Miki Takenaka

Clinicopathologic analysis of combined hepatocellular-cholangiocarcinoma according to the latest WHO classification.

Combined hepatocellular-cholangiocarcinoma comprises <1% of all liver carcinomas. The histogenesis of combined hepatocellular-cholangiocarcinoma has remained unclear for many years. However, recent advances in hepatic progenitor cell (HPC) investigations have provided new insights. The concept that combined hepatocellular-cholangiocarcinoma originates from HPCs is adopted in the chapter “combined hepatocellular-cholangiocarcinoma” of the latest World Health Organization (WHO) classification. In this study, we conducted clinicopathologic analysis of combined hepatocellular-cholangiocarcinoma according to the latest WHO classification. Fifty-four cases were included in this study. Pathologic diagnosis was made according to the WHO classification. When a tumor contained plural histologic patterns, predominant histologic pattern (≥50%) was defined. Minor histologic patterns were also appended. Immunohistochemical staining with biliary markers (CK7, CK19, and EMA), hepatocyte paraffin (HepPar)-1, HPC markers (CD56, c-kit, CD133, and EpCAM), and vimentin was performed. Forty-five and 50 patients were analyzed for progression-free survival and overall survival, respectively. Ten, 1, 32, and 11 cases were diagnosed as: combined hepatocellular-cholangiocarcinoma, classical type; combined hepatocellular-cholangiocarcinoma, stem cell features, typical subtype; combined hepatocellular-cholangiocarcinoma, stem cell features, intermediate cell subtype; and combined hepatocellular-cholangiocarcinoma, stem cell features, cholangiolocellular type, respectively. Combined hepatocellular-cholangiocarcinomas usually have high expression of biliary markers. CD56, c-kit, and EpCAM were expressed to various degrees in all combined hepatocellular-cholangiocarcinomas apart from the hepatocellular carcinoma component of combined hepatocellular-cholangiocarcinoma, classical type. The expression of CD133 and vimentin was observed only in combined hepatocellular-cholangiocarcinoma, stem cell features of intermediate cell subtype and cholangiolocellular subtype. The expression of CD133, EpCAM, and vimentin was significantly high in combined hepatocellular-cholangiocarcinoma, subtypes with stem cell features, especially cholangiolocellular subtype. Minor histologic patterns were significantly frequent in combined hepatocellular-cholangiocarcinoma, subtypes with stem cell features, compared with combined hepatocellular-cholangiocarcinoma, classical type. There was no significant difference in clinical outcome between each subtype. Combined hepatocellular-cholangiocarcinoma has wide histologic diversity and shows immunophenotypic expression of not only biliary markers but also HPC markers to various degrees, suggesting that the histogenesis of combined hepatocellular-cholangiocarcinoma could be strongly associated with HPCs. Our results pathologically validate the latest WHO classification of combined hepatocellular-cholangiocarcinoma. However, the complex mixture of histologic subtypes has presented a challenge to the classification of combined hepatocellular-cholangiocarcinoma. Further study should be conducted using a large cohort to support this classification.

FOXP3 expression in tumor cells and tumor-infiltrating lymphocytes is associated with breast cancer prognosis

The forkhead box protein 3 (FOXP3) transcription factor is highly expressed in tumor cells as well as in regulatory T cells (Tregs). It plays a tumor-enhancing role in Tregs and suppresses carcinogenesis as a potent repressor of several oncogenes. The clinical prognostic value of FOXP3 expression has not yet been elucidated. In this study, immunohistochemistry was used to investigate the prognostic significance of FOXP3 expression in tumor cells and tumor-infiltrating lymphocytes (TILs) in breast cancer patients. Of the 100 tumor specimens obtained from primary invasive breast carcinoma, 63 and 57% were evaluated as FOXP3+ tumor cells and as being highly infiltrated by FOXP3+ lymphocytes, respectively. Although FOXP3 expression in tumor cells was of no prognostic significance, FOXP3+ lymphocytes were significantly associated with poor overall survival (OS) (n=98, log-rank test P=0.008). FOXP3 exhibited a heterogeneous subcellular localization in tumor cells (cytoplasm, 31%; nucleus, 26%; both, 6%) and, although cytoplasmic FOXP3 was associated with poor OS (P= 0.058), nuclear FOXP3 demonstrated a significant association with improved OS (P=0.016). Furthermore, when patients were grouped according to their expression of tumor cytoplasmic FOXP3 and lymphocyte FOXP3, there were notable differences in the Kaplan-Meier curves for OS (P<0.001), with a high infiltration of FOXP3+ lymphocytes accompanied by a cytoplasmic FOXP3+ tumor being the most detrimental phenotype. These findings indicated that FOXP3 expression in lymphocytes as well as in tumor cells may be a prognostic marker for breast cancer. FOXP3 in tumor cells may have distinct biological activities and prognostic values according to its localization, which may help establish appropriate cancer treatments.

Broad fibrovascular cores may not be an exclusively benign feature in papillary lesions of the breast: a cautionary note

Aims A prominent fibrovascular stromal core is one of the widely accepted histological features of breast papillomas, but some papillary carcinomas also show such broad fibrovascular cores, leading to confusion in diagnosis, particularly in needle biopsy specimens. We investigated the histological characteristics of papillary lesions, focusing on broad fibrovascular cores and their relationship with the architectural patterns. Methods Among 185 cases of needle biopsies of papillomas and papillary carcinomas, the number of cases with broad fibrovascular cores in each group was compared. The broad fibrovascular core density in the subsequently resected specimens was evaluated and compared between papillary predominant pattern (papillary structures >80% of tumours) and mixed pattern (papillary, solid, cribriform and others) within the lesions. Results Significantly more papillary carcinomas than papillomas and B3 atypical papillary lesions had broad fibrovascular cores (p=0.0091 and p=0.0164, respectively). The papillary predominant pattern was more prominent in carcinomas than in papillomas in the needle biopsies (p=0.048) and showed the same tendency in the resections (p=0.058). The broad fibrovascular core density was significantly lower in the 18 papillomas than in the 37 papillary carcinomas (p=0.0079) and was not significantly different between the papillary predominant and mixed patterns in carcinomas and papillomas. Conclusions Broad fibrovascular cores in mammary papillary lesions are not specific for papillomas, as they are also present focally in papillary carcinomas. As the frequency of papillary carcinoma with broad fibrovascular cores is relatively high, caution in diagnosis has to be exercised, especially in needle biopsy specimens.

Usefulness of endoscopic breast-conserving surgery for breast cancer

PurposeWe compared the safety, invasiveness and cosmetic outcomes between endoscopic breast-conserving surgery (endoscopic group) and surgery under direct vision (direct vision group) for treating breast cancer.MethodsWe compared 100 cases of endoscopic surgery with 150 cases of direct vision surgery. The safety was evaluated in terms of the blood loss, length of the operation and presence or absence of complications, whereas the degree of invasiveness was assessed using preoperative and postoperative leukocyte counts, neutrophil counts, interleukin (IL-6) levels and fever. The cosmetic outcome was assessed on the basis of a breast evaluation by the medical staff and the patient’s subjective satisfaction.ResultsIn both groups, serious postoperative complications were absent. No significant differences were observed in the leukocyte counts, neutrophil counts, IL-6 level or fever between the groups. An evaluation of the cosmetic outcomes by the staff showed a more favorable breast size, breast shape and scar condition in the endoscopic group. A significantly higher level of patient satisfaction was also observed in the endoscopic group. Postoperative local recurrence was absent.ConclusionsThe endoscopic approach showed comparable safety and invasiveness, and provided better postoperative cosmetic outcomes than direct vision surgery. Our results suggest that endoscopic breast-conserving surgery is a potentially useful surgical method for the treatment of breast cancer.

Intrahepatic cholangiocarcinoma with sarcomatous change producing granulocyte-colony stimulating factor.

To the editor: Granulocyte-colony stimulating factor (G-CSF) is a naturally occurring glycoprotein that stimulates the proliferation and maturation of precursor cells in bone marrow into fully differentiated neutrophils. Since G-CSF producing lung cancer was initially reported in 1977, G-CFS producing malignant neoplasms, such as hepatocellular carcinoma (HCC), bladder cancer, uterine cervix cancer, pancreatic cancer, and so forth, has been reported. Intrahepatic cholangiocarcinoma (ICC) is a relatively infrequent tumor in most populations, but is the second most common primary hepatic malignancy following HCC. Only five ICCs have been reported to show G-CSF production with marked leucocytosis. Herein, we report a case of ICC with sarcomatous change presenting marked leukocytosis and discuss the association between ICC and G-CSF with respect to hepatic stem/progenitor cells (HSPCs). A 62-year-old woman was hospitalized for a large mass with a maximal diameter of 8 cm in the left lobe of the liver. She had a history of chronic hepatitis type C, and had been examined periodically in our hospital for 20 years. When she underwent examination by ultrasonography 5 months prior to the admission, the mass lesion was not detected in the liver. Physical examination on admission revealed high fever (38.4°C), epigastralgia, hepatomegaly and non-pitting edema in the lower extremities. Laboratory data on admission showed mild leukocytosis (11 900/mL), mild anemia, hypoalbuminemia and elevation of C-reactive protein. Serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 were markedly elevated to 104.9 ng/mL (normal: <2.5 ng/mL) and 5983.7 U/mL (normal: <37 U/mL), respectively. Abdominal computed tomography showed a large low density mass measuring 10 ¥ 6 cm in the left lobe of the liver. Metastasis of lymph nodes or other organs was not detected. Based on these findings, she was clinically diagnosed with ICC and underwent chemotherapy using gemcitabine (1400 mg/day). However, chemotherapy had no effect. With the tumor progression, white blood cell count and CEA were elevated up to 50 500/mL and 227.0 ng/mL, respectively. She died of liver failure approximately 3 months after admission. Autopsy was performed. The liver weighed 2470 g. The cut surface showed a yellowish solid mass measuring 12.2 ¥ 8.5 cm with massive necrosis and hemorrhage in the left lobe of the liver. Innumerable small nodules had diffusely invaded the bilateral lobes of the liver. Histopathologically, the tumor was composed of two different components. One was an adenocarcinoma component, the other was a sarcomatous component. In the former component, tumor cells were proliferative in glandular fashion with mucin production in a relatively limited part (Fig. 1a: left side). The latter component showed that tumor cells with loose cohesiveness and marked pleomorphism were diffusely proliferative (Fig. 1a: right side). Numerous atypical mitoses were encountered. Neutrophils infiltration was evident inside tubular structures of adenocarcinoma component and around sarcomatous component. The expression of G-CSF was observed both adenocarcinoma and sarcomatous components immunohistochemically (Fig. 1b). Both components were positive for vimentin (Fig. 1c). All of the tumor cells were positive for cytokeratin (CK) 7, CK19, CK CAM 5.2 and negative for hepatocyte paraffin-1 and epithelial cell adhesion molecule. These findings indicate this tumor is a moderately differentiated adenocarcinoma with sarcomatous change. The inner rims of small ducts in the adenocarcinoma component were positive for CD56 and CD 133, which are representative markers of HSPCs (Fig. 1d). The tumor metastasized to bilateral lung diffusely, bronchopulmonary and para-aortic lymph nodes. Background non-carcinomatous hepatic tissue showed the formation of regenerative nodules and infiltration of mononuclear cells in the portal area, which corresponded to cirrhosis associated with hepatitis C virus infection. There were no apparent infection foci causing severe leucocytosis in other organs. The diagnostic criteria of G-CSF producing tumor are as follows: (i) extreme leukocytosis, (ii) elevated G-CSF activity, (iii) drop in white blood cell count after tumor resection, or (iv) proof of G-CSF production in the tumor. Our present case revealed marked leucocytosis. Moreover, G-CSF production was confirmed by immunohistochemical staining although the serum G-CSF level was not examined. It is reasonable to regard this tumor as a G-CSF producing tumor because leukocytosis deteriorated with the tumor progression and there were no other factors causing leukocytosis. The prognosis of patients with a G-CSF-producing tumor is extremely poor. ICC rarely causes marked leucocytosis. To the best of our knowledge searched by PubMed, only five cases of G-CSF producing ICC with marked leucocytosis have ever been reported (Table 1). Out of these, squamous cell carcinoma, adenosquamous cell carcinoma and adenocarcinoma were pathologically diagnosed in one, one and three cases, respectively. The average prognosis of them was 49 days. G-CSF was considered to be a major autocrine growth factor in rapid tumor proliferation and metastasis. Autocrine Pathology International 2013; 63: 233–235 doi:10.1111/pin.12051 bs_bs_banner

Treatment outcome in patients with stage III breast cancer treated with neoadjuvant chemotherapy

Despite the good responses of patients (pts) with stage III breast cancer to neoadjuvant chemotherapy (NAC), most eventually relapse and have a poor prognosis. We investigated the prognostic indicators in pts with stage III breast cancer treated with NAC, using epirubicin and/or docetaxel. A total of 22 women with stage III breast cancer underwent NAC between January 2005 and May 2011. The regimens of NAC comprised ED (epirubicin 60 mg/m2 and docetaxel 60 mg/m2) in 10 cases, FEC (fluorouracil 500 mg/m2, epirubicin 75–100 mg/m2 and cyclophosphamide 500 mg/m2) in 10 cases and EC (epirubicin 60 mg/m2 and cyclophosphamide 600 mg/m2) in two cases. Following four cycles of each regimen, a further four cycles of D (docetaxel 70 mg/m2) were undertaken in nine cases. Subsequent to the completion of NAC and surgery, we assessed the clinicopathological results and performed prognostic analyses. Statistical analyses concerning disease-free survival (DFS) or overall survival (OS) were conducted by a Cox proportional hazard model. The median survival time was 66 months and there were 12 distant metastases and two local recurrences. Multivariate analyses showed the number of metastatic axillary lymph nodes (ALNs) [hazard ratio (HR), 1.079; P=0.023] was correlated with DFS, while the Ki-67 labeling index (HR, 1.109; P=0.042) and the number of meta-static ALNs (HR, 1.087; P=0.023) were correlated with OS. In conclusion, even if pts with stage III breast cancer show good responses to NAC using epirubicin and/or docetaxel, the majority eventually relapse and have a poor prognosis. The Ki-67 labeling index and the number of involved ALNs are suggested as prognostic indicators in stage III breast cancer.

Active targeting nanoparticle for breast cancer diagnosis and treatment.

163 Background: Breast cancer remains a major ongoing public health problem among women. Nanotechnology is the exciting field focused on man-made materials in the size range of 1-100 nanometers (nm). Nanoparticles (NPs) are on the scale of many cellular-level processes and hence are attractive for targeting breast cancer. Emerging nanotechnologies promise new approaches to early detection and treatment of breast cancer. Our group has reported Gold Speckled Silica NPs (GSS) as multimodal contrast agents for fluorescence, magnetic resonance and photoacoustic tomographic (PAT) imaging. The near infrared (NIR) optical absorption property of these particles makes them potentially useful for therapeutic applications such as thermal ablation of tumors. Fulfilling the promise of nanotechnologies for patients with metastatic breast cancer, necessitates delivery of nanomaterials to sites of breast cancer. Now we have focused on the cancer metabolism, we have recently developed active targeting NPs with surface functionalizing agent such as glucose conjugated NPs. We hypothesize that active targeting NPs is more incorporated into cancer cells compared to normal NPs. METHODS Human breast cancer cells, BT474, were incubated with active targeting NPs or normal NPs (as control). The tumor cell uptake was assessed using flow cytometry and fluorescence microscopy experiments. RESULTS Uptake of active targeting NPs was significantly higher than uptake of normal NPs. CONCLUSIONS Active targeting NPs can be used as suitable targeting NPs for development of imaging agents for early diagnosis of breast cancer. Evolving bio-nanotechnologies such as active targeting NPs promise to enhance the early detection and non-invasive treatment of breast cancer.

A multicenter phase II study of S-1 combined with irinotecan (CPT-11) for patients with advanced/recurrent breast cancer.

e11528 Background: Irinotecan (CPT-11) is an inhibitor of topoisomerase I, an enzyme necessary for DNA replication and S-1 has been developed as an oral drug consisting of the 5-FU prodrug tegafur combined with the two modulators of 5-FU activity. They have been shown to be effective in patients (pts) with advanced/recurrent breast cancer with a considerable single-agent activity, respectively. This study to evaluate the clinical effect of CPT-11 combined S-1 for advanced or recurrent breast cancer (BC). METHODS This is an open-label, multicenter, single-arm, phase II study. The primary objective is to evaluate the effect of S-1 plus CPT-11 regimen on clinical response, secondary objective included evaluating the safety, time to next progression and duration, the QOL during the treatment will also be evaluated. The planned sample size is 35-55. Patient eligibility criteria: All pts with histologically confirmed BC with unresectable or metastatic diseases, measurable lesions, PS 0-2, age between 18 and 80. Prior adjuvant chemotherapy finished at least 6 months before enrollment was allowed. Treatment schedule: S-1 80 mg/m2 p.o. twice daily on days 3 to 7, 10 to 14, and 17 to 21 and CPT-11 60 mg/m2 i.v. on day 1, 8, 15 with a 1-week interval until disease progression or unacceptable toxicities. Both recommended doses of S-1 and CPT-11 was based on our previous Phase I study. (Ogata et al. abstr 2535, ASCO 2008) Results: The enrollment have begun from January 2009, currently total 24 pts were enrolled in this study. The median age was 56.5 years (range, 38-73). Fourteen pts had recurrent disease after previous curative mastectomy and 10 had previous adjuvant chemotherapy. CONCLUSIONS CPT-11+S1 is a promising regimen for the treatment of refractory BC pts. This trial will futher assess efficacy and safety using the standard response evaluation criteria in solid tumors (RECIST) and the National Cancer Institute Common Toxicity Criteria (version 3.0) in these pts.

First-line Treatment of Metastatic Breast Cancer: Focus on Bevacizumab

As vascular endothelial growth factor (VEGF) plays a central role in tumor growth, invasion and metastasis, inhibiting tumor angiogenesis by blocking the actions of VEGF is a rational therapeutic strategy. Drugs targeting the VEGF system are currently in development and at the most advanced stage of development is bevacizumab. The effect of bevacizumab on breast cancer has been examined in many clinical trials, and promising results have been reported. The clinical effect of bevacizumab monotherapy for breast cancer is not clear; however, the ECOG-E2100 study showed that first-line anti-angiogenic therapy using bevacizumab combined with paclitaxel clearly improved the response for earlier stage metastatic breast cancer (MBC). As a stronger anti-tumor effect is expected when prescribing bevacizumab for patients at an early stage of MBC, many first-line clinical trials using bevacizumab with other combination regimens are currently ongoing. Although the common side effects of bevacizumab are hypertension, proteinuria, wound-healing complications, and thromboembolism, it is a comparatively safe agent. It is expected that the many ongoing clinical trials will establish bevacizumab as a standard first-line therapy for MBC.