Characterization of molecular scores and gene expression signatures in primary breast cancer, local recurrences and brain metastases.

BACKGROUND: Breast cancer is a leading cause of cancer-related death in women worldwide. Despite extensive studies in all areas of basic, clinical and applied research, accurate prognosis remains elusive, thus leading to overtreatment of many patients. Diagnosis could be improved by introducing multigene molecular scores in standard clinical practice. Several tests that work with formalin-fixed tissue have become routine. Molecular scores usually include several genes representing processes, response to oestrogens, progestogens and human epidermal growth factor receptor 2 (Her2), respectively, which are combined additively in single values. These multi-gene scores have the advantage of being more robust and reproducible than single-gene scores. Their utility may be further enhanced by combining them with classical diagnostic parameters. Here, we present an exploratory study comparing the RISK and research versions of Oncotype DX recurrence score (RS), Prosigna Risk of Recurrence (ROR) and EndoPredict (EP) with respect to their prognostic potential for ipsilateral recurrence and/or distant relapse in brain, and we compared the scores to the intrinsic subtypes based on PAM50. METHODS: RNA was extracted from formalin-fixed, paraffin-embedded (FFPE) tissue cores of primary tumours, local recurrences and brain metastases. Gene expression was measured on a NanoString nCounter Analysis System. Intrinsic subtypes and molecular scores were computed according to published literature and RISK, RS, ROR and EP were compared against each other and to the intrinsic subtypes Luminal A (lumA), Luminal B (lumB), Her2-enriched (Her2↑), Basal-like (basal), and Normal-like (normal) of PAM50. Local recurrences and brain metastases were compared to their corresponding primary tumours. RESULTS: All four molecular scores were highly correlated. Highest correlations were observed among genes related to proliferation while lower correlations were found among oestrogen-related genes. The scores were significantly higher in primary tumours progressing to brain metastases as compared to recurrence-free primary tumours and primary tumours that relapsed as local recurrences. CONCLUSIONS: RISK and ROR-P are prognostic for primary tumours metastasizing to the brain. All four scores, RISK, RS, EP and ROR-P failed to discriminate between primary tumours that remained recurrence-free and primary tumours relapsing as local recurrences.

A randomized controlled clinical and histopathological trial comparing excisional biopsies of oral fibrous hyperplasias using CO2 and Er:YAG laser.

This study was conducted in order to compare clinical and histopathological outcomes for excisional biopsies when using pulsed CO2 laser versus Er:YAG laser. Patients (n = 32) with a fibrous hyperplasia in the buccal mucosa were randomly allocated to the CO2 (140 Hz, 400 µs, 33 mJ) or the Er:YAG laser (35 Hz, 297 µs, 200 mJ) group. The duration of excision, intraoperative bleeding and methods to stop the bleeding, postoperative pain (VAS; ranging 0-100), the use of analgesics, and the width of the thermal damage zone (µm) were recorded and compared between the two groups. The median duration of the intervention was 209 s, and there was no significant difference between the two methods. Intraoperative bleeding occurred in 100% of the excisions with Er:YAG and 56% with CO2 laser (p = 0.007). The median thermal damage zone was 74.9 µm for CO2 and 34.0 µm for Er:YAG laser (p < 0.0001). The median VAS score on the evening after surgery was 5 for the CO2 laser and 3 for the Er:YAG group. To excise oral soft tissue lesions, CO2 and Er:YAG lasers are both valuable tools with a short time of intervention and postoperative low pain. More bleeding occurs with the Er:YAG than CO2 laser, but the lower thermal effect of Er:YAG laser seems advantageous for histopathological evaluation.

Tomosynthesis-guided vacuum-assisted breast biopsy: A feasibility study.

PURPOSE: Evaluation of feasibility and clinical performance of a tomosynthesis-guided vacuum-assisted breast biopsy (TVAB) system compared to Stereotaxy (SVAB). MATERIALS AND METHODS: All biopsies were performed on consecutive patients: 148 TVAB biopsies and 86 biopsies on different patients using SVAB. Evaluation criteria for each biopsy were technical feasibility, histopathology, procedure time, and complications. RESULTS: All 148 TVAB biopsies were technically successful, and gained the targeted groups of microcalcifications (100 %). In 1 of 86 SVAB procedures, it was not possible to gain the targeted microcalcifications (1 %), in 3 of 86 the needle had to be adjusted (4 %). All TVAB biopsies were performed without clinically relevant complications. Distortions were biopsied exclusively by TVAB, mean size 0.9 cm, p < 0.0001. Of the 24 distortions, 13 were cancer, 11 Radial Scars/ CSL. The mean procedure time for TVAB was 15.4 minutes (range 7-28 min), for SVAB 23 minutes (range 11-46 min), p < 0.0001. CONCLUSIONS: TVAB is able to biopsy small architectural distortions with high accuracy. TVAB is easily feasible and appears to have the same degree of clinical performance for diagnosing microcalcifications. The increased number of biopsied distortions by TVAB is presumably due to increased use of tomosynthesis and its diagnostic potential. KEY POINTS: • TVAB is easily feasible. • TVAB is able to target architectural distortions with high accuracy. • TVAB diagnoses microcalcifications with the same clinical performance as SVAB.

Pulsed versus continuous wave CO2 laser excisions of 100 oral fibrous hyperplasias: a randomized controlled clinical and histopathological study.

BACKGROUND: In experimental animal studies, pulsing the CO2 laser beam has been shown to reduce the thermal damage zone of excised oral mucosal tissue. However, there is still controversy over whether this is borne out under clinical conditions. OBJECTIVE: To compare the outcome following excisional biopsies of fibrous hyperplasias using a pulsed (cf) versus a continuous wave (cw) CO2 laser mode regarding the thermal damage zone, duration of surgeries, intra- and postoperative complications, postoperative pain sensation, scarring and/or relapse during the initial 6 months. MATERIALS AND METHODS: One hundred Swiss-resident patients with a fibrous hyperplasia in their buccal mucosa were randomly assigned to the cw mode (5 W) or the cf mode (140 Hz, 400 microseconds, 33 mJ, 4.62 W) group. All excisions were performed by one single oral surgeon. Postoperative pain (2 weeks) was recorded by visual analogue scale (VAS; ranging from 0 to 100). Intake of analgesics and postoperative complications were recorded in a standardized study form. The maximum width of the collateral thermal damage zone was measured (µm) in excision specimens by one pathologist. Intraoral photographs at 6-month follow-up examinations were evaluated regarding scarring (yes/no). RESULTS: Median duration of the excision was 65 seconds in the cw and 81 seconds in the cf group (P = 0.13). Intraoperative bleeding occurred in 16.3% of the patients in the cw and 17.7% of the cf group. The median value of the thermal damage zone was 161(±228) µm in the cw and 152(± 105) µm in the cf group (P = 0.68). The reported postoperative complications included swelling in 19% and minor bleeding in 6% without significant differences between the two laser modes. When comparing each day separately or the combined mean VAS scores of both groups between Days 1-3, 1-7, and 1-15, there were no significant differences. However, more patients of the cw group (25%) took analgesics than patients of the cf group (9.8%) resulting in a borderline significance (P = 0.04). Scarring at the excision site was found in 50.6% of 77 patients after 6 months, and more scars were identified in cases treated with the cf mode (P = 0.03). CONCLUSIONS: Excision of fibrous hyperplasias performed with a CO2 laser demonstrated a good clinical outcome and long-term predictability with a low risk of recurrence regardless of the laser mode (cf or cw) used. Scarring after 6 months was only seen in 50.6% of the cases and was slightly more frequent in the cf mode group. Based on the findings of the present study, a safety border of 1 mm appears sufficient for both laser modes especially when performing a biopsy of a suspicious soft tissue lesion to ensure a proper histopathological examination.

Bilateral necrotizing sialometaplasia of the hard palate in a patient with bulimia: a case report and review of the literature.

Necrotizing sialometaplasia (NS) is a rare and benign lesion that mostly affects the posterior hard palate. Its importance resides in its clinical and microscopic characteristics, which can closely mimic malignant neoplasias, in particular oral squamous cell carcinoma and mucoepidermoid carcinoma. Accurate histopathologic evaluation of an incisional biopsy is considered as the diagnostic gold standard. NS lesions heal spontaneously within weeks, and no further treatment is necessary. We report a case of a bilateral palatal NS in a 22-yearold woman with bulimia, where an incisional biopsy confirmed the clinical diagnosis. The different clinical stages of the lesions from onset to resolution and the possible etiologic factors are described in detail, as well as a discussion of the differential diagnoses of palatal ulcers. When taking a biopsy from suspicious oral lesions, care has to be taken that an appropriate tissue sample is harvested, and the histopathologic analysis is performed by an experienced pathologist to establish a correct diagnosis.

Does a pulsed mode offer advantages over a continuous wave mode for excisional biopsies performed using a carbon dioxide laser?

PURPOSE: Animal studies of excisional biopsies have shown less thermal damage when a carbon dioxide (CO(2)) laser (10.6 µm) is used in a char-free (CF) mode than in a continuous-wave (CW) mode. The authors' aim was to evaluate and compare clinical and histopathologic findings of excisional biopsies performed with CW and CF CO(2) laser (10.6 µm) modes. MATERIALS AND METHODS: This prospective randomized controlled clinical trial included 60 patients with similar fibrous hyperplasias of the buccal plane willing to undergo excisional CO(2) laser biopsy. Patients were randomly allocated to the CW (5 W) or CF (140 Hz, 400 µs, 33 mJ) group. Duration of surgery, intra- and postoperative complications, and the width (micrometers) of the histopathologic collateral thermal damage zone were registered as primary outcome variables. Secondary outcome variables were pain (patients filled in a visual analog scale [VAS]) and analgesic intake (recorded by patients). RESULTS: The study group consisted of 36 women and 24 men with a median age of 50.5 years. Median durations of surgery were 74.5 seconds in the CW group and 83.5 seconds in the CF group. Intraoperative venous bleeding occurred in 16.7% of patients in the CW group and in 13.3% of patients in the CF group. Median areas of histopathologic collateral damage zones were similar in the CW group (166.5 µm) and the CF group (162.5 µm). There was no statistically significant difference between the VAS values of the 2 groups. Analgesic intake was recorded by 16.7% of patients in the CW group and by 6.7% of patients in the CF group (P = .23, not significant). No statistically significant correlation was found between areas of thermal damage zones and postoperative VAS scores. CONCLUSIONS: In contrast to previous animal studies, no significant difference was found in the widths of thermal damage zones between the CW and CF groups. The VAS values and analgesic intake were low in the 2 groups. The 2 CO(2) laser modes are appropriate for the excision of intraoral mucosal lesions. A safety border of at least 1 mm is recommended regardless of the laser mode used.

Asymptomatic ossifying fibroma of the mandible: a case presentation.

Ossifying fibromas are rare benign bone-related lesions of the jaw. Early diagnosis based on clinical, radiologic, and pathohistologic findings is essential, since undetected lesions may expand and cause considerable functional and cosmetic problems. The treatment of choice is purely surgical. Periodic clinical and radiologic follow-up should be scheduled, since recurrence is possible. The present article describes the diagnostic procedures, surgical management, and follow-up of an asymptomatic ossifying fibroma in the mandible of a 21-year-old man.

Expansive nasopalatine duct cysts with nasal involvement mimicking apical lesions of endodontic origin: a report of two cases.

INTRODUCTION: The nasopalatine duct cyst (NPDC) is the most frequent nonodontogenic cyst of the jaws and can be misinterpreted as an apical lesion of endodontic origin. METHODS: In the first case, a 17-year-old male patient was referred because of a pressure sensation in the anterior maxilla. The teeth #7, #8, #10, and #11 responded to cold sensitivity testing, and on tooth #9 an endodontic treatment had been performed 3 years ago. Only periapical radiographs had been taken, and a radicular cyst was suspected. In the second case, a 42-year-old man reported inconvenience wearing his upper removable partial denture. Suspecting a jaw cyst in the anterior maxilla, the general dental practitioner referred the patient. RESULTS: Limited cone-beam computed tomography scans visualized the expansion of the cysts and the involvement of the neighboring structures in both cases. In both patients, the NPDCs were treated first by marsupialization in local anesthesia and second with cystectomy in general anesthesia with reconstruction of the defect areas with bone gained from the iliac crest. The final diagnosis was achieved by histopathological examination. CONCLUSIONS: If not diagnosed early, the NPDC can expand through the palatal and/or buccal cortical wall and also into the nasal cavity. The more expansive the NPDC is becoming, the more complex the final diagnosis is and the subsequent surgical therapy.

CO2 and diode laser for excisional biopsies of oral mucosal lesions. A pilot study evaluating clinical and histopathological parameters.

PURPOSE: The present pilot study evaluates the histopathological characteristics and suitability of CO2 and diode lasers for performing excisional biopsies in the buccal mucosa with special emphasis on the extent of the thermal damage zone created. PATIENTS AND METHODS: 15 patients agreed to undergo surgical removal of their fibrous hyperplasias with a laser. These patients were randomly assigned to one diode or two CO2 laser groups. The CO2 laser was used in a continuous wave mode (cw) with a power of 5 W (Watts), and in a pulsed char-free mode (cf). Power settings for the diode laser were 5.12 W in a pulsed mode. The thermal damage zone of the three lasers and intraoperative and postoperative complications were assessed and compared. RESULTS: The collateral thermal damage zone on the borders of the excisional biopsies was significantly smaller with the CO, laser for both settings tested compared to the diode laser regarding values in pm or histopathological index scores. The only intraoperative complication encountered was bleeding, which had to be controlled with electrocauterization. No postoperative complications occurred in any of the three groups. CONCLUSIONS: The CO2 laser seems to be appropriate for excisional biopsies of benign oral mucosal lesions. The CO2 laser offers clear advantages in terms of smaller thermal damage zones over the diode laser. More study participants are needed to demonstrate potential differences between the two different CO2 laser settings tested.

Molecular risk assessment of BIG 1-98 participants by expression profiling using RNA from archival tissue.

BACKGROUND: The purpose of the work reported here is to test reliable molecular profiles using routinely processed formalin-fixed paraffin-embedded (FFPE) tissues from participants of the clinical trial BIG 1-98 with a median follow-up of 60 months. METHODS: RNA from fresh frozen (FF) and FFPE tumor samples of 82 patients were used for quality control, and independent FFPE tissues of 342 postmenopausal participants of BIG 1-98 with ER-positive cancer were analyzed by measuring prospectively selected genes and computing scores representing the functions of the estrogen receptor (eight genes, ER_8), the progesterone receptor (five genes, PGR_5), Her2 (two genes, HER2_2), and proliferation (ten genes, PRO_10) by quantitative reverse transcription PCR (qRT-PCR) on TaqMan Low Density Arrays. Molecular scores were computed for each category and ER_8, PGR_5, HER2_2, and PRO_10 scores were combined into a RISK_25 score. RESULTS: Pearson correlation coefficients between FF- and FFPE-derived scores were at least 0.94 and high concordance was observed between molecular scores and immunohistochemical data. The HER2_2, PGR_5, PRO_10 and RISK_25 scores were significant predictors of disease free-survival (DFS) in univariate Cox proportional hazard regression. PRO_10 and RISK_25 scores predicted DFS in patients with histological grade II breast cancer and in lymph node positive disease. The PRO_10 and PGR_5 scores were independent predictors of DFS in multivariate Cox regression models incorporating clinical risk indicators; PRO_10 outperformed Ki-67 labeling index in multivariate Cox proportional hazard analyses. CONCLUSIONS: Scores representing the endocrine responsiveness and proliferation status of breast cancers were developed from gene expression analyses based on RNA derived from FFPE tissues. The validation of the molecular scores with tumor samples of participants of the BIG 1-98 trial demonstrates that such scores can serve as independent prognostic factors to estimate disease free survival (DFS) in postmenopausal patients with estrogen receptor positive breast cancer.

Palatal swelling as the first and only manifestation of extranodal follicular non-Hodgkin lymphoma: a case presentation.

Non-Hodgkin lymphomas (NHLs) in the head and neck region are malignant lymphoid neoplasms that usually originate from B-lymphocytic cell lines. Primary extranodal manifestations of this hematolymphoid tumor in the oral cavity are rare and involve the maxillary jaw including the palatal soft tissues, the mandible, and gingival tissues in patients between 60 and 70 years of age without sex predilection. This case report of an extra-nodal NHL in the palate of a 75-year-old patient emphasizes the importance of accurate clinical, radiographic, and histologic diagnostic procedures to avoid delayed diagnosis or inappropriate treatment strategies. Chemotherapy, radiotherapy, or a combination of the two with a regular clinical and hemic follow-up is recommended.

Canalicular adenoma of a minor salivary gland on the palate: a case presentation.

Canalicular adenomas are uncommon, benign epithelial neoplasms of the salivary glands that usually involve the upper lip and buccal mucosa of elderly people. Differential diagnosis of the canalicular adenoma versus adenocarcinoma is important, as it may result in unjustified radiotherapy or extensive and aggressive surgery. Despite the benign nature of canalicular adenomas, complete surgical removal and a regular clinical follow-up are recommended. The present article describes the diagnostic procedures, surgical management, and follow-up of a canalicular adenoma involving the palate of a 71-year-old man.

Histology of periapical lesions obtained during apical surgery.

The aim of this was to evaluate the histology of periapical lesions in teeth treated with periapical surgery. After root-end resection, the root tip was removed together with the periapical pathological tissue. Histologic sectioning was performed on calcified specimens embedded in methylmethacrylate (MMA) and on demineralized specimens embedded in LR White (Fluka, Buchs, Switzerland). The samples were evaluated with light and transmission electron microscopy (TEM). The histologic findings were classified into periapical abscesses, granulomas, or cystic lesions (true or pocket cysts). The final material comprised 70% granulomas, 23% cysts and 5% abscesses, 1% scar tissues, and 1% keratocysts. Six of 125 samples could not be used. The cystic lesions could not be subdivided into pocket or true cysts. All cysts had an epithelium-lined cavity, two of them with cilia-lined epithelium. These results show the high incidence of periapical granulomas among periapical lesions obtained during apical surgery. Periapical abscesses were a rare occasion. The histologic findings from samples obtained during apical surgery may differ from findings obtained by teeth extractions. A determination between pocket and true apical cysts is hardly possible when collecting samples by apical surgery.

Apocrine papillary cystadenoma of a minor salivary gland on the lower lip: case presentation.

Cystadenomas are a rare, painless, and slow-growing benign epithelial tumor of the salivary gland. This article describes the case of a papillary cystadenoma in the lower lip of a 46-year-old man. The lesion was removed using a carbon dioxide laser, and there were no signs of recurrence 1 year postoperatively.

Loss of pulp sensitivity and pain as the first symptoms of a Ewing's sarcoma in the right maxillary sinus and alveolar process: report of a case.

This case report describes the diagnosis and treatment of a Ewing's sarcoma in the right maxillary sinus and alveolar bone of a 19-year-old female patient. The first clinical symptoms were a loss of sensitivity of the premolars and first molar in the right maxilla and acute pain located in the area of these teeth. Initially, the referring dentist had treated these findings as an acute apical periodontitis with root canal medication. Because swellings on the palatal and buccal aspects of the teeth occurred and could not be treated with incision and drainage, the dentist referred the patient. Cone-beam computed tomography revealed a proliferation of soft tissue in the right maxillary sinus, with a radiopaque material at the tip of the mesiobuccal root of the first molar and resorptive signs of the mesiobuccal and distobuccal roots of the first molar. The palatal cortical bone of the right alveolar process seemed to be intact. After explorative surgery with biopsies from the buccal, palatal, and sinus proliferation areas, the pathologist diagnosed the lesion as a Ewing's sarcoma. Treatment of the patient consisted of initial chemotherapy, hemimaxillectomy, and postsurgical chemoradiotherapy.

[Oral erythroplakia and erythroleukoplakia: red and red-white dysplastic lesions of the oral mucosa--part 2: cytodiagnosis, pathogenesis, therapy, and prognostic aspects]. / Erythroplakie und Erythroleukoplakie: Rote und rot-weisse Risikoläsionen der Mundhöhlenschleimhaut. Teil 2: Aktuelle Aspekte zur Zytodiagnostik, Pathogenese, Therapie und Prognose.

The second part of the present review article presents and discusses the current literature regarding cytodiagnostic aspects, pathogenesis, therapy, incidence of recurrence, and malignant transformation rate of oral erythroplakia (OE) and oral erythroleukoplakia (OEL). Oral cytopathology, eventually in combination with DNA cytometry, can add valuable information to conventional histopathology, but is not able yet to replace the aforementioned. Numerous molecular genetic variants have been studied in precancerous lesions to gain knowledge about the prognosis of these lesions. Still, there are no evidence-based parameters available to safely detect precursor lesions that will undergo malignant transformation in the future. Excision of OE and OEL should be performed with a margin of safety using the CO2 laser or a scalpel. Data about incidence of recurrence and malignant tranformation rates of OE are mostly based upon case reports or case series. The OEL has a significantly higher risk of malignant transformation than oral leukoplakias.

[Oral erythroplakia and erythroleukoplakia: red and red-white dysplastic lesions of the oral mucosa--part 1: epidemiology, etiology, histopathology and differential diagnosis]. / Erythroplakie und Erythroleukoplakie: Rote und rot-weisse Risikoläsionen der Mundhöhlenschleimhaut. Teil 1: Epidemiologie, Atiologie, Histopathologie und Differenzialdiagnose.

Oral erythroplakia (OE) and oral erythroleukoplakia (OEL; synonym: speckled leukoplakia) are working diagnoses for red and red-white lesions of the oral mucosa after exclusion of all other possible diagnoses for lesions with a similar clinical appearance. A good knowledge of oral medicine and possible differential diagnoses of oral mucosal pathologies is mandatory to correctly detect OE and OEL on this exclusion basis. In the present review article in a series of two, epidemiologic data, etiologic factors, possible differential diagnoses, and the histopathologic characteristics of OE and OEL will be presented and discussed regarding the current literature. A thorough histopathologic examination of these epithelial precursor lesions is mandatory to recognise the presence and the severity of epithelial dysplasia, which is a decisive factor for the subsequent treatment planning.

Expression profiling with RNA from formalin-fixed, paraffin-embedded material.

BACKGROUND: Molecular characterization of breast and other cancers by gene expression profiling has corroborated existing classifications and revealed novel subtypes. Most profiling studies are based on fresh frozen (FF) tumor material which is available only for a limited number of samples while thousands of tumor samples exist as formalin-fixed, paraffin-embedded (FFPE) blocks. Unfortunately, RNA derived of FFPE material is fragmented and chemically modified impairing expression measurements by standard procedures. Robust protocols for isolation of RNA from FFPE material suitable for stable and reproducible measurement of gene expression (e.g. by quantitative reverse transcriptase PCR, QPCR) remain a major challenge. RESULTS: We present a simple procedure for RNA isolation from FFPE material of diagnostic samples. The RNA is suitable for expression measurement by QPCR when used in combination with an optimized cDNA synthesis protocol and TaqMan assays specific for short amplicons. The FFPE derived RNA was compared to intact RNA isolated from the same tumors. Preliminary scores were computed from genes related to the ER response, HER2 signaling and proliferation. Correlation coefficients between intact and partially fragmented RNA from FFPE material were 0.83 to 0.97. CONCLUSION: We developed a simple and robust method for isolating RNA from FFPE material. The RNA can be used for gene expression profiling. Expression measurements from several genes can be combined to robust scores representing the hormonal or the proliferation status of the tumor.