Evaluation of hereditary/familial breast cancer patients with multigene targeted next generation sequencing panel and MLPA analysis in Turkey.

Breast cancer, a worldwide leading cause of cancer in women, may occur in familial cases. Germline mutations in BRCA1/2 genes are responsible for 15% of the familial cases. With the power of next generation sequencing (NGS) analysis, it is possible to analyze genes related to hereditary susceptibility to breast cancer and investigate the genetic etiology more thoroughly. In this study, we investigated 30 genes identified frequent pathogenic alleles in Turkish population. The study includes 495 unrelated individuals diagnosed with breast cancer who are selected for genetic testing according to NCCN criteria for hereditary breast cancer. All patients were analyzed by NGS for BRCA1/2 genes. Deletion/duplication investigation by Multiplex ligation-dependent probe amplification (MLPA) and massive sequencing of 30 breast cancer-related genes (Oncorisk Gene Panel) were performed in a stepwise manner. BRCA1/2 variants are the most frequent pathogenic variants which are found in 45 of 495 (9.1%) patients. Four previously unreported, novel, pathogenic variants of BRCA2 gene are identified. In four cases, exonic deletions of BRCA1/2 genes are determined and there is no duplication of these genes. NGS panel investigation involving other moderate-high risk genes contributed genetic diagnosis in an extra 39 out of 419 (9.3%) cases. Our study presents the cost effectiveness of the gene panel approach. We suggest that gene panels should be the first-tier genetic testing for hereditary breast cancer and MLPA analysis of BRCA1/2 genes should be investigated as a complementary method of NGS analysis.

Prognostic Importance of Tumor Deposits in the Ipsilateral Axillary Region of Breast Cancer Patients.

Tumor deposits (TD) are irregular discrete tumor masses in adipose tissue, discontinuous from the primary tumor, that are described in various cancers. The incidence and/or prognostic value of TD in breast carcinomas have not been studied so far. We reevaluated 145 breast cancer patients, diagnosed and treated between 2001 and 2006 at our institution for the presence and incidence of TD. Histologic type, grade, size of the primary tumor, estrogen receptor, progesterone receptor, human epidermal growth factor receptor-2 status of the tumor, and presence of peritumoral lymphovascular invasion were included in the data. TD were detected in 42 cases (29.0%). The mean age of the patients was 52.2 years (27-82). Most patients (79.3%) had either invasive carcinoma of no special type (NST) or invasive lobular carcinoma, and most tumors (86.9%) were either grade 2 or 3. After excluding TD from the number of metastatic lymph nodes, the pN status of 9 patients changed. Univariate analysis of 110 patients with follow-up information revealed that the new pN status (p = 0.036), presence of local recurrence (p = 0.016) and TD (p = 0.003) were significantly correlated with distant metastases. The median follow-up of the patients was 84 months (5-161), 10-year disease-free survival and overall survival were 67.2% and 73.7%, respectively. In multivariate analysis, presence of TD remained independently associated with distant metastasis (p = 0.002). The probability of distant metastasis was 3.3 times higher in patients with TD. These results emphasize that TD are present in breast cancer patients, and that their presence should warn the clinician in terms of possible distant metastasis. Therefore, presence of TD, the evaluation of which is neither time consuming nor require sophisticated methods, should be included in pathology reports.

Efficacy and safety of breast radiothermometry in the differential diagnosis of breast lesions.

AIM OF THE STUDY: The aim of this study is to research the contribution of radiothermometry (RTM) to the characterization of breast masses, the differentiation of malignant-benign masses and diagnosis of early stage breast cancer. MATERIAL AND METHODS: This prospective study comprised 182 cases of patients diagnosed with a breast mass and a control group of 55 cases: a total of 237. RESULTS: When histopathology is accepted as the gold standard among diagnostic methods, the sensitivity, specificity, and positive-negative predictive value for RTM were 90.9%, 20.8%, 61.2% and 62.5%, respectively. Consistency was 0.129. When compared with mammography the same values for RTM examination are 87%, 81.4%, 58% and 95.5%. Consistency was 0.582. Evaluating with respect to size of the mass accepting mammography as the gold standard, RTM examination had sensitivity, specificity, positive and negative predictive values for masses 2 cm and above of 88.9%, 83.3%, 88.9% and 83.3%. Consistency was 0.722. The consistency of RTM for lesion diagnosis in BI-RADS II breast structure is higher than the consistency of mammography. CONCLUSIONS: Identification of lesions in the breast and presence of microcalcification by RTM shows that it is more trustworthy compared to mammography. When compared with mammography the validity results for RTM show there is a good level of conformity between the two methods. When evaluated based on the area below the ROC cure and compared to mammography, RTM is sufficiently successful at evaluating positive and negative cases.

Evaluation of Neoadjuvant Chemotherapy Response with Dynamic Contrast Enhanced Breast Magnetic Resonance Imaging in Locally Advanced Invasive Breast Cancer.

OBJECTIVE: The reliability of traditional methods such as physical examination, ultrasonography (US) and mammography is limited in determining the type of treatment response in patients with neoadjuvant chemotherapy (NAC) application for locally advanced breast cancer (LABC). Dynamic contrast-enhanced magnetic resonance imaging (MRI) is gaining popularity in the evaluation of NAC response. This study aimed to compare NAC response as determined by dynamic contrast-enhanced breast MRI in patients with LABC to histopathology that is the gold standard; and evaluate the compatibility of MRI, mammography and US with response types. MATERIALS AND METHODS: The US, mammography and MRI findings of 38 patients who received NAC with a diagnosis of locally advanced breast cancer and surgical treatment were retrospectively analyzed and compared to histopathology results. Type of response to treatment was determined according to the "Criteria in Solid Tumors Response Evolution 1.1" by mammography, US and MRI criteria. The relationship between response types as defined by all three imaging modalities and histopathology were evaluated, and the correlation of response type as detected by MRI and pathological response and histopathological type of breast cancer was further determined. For statistical analysis, the chi-square, paired t test, correlation and kappa tests were used. RESULTS: There is a statistical moderate positive correlation between response type according to pathology and MRI (kappa: 0.63). There was a weak correlation between response type according to mammography or US and according to pathology (kappa: 0.2). When the distribution of treatment response by MRI is stratified according to histopathological types, partial response was higher in all histopathological types similar to the type of pathologic response. When compared with pathology MRI detected treatment response accurately in 84.2% of the patients. CONCLUSION: Dynamic contrast-enhanced breast MRI appears to be a more effective method than mammography or US in the evaluation of response to neoadjuvant chemotherapy. MRI evaluation of LABC is accepted as the appropriate radiological approach.

Warthin-like papillary carcinoma of the thyroid: a case series and review of the literature.

Warthin-like tumor of the thyroid is a recently described rare variant of thyroid papillary carcinoma. The distinguishing histological feature of this variant is papillary foldings lined by oncocytic neoplastic cells with clear nuclei and nuclear pseudoinclusions, accompanied by prominent lymphocytic infiltrate in the papillary stalks. Its prognosis has been reported to be almost similar to conventional papillary carcinoma. In this case series, we report four cases with Warthin-like papillary carcinoma of the thyroid, diagnosed at Dokuz Eylul University Faculty of Medicine Department of Pathology in 2008 and 2009. Three patients were female. The mean patient age was 39 years (range, 20-56) and the mean tumor size was 1.7 cm (range, 0.9-2.0 cm). All of the cases had lymphocytic thyroiditis in the background. None of the tumors showed lymphovascular invasion. The patients are free of any recurrence and/or distant metastasis with a mean follow-up of 25 months. This rare variant of thyroid papillary carcinoma with distinct histopathological features should be indicated in pathology reports. Further studies and long-term follow-up of patients are needed to highlight the biological behavior of this variant.

Invasive micropapillary carcinoma of the breast: a clinicopathologic study of 103 cases of an unusual and highly aggressive variant of breast carcinoma.

Invasive micropapillary carcinoma (IMPC) of the breast is an uncommon, highly aggressive breast cancer that may occur in pure and mixed forms. Our aim in this study is to investigate the relationship between clinical, histopathologic, and immunohistochemical features of pure and mixed IMPC cases diagnosed and treated at our institution. One hundred and three IMPC cases diagnosed at our institution over a period of 19 years have been selected. Clinical, histopathologic features, as well as hormone status and c-erb-B2 overexpression of tumors were re-evaluated. Mann-Whitney U, chi-squared, Kaplan-Meier, and Fisher's exact tests were used for statistical analyses. Results were considered to be significant at p < 0.05. Twenty cases (19.4%) were pure, and 83 cases (80.6%) were mixed IMPC. The most common nonmicropapillary invasive carcinoma component in mixed cases was invasive ductal carcinoma (IDC; 78.3%). Progesterone receptor was significantly less positive in pure IMPC cases (p = 0.031). There was no statistically significant difference between the two groups, in terms of mean age of the patients (53.0 versus 52.8), mean tumor size (26.6 mm versus 27.7 mm), presence of high-grade tumor (p = 0.631), presence of sentinel lymph node (SN) metastasis (p = 1.000), axillary lymph node metastasis (p = 1.000), lymphatic invasion (p = 1.000) and blood vessel invasion (p = 0.475), c-erbB-2 overexpression of tumor cells (p = 0.616), distant metastasis (p = 0.549), or overall survival (p = 0.759). The local recurrence rate of the two groups was not statistically significant either (16.7% versus 4.3%). However, local recurrence was detected 12% more commonly (p = 0.100), and ~8 months earlier (p = 0.967) in pure IMPC cases, compared to mixed cases. In addition, presence of local recurrence was found to be statistically significantly associated with estrogen receptor (ER) status (p = 0.004), progesterone receptor (PR) status (p = 0.001), and c-erb-B2 overexpression (p = 0.016) in all patients. Overall survival rate was significantly associated with ER staining of the tumor (log-rank = 0.028). Our findings suggest that hormone receptor negativity may explain the more aggressive behavior of pure IMPC compared to mixed cases. Besides, longer survival period of patients with ER positivity, and the relationship of hormone status and c-erb-B2 overexpression and local recurrence further support favorable prognostic value of hormone receptors in invasive breast cancer.

Validation of three breast cancer nomograms and a new formula for predicting non-sentinel lymph node status.

BACKGROUND: The aim of the study was to evaluate the available breast nomograms (MSKCC, Stanford, Tenon) to predict non-sentinel lymph node metastasis (NSLNM) and to determine variables for NSLNM in SLN positive breast cancer patients in our population. MATERIALS AND METHODS: We retrospectively reviewed 170 patients who underwent completion axillary lymph node dissection between Jul 2008 and Aug 2010 in our hospital. We validated three nomograms (MSKCC, Stanford, Tenon). The likelihood of having positive NSLNM based on various factors was evaluated by use of univariate analysis. Stepwise multivariate analysis was applied to estimate a predictive model for NSLNM. Four factors were found to contribute significantly to the logistic regression model, allowing design of a new formula to predict non-sentinel lymph node metastasis. The AUCs of the ROCs were used to describe the performance of the diagnostic value of MSKCC, Stanford, Tenon nomograms and our new nomogram. RESULTS: After stepwise multiple logistic regression analysis, multifocality, proportion of positive SLN to total SLN, LVI, SLN extracapsular extention were found to be statistically significant. AUC results were MSKCC: 0.713/Tenon: 0.671/Stanford: 0.534/DEU: 0.814. CONCLUSIONS: The MSKCC nomogram proved to be a good discriminator of NSLN metastasis in SLN positive BC patients for our population. Stanford and Tenon nomograms were not as predictive of NSLN metastasis. Our newly created formula was the best prediction tool for discriminate of NSLN metastasis in SLN positive BC patients for our population. We recommend that nomograms be validated before use in specific populations, and more than one validated nomogram may be used together while consulting patients.

Factors predicting non-sentinel lymph node involvement in sentinel node positive breast carcinoma.

OBJECTIVE: In routine practice, axillary lymph node dissection is performed in early invasive breast cancer patients with positive sentinel node biopsy. However, sentinel node is the only involved axillary node in 40-70% of patients, and determining factors that predict axillary non-sentinel node involvement will therefore prevent unnecessary axillary lymph node dissection and decrease morbidity. MATERIAL AND METHOD: In this study, 119 invasive breast cancer patients with sentinel node metastasis who underwent axillary lymph node dissection between 1998-2009 at our institution were studied. Primary tumor characteristics and features of the metastatic tumors in sentinel nodes, such as microanatomic location, size of metastasis, and the ratio of metastatic tumor area to the total sentinel node area were evaluated. Student's t-test and multivariate logistic regression were used for statistical analysis. RESULTS: The mean age of the patients was 50.7 years (28-80). Forty-three patients (36%) had invasive ductal and 25 patients (21%) had invasive lobular carcinoma. Most of the patients had either pT1 (44%) or pT2 (54%) tumors. Fifty-four patients (45%) had no further positive nodes in the axilla. The metastatic deposits in the sentinel node were subcapsular in 16 patients (13%). The percent area of sentinel node occupied by tumor (p < 0.001), number of sentinel nodes (p=0.041), and microanatomic location of metastatic tumor (p=0.002) were significantly associated with non-sentinel node metastasis in univariate analysis. The percent area of sentinel node occupied by tumor (p < 0.001) and number of sentinel nodes (p=0.033) remained significantly associated with non-sentinel node involvement in multivariate analysis. CONCLUSION: In patients with invasive breast cancer and positive sentinel node, area percent of sentinel node occupied by tumor, and the number of sentinel nodes removed are independently predictive of non-sentinel node involvement.

Clinical images. Solitary fibrous tumor of the perithyroidal soft tissue mimicking substernal goiter.

Solitary fibrous tumor is an uncommon neoplasm. We present a case of solitary fibrous tumor of the perithyroidal soft tissue mimicking a substernal goiter.

Papillary carcinoma arising in subhyoid ectopic thyroid gland with no orthotopic thyroid tissue.

Ectopic thyroid gland with no orthotopic thyroid tissue is extremely rare. The authors present a case of a follicular variant of papillary carcinoma developed from an ectopic thyroid gland with no orthotopic thyroid tissue.

Carnitine protects the intestine against reperfusion injury in rats.

BACKGROUND: Although the negative effects of ischemia on anastomotic healing have been shown in many studies, there is no adequate information on the effects of reperfusion injury. Therefore, in this study, we investigated the effect of ischemia-reperfusion (IR) injury on intestinal anastomosis and the protective efficiency of carnitine in an experimental relatively short intestinal ischemia and long duration reperfusion model. METHODS: Animals were divided into three groups (n=14). Each group was separated into two subgroups. In subgroups A, morphologic injury and the number of perfused intestinal muscular microvessels were analyzed to show "no-reflow phenomenon." Intestinal resection and anastomosis were performed in subgroups B. Carnitine group (IRCarG) received 200 mg/kg intravenous carnitine 2 min prior to reperfusion. Malonyldialdehyde, nitric oxide levels in tissue and blood, collagen levels, bursting pressures, and histopathologic evaluation of anastomosis were measured in subgroups B. RESULTS: Morphologic damage was statistically lower, number of perfused microvessels and epithelial regeneration were statistically higher in IRCarG, compared with ischemia-reperfusion group (P=0.03, P=0.008, P=0.05, respectively). CONCLUSION: Carnitine application prior to reperfusion may reduce the severity of the reperfusion injury by preventing the occurrence of no-reflow phenomenon, increase the number of perfused microvessels in the ischemic intestine, and may improve epithelial regeneration in intestinal anastomosis.

Papillary thyroid carcinoma mimicking anaplastic thyroid carcinoma following fine-needle aspiration biopsy.

BACKGROUND: Cutaneous metastases from well-differentiated thyroid carcinomas are rare and usually identified in patients with widely disseminated disease. Fine-needle aspiration biopsy (FNAB) has become an acceptable method for the assessment of thyroid nodules. Very rarely needle track dissemination of tumor cells in the thyroid nodule occurs, but, when this occurs, it is evident many years after the FNAB. We report a patient who appears to have tumor dissemination from an FNAB needle track only 4 months after the procedure. SUMMARY: An 85-year-old female presented with a mass on her neck, skin ulceration, and hemorrhage 4 months after FNAB was performed for a thyroid nodule by another physician. A second FNAB with ultrasound guidance yielded cytology diagnostic of papillary thyroid carcinoma. Papillary thyroid carcinoma was confirmed by surgical dissection of the mass, and a linear array of tumor was noted in skin and muscle was performed again, and the cytological diagnosis revealed papillary carcinoma. After surgical resection, the histopathological diagnosis determined the nodules to be papillary carcinoma. Metastatic deposits appeared in the skin and the muscle. The linear array and the site of metastases implied that seeding most probably resulted from the needle biopsy. CONCLUSION: Although FNAB is a useful tool for the diagnosis of thyroid nodules, it is important to consider the risk of tumor cell dissemination.

Predicting invasive phenotype with CDH1, CDH13, CD44, and TIMP3 gene expression in primary breast cancer.

We aimed to determine changes in the expression of the genes CDH1, CDH13, CD44, and TIMP3 to look for any relationship between them, HER2 and ESR1 expression at the RNA level, and the histopathological properties of tumors. We also analyzed the expression properties of double-negative (estrogen receptor [ER] and human epidermal growth factor receptor [HER2] both negative) breast tumors. Expression status was studied in fresh tissue at the mRNA level with quantitative PCR using hydrolysis probes. Sixty-two cancer patients and four normal controls were included in the study. When the tumor group was analyzed as a whole, the correlations of ESR1 with CDH1, CDH13, and TIMP3 were P < 0.05, P < 0.005, and P < 0.005, respectively. In ER-positive tumors, CDH1 and CDH13 were correlated directly (P < 0.005) when HER2 was correlated with CDH1, CDH13, and TIMP3 indirectly (P < 0.005, P < 0.005, and P < 0.05, respectively). CDH1 and CD44 had a strong indirect correlation (P < 0.005) in ER-negative tumors. There were significant differences in the expression levels of the CDH13, TIMP3, and CD44 genes (P < 0.005, P < 0.005, and P < 0.05, respectively) between the ER-positive and -negative groups. All four genes were found to be correlated with invasive properties in both ER-positive and -negative tumors. In double-negative tumor samples, only CD44 had a significant and strong correlation with stage, lymph node involvement, and metastasis (P < 0.05, P < 0.005, and P < 0.05, respectively). As a conclusion, a decrease in CDH1, CDH13, and TIMP3 expression levels with an increase in CD44 can be used as an indicator for invasion in both ER-positive and -negative breast tumors. In double-negative tumor tissues, CD44 can be considered a marker for aggressive properties.

Pathologic nipple discharge in patients with radiologically invisible mass: review of 28 consecutive sub-areolar explorations.

The carcinoma frequency of clinically and radiologically negative pathologic nipple discharges (PNDs) and the optimum management strategy of these cases are still unclear. In this study, the frequency of cancer and the situation of the classic surgical intervention in patients with PND and invisible mammographic and ultrasonographic results are reviewed. The data pertaining to the cases of sub-areolar exploration and major duct excision in a surgery clinic of university hospital from December 2002 to June 2007 have been examined in detail. In 28 cases with PND, which did not have any findings during conventional radiologic examinations, 21% of cases had malignant, and 7% of cases had atypical ductal hyperplasia. The frequency of invasive or in situ carcinoma is not low in clinically and radiologically negative PNDs. Sub-areolar exploration and major duct excision seems to be an appropriate and definitive diagnostic and therapeutic option in this special patient group.

Unilateral juvenile (virginal) hypertrophy of the breast.

Juvenile hypertrophy of the breast (JHB) is an uncommon, benign disorder and typically occurs in peri-pubertal females. The etiology ofJHB is uncertain. It may represent an end-organ hypersensitivity of the breast to normal levels of sex steroids. Clinically, it is characterized by rapid enlargement of breasts, either unilateral or bilateral. The definitive diagnosis is made by histopathologic examination. Treatment recommendations include surgery and hormonal therapy, although hormonal manipulation is still controversial in pediatric patients. Here we report a 13-year-old girl with unilateral JHB who did not require surgery or medical treatment.

Exposure of surgical staff in surgical probe applications in radioguided parathyroidectomy.

The aim of this study is to calculate the exposure of surgical staff during radioguided parathyroidectomy. Two parathyroidectomy operations on patients with parathyroid adenoma were selected. Fifty-centimeter spaced circles were drawn surrounding the operation bed on the floor of the operation room. During the operation, radiation dose was measured according to the drawn circles at distances of 50-200 cm from the side of patient's head, bilateral neck and abdomen while the patient lied on the operation bed. All the operations were recorded throughout with a video camera. Three physicians watched all records. The time spent at each distance for every staff during the operation was recorded. Whole body dose to senior surgeon was calculated as 8.78-11.00 microSv which means that a senior surgeon can perform 91-114 procedures per year to reach the annual International Commission on Radiological Protection (ICRP) radiation dose limit for a member of the public. We concluded that radiation risk to the surgical staff is low from radioguided parathyroidectomy.

Prospective trial of intensive decongestive physiotherapy for upper extremity lymphedema.

BACKGROUND: The aim of this study was to evaluate the effects of kinesiophobia, quality of life, and home exercise programs on women with upper extremity lymphedema. METHODS: A total of 62 women with lymphedema after breast cancer treatments were provided a protocol of complete decongestive therapy (CDT). This protocol involved manual lymphatic drainage (MLD), compression garments, skin care, and remedial exercises. The women were taken to a 12-week therapy program once per day, 3 days per week. A home program, consisting of compression bandage exercises, skin care and walking was recommended. Absolute volume and percentage of volume of the lymphedema were compared before and after treatment. The kinesiophobia, quality of life, and home-based program were assessed before and after physiotherapy. RESULTS: Strong correlations were found between the severity of edema and fear of movement. There was a significant negative relationship among the fear of movement, quality of life, and home-based exercises program. Mean initial lymphedema volume was 925 ml, and the percentage of lymphedema was 47.1%. After decongestive physiotherapy, the lymphedema volume and percentage were 510 ml and 21.3% (P < 0.05), respectively. There was also a trend toward improvement in general well-being (P < 0.05). CONCLUSION: In upper extremity lymphedema, the use of complex physiotherapy programs (CDP) can decrease edema and fear of activity, and increase the quality of life.

Metastatic tumors in the breast: a report of 5 cases and review of the literature.

Breast cancer is the most common malignancy in women. However, metastases to the breast from nonmammary malignant neoplasms are rare and were detected at a rate of 0.28% in our series. Clinical and pathologic findings in 5 cases of metastatic tumors (malign mesenchymal tumor, squamous cell carcinoma of the tongue, non-Hodgkin lymphoma, and Sézary syndrome) in the breast are presented and discussed with respect to the literature. Detailed clinical history and a multidisciplinary approach are useful in establishing correct diagnosis and preventing unnecessary radical surgery.

DNA copy number changes detected by comparative genomic hybridization and their association with clinicopathologic parameters in breast tumors.

The purpose of this study was to use comparative genomic hybridization (CGH) to screen breast tumors for copy number changes: 22 ductal, 9 lobular, 7 mixed, 2 micropapillary carcinomas, and 2 ductal carcinoma in situ were studied and various regional genomic imbalances were detected. The majority of the aberrations identified in this study were in line with previous CGH findings. The most frequent DNA sequence copy number changes were 1q, 8q, and 20q gains. The frequency of 16q losses was significantly higher in lobular carcinomas. The nodal involvement was 10 times higher in cases showing losses of 13q than in cases having normal peak profile at this region. Estrogen receptor positivity was significantly higher in cases displaying 20q gains and 16q losses. Unambiguous high-level DNA amplifications have also been detected. These mapped to 4q31, 6q21 approximately q22, 8q21 approximately q24, 8p11.2 approximately p12, 11q13, 15q24 approximately qter, 20q13.1 approximately qter, and 20q12 approximately qter chromosomal locations. Our results highlight several chromosomal regions that may be important in the molecular genetics of distinct clinicopathologic breast cancer subgroups.