Morphological parameters of lobular in situ neoplasia in stereotactic 11-gauge vacuum-assisted needle core biopsy do not predict the presence of malignancy on subsequent surgical excision.

AIMS: The management of lobular in situ neoplasia (LN) when diagnosed on core biopsy remains a controversial issue. The present study aimed to investigate the association between morphological parameters of LN on vacuum-assisted needle core biopsy (VANCB) and the presence of malignancy (ductal carcinoma in situ, pleomorphic lobular carcinoma in situ, or invasive carcinoma) at surgical excision (SE). METHODS AND RESULTS: The study included 14 pathology departments in Italy. Available slides from 859 cases of VANCB reporting an original diagnosis of flat epithelial atypia, atypical ductal hyperplasia or LN, all with subsequent surgical excision, were reviewed. Overall, 286 cases of LN, pure or associated with other lesions, were identified, and a malignant outcome was reported at excision for 51 cases (17.8%). Among the 149 cases of pure LN, an increased risk of malignancy emerged in women in mammographic categories R4-R5 as compared with those in categories R2-R3 (OR 2.46; P = 0.048). In the series, a statistically significant decreased malignancy risk emerged among cases without determinant microcalcifications (P = 0.04). CONCLUSIONS: Our results suggest that the diagnosis of pure LN on VANCB warrants follow-up excision, because clinicopathological parameters do not allow the prediction of which cases will present carcinoma at surgical excision.

Sentinel lymph node biopsy in patients with pure and high-risk ductal carcinoma in situ of the breast.

AIMS AND BACKGROUND: The role of sentinel lymph node biopsy in patients initially diagnosed with ductal carcinoma in situ resides in determining the predictors of invasive disease. The aim of the present study was to examine the incidence of sentinel lymph node metastases in a selected group of patients, with characteristics of high-risk ductal carcinoma in situ, in order to determine the clinical usefulness of sentinel lymph node biopsy. METHODS: A total of 90 patients with a biopsy diagnosis of ductal carcinoma in situ were treated. Fifty-two patients with high-risk ductal carcinoma in situ had sentinel lymph node biopsy. The following characteristics of the primary tumor were considered as indicative of a risk of invasive disease: presence of palpable mass, mammographic mass, multicentric disease that required mastectomy, and histologically high nuclear grade or non-high nuclear grade with necrosis. Subdermal injections of 99mTc-labeled human albumin and subareolar injection of blue dye were used for sentinel lymph node identification. All sentinel nodes were sectioned serially and stained with hematoxylin and eosin. Immunohistochemical analysis was performed using a cytokeratin monoclonal antibody. RESULTS: A positive sentinel lymph node was found in only one patient (1.9%). The patient had a double lesion, and core-needle biopsy showed an atypical ductal hyperplasia and a intermediate degree of ductal carcinoma in situ. At pathologic review of the specimen, no invasive aspect was detected. CONCLUSIONS: The results of our study indicate that sentinel lymph node metastasis in pure ductal carcinoma in situ is extremely uncommon. We therefore suggest that sentinel lymph node biopsy might be indicated for patients with ductal carcinoma in situ detected as a palpable mass or as large extensive microcalcifications, as well as for patients who are undergoing mastectomy, especially with immediate reconstruction.

Dissection of major cancer gene variants in subsets of circulating tumor cells in advanced breast cancer.

Enumeration of circulating tumor cells (CTCs) may reflect the metastatic potential of breast cancer (BC). By using the DEPArray, we investigated CTCs with respect to their epithelial-to-mesenchymal transition phenotype and compared their genomic heterogeneity with tissue biopsies. Seventeen stage IV BC patients were enrolled. Pre-enriched CTC suspensions were stained with fluorescent-labeled antibodies to epithelial (E) and mesenchymal (M) markers. CTC samples were processed by DEPArray system and clustered in relation to their markers. DNA from CTCs, as well as from primary tumor samples, was sequenced by next generation sequencing to assess the mutational state of 50 major cancer-related genes. We identified four different CTC subsets that harbored different gene variants. The most heterogenous CTC subsets included the M+/E- phenotype, which, however, expressed only 7 repeatedly mutated genes, while in the M-/E+ subset multiple mutations affected only 2 out of 50 genes. When matching all gene variants among CTC subsets, a small number of mutations was shared by only 4 genes, namely ATM, FGFR3, PIK3CA, and TP53 that, however, were absent in primary tumors. Our results postulate that the detected mutations in all CTC subsets may be considered as genomic markers of metastatic dissemination to be investigated during early stages of BC.

Sentinel lymph node biopsy in multiple breast cancer using subareolar injection of the tracer.

We performed subdermal injection of (99m)Tc-labelled albumin combined with subareolar (SA) injection of blue dye to axillary lymphatic mapping and sentinel lymph node biopsy (SLNB) in patients with multifocal and multicentric breast cancer to evaluate the feasibility and accuracy of this technique. A retrospective analysis of our experience on 235 SLNB showed that 30(12.7%) had multiple cancer (MC) on final pathologic examination and was considered in relation to the aim of the study. Mean age was 57.19 years (range 24-90). Mean number of SLNs identified was 1.93 (range 1-5). Mean number of axillary LNs examined was 18.10 (range 12-27). Overall successful identification was 100% with a false negative (FN) rate of 6.25%. Overall accuracy of lymphatic mapping and sensitivity was 96.6% and 93.7%, respectively. SLNB using the SA injection technique may be an alternative to complete axillary dissection in patients with multiple breast cancers and a clinically negative axilla.

An international study comparing conventional versus mRNA level testing (TargetPrint) for ER, PR, and HER2 status of breast cancer.

To compare results from messenger RNA (mRNA)-based TargetPrint testing with those from immunohistochemistry (IHC) and in situ hybridization (ISH) conducted according to local standard procedures at hospitals worldwide. Tumor samples were prospectively obtained from 806 patients at 22 hospitals. The mRNA level of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) was assessed by TargetPrint quantitative gene expression readouts. IHC/ISH assessments were performed according to local standards at the participating hospitals. TargetPrint readout showed a high concordance with IHC/ISH of 95 % (kappa 0.81) for ER, 81 % (kappa 0.56) for PR, and 94 % (kappa 0.76) for HER2. The positive/negative agreement between TargetPrint and IHC for ER, PR, and HER2 was 96 %/87 %, 84 %/74 %, and 74 %/98 %, respectively. The concordance rate in IHC/ISH results between hospitals varied: 88-100 % for ER (kappa 0.50-1.00); 50-100 % for PR (kappa 0.20-1.00); and 90-100 % for HER2 (kappa 0.59-1.00). mRNA readout of ER, PR, and HER2 status by TargetPrint was largely comparable to local IHC/ISH analysis. However, there was substantial discordance in IHC/ISH results between different hospitals. When results are discordant, the use of TargetPrint would improve the reliability of hormone receptor and HER2 results by prompting retesting in a reference laboratory.

Elaboration of a nomogram to predict nonsentinel node status in breast cancer patients with positive sentinel node, intraoperatively assessed with one step nucleic amplification: Retrospective and validation phase.

BACKGROUND: Tumor-positive sentinel lymph node (SLN) biopsy results in a risk of non sentinel node metastases in micro- and macro-metastases ranging from 20 to 50%, respectively. Therefore, most patients underwent unnecessary axillary lymph node dissections. We have previously developed a mathematical model for predicting patient-specific risk of non sentinel node (NSN) metastases based on 2460 patients. The study reports the results of the validation phase where a total of 1945 patients were enrolled, aimed at identifying a tool that gives the possibility to the surgeon to choose intraoperatively whether to perform or not axillary lymph node dissection (ALND). METHODS: The following parameters were recorded: Clinical: hospital, age, medical record number; Bio pathological: Tumor (T) size stratified in quartiles, grading (G), histologic type, lymphatic/vascular invasion (LVI), ER-PR status, Ki 67, molecular classification (Luminal A, Luminal B, HER-2 Like, Triple negative); Sentinel and non-sentinel node related: Number of NSNs removed, number of positive NSNs, cytokeratin 19 (CK19) mRNA copy number of positive sentinel nodes stratified in quartiles. A total of 1945 patients were included in the database. All patient data were provided by the authors of this paper. RESULTS: The discrimination of the model quantified with the area under the receiver operating characteristics (ROC) curve (AUC), was 0.65 and 0.71 in the validation and retrospective phase, respectively. The calibration determines the distance between predicted outcome and actual outcome. The mean difference between predicted/observed was 2.3 and 6.3% in the retrospective and in the validation phase, respectively. The two values are quite similar and as a result we can conclude that the nomogram effectiveness was validated. Moreover, the ROC curve identified in the risk category of 31% of positive NSNs, the best compromise between false negative and positive rates i.e. when ALND is unnecessary (<31%) or recommended (>31%). CONCLUSIONS: The results of the study confirm that OSNA nomogram may help surgeons make an intraoperative decision on whether to perform ALND or not in case of positive sentinel nodes, and the patient to accept this decision based on a reliable estimation on the true percentage of NSN involvement. The use of this nomogram achieves two main gools: 1) the choice of the right treatment during the operation, 2) to avoid for the patient a second surgery procedure.

Oro-vaginal-vulvar lichen planus: report of two new cases.

Atrophic-erosive lichen planus with oral and genital involvement is a rare condition and is often difficult to diagnose. Patients seldom report genital symptoms to the dentist and dentists do not generally investigate about genital lesions. Delays in diagnosis may cause complications and affect the quality of life. We report the clinical and histopathological features of two new cases of oro-vaginal-vulvar lichen planus and review current treatment options for this condition. Genital lichen planus should be suspected in case of atrophic-erosive oral lichen planus. A thorough multidisciplinary medical management and active early treatment are necessary to improve symptoms and prevent genital sequelae. This might also be a relevant prevention strategy for the risk of squamous cell carcinoma, although data to fully support this statement still need investigation.

Metaplastic carcinoma of the breast with dominant squamous and sebaceous differentiation in the primary tumor and osteochondroid metaplasia in a distant metastasis: report of a case with review of sebaceous differentiation in breast tumors.

Metaplastic breast carcinoma is an uncommon tumor that develops from conventional ductal mammary carcinoma, usually consisting of squamous and/or spindle cell components and/or mesenchymal elements. Although several morphological subtypes of metaplastic breast carcinoma are known, sebaceous metaplasia has not yet been described in this context. The authors report a case of an 84-year-old woman with a huge, ulcerated primary tumor in her left breast that had already been present for 10 years. Pulmonary and bone metastases and a tumor nodule in the contralateral breast were also detected at the time of admission. Left simple mastectomy was performed. Histological examination of the tumor revealed metaplastic carcinoma consisting of ductal carcinoma, which immunohistochemically exhibited a triple-negative immunoprofile, along with dominant areas of squamous and sebaceous differentiation. Adjuvant chemotherapy was subsequently given with partial regression of the systemic metastases. Seven months after surgery and diagnosis, a new, rapidly growing, large soft tissue metastatic tumor appeared in the intramuscular compartment of the patient's right thigh, which was removed and histologically examined. Morphologically this metastatic tumor showed ductal adenocarcinoma along with areas of sebaceous differentiation and, in addition, osteochondroid metaplasia. Immunohistochemically, unlike the primary, this tumor expressed HER-2. The case is presented because of its rarity, and sebaceous differentiation is also proposed as a novel type of metaplasia in this context, expanding the spectrum of the histological patterns of metaplastic breast carcinoma. The literature concerning breast sebaceous lesions is reviewed, and the hypothetical biological mechanisms responsible for the tumor pathogenesis in this case are discussed.

Morphological parameters of flat epithelial atypia (FEA) in stereotactic vacuum-assisted needle core biopsies do not predict the presence of malignancy on subsequent surgical excision.

Flat epithelial atypia (FEA) may represent the earliest precursor of low-grade breast cancer and often coexists with more advanced atypical proliferative breast lesions such as atypical ductal hyperplasia (ADH) and lobular intraepithelial neoplasia (LIN). The present study aims to investigate the association between morphological parameters of FEA and presence of malignancy at surgical excision (SE) and the clinical significance of the association of FEA with ADH and/or LIN. This study included 589 cases of stereotactic 11-gauge vacuum-assisted needle core biopsy (VANCB), reporting a diagnosis of FEA, ADH or LIN with subsequent SE from 14 pathology departments in Italy. Available slides were reviewed, with 114 (19.4 %) showing a malignant outcome at SE. Among the 190 cases of pure FEA, no statistically significant association emerged between clinical-pathological parameters of FEA and risk of malignancy. Logistic regression analyses showed an increased risk of malignancy according to the extension of ADH among the 275 cases of FEA associated with ADH (p = 0.004) and among the 34 cases of FEA associated with ADH and LIN (p = 0.02). In the whole series, a statistically significant increased malignancy risk emerged according to mammographic R1-R3/R4-R5 categories (OR = 1.56; p = 0.04), extension (OR = 1.24; p = 0.04) and grade (OR = 1.94; p = 0.004) of cytological atypia of FEA. The presence of ADH was associated with an increased malignancy risk (OR = 2.85; p < 0.0001). Our data confirm the frequent association of FEA with ADH and/or LIN. A diagnosis of pure FEA on VANCB carries a 9.5 % risk of concurrent malignancy and thus warrants follow-up excision because none of the clinical-pathological parameters predicts which cases will present carcinoma on SE.

Familial and sporadic breast cancers: differences in clinical, histopathological, and immunohistochemical features.

In the present study, the authors investigated the clinical, histopathological, and immunohistochemical features in familial breast cancer (FBC) patients and compared them with findings in sporadic breast cancers (SBCs); hormone receptor status was stratified by age. A total of 849 patients treated for breast cancer were included in the study. The patients were stratified into 2 groups: FBC, 160 patients (19%), and SBC, 689 patients (81%). FBC tumors differed from SBC tumors by earlier age of diagnosis and low content of progesterone receptor (PR). These characteristics should be of value in evaluating the possibility of mutation and in targeting mutation screening in such families. PR gene polymorphism leads to an increased risk of breast cancer because it determines inadequate control of estrogen receptor (ER)-driven proliferative function. ER+/PR- tumors more frequently showed HER2 (human epidermal growth factor receptor) overexpression and represent a distinct subset in FBC patients. The authors suggest that late-onset FBCs need more intensive therapy and a more careful follow-up.

Sentinel lymph node micrometastasis and risk of non-sentinel lymph node metastasis: validation of two breast cancer nomograms.

INTRODUCTION: The aim of this study is to validate the predictive value of the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram and the Tenon score system in our sentinel lymph node (SLN)-positive series, and to define their actual usefulness when applied to the subgroup of patients with micrometastasis in SLN. PATIENTS AND METHODS: The study population consisted of 95 patients: 68 with macrometastasis and 27 with micrometastasis in the SLN. The predicted probability of non-SLN metastasis was calculated for each patient by using a computerized model from the MSKCC Web site. Furthermore, we have applied the Tenon score to our dataset. The receiver operating characteristic (ROC) curves were drawn and the areas under the curve (AUCs) were calculated to assess the discriminative power of the nomograms. The ROCs and relative AUCs were calculated both for all the patients in the study and for 2 subgroups. RESULTS: The AUC for the entire study population was 0.720 in MSKCC nomogram: and 0.754 in Tenon nomogram. In 68 patients with macrometastasis in SLN, the AUC was 0.760 in MSKCC nomogram and 0.707 in Tenon score. Micrometastasis in SLN were found in 27 patients: AUC was 0.595 in MSKCC nomogram and 0.734 in Tenon score. CONCLUSION: In our results the MSKCC nomogram did not provide a reliable predictive model for identifying patients with low risk of non-SLN metastasis in the event of micrometastasis in SLN. Our validation study shows that the Tenon score is more accurate and useful in patients with micrometastasis in SLN.

A further validation of subareolar injection technique for breast sentinel lymph node biopsy.

BACKGROUND: In this study we performed subdermal injection of (99m)Tc-labeled albumin combined with subareolar (SA) injection of blue dye, and we compared this technique with two techniques previously used in terms of the success of sentinel lymph node (SLN) identification, false-negative (FN) rate, and the overall accuracy and sensitivity of the three procedures. In all patients we performed a complete axillary lymph node dissection. METHODS: From January 1999 to September 2004, a total of 195 patients with localized breast cancer were treated. Patients were subdivided into three groups. In patients in group 1 (n = 115; January 1999 to December 2001), lymphoscintigraphy together with injection of vital dye was performed; in group 2 (n = 40; January to October 2002), SA injection of blue dye alone was performed; and in group 3 (n = 40; November 2002 to September 2004), SA injection of blue dye and subdermal injection of radioisotope was performed. RESULTS: The success rate of identifying an SLN by a combination of the two techniques was 95% in group 1 and 100% in group 3. The FN rate was 9% in group 1 and 0% in groups 2 and 3. The overall accuracy of lymphatic mapping was 97% in group 1 and 100% in groups 2 and 3. Sensitivity was 91% in group 1 and 100% in groups 2 and 3. CONCLUSIONS: This study of SA injection for SLN biopsy using dual tracers demonstrates a high SLN identification rate and an absent FN rate. We propose that injection into the SA plexus is the optimal way to perform lymphatic mapping of the breast. This technique seems to be feasible even in patients with multicentric cancers.

Osteoblastoma of the mandible: clinicopathologic study of four cases and literature review.

BACKGROUND: Osteoblastoma is a benign bone tumor accounting for 1% of all bone tumors; it commonly involves the spine and the sacrum of young individuals, with less than 5% being localized to the posterior mandible. In view of its rarity in the maxilla and mandible, osteoblastoma is rarely diagnosed as such in the absence of interdisciplinary cooperation. METHODS: A retrospective study of four benign osteoblastomas was performed based on a review of the clinical, radiographic, and histopathologic features of all cases. RESULTS: The tumors involved the posterior mandible of young patients (age range, 10-21 years; two male and two female patients) and appeared as painful bone expansions. Radiologically, they were poorly defined, radiolucent/radiopaque lesions containing calcifications and not showing sclerotic borders or periosteal reactions. Histologically, they were composed of osteoid and woven bone surrounded by plump osteoblast-like cells with interposed fibroblasts, inflammatory cells, and red blood cells. All patients were disease free after prolonged follow-up. CONCLUSIONS: Osteoblastomas may be distinguished from other bone tumors, fibro-osseous lesions, and odontogenic neoplasms on the basis of integrated clinical, radiologic, and histologic features and usually manifest an indolent clinical course.

Effect of the use of vital dye, lymphoscintigraphy, or a combination for axillary lymphatic mapping and sentinel node biopsy in breast cancer.

Axillary dissection in patients with breast cancer is associated with significant morbidity. Because 85% of the patients with a cancer < or = 1 cm have negative axillary nodal status, axillary dissection in these patients is only a staging procedure. A study of the sentinel lymph node (SLN) biopsy has been developed to determine axillary nodal status by means of a minimally invasive procedure. The aim of our study was to estimate the degree of reliability for identifying the SLN using a vital dye or lymphoscintigraphy, or a combination of the two. From January 1999 to May 2000 a series of 60 patients with breast cancer were evaluated for enrollment in the study. For the mapping procedure, lymphoscintigraphy in combination with injection of vital blue dye was performed in 24 patients, and vital dye alone was utilized in 36. Complete axillary dissection was performed in all patients after SLN biopsy. The mapping procedure was possible in 59 cases (98.3%). The SLNs were positive in 19 patients (32.2%) and negative in 40; in 38 of the 40 patients all axillary nodes were negative. There was concordance in 57 of 59 cases (96.6%). The false-negative rate was 5% (2/40). The overall sensitivity of the SLN biopsy was 90.4% (19/21), with a negative predictive value of 95% (38/40). Our results indicate that SLN biopsy guided by a gamma probe in combination with vital dye can identify a negative axilla with high accuracy. We conclude that the use of both techniques produces an optimal result, as they are complementary.