Circulating Tumor DNA in the Management of Early-Stage Breast Cancer.

Liquid biopsies refer to the isolation and analysis of tumor-derived biological material from body fluids, most commonly blood, in order to provide clinically valuable information for the management of cancer patients. Their non-invasive nature allows to overcome the limitations of tissue biopsy and complement the latter in guiding therapeutic decision-making. In the past years, several studies have demonstrated that circulating tumor DNA (ctDNA) detection can be used in the clinical setting to improve patient prognosis and monitor therapy response, especially in metastatic cancers. With the advent of significant technological advances in assay development, ctDNA can now be accurately and reliably identified in early-stage cancers despite its low levels in the bloodstream. In this review, we discuss the most important studies that highlight the potential clinical utility of ctDNA in early-stage breast cancer focusing on early diagnosis, detection of minimal residual disease and prediction of metastatic relapse. We also offer a concise description of the most sensitive techniques that are deemed appropriate for ctDNA detection in early-stage cancer and we examine their advantages and disadvantages, as they have been employed in various studies. Finally, we discuss future perspectives on how ctDNA could be better integrated into the everyday oncology practice.

Prognostic utility of ß-tubulin isotype III and correlations with other molecular and clinicopathological variables in patients with early breast cancer: a translational Hellenic Cooperative Oncology Group (HeCOG) study.

We evaluated the prognostic and predictive utility of ß-tubulin isotype III (TUBB3) tumour gene transcription in early breast cancer patients enrolled in a randomised study. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was applied for assessment of TUBB3, ER, PgR, HER2 and MAPT messenger RNA and immunohistochemistry (IHC) for protein expression in 314 patients enrolled in trial HE10/97, evaluating epirubicin-alkylator adjuvant chemotherapy with or without paclitaxel. High TUBB3 mRNA status was associated with advanced T stage, high histological grade, low mRNA and protein levels of ER, PgR and MAPT, and high levels of HER2 (p < 0.001). At a median follow-up of 98 months, multivariate analysis showed high TUBB3 mRNA status to have prognostic significance for DFS (HR = 1.83, 95% CI 1.25-2.68, p = 0.002) and OS (HR = 1.71, 95% CI 1.03-2.83, p = 0.038), along with the number of involved axillary nodes, PgR mRNA status and tumour grade. TUBB3 mRNA levels did not predict benefit from inclusion of paclitaxel in adjuvant chemotherapy (test for interaction p = 0.96 for OS, p = 0.46 for DFS). Transcriptional activity of ß-tubulin isotype III in early breast cancer is an adverse prognostic factor, though not a predictive one for taxane efficacy.

Rapid Assessment of Resection Margins During Breast Conserving Surgery Using Intraoperative Flow Cytometry.

BACKGROUND: Positive margins are the most important factor for recurrence of the disease after breast-conserving surgery. Several methods have been developed throughout the years to evaluate the margin status during surgery in an attempt to assist the surgeon in excising the whole tumor at once, a goal that has not yet been accomplished. PATIENTS AND METHODS: In our study, we compared intraoperative flow cytometry (iFC) with cytology and pathology in order to evaluate 606 samples of margins and tumors corresponding to 99 patients with invasive ductal carcinoma of no special type and invasive lobular carcinoma obtained from breast-conserving surgeries. RESULTS: Using the pathology as the gold standard, flow cytometry had 93.3% sensitivity, 92.4% specificity, and 92.5% accuracy. Cytology had 82.3% sensitivity, 94.6% specificity, and 94.2% accuracy. CONCLUSIONS: Our data support the suggestion that iFC is a novel, reliable technique that allows rapid evaluation of the excision margins of lumpectomies, thus improving the precision of breast-conserving surgery. Among the advantages of iFC are that it does not rely on the expertise of a pathologist or cytologist, it is low cost, and it has no additional psychological effect on patients, because no re-operation is needed.

PD-L1 Expression and Tumor-infiltrating Lymphocytes in Breast Cancer: Clinicopathological Analysis in Women Younger than 40 Years Old.

BACKGROUND/AIM: To evaluate the association between programmed cell death ligand 1 (PD-L1) expression on both tumor cells (TC) and inflammatory cells (IC), tumor infiltrating lymphocytes (TILs), CD3+ and CD8+ lymphocytes and other clinicopathological parameters in primary infiltrative breast cancer (IBC) of young women, a population shown to have a worse prognosis. MATERIALS AND METHODS: A retrospective study was performed collecting data from patients younger than 40 years old. Forty-five young women with IBC were included. Whole tissue sections were used to evaluate all parameters. RESULTS: Twenty percent (20%) of cases showed PD-L1 expression by tumor cells (PDL1TC) and 44.4% showed PD-L1 expression by immune cells (PDL1IC). Furthermore, 28.88% revealed high stromal TILs. PDL1TC and PDL1IC expression were significantly associated with tumor diameter and expression of estrogen (ER) and progesterone (PR) receptors and Ki67. PDL1TC expression was also associated with grade. High TILs were associated with tumor diameter, ER and Ki67 expression. PDL1TC, PDL1IC expression and TILs were associated with the density of CD3+ and CD8+ lymphocytes. CONCLUSION: Our results are similar to those of other age groups, as reported in the literature.

Early gastric carcinoma with oncocytic features and extensive metastases.

We present the case of a 63-year-old Caucasian woman with early gastric adenocarcinoma, suffering from extensive metastases at the time of initial presentation. Microscopic examination of the gastrectomy specimen revealed an invasive adenocarcinoma with oncocytic features. Interestingly, despite the fact that the carcinoma was pT1, it also was found to be N2, stage IV. The biologic behavior of oncocytic adenocarcinoma of the stomach is still unclear. We would like to present this case, so that its clinicopathological characteristics can be added to the few cases already published.

Primary mantle cell lymphoma of the conjunctiva: a case report.

Primary non-Hodgkin's lymphomas of the conjunctiva are uncommon. They are almost exclusively extranodal marginal zone B-cell lymphomas/mucosa-associated lymphoid tissue lymphomas. In this study, we report an extremely rare case of conjunctival mantle cell lymphoma in a 78-year-old man, presenting as a unilateral epibulbar mass.

B-cell differentiation, apoptosis and proliferation in diffuse large B-cell lymphomas.

Diffuse large B-cell lymphomas (DLBCL) represent the most common type of adult non-Hodgkin's lymphomas in Western countries and are characterized by heterogeneous clinical, histological, immunophenotypic and genetic features. Recent investigations using cDNA and oligonucleotide microarrays have identified molecularly distinct groups of DLBCL with respect to the B-cell differentiation gene expression profile: the germinal center (GC) B-cell-like DLBCL, the activated B-cell-like DLBCL and the type 3 DLBCL. The GC B-cell-like DLBCL were characterized by the expression of genes of the normal GC B-cells, the activated B-cell-like DLBCL were characterized by the expression of genes that are normally induced luring in vitro activation of peripheral blood B-cells, while the type 3 DLBCL did not express either set of genes at a high level. Patients with GC B-cell-like DLBCL had more favorable clinical outcome than those with activated B-cell-like or type 3 DLBCL. Immunohistochemical studies have shown that the bc16/CD10/MUM1/CD138 B-cell differentiation immunophenotypes are prognostically relevant and may predict the cDNA classification in a sizable fraction of DLBCL. In the last few years, there has been accumulating molecular and immunohistochemical evidence indicating links between B-cell differentiation gene expression profiles and expression of apoptosis and cell cycle-associated genes in DLBCL. The present review summarizes data with respect to the relationships between B-cell differentiation, apoptosis and proliferation in DLBCL.

Cell cycle and apoptosis deregulation in classical Hodgkin lymphomas.

Classical Hodgkin lymphomas (cHL) have now been recognized as B-cell lymphomas with some exceptional cases of T-cell origin. In recent years, there has been accumulating evidence that Hodgkin and Reed-Sternberg (H/RS) cells, the presumed neoplastic-cell population in cHL, are characterized by a profound disturbance of the cell cycle and apoptosis regulation. The constitutive activation of the nuclear factor (NF)-kappaB pathway, which is considered to be involved in the proliferation and survival of H/RS cells. Moreover, substantial evidence that H/RS cells have defective cell cycle and apoptosis regulation has been provided by studies showing that these cells are characterized, in a large proportion of cases, by alterations of the p53, Rb and p27 tumor suppressor pathways, overexpression of cyclins involved in the G1/S and G2/M transition such as cyclins E, D2, D3, A and B1, overexpression of cyclin-dependent kinases such as CDK1, 2 and 6 and overexpression of anti-apoptotic proteins such as c-FLIP, bcl-xl, c-IAP2, X-linked I4P and survivin. Recent studies suggest that interleukin 13 (IL-13) is an important growth and survival factor in H/RS cells. Furthermore, the Epstein-Barr Virus (EBV), which is present in H/RS cells in about 30-50% of cHL, has been shown to affect the cell cycle and apoptosis regulation in cHL. The present review summarizes data with respect to the cell cycle and apoptosis deregulation in cHL.

An unusual presentation of a patient with advanced prostate cancer, massive ascites and peritoneal metastasis: Case report and literature review.

We describe the case of a patient with prostate cancer, ascites, omental and bone metastases, an extremely rare clinical variant that warrants further investigation, and review the relevant literature.

Cluster analysis of apoptosis-associated bcl2 family proteins in diffuse large B-cell lymphomas. Relations with the apoptotic index, the proliferation profile and the B-cell differentiation immunophenotypes.

BACKGROUND: There is evidence that apoptotic mechanisms mediated by bcl2 family proteins are involved in the pathogenesis of diffuse large B-cell lymphomas (DLBCL). In order to gain further insight into the apoptosis profile of DLBCL, 79 cases were investigated to determine whether distinct clusters of the combined expression levels of bcl2 family proteins can be identified in these lymphomas. MATERIALS AND METHODS: The combined immunohistochemical expression levels of the proteins bax, bak, bad, bid, bcl2 and bcl-xl were evaluated by cluster and discriminant analysis. The produced clusters were analyzed in relation to the apoptotic index, the proliferation profile and the B-cell differentiation immunophenotypes. RESULTS: Cluster analysis produced: a) a low expression (69/79 cases) and a high expression pro-apoptotic cluster (10/79 cases) for the combined expression levels of the pro-apoptotic proteins bax, bak, bad and bid and b) a low expression (37/76 cases) and a high expression antiapoptotic cluster (39/76 cases) for the combined expression levels of anti-apoptotic proteins bcl2 and bcl-xl. The decreasing order of discriminant power for the percentages of tumor cells expressing pro-apoptotic and anti-apoptotic proteins was % bax + cells> % bak+ cells> % bid+ cells> % bad+ cells and % bcl2+ cells> % bcl-xl+ cells, respectively. The high expression pro-apoptotic cluster was significantly associated with higher mean values of Ki67 (p=0.047) and cyclin A (p=0.033) expression. The high expression pro-apoptotic cluster was significantly associated with the germinal center B-cell bc16/CD10/MUM1/CD138 differentiation immunophenotype (p=0.043). CONCLUSION: This study identified distinct clusters of DLBCL with respect to the combined expression levels of the apoptosis-associated bcl2 family proteins. These findings, taken together with our previous observations that distinct clusters with respect to the apoptotic index and the proliferation profile are identified in DLBCL, indicate that subgroups with distinct cellular kinetic properties can be defined in these lymphomas. The cluster analysis approach might be useful for the identification of subgroups of DLBCL with different clinical behavior since increased proliferation and apoptosis were reported to be associated with aggressive tumor behavior in these lymphomas.

Expression of vascular endothelial growth factor (VEGF) and association with microvessel density in benign prostatic hyperplasia and prostate cancer.

BACKGROUND: Tumor angiogenesis is an absolute requirement for tumor growth and a prognostic factor for various malignant neoplasms. Recent reports in the literature have addressed the importance of the VEGF system in benign prostatic hyperplasia (BPH) and adenocarcinoma, however the results are controversial. The aim of the present study was to determine and compare the levels of VEGF expression and vascularity in BPH and prostate carcinoma. MATERIALS AND METHODS: We examined 60 prostate adenocarcinomas and 64 benign prostatic hyperplasias. Angiogenesis was estimated by determining microvessel counts (MVC), with the use of anti-CD31 and anti-CD34 antibodies. Expression of VEGF was also evaluated immunohistochemically. RESULTS AND CONCLUSION: Our data showed that angiogenesis was more prominent in carcinomas than in BPH. Furthermore, increased MVC was significantly associated with high-grade carcinomas. Angiogenesis was correlated with VEGF expression and it was, at least in part, mediated by the latter. Thus, prostate adenocarcinoma may represent a suitable neoplasm for antiangiogenic treatment in combination with conventional therapies.

Intramural pregnancy with negative maternal serum b-HCG.

We report an extremely rare case of intramural pregnancy with negative maternal b-HCG value. The patient underwent a "myomectomy" but the pathology examination revealed chorionic villi consistent with ectopic pregnancy. Diagnosis is very difficult in cases with menorrhagia and especially when pregnancy is not suspected.

Pure small cell carcinoma of the prostate: a case report and literature review.

Primary small cell carcinoma of the prostate (SCPCa) is a rare pathologic entity with unique clinical features and a poor prognosis. We present a case of a patient diagnosed with pure SCPCa treated with a combined chemo-radiotherapeutic approach. Pathological findings showed that the neoplastic cells exhibited positivity for pancytokeratin, synaptophysin, thyroid transcription factor-1 and CD56. Immunostaining for prostate-specific antigen was negative, while serum prostate-specific antigen was within normal limits. We review the available literature to gain additional information about diagnosis, treatment and prognosis of pure SCPCa.

Diagnosis and endoscopic treatment of esophago-bronchial fistula due to gastric heterotopy.

Heterotopic gastric mucosa patches are congenital gastrointestinal abnormalities and have been reported to occur anywhere along the gastrointestinal tract from mouth to anus. Complications of heterotopic gastric mucosa include dysphagia, upper gastrointestinal bleeding, upper esophageal ring stricture, adenocarcinoma and fistula formation. In this case report we describe the diagnosis and treatment of the first case of esophago-bronchial fistula due to heterotopic gastric mucosa in mid esophagus. A 40-year old former professional soccer player was referred to our department for treatment of an esophago-bronchial fistula. Microscopic examination of the biopsies taken from the esophageal fistula revealed the presence of gastric heterotopic mucosa. We decided to do a non-surgical therapeutic endoscopic procedure. A sclerotherapy catheter was inserted through which 1 mL of ready to use synthetic surgical glue was applied in the fistula and it closed the fistula opening with excellent results.

Sjogren's syndrome in a patient with ulcerative colitis and primary sclerosing cholangitis: Case report and review of the literature.

Inflammatory bowel disease has been reported to co-exist with other autoimmune diseases. Sjogren's syndrome is an autoimmune disorder characterized by xerostomy and/or xerophthalmy. Sjogren's syndrome occurring in IBD has been very rarely reported. A 45-year old woman diagnosed ten years ago with ulcerative pancolitis and primary sclerosing cholangitis was referred to our outpatient IBD clinic because of xerostomy but not for xerophthalmy for the previous three months. The patient had been under azathioprine maintenance treatment (2 mg/kg) and achieved long-term disease remission for the past 4 years. Patient clinical examination and laboratory tests were unremarkable. Salivary gland biopsy and complete ophthalmologic investigation were performed and the patient was diagnosed with Sjogren's syndrome. Understanding sicca manifestations in IBD is difficult since the pathogenesis of this intestinal disorder is not yet clear. Of these complex autoimmune phenomena which occur along with IBD it is quite difficult to categorize concomitant Sjogren's syndrome as primary or secondary and literature is conflicting. The possibility of Sjogren's syndrome should always be considered and properly investigated in patients diagnosed with inflammatory bowel disease who develop a constellation of constitutional sicca symptoms.

Synchronous primary tumors of the kidney and the ovaries: Imaging findings.

The simultaneous presence of primary carcinomas in the same patient is uncommon and synchronous primary tumors involving the kidney and ovary are extremely rare. There are a few reports in the English literature of synchronous primary malignancies of the kidney and the ovaries, but no data regarding their imaging features. We present a case of an elderly woman, diagnosed with bilateral ovarian clear cell carcinomas and a simultaneous clear cell carcinoma of the right kidney, evaluated by multidetector CT and MR imaging.

Rectal Epstein-Barr virus-positive Hodgkin's lymphoma in a patient with Crohn's disease: case report and review of the literature.

We present the case of a 35-year-old man with Crohn's disease diagnosed at the age of 27, several months after an operation for small-bowel adenocarcinoma. Seven years after the adenocarcinoma diagnosis, the patient presented with severe continuous anal pain and diarrhea. In parallel with antibiotic administration, the patient was given treatment with Infliximab, but without clinical symptom amelioration. Sigmoidoscopy and subsequent biopsies from an ulcerated rectal area supported the diagnosis of Epstein-Barr virus-positive (EBV+) primary Hodgkin's lymphoma. Infliximab administration was immediately discontinued and the patient underwent oncological follow-up and began a course of chemotherapy. Only a few cases with primary gastrointestinal Hodgkin's lymphoma in Crohn's disease patients have so far been reported, including a variety of scenarios on the causal relationship including disease duration, presence of EBV, long-term immunosuppressive treatment and, recently, anti-TNFalpha administration.

Diffuse large B-cell lymphomas with germinal center B-cell-like differentiation immunophenotypic profile are associated with high apoptotic index, high expression of the proapoptotic proteins bax, bak and bid and low expression of the antiapoptotic protein bcl-xl.

The aim of this study was to analyze the relations between differentiation immunophenotypes and the status of apoptosis and proliferation in diffuse large B-cell lymphomas. Therefore, the bcl6/CD10/MUM1/CD138 differentiation immunophenotypic profiles were studied in relation to (a) the apoptotic index, (b) the apoptosis-associated bcl2 family proteins bcl2, bcl-xl, bax, bak, bad and bid, (c) the proliferation index (Ki67) and (d) the cell cycle proteins cyclin A, cyclin B1, cyclin D3, cyclin E, p53, Rb, p16 and p27 in 79 cases of diffuse large B-cell lymphomas. Two major differentiation immunophenotypic profiles were distinguished: the germinal center B-cell-like profile; 31 cases (bcl6+/CD10+/-/MUM1-/CD138-: 29 cases and bcl6-/CD10+/MUM1-/CD138-: two cases) and the nongerminal center B-cell-like profile (bcl6+/-/CD10-/MUM1+/CD138-); 48 cases. The expression of bax, bak and bid and the apoptotic index were significantly higher in the germinal center B-cell-like profile than in the nongerminal center B-cell-like profile (P=0.045, 0.018, 0.003 and 0.034, respectively). In contrast, the expression of bcl-xl was significantly lower in the germinal center B-cell-like profile than in the nongerminal center B-cell-like profile (P=0.026). The expression of bcl6 and CD10 showed significant positive correlation with the expression of bax (r=0.659, P<0.001 and r=0.240, P=0.033, respectively), bak (r=0.391, P<0.001 and r=0.233, P=0.039, respectively) and bid (r=0.652, P<0.001 and r=0.238, P=0.035, respectively) and significant negative correlation with the expression of bcl-xl (r=-0.536, P<0.001 and r=-0.250, P=0.029, respectively). The expression of MUM1 showed significant negative correlation with the expression of bax (r=-0.276, P=0.014) and bid (r=-0.266, P=0.018) and significant positive correlation with the expression of bcl-xl (r=0.238, P=0.037). The above findings indicate that diffuse large B-cell lymphomas with germinal center B-cell-like immunophenotypic profile are associated with increased apoptosis status, high expression of the proapoptotic proteins bax, bak and bid and low expression of the antiapoptotic protein bcl-xl.