Esther Cheng

Neoadjuvant chemotherapy induces breast cancer metastasis through a TMEM-mediated mechanism

Chemotherapy induces prometastatic changes in breast cancer, reversible by TIE2 or MENA inhibition. Closing the door to cancer cells Breast cancer is one of the most common tumor types, and metastasis greatly increases the risk of death from this disease. By studying the process of intravasation or entry of cells into the vasculature, Karagiannis et al. discovered that, in addition to killing tumor cells, chemotherapy treatment can also increase intravasation. Groups of cells collectively known as tumor microenvironment of metastasis (TMEM) can serve as gateways for tumor cells entering the vasculature, and the authors discovered that several types of chemotherapy can increase the amounts of TMEM complexes and circulating tumor cells in the bloodstream. The researchers also determined that a drug called rebastinib can interfere with TMEM activity and help overcome the increased risk of cancer cell dissemination. Breast cancer cells disseminate through TIE2/MENACalc/MENAINV-dependent cancer cell intravasation sites, called tumor microenvironment of metastasis (TMEM), which are clinically validated as prognostic markers of metastasis in breast cancer patients. Using fixed tissue and intravital imaging of a PyMT murine model and patient-derived xenografts, we show that chemotherapy increases the density and activity of TMEM sites and Mena expression and promotes distant metastasis. Moreover, in the residual breast cancers of patients treated with neoadjuvant paclitaxel after doxorubicin plus cyclophosphamide, TMEM score and its mechanistically connected MENAINV isoform expression pattern were both increased, suggesting that chemotherapy, despite decreasing tumor size, increases the risk of metastatic dissemination. Chemotherapy-induced TMEM activity and cancer cell dissemination were reversed by either administration of the TIE2 inhibitor rebastinib or knockdown of the MENA gene. Our results indicate that TMEM score increases and MENA isoform expression pattern changes with chemotherapy and can be used in predicting prometastatic changes in response to chemotherapy. Furthermore, inhibitors of TMEM function may improve clinical benefits of chemotherapy in the neoadjuvant setting or in metastatic disease.

Cystic Neutrophilic Granulomatous Mastitis: Further Characterization of a Distinctive Histopathologic Entity Not Always Demonstrably Attributable to Corynebacterium Infection.

Granulomatous lobular mastitis (GLM) is an uncommon condition that typically occurs in parous, reproductive-aged women and can simulate malignancy on the basis of clinical and imaging features. A distinctive histologic pattern termed cystic neutrophilic granulomatous mastitis (CNGM) is seen in some cases of GLM and has been associated with Corynebacterium infection. We sought to further characterize the clinical, imaging, and histopathologic features of CNGM by studying 12 cases and attempted to establish the relationship of this disease with Corynebacterium infection. Patients were women ranging in age from 25 to 49 years (median: 34 y), and all presented with a palpable mass that was painful in half of the cases. In 2 of 9 cases, imaging was highly suspicious for malignancy (BI-RADS 5). CNGM was characterized by lobulocentric granulomas with mixed inflammation and clear vacuoles lined by neutrophils within granulomas. Gram-positive bacilli were identified in 5/12 cases. In 4 patients, the disease process worsened after the diagnostic core biopsy, with the development of a draining sinus in 2 cases. No growth of bacteria was seen in any microbial cultures. No bacterial DNA was identified by 16S rDNA polymerase chain reaction for 1 case that showed gram-positive bacilli on histology. Patients were treated with variable combinations of surgery, antibiotics, and steroids. The time to significant resolution of symptoms ranged from 2 weeks to 6 months. Similar to other forms of GLM, CNGM can mimic malignancy clinically and on imaging. When encountered in a needle core biopsy sample, recognition of the characteristic histologic pattern and its possible association with Corynebacterium infection can help guide treatment.

Residual Pure Intralymphatic Breast Carcinoma Following Neoadjuvant Chemotherapy Is Indicative of Poor Clinical Outcome, Even in Node-Negative Patients

Residual carcinoma confined to lymphovascular spaces following neoadjuvant chemotherapy (NAC) for invasive breast carcinoma is an uncommon finding. We studied pathologic features and outcome for patients with pure intralymphatic carcinoma (PIC) following NAC, a pattern of residual disease reported to have a poor outcome in the only previously published series of this entity. Six of 284 (2.1%) patients treated with NAC were studied. All 6 patients had axillary lymph node involvement before NAC. Tumors were triple-negative (n=3) and HER2+ (n=3: 2 ER+, 1 ER−). Two patients presented with clinical findings of inflammatory carcinoma. Three of 5 pre-NAC core biopsies showed lymphovascular invasion. Three patients showed complete clinical response to NAC, and 3 showed partial response. Post-NAC surgical specimens showed foci of intralymphatic carcinoma in the breast spanning an extent of 0.5 mm to 0.5 cm. Residual ductal carcinoma in situ was present in 2 cases. Four of 6 patients converted to node-negative following NAC. One patient had distant metastasis at presentation and 1 patient died of pulmonary embolism 2 months after surgery. Three of the 4 remaining patients developed distant metastasis, of which 2 first recurred locally (in mean follow-up of 46.5 mo). Patients with PIC had significant greater risk for relapse (hazard ratio, 10.18 [1.97, 52.58]; P=0.006) compared with other NAC-treated patients, after controlling for residual lymph node involvement, tumor size, tumor subtype, histologic grade, and age. Residual PIC following NAC is associated with poor outcome, including in patients that are node-negative following NAC.

Subareolar Sclerosing Ductal Hyperplasia: Further Characterization of a Distinctive Clinicopathological Entity

Subareolar sclerosing duct hyperplasia (SSDH) remains to be fully characterized nearly 20 years after initial description. Thirty-five SSDH cases diagnosed over a 16-year period (January 2000 to December 2015) were reviewed. All patients were female (mean age = 59 years, range = 18-80) who had presented with a unilateral solitary lesion (left 22, right 13) with a mean size of 1.3 cm (range = 0.4-3.0 cm), and showed florid and papillary epithelial hyperplasia with dense sclerosis without involvement of nipple or areolar epidermis. Significant lesions concurrent within SSDH included low-grade adenosquamous carcinoma (n = 1), ductal carcinoma in situ (DCIS; n = 1), lobular carcinoma in situ (LCIS; n = 1), and atypical ductal hyperplasia (ADH; n = 13). No case of SSDH recurred in a mean follow-up of 44 months (range = 6-189). Subsequent significant lesions occurred in 6 patients: DCIS (n = 3; ipsilateral 2, contralateral 1), ipsilateral ADH (n = 2), and ipsilateral atypical lobular hyperplasia (n = 1). Long-term follow-up for patients with SSDH is indicated as DCIS can occur subsequently in either breast.

Juvenile Papillomatosis (Swiss-Cheese Disease) of Breast in an Adult Male With Sequential Diagnoses of Ipsilateral Intraductal, Invasive, and Widely Metastatic Carcinoma: A Case Report and Review of the Disease in Males

Juvenile papillomatosis of the breast (JPB, also known as Swiss cheese disease) is a rare ailment that typically afflicts young females, and presents as a mass-forming lesion. The lesional mass usually comprises multiple cysts and duct stasis, amid a variety of proliferative and nonproliferative epithelial changes. The proliferative changes include papillary hyperplasia, florid hyperplasia, and papillary apocrine hyperplasia. Concurrent carcinoma (either in situ or invasive) is present in approximately 10% of cases at presentation, and subsequent carcinoma (either in situ or invasive) is diagnosed in about 10% of patients. About 20% of patients have a strong family history of breast carcinoma. A total of 10 cases of JPB have been previously reported in males, both children and adults, only one of which, in a 33-year-old, was associated with invasive carcinoma. Here, another case of JPB in a 45-year-old male—one with subsequent sequential diagnoses of ipsilateral intraductal carcinoma, invasive carcinoma, and widely metastatic carcinoma over the course of 15 years—is reported.

Bilateral Multiple Mammary Myofibroblastomas in an Adult Male

In 2007, a 74-year-old male resident of New Mexico presented with bilateral breast masses. Notable history included cutaneous melanoma (status-post wide resection, in 1987) and prostatic adenocarcinoma (status-post radical prostatectomy, in 1992); without evidence of recurrence or metastases from either malignancy. Mammography showed 3 well-circumscribed, round, and homogeneous masses in the right (R) breast (largest 1.4 cm), and 2 similar masses in the left (L, largest 1.7 cm) (Figure 1A and B). These tumors were present in different quadrants, at variable distances from the respective nipples. Ultrasound examination revealed all 5 masses to be solid (Figure 1C and D). Needle core biopsies of the bilateral masses showed histologically similar spindle cell neoplasms. The lesional spindle cells displayed pale cytoplasm and elongated nuclei with micronucleoli, and were arranged in fascicles amid wispy straps of collagen. Neither nuclear atypia nor mitotic activity was evident (Figure 2). The spindle cells were immunoreactive for CD34, desmin, estrogen receptor, and Bcl-2 (Figure 3). Based on these findings, the diagnosis of bilateral multiple mammary myofibroblastomas (MM) was rendered. Clinical observation, and not surgical excision, was opted for. The subsequent 8 years were uneventful. In 2015, the patient was diagnosed to have mantle cell lymphoma. Computed tomography, performed as part of 735895 IJSXXX10.1177/1066896917735895International Journal of Surgical PathologyViswanathan et al research-article2017

Solitary Neurofibroma of the Breast, and “The Man From Istanbul” Syndrome

A 40-year-old asymptomatic woman, with neither medical nor family history of any pertinent disease, underwent her first breast screening evaluation. The mammogram showed unilateral focal ill-defined “asymmetry.” An ultrasound examination revealed the “asymmetry” to represent an ovoid 0.8 cm nodule in left breast at 12:00, 2 cm from nipple (Figure 1A). A needle core biopsy showed the lesion to comprise mainly of sheaves of twisted spindle cells set amid bands of rippling collagen and loose fibromyxoid matrix (lending a “shredded carrot” look; Figure 1B and C). Diffuse nuclear and cytoplasmic immunoreactivity for S100 protein (in the lesional Schwann cells) was evident (Figure 1D). Based on the aforesaid features, the diagnosis of neurofibroma (NF) was rendered. The patient desired removal of the lesion. The subsequently performed excision showed a pearly mass with a glistening cut surface. Histopathologically, the circumscribed but unencapsulated lesion was similar to that observed in the needle core biopsy (reactive changes of which were evident), and lay amid otherwise unremarkable breast tissue (Figure 1E and F). One year after excision, the patient showed no evidence of breast disease—either clinically or on imaging. Intramammary peripheral nerve sheath tumors— including NF and schwannomas—are uncommon. Intramammary NF typically occur as an asymptomatic and solitary lesion, although multiple mainly cutaneous-based ones can ensue in neurofibromatosis type 1. The macroscopic and microscopic appearances of NF are largely similar in all locations, although its myxoid variant has been described in the breast as elsewhere. The occurrence of NF in the breast exemplifies the phenomenon of a common tumor occurring in an uncommon location, and the diagnosis is straightforward “but only if the pathologist thinks of the possibility (a good example of Dr Ackerman’s “The man from Istanbul” syndrome). The latter 728337 IJSXXX10.1177/1066896917728337International Journal of Surgical PathologyCheng et al research-article2017

Abstract 67: Chemotherapy induced pro-metastatic changes in the primary breast tumors of racially diverse patients

Neoadjuvant chemotherapy (NAC) induces influx of bone marrow-derived proangiogenic Tie2hi monocytes into the primary tumor, resulting in increased density of perivascular Tie2hi macrophages (1). Perivascular Tie2hi/Vegfhi macrophages in physical contact with Mena expressing cancer cells create micro-anatomic sites of transient vascular permeability called TMEM, which mediate cancer cell intravasation and dissemination (2). Cancer cells capable of intravasation via TMEM sites express high level of MenaINV, an isoform of Mena, induced by macrophage contact, which renders tumor cells intravasation-competent (3, 4). Consequently, breast cancers from mice and patients treated with NAC have increased density of TMEM sites and show increased expression of MenaINV (1) Moreover, in PyMT mouse mammary carcinoma and patient derived xenografts, NAC increases the number of circulating tumor cells and lung metastasis (1). The Tie2-inhibitor rebastinib, which inhibits TMEM function, can reverse chemotherapy-induced increases in the number of CTCs and lung metastasis in mouse mammary carcinoma (1, 5). Although NAC induces pro-metastatic changes in breast cancer microenvironment, large randomized prospective studies did not find significant differences in distant-recurrence free survival (DRFS) and overall survival (OS) between breast cancer patients treated with adjuvant and neoadjuvant chemotherapy in predominantly white populations. Since the breast cancer microenvironment in black women has higher microvascular density and density of Tie2hi macrophages, suggesting that black women may be more prone to develop TMEM-associated pro-metastatic changes in response to NAC, we questioned if there is a difference in DRFS in black women treated with NAC compared to AC. We evaluated DRFS in 1,211 racially diverse patients with localized or regionally advanced breast cancer treated with neoadjuvant or adjuvant chemotherapy between January 2000 and December 2016 and found that black patients with localized breast cancer treated with systemic neoadjuvant chemotherapy not only have inferior DRFS compared to white patients, but also worse DRFS when compared to black patients treated with adjuvant chemotherapy, after adjustment for clinical covariates in multivariate analysis. The biologic factors contributing to this finding, in particular TMEM-mediated pro-metastatic changes have been evaluated and will be discussed. 1. Karagiannis et al, Sci Transl Med. 2017;9:397. 2. Harney et al, Cancer discovery. 2015;5:932. 3. Pignatelli J et al, Sci Rep. 2016;6:37874. 4. Pignatelli J et al, Sci Signal. 2014;7:353. 5. Harney et al, Mol Cancer Ther. 2017;16:2486. Citation Format: George S. Karagiannis, Jessica M. Pastoriza, Sonali Lanjawar, Yarong Wang, David Entenberg, Esther Cheng, Timothy M. Dalfonso, Joan G. Jones, Jesus Anampa, Thomas E. Rohan, Joseph A. Sparano, John S. Condeelis, Maja H. Oktay. Chemotherapy induced pro-metastatic changes in the primary breast tumors of racially diverse patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 67.

Mammary juvenile papillomatosis (“Swiss cheese” disease): Study of 121 cases reiterates need for long-term follow-up

Dear Editor, Juvenile papillomatosis (JP) is a rare, localized, and unilateral breast disease that typically effects younger women.1–6 The disease usually presents as a palpable, firm, circumscribed, and mobile mass. Imaging studies and gross examination show a mass with variably sized cysts. The latter nearly always span less than 2.0 cm. The multicystic appearance resembles Swiss cheese—which explains the alternate designation for JP, ie, “Swiss cheese” disease. Microscopically, JP exhibits changes including (a) ductal papillomatosis, (b) cysts: apocrine and non‐apocrine, (c) florid and papillary apocrine hyperplasia, (d) sclerosing adenosis, and (e) duct stasis with histiocytes.1–6 Rosen et al first described JP in 1980, and in the seminal paper announced the establishment of a registry for the disease. In 1982, based on data in this registry, Rosen et al concluded that JP “may be a marker for breast cancer for the patients family” and “the patient may be at increased risk.” In 1985, Rosen et al reported on a cohort of 180 JP cases, four of whom had concurrent invasive carcinoma (ipsilateral: 2, contralateral: 2) and three had classic type of lobular carcinoma in situ (LCIS) (all three ipsilateral). One patient developed “early” invasive ductal carcinoma 9 years later, and another developed ductal carcinoma in situ (DCIS) 12 years later— both patients had bilateral JP (synchronous in the former case, and metachronous in the latter). About 28% of patients had family history of breast carcinoma, mostly in second‐degree relatives. This report established the need for “careful clinical surveillance” of patients with JP and female relatives thereof. In 1990, Rosen et al published another study of 41 JP patients with a median follow‐up of 14 years, and concluded that the risk for carcinoma in these patients “should be greatest with a positive family history and recurrent bilateral JP.” The clinical implications of JP have not been further elucidated since these four reports by Rosen et al—except in much smaller series and in case reports. 6, 8–10 We reviewed 121 cases diagnosed with JP over a 17‐year period (2001‐2017). The pathological diagnosis was confirmed in each case. Key clinical and pathological data were obtained and analyzed. The mean age at diagnosis was 34.1 (range 13‐77) years. 120 patients were female. Four cases presented with bilateral masses. Of those that were unilateral, JP involved the left breast in 59, and the right in 58. 94 (78%) presented with a palpable mass, and 16 (13%) with an imaging abnormality (usually a mass with cysts). Grossly, each specimen was multicystic (Figure 1). Microscopically, all showed a variety of proliferative and nonproliferative changes (vide supra) (Figure 2). One (0.8%) case of classic invasive lobular carcinoma associated with lobular carcinoma in situ (LCIS) in a 46‐year‐old woman was concurrent at initial diagnosis of JP (and was intimately associated with the index lesion). Additionally, contemporaneous at initial diagnosis were four (3.3%) cases of ductal carcinoma in situ (DCIS). The DCIS cases occurred in women with a mean age of 47.5 (range 28‐

Sentinel Lymph Nodes in Classic Invasive Lobular Carcinoma of the Breast: Cytokeratin Immunostain Ensures Detection, and Precise Determination of Extent, of Involvement

The assessment of sentinel lymph nodes (SLN) on hematoxylin and eosin (H&E)–stained sections in cases of classic type of invasive lobular carcinoma (cILC) is considered unreliable, particularly in cases with minimal involvement, that is by either isolated tumor cells (pN0i+) or micrometastases (pN1mi). Although the impact of minimal SLN involvement has been shown to be insignificant in most clinical trials (even though cILC was either under-represented or not separated in the respective cohorts), the results of MIRROR trial did emphasize the need for additional therapy in cases with minimally involved SLN to ensure improved disease-free survival. We sought to study the role of cytokeratin immunohistochemistry (CK-IHC) in evaluating SLN in cILC. A total of 582 cILC cases with SLN diagnosed over a 12-year period (2005 to 2016) were reviewed. In all, 394/582 (68%) cases had H&E(−)/CK(−) SLN. In total, 188/582 (32%) cases showed some degree of SLN involvement of which 143/582 (25%) cases had readily identifiable SLN involvement on H&E slides. Overall, 45/582 (7.7%) cases had H&E(−)/CK(+) SLN. The following data relate to the latter subset of 45 cases. Mean age of patients: 61 y (range: 32 to 86 y); right: 24 (53%), left: 21 (47%); multifocal and/or multicentric: 22 (49%); mean size: 2.0 cm (range: 0.25 to 4.4 cm); mean number of SLN: 2.5; mean number of involved SLN: 1.2; and cases with prior needle core or excisional biopsy: 45 (100%). CK(+) cells were identified in isolation or in loose clusters, either in subcapsular sinuses or nodal cortex or both. Overall, 30/45 (67%) showed ⩽200 CK(+) cells (ie, pN0i+), and 15/45 (33%) showed >200 CK(+) cells (ie, pN1mi). In total, 15/45 (33%) cases underwent axillary lymph node dissection, of which 4/45 (9%) cases were positive. cILC recurred in 3/45 (7%) cases. On statistical analyses, the number of CK(+) cells (⩽/>200) did not correlate with either axillary lymph node-positivity or with recurrence. Number of CK(+) cells (⩽/>200) readily distinguished pN0i+ from pN1mi based on AJCC’s numerical criteria. CK(+) cells could be quantified in linear terms (ie, AJCC’s size criteria of pN0i+ and pN1mi was applicable) in only 2 cases. On the basis of these findings, the use of CK-IHC staining should be considered for SLN in cases of cILC to ensure detection, and precise determination of extent, of involvement; however, the prognostic significance of this procedure would have to await results of additional studies with long-term follow-up.