Genetic Variants and Tumor Immune Microenvironment: Clues for Targeted Therapies in Inflammatory Breast Cancer (IBC).

To better understand the etiology of inflammatory breast cancer (IBC) and identify potential therapies, we studied genomic alterations in IBC patients. Targeted, next-generation sequencing (NGS) was performed on cell-free DNA (cfDNA) (n = 33) and paired DNA from tumor tissues (n = 29) from 32 IBC patients. We confirmed complementarity between cfDNA and tumor tissue genetic profiles. We found a high incidence of germline variants in IBC patients that could be associated with an increased risk of developing the disease. Furthermore, 31% of IBC patients showed deficiencies in the homologous recombination repair (HRR) pathway (BRCA1, BRCA2, PALB2, RAD51C, ATM, BARD1) making them sensitive to poly (ADP-ribose) polymerase (PARP) inhibitors. We also characterized the tumor-infiltrating lymphocytes (TILs) in tumor tissue biopsies by studying several markers (CD4, CD8, FoxP3, CD20, PD-1, and PD-L1) through immunohistochemistry (IHC) staining. In 7 of 24 (29%) patients, tumor biopsies were positive for PD-L1 and PD-1 expression on TILs, making them sensitive to PD-1/PD-L1 blocking therapies. Our results provide a rationale for considering PARP inhibitors and PD-1/PDL1 blocking immunotherapy in qualifying IBC patients.

Molecular docking-guided synthesis of NSAID-glucosamine bioconjugates and their evaluation as COX-1/COX-2 inhibitors with potentially reduced gastric toxicity.

Non-steroidal anti-inflammatory drugs (NSAIDs) are a powerful class of inhibitors targeting two isoforms of the family of cyclooxygenase enzymes (COX-1 and COX-2). While NSAIDs are widely used in the management of pain, in particular as a treatment for osteo- and rheumatoid arthritis, their long-term use has been associated with numerous on- and off-target effects. As the carboxylic acid moiety present in common NSAIDs is responsible for some of their adverse effects, but is not required for their anti-inflammatory activity, we sought to mask this group through direct coupling to glucosamine, which is thought to prevent cartilage degradation. We report herein the conjugation of commonly prescribed NSAIDs to glucosamine hydrochloride and the use of molecular docking to show that addition of the carbohydrate moiety to the parent NSAID can enhance binding in the active site of COX-2. In a preliminary, in vitro screening assay, the diclofenac-glucosamine bioconjugate exhibited 10-fold greater activity toward COX-2, making it an ideal candidate for future in vivo studies. Furthermore, in an intriguing result, we observed that the mefenamic acid-glucosamine bioconjugate displayed enhanced activity toward COX-1 rather than COX-2.

Expression of p40 in Primary Cutaneous Mucinous Carcinoma Versus Primary Mucinous Carcinomas of the Breast and Colon.

BACKGROUND: The transcription factor p63 is a homolog of p53, expressed in basal layers of epithelia and myoepithelial cells. Some studies have suggested that p63 may provide utility in differentiating primary versus metastatic mucinous carcinoma of the skin, given its preferential expression in primary adnexal neoplasms. There have been few studies investigating the expression patterns of p40, an isoform of p63, in primary cutaneous mucinous carcinomas. METHODS: An immunohistochemical panel including p40, CK7, CK20, estrogen receptor, and progesterone receptor was applied to primary mucinous carcinomas of the skin, breast, and colon. RESULTS: Only a small subset (25%) of primary cutaneous mucinous carcinomas displayed focal positive staining with p40, similar to what has been reported in the literature for p63. All primary mucinous carcinomas of skin and breast labeled positively with CK7, estrogen receptor, and progesterone receptor. Primary colon mucinous carcinomas were only positive for CK20. CONCLUSIONS: Based on these results, p40 seems to be an insufficient marker for distinguishing primary versus metastatic mucinous carcinoma due to its low rate of positivity in primary cutaneous mucinous carcinomas.

Cytological interpretation of p16 immunohistochemistry in head and neck carcinomas: does the choice of fixative matter?

INTRODUCTION: Fine-needle aspiration (FNA) of nodal metastases plays a key role in the diagnosis of oropharyngeal squamous cell carcinoma (OPSCC). Because of significant clinical implications of human papillomavirus (HPV)-related OPSCC, immunohistochemistry for p16 as a surrogate marker for high-risk HPV is an important ancillary test. After our laboratory switched from CytoLyt to formalin fixative for FNA needle rinses generating cell block (CB) material, we investigated the impact of this protocol change on the accuracy of p16 results. MATERIALS AND METHODS: FNA specimens of head and neck lesions with p16 staining performed on CB, from 1 year before and after the implementation of formalin-fixed CB (FCB) were identified. Nuclear and cytoplasmic p16 expression was scored and compared to p16 status on corresponding surgical specimens. RESULTS: There were no false-positive results with either fixative. CytoLyt-fixed CB (CCB) had 47% (7 of 15) false-negative cases, whereas FCB had none, with 100% diagnostic accuracy for p16-negative (n = 6) and p16-positive (n = 15) results. False-negative CCB showed 0% to 10% nuclear and 0% to 65% weak cytoplasmic staining, whereas true-positive CCB showed 10% to 85% nuclear and 35% to 90% cytoplasmic staining. p16-negative FCB showed 0% nuclear and cytoplasmic staining, and p16-positive FCB showed 30% to 100% moderate-strong nuclear and cytoplasmic staining. Interobserver variability was greater with CCB. CONCLUSIONS: In our laboratory, formalin fixation of CB material improved the accuracy of p16 interpretation. Staining in FCB was also more robust than CCB, which showed weaker cytoplasmic and more focal nuclear staining. Therefore, we advocate formalin fixation for head and neck cytology specimens that may require p16 testing.

Malignant phyllodes tumor with extensive lipomatous differentiation.

Phyllodes tumors are uncommon neoplasms of the breast. Lipomatous differentiation of malignant phyllodes tumor is a rare stromal alteration of this fibroepithelial tumor, demonstrated as a fat-containing mass on imaging. We present the case of a 46-year-old woman who was diagnosed with a malignant phyllodes tumor of the breast that demonstrated extensive lipomatous differentiation.

Aggressive Mammary Cancers Lacking Lymphocytic Infiltration Arise in Irradiated Mice and Can Be Prevented by Dietary Intervention.

Because the incidence of breast cancer increases decades after ionizing radiation exposure, aging has been implicated in the evolution of the tumor microenvironment and tumor progression. Here, we investigated radiation-induced carcinogenesis using a model in which the mammary glands of 10-month-old BALB/c mice were transplanted with Trp53-null mammary tissue 3 days after exposure to low doses of sparsely ionizing γ-radiation or densely ionizing particle radiation. Mammary transplants in aged, irradiated hosts gave rise to significantly more tumors that grew more rapidly than those in sham-irradiated mice, with the most pronounced effects seen in mice irradiated with densely ionizing particle radiation. Tumor transcriptomes identified a characteristic immune signature of these aggressive cancers. Consistent with this, fast-growing tumors exhibited an immunosuppressive tumor microenvironment with few infiltrating lymphocytes, abundant immunosuppressive myeloid cells, and high COX-2 and TGFß. Only irradiated hosts gave rise to tumors lacking cytotoxic CD8+ lymphocytes (defined here as immune desert), which also occurred in younger irradiated hosts. These data suggest that host irradiation may promote immunosuppression. To test this, young chimera mice were fed chow containing a honeybee-derived compound with anti-inflammatory and immunomodulatory properties, caffeic acid phenethyl ester (CAPE). CAPE prevented the detrimental effects of host irradiation on tumor growth rate, immune signature, and immunosuppression. These data indicated that low-dose radiation, particularly densely ionizing exposure of aged mice, promoted more aggressive cancers by suppressing antitumor immunity. Dietary intervention with a nontoxic immunomodulatory agent could prevent systemic effects of radiation that fuel carcinogenesis, supporting the potential of this strategy for cancer prevention.

Cytohistologic correlation of basaloid salivary gland neoplasms: Can cytomorphologic classification be used to diagnose and grade these tumors?

BACKGROUND: Basaloid salivary gland neoplasms (BSNs), which include benign primary tumors and primary or metastatic malignancies, show overlapping morphology in fine-needle aspiration (FNA). The Milan system recommends assigning a grade (low or high) to malignant salivary neoplasms because of the impact on surgical planning. This study investigated cytomorphologic features of BSNs on FNA that would help to favor a high-grade malignancy over a low-grade malignancy or a benign tumor. METHODS: Two pathologists performed a double-blinded cytologic evaluation of FNA cases diagnosed as BSNs that had corresponding surgical resections. The diagnosis made with the Milan system was correlated with the final surgical diagnosis and grade. Cytologic sensitivity, specificity, and predictive values were calculated. RESULTS: There were 132 BSN FNA cases; cytology slides were available for 77 of 87 patients who had undergone resection. The risk of malignancy for the benign neoplasm (BN), salivary gland neoplasm of uncertain malignant potential (SUMP), suspicious for malignancy (SFM), and malignant categories were 13.6%, 22%, 100%, and 100%, respectively. The sensitivity of the malignant/SFM category was 51.7%; another 37.9% of confirmed malignancies were diagnosed as SUMP. The specificity of the BN category was 86%. Favoring a high-grade malignancy on FNA had 100% accuracy (5 of 5). Favoring a low-grade malignancy on FNA had 75% accuracy (6 of 8). The most specific cytomorphologic clues for a high-grade malignancy were necrotic/apoptotic debris, mitoses, discohesion, and anisonucleosis. CONCLUSIONS: BSNs encompass a broad spectrum of primary and metastatic tumors. Necrotic/apoptotic debris, mitotic activity, discohesion, and significant anisonucleosis, alone or especially in combination, should make a cytopathologist suspect a high-grade malignancy.

Prostatic Stromal Tumors of Uncertain Malignant Potential.

We present a 53-year-old man with a multilocular solid and cystic mass measuring 19 cm on cross-sectional imaging. After undergoing pelvic mass excision, final histopathology confirmed the diagnosis of primary prostatic stromal tumor of uncertain malignant potential (STUMP). Prostatic STUMPs are rare mesenchymal tumors with diverse histologic patterns. They are distinct from prostatic stromal sarcomas as they do not behave aggressively, although some may occasionally demonstrate local recurrence after resection. Due to their unpredictable malignant potential, lack of correlation between histologic patterns, and sarcomatous differentiation, these patients warrant surgical excision and close follow-up.

Sensitivity of Fine-Needle Aspiration and Imaging Modalities in the Diagnosis of Low-Grade Mucoepidermoid Carcinoma of the Parotid Gland.

OBJECTIVE: To determine the diagnostic accuracy of fine-needle aspiration (FNA) and imaging modalities for low-grade mucoepidermoid carcinoma (MEC) of the parotid gland. METHODS: Retrospective chart review of patients diagnosed with low-grade MEC of the parotid gland following surgical excision between January 2010 and June 2018. Imaging from patients with MEC were randomly mixed with imaging from patients with benign pathology and reviewed in a blinded fashion. Main outcome measure was sensitivity. RESULTS: A total of 24 patients were confirmed to have had low-grade MEC on final pathology, with a total of 31 FNAs performed between them. Twelve of 31 FNAs were positive for low-grade MEC, with a sensitivity of 39%. A total of 27 imaging studies were reviewed, which included 16 patients with low-grade MEC and 11 patients with benign pathology. Of these 27 imaging studies, 10 were declared indeterminate. Of the remaining 17 imaging studies, 13 were reviewed as malignant (11 true positive and 2 false positive) and 4 as benign (4 true negative). Overall magnetic resonance imaging (MRI) sensitivity for low-grade MEC was 100% (9/9) with 95% CI (0.66-1.0) when considering indeterminate results as positive for malignancy. CONCLUSION: This study reaffirms that for low-grade MEC, sensitivity of FNA is poor. MRI provides an important diagnostic tool in the evaluation of salivary gland neoplasms, due to its increased sensitivity for low-grade MEC when considering indeterminate results as positive. This provides confidence in the diagnosis of benign tumors and allows appropriate counseling of all options to the patient, including observation. Imaging and low threshold of excision should be considered despite an inflammatory or benign FNA.

Benign vascular lesions of the breast diagnosed by core needle biopsy do not require excision.

AIMS: Surgical excision of all benign vascular lesions of the breast identified by core needle biopsy has been recommended in the past to rule out a more serious lesion. In this study we investigated the clinical, radiological and pathological findings in patients diagnosed with a benign vascular lesion at our institution to assess whether excision may be spared for lesions without atypia. METHODS AND RESULTS: We searched the electronic medical record for patients with a vascular lesion of the breast diagnosed between 2000 and 2015. The study population consisted of 84 patients, 83 females and one male. The index diagnoses included 76 benign vascular lesions, five vascular lesions with cytological atypia and three angiosarcomas. A radiologist reviewed all pre- and post-biopsy imaging studies; all cases had concordant radiological and pathological findings. Based on radiological and histological correlation, the vascular lesion accounted for the radiological target in 40 (48%) cases and was deemed an incidental finding in 44 (52%). Seven of 32 (22%) targeted and 10 of 44 (23%) incidental benign vascular lesions underwent surgical excision; there were no upgrades at excision. No recurrences or clinical events were observed in patients with a targeted or incidental benign vascular lesion with a median follow-up of 39 months and 40.6 months, respectively. CONCLUSION: Our data suggest that benign vascular lesions diagnosed on core biopsy with concordant radiological and pathological findings do not warrant surgical excision.

Breast intraductal papillomas without atypia in radiologic-pathologic concordant core-needle biopsies: Rate of upgrade to carcinoma at excision.

BACKGROUND: The surgical management of mammary intraductal papilloma without atypia (IDP) identified at core-needle biopsy (CNB) is controversial. This study assessed the rate of upgrade to carcinoma at surgical excision (EXC). METHODS: This study identified women with a CNB diagnosis of intraductal papilloma without atypia or carcinoma at a cancer center between 2003 and 2013. Radiologic-pathologic concordance was assessed for all cases, and discordant cases were excluded. The radiologic and clinicopathologic features of patients with a CNB diagnosis of IDP were correlated with an upgrade to carcinoma at EXC. RESULTS: The study population consists of 189 women with 196 IDPs; 166 women (171 IDPs) underwent EXC. The upgrade rate was 2.3% (4 of 171). The upgraded lesions were 2 invasive lobular carcinomas and 2 cases of ductal carcinoma in situ (DCIS). One case of DCIS involved the residual IDP, whereas the other 3 carcinomas were ≥ 8 mm away. Twenty-four women (25 IDPs) did not undergo EXC and had stable imaging on follow-up (median, 23.5 months). CONCLUSIONS: The upgrade rate at EXC for IDPs diagnosed at CNB with radiologic-pathologic concordance was 2.3%. These findings suggest that observation is appropriate for patients with radiologic-pathologic concordant CNB yielding IDP, regardless of its size. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2819-2827. © 2016 American Cancer Society.

Densely ionizing radiation acts via the microenvironment to promote aggressive Trp53-null mammary carcinomas.

Densely ionizing radiation, which is present in the space radiation environment and used in radiation oncology, has potentially greater carcinogenic effect compared with sparsely ionizing radiation that is prevalent on earth. Here, we used a radiation chimera in which mice were exposed to densely ionizing 350 MeV/amu Si-particles, γ-radiation, or sham-irradiated and transplanted 3 days later with syngeneic Trp53-null mammary fragments. Trp53-null tumors arising in mice irradiated with Si-particles had a shorter median time to appearance and grew faster once detected compared with those in sham-irradiated or γ-irradiated mice. Tumors were further classified by markers keratin 8/18 (K18, KRT18), keratin 14 (K14, KRT14) and estrogen receptor (ER, ESR1), and expression profiling. Most tumors arising in sham-irradiated hosts were comprised of both K18- and K14-positive cells (K14/18) while those tumors arising in irradiated hosts were mostly K18. Keratin staining was significantly associated with ER status: K14/18 tumors were predominantly ER-positive, whereas K18 tumors were predominantly ER-negative. Genes differentially expressed in K18 tumors compared with K14/18 tumor were associated with ERBB2 and KRAS, metastasis, and loss of E-cadherin. Consistent with this, K18 tumors tended to grow faster and be more metastatic than K14/18 tumors, however, K18 tumors in particle-irradiated mice grew significantly larger and were more metastatic compared with sham-irradiated mice. An expression profile that distinguished K18 tumors arising in particle-irradiated mice compared with sham-irradiated mice was enriched in mammary stem cell, stroma, and Notch signaling genes. These data suggest that carcinogenic effects of densely ionizing radiation are mediated by the microenvironment, which elicits more aggressive tumors compared with similar tumors arising in sham-irradiated hosts.

Cystic lesions of the adrenal gland: our experience over the last 20 years.

Cystic lesions of the adrenal gland are uncommon, often presenting with nonspecific clinical and radiologic findings, and are thus underrecognized. They are occasionally associated with malignant neoplasms, which can greatly mimic benign lesions and carry detrimental clinical consequences if misdiagnosed. Here we present our 20-year experience (1992-2012) with these lesions at an academic medical center. Among more than 4500 adrenal gland specimens, 31 cases of adrenal lesions with a predominant cystic component were identified in 30 patients with an age range of 34 to 86 years (median, 55.5 years) and a male/female ratio of 13:17. Macroscopic descriptions, available histologic and immunostain slides, and available radiologic records were reviewed for all included cases. Radiologic studies and gross examination correlated well, and hemorrhage (26 cases; 84%) and encapsulation (25 cases; 81%) appeared to be nonspecific radiologic/gross features shared across histologic subtypes. Microscopic review identified 12 cases (39%) of pseudocysts, 2 cases (6%) of endothelium-derived cysts, and 17 cases (55%) of epithelium-derived cysts. Among these 31 cystic adrenal lesions, 2 cases (6%) were malignant neoplasms (1 epithelioid angiosarcoma, 1 adrenocortical carcinoma). Radiologic impression and histopathologic diagnosis were concordant in 11 (73%) of the 15 cases for which radiologic records were available. This study represents the second largest case series to date on cystic adrenal lesions and presents a comprehensive review on their demographic, clinical, radiologic, and gross and microscopic pathologic features, as well as their differential diagnoses.

Mucosal eosinophilia: prevalence and racial/ethnic differences in symptoms and endoscopic findings in adults over 10 years in an urban hospital.

BACKGROUND: Eosinophilic esophagitis is a chronic inflammatory disease with mucosal accumulation of eosinophils. There is a paucity of data among racial/ethnic groups other than white patients. AIM: To determine if racial/ethnic differences exist in clinical presentation, endoscopic appearance, and biopsy results in adult patients (age ≥18 y) with mucosal eosinophilia and examine the prevalence of mucosal eosinophilia at an urban hospital over a 10-year period. METHODS: Pathology reports searched at Temple University Hospital 2000 to 2009; key words: "eosinophils", "esophagus", and "biopsy". Clinical and endoscopic records reviewed on patients with ≥15 eosinophils/high power field. RESULTS: A total of 64 adults (average age, 41 y; 62% male patients; 81% white, 12% black, and 6% Hispanic). White patients were significantly younger (P=0.03). Adult mucosal eosinophilia diagnosis increased by 833% (3 in 2000 to 25 in 2009); black/Hispanic diagnosis increased by 500% (1 in 2000 to 5 in 2009). Solid food dysphagia was more common among white patients (72% vs. 0.33%, P=0.02). Reflux symptoms were more common in black/Hispanic patients (42% vs. 22%, P=0.16). Normal endoscopy (42% vs. 13%, P=0.04) and reflux changes (41% vs. 21%, P=0.16) were more common in black/Hispanic patients. Furrows (42% vs. 8%, P=0.04) and rings (46% vs. 0%, P=0.002) were more common in white patients. Average eosinophil counts did not vary between groups. CONCLUSIONS: Mucosal eosinophilia presents with significant differences between racial/ethnic groups in age at onset, symptoms at presentation, and endoscopic features. Differences may reflect different phenotypes of the same disease or separate disease entities.

Glanzmann's thrombasthenia: report of a case and review of the literature.

Glanzmann's thrombasthenia is a rare congenital bleeding disorder. Patients usually present with mucocutaneous bleeding and excessive bleeding associated with trauma and/or surgery. Patients have an increased bleeding time and a normal platelet count with abnormal platelet function assays. Genetically, Glanzmann's thrombasthenia is associated with mutations in the genes which encode for glycoproteins, GPIIb or GPIIIa. Defects in these genes lead to a lack of or highly reduced expression of the glycoprotein complex (GPIIb/GPIIIa), resulting in platelet dysfunction. Bleeding is managed by platelet transfusions. Bone marrow transplants have been used successfully in rare cases. With proper supportive care Glanzmann's thrombasthenia has a very good prognosis.

Hermansky-pudlak syndrome: report of a case and review of the literature.

Hermansky-Pudlak syndrome is a rare autosomal recessive disorder characterized by excessive bleeding post surgery. Here we reported such a case and reviewed the clinicopathological features and our current understanding of this rare congenital disorder.