted a prospective randomized controlled study to evaluate efficacy of ultrasonic shears over cautery for axillary dissection. Between April 2011 and April 2013, 92 patients were randomized to undergo axillary dissection with either ultrasonic shears (n = 46) or electrocautery (n = 46). Primary endpoints were time till drain removal and cumulative axillary drainage. Categorical data were compared by Pearson's chi-squared test. Continuous variables were compared by Independent t test or Mann Whitney U test. Data was analyzed using SPSS version 18.0. Both groups were comparable with respect to clinical and pathologic characteristics. Clinical characteristics of mean age, body mass index, side of tumor, neoadjuvant chemotherapy, and type of surgery (breast conservation or mastectomy) were similar. Pathologic variables (weight of specimen, number of lymph nodes harvested, pathologic T and N status, as well as grade of tumor) were also comparable among the two groups. There was no statistically significant difference in either primary endpoint of time till drain removal (15 vs. 14.5 days, p = 0.73) or cumulative axillary drainage (1,260 vs. 1,086.5 ml, p = 0.79). Patient and disease characteristics among the two groups were similar. But, there was no difference in either primary endpoint of cumulative axillary drainage or time to drain removal. We conclude that there is no advantage to use of ultrasonic shears over cautery in reducing drainage following axillary dissection for breast cancer.

Use of ultrasonic shears in patients with breast cancer undergoing axillary dissection-a pilot study.

Patients with breast cancer and positive sentinel node biopsy usually require axillary dissection. Different instruments are used for axillary dissection like regular scalpel,monopolar cautery, bipolar cautery etc. All these instruments are having its advantages and disadvantages. Our dept did a pilot study to know the efficacy of ultrasonic shears over cautery for axillary dissection. Parameters considered were cumulative drain amount, number of days with the drain and number of lymphnodes harvested. Ultrasonic shear machine delivers precisely directed mechanical energy with an ultrasonic vibrating blade.A single device dissects, cuts, grasps, spot coagulates. This machine was used for doing axillary dissection in one group and regular cautery in the other group. Study period was from April 2011 to June 2011 at Dept of Surgical Oncology, St Johns Hospital, Bangalore. Nine people in the ultrasonic shear group and 11 people in the cautery group were included in the pilot study. No significant difference were noticed in the cumulative drain amount, number of days with the drain, and number of lymphnodes harvested in both the groups. Axillary dissection using ultrasonic shears do not show any significant difference in the cumulative drain amount, number of days with the drain, and number of lymphnodes harvested. These are the findings of the pilot study, further prospective randomized studies are required for substantiating the findings.

Unicystic ameloblastoma of the mandible--an unusual case report and review of literature.

Ameloblastoma is a true neoplasm of odontogenic epithelial origin. It is the second most common odontogenic neoplasm, and only odontoma outnumbers it in reported frequency of occurrence. Its incidence, combined with its clinical behavior, makes ameloblastoma the most significant odontogenic neoplasm. Unicystic ameloblastoma (UA) refers to those cystic lesions that show clinical, radiographic, or gross features of a mandibular cyst, but on histologic examination show a typical ameloblastomatous epithelium lining part of the cyst cavity, with or without luminal and/or mural tumor growth. It accounts for 5-15% of all intraosseous ameloblastomas. We report a case of unicystic ameloblastoma in a 30-year-old female, and review the literature.

Breast cancer presenting as parotid tumour - first reported case in literature.

Breast cancer presenting as parotid tumour is very rare. This is the first reported case in which parotid tumour was the presenting complaint of the patient. Since the patient was estrogen and progesterone receptor positive - was put on hormone therapy and responded well.