Patricia A. Thomas

Role for Glucose Transporter 1 Protein in Human Breast Cancer

Glycolysis is increased in cancer cells compared with normal cells. It has been shown that glucose enters cells via a family of five functional glucose transporters (GLUT). However, GLUT expression appears to be altered in human breast cancer, which may serve as a selective advantage and facilitate the metastatic potential of these cells. The relationship of GLUT isoform expression and breast cancer cell invasiveness has not been adequately addressed. Thus, the purpose of this study was to investigate whether an association exists between GLUT expression and human breast cancer cell invasiveness. Invasiveness of the human breast cancer lines MCF-7, MDA-MB-435 and MDA-MB-231 was measured using anin vitro assay and compared with cellular GLUT isoform expression, assessed by Western blot analysis and verified by immunohistochemistry in a poorly differentiated human ductal breast cancer. Cell surface GLUT-1 expression was associated with the invasive ability of MCF-7 (2.0 ± 0.02%), MDA-MB-435 (6.4 ±0.4%), and MDA-MB-231 (19.3 ± 2.0%). However, GLUT-2 and GLUT-5 were inversely associated with invasiveness; GLUT-3 expression was variable; and GLUT-4 was undetected. In a poorly differentiated human ductal breast cancer,in situ GLUT-1 staining was intense. GLUT-1 expression was associated with the in vitro invasive ability of human breast cancer cells which was validatedin situ. If this relationship is found to exist in a larger number of human breast cancer tissues, it may be possible to develop diagnostic and therapeutic strategies based on targeted GLUT isoform expression.

Angiosarcoma of the breast: a clinicopathologic analysis of cases from the last 10 years

Breast angiosarcoma may occur de novo, or as a complication of radiation therapy, or chronic lymphedema secondary to axillary lymph node dissection for mammary carcinoma. In our effort to characterize the clinicopathologic features of breast angiosarcoma, we reviewed all breast angiosarcoma cases in the University of Kansas Medical Center and Ohio State University Medical Center archives from 1997 to 2007. Clinical histories and follow-up data for identified patients were reviewed. The tumors were graded histologically according to Rosens method. Only 11 angiosarcomas were identified among more than 5000 malignant breast neoplasms (0.1%-0.2% incidence) for the last 10 years. Eight cases (6 high grade, 1 intermediate grade, 1 low grade) were identified as postradiation angiosarcoma (postradiation time interval, 4-12 years), and 3 cases were identified as primary angiosarcomas (1 high grade, 2 low grade). Follow-up (median, 36 months) revealed that 3 cases of postradiation angiosarcoma recurred as skin and/or chest wall lesions and 1 case of primary angiosarcoma developed liver metastases (all high-grade). In conclusion, breast angiosarcoma remains a rare disease. Rosens method for grading breast angiosarcoma is easy to implement and correlates well with clinical outcome. There are no distinct clinical or histologic differences between primary and postradiation breast angiosarcomas.

Grading invasive ductal carcinoma of the breast: advantages of using automated proliferation index instead of mitotic count

Breast carcinomas are graded according to the “Nottingham modification of the Bloom–Richardson system” (SBR). The system is hindered, however, by lack of precision in assessing all three parameters including nuclear grade, mitosis, and tubular formation, leading to an element of subjectivity. Our objective was to evaluate a new grading system [the nuclear grade plus proliferation (N+P) system] for subjectivity, ease, and better representation of tumor biology. Its components are nuclear grade and automated proliferation index. Invasive ductal carcinomas, consisting of 137 SBR grade I, 247 grade II, and 266 grade III, were re-evaluated by the N+P system. The two systems were compared with each other and correlated with patients’ overall survival, tumor size, angiolymphatic invasion, lymph node status, and biomarker status including estrogen receptor, progesterone receptor, p53, epidermal growth factor receptor, BCL-2, and Her-2. Although there was an agreement between the two systems with histologic and prognostic parameters studied, there was 37% disagreement when grading individual tumors. Fifty-three percent of SBR grade II tumors were “down-graded” to N+P grade I, and 7% were “up-graded” to N+P grade III. Distinction among the different histologic grades for overall survival curves was better indicated by the N+P than the SBR system.

Expression profiling of in vivo ductal carcinoma in situ progression models identified B cell lymphoma-9 as a molecular driver of breast cancer invasion

IntroductionThere are an estimated 60,000 new cases of ductal carcinoma in situ (DCIS) each year. A lack of understanding in DCIS pathobiology has led to overtreatment of more than half of patients. We profiled the temporal molecular changes during DCIS transition to invasive ductal carcinoma (IDC) using in vivo DCIS progression models. These studies identified B cell lymphoma-9 (BCL9) as a potential molecular driver of early invasion. BCL9 is a newly found co-activator of Wnt-stimulated β-catenin-mediated transcription. BCL9 has been shown to promote progression of multiple myeloma and colon carcinoma. However BCL9 role in breast cancer had not been previously recognized.MethodsMicroarray and RNA sequencing were utilized to characterize the sequential changes in mRNA expression during DCIS invasive transition. BCL9-shRNA knockdown was performed to assess the role of BCL9 in in vivo invasion, epithelial-mesenchymal transition (EMT) and canonical Wnt-signaling. Immunofluorescence of 28 patient samples was used to assess a correlation between the expression of BCL9 and biomarkers of high risk DCIS. The cancer genome atlas data were analyzed to assess the status of BCL9 gene alterations in breast cancers.ResultsAnalysis of BCL9, by RNA and protein showed BCL9 up-regulation to be associated with DCIS transition to IDC. Analysis of patient DCIS revealed a significant correlation between high nuclear BCL9 and pathologic characteristics associated with DCIS recurrence: Estrogen receptor (ER) and progesterone receptor (PR) negative, high nuclear grade, and high human epidermal growth factor receptor2 (HER2). In vivo silencing of BCL9 resulted in the inhibition of DCIS invasion and reversal of EMT. Analysis of the TCGA data showed BCL9 to be altered in 26 % of breast cancers. This is a significant alteration when compared to HER2 (ERBB2) gene (19 %) and estrogen receptor (ESR1) gene (8 %). A significantly higher proportion of basal like invasive breast cancers compared to luminal breast cancers showed BCL9 amplification.ConclusionBCL9 is a molecular driver of DCIS invasive progression and may predispose to the development of basal like invasive breast cancers. As such, BCL9 has the potential to serve as a biomarker of high risk DCIS and as a therapeutic target for prevention of IDC.

Myoepithelial carcinoma of the breast arising in an adenomyoepithelioma: mammographic, ultrasound and histologic features.

A 56-year-old postmenopausal woman discovered a lump in her right breast in January 2005. Physical examination revealed an ill-defined firm area at the 10 o’clock position, without palpable axillary lymphadenopathy. Mammographic studies (Fig. 1) showed a 2-cm microlobulated partially obscured, partially ill defined spherical mass without calcifications. Multiple real-time gray scale images of the right breast on the ultrasound showed a solid, microlobulated hypoechoic mass with maximum diameter of 18 mm

Primary malignant melanoma of the esophagus: A rare entity diagnosed by endoscopic ultrasound guided fine‐needle aspiration

Dear Dr. Bedrossian: Primary melanoma of the esophagus is a rare entity. Here we describe a case of primary esophageal melanoma diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). We discuss characteristic cytologic features and differential diagnoses as well as emphasize the importance of adequately triaging an EUS-FNA specimen. To our knowledge, this is the first reported case of esophageal melanoma diagnosed by EUS-FNA. A 47-year-old woman presented with dysphagia. Endoscopic examination revealed a 15-mm ulcerated submucosal lesion in the upper esophagus, 25 cm from the incisors (Fig. 1A). Ultrasonic examination showed a submucosal hypoechoic lesion (Fig. 1B). EUS-FNA of this lesion was performed. There was another hypoechoic submucosal lesion located at 20 cm; this lesion was not biopsied. No enlarged periesophageal, mediastinal or celiac lymph nodes were seen. Five fine-needle aspiration passes were performed. Smears were air-dried and stained with Diff-Quik stain on site. The first, second, and third passes were determined adequate for evaluation by on-site assessment. The fourth pass was put into RPMI for flow cytometry study, and the fifth pass was rinsed in CytoLyt for a cellblock preparation. The smears were highly cellular and were composed of singly dispersed cells and many stripped nuclei (Fig. 2A). The background appeared granular from the sloughed fragile cytoplasm. The cells were large, with round nuclei, prominent nucleoli, and scant to moderate cytoplasm (Fig. 2B). Fine cytoplasmic vacuoles were seen as well as binucleated cells (Fig. 2C). Rare cytoplasmic melanin pigment was noted (Fig. 2D). The cellblock sections showed similar malignant cells, some with intracellular pigment (Fig. 3A). Immunohistochemical stains performed on the cell block material showed the tumor cells to be negative for pan-cytokeratin and CD45, focally positive for S-100, and positive for melanoma cocktail (Fig. 3B). Flow cytometry study was negative for a lymphoproliferative disorder. A diagnosis of ‘‘malignant cells present, favor malignant melanoma’’ was made. The patient underwent esophagectomy at an outside institution. The resection specimen showed a 4.5 cm nodular and polypoid submucosal mass in the proximal esophagus. The diagnosis was confirmed to be malignant melanoma. Metastatic melanoma was also identified in two paraesophageal lymph nodes. The patient did not have any skin lesions upon thorough clinical examination. She received palliative chemotherapy and is alive and well 20 months after her initial diagnosis. Malignant melanoma, representing only 0.1–0.2 % of all primary esophageal cancers, is an aggressive neoplasm with early hematogenous and lymphatic dissemination. Approximately 50% of patients have metastatic disease at diagnosis, and the mean survival is reported to be 13.4 months. The overall 5-year survival rate is about 1.7%, and only rarely is long-term survival reported. Early reported cases were not always able to show local evolution from a precursor melanocytic lesion, and therefore the primary nature of esophageal melanomas has been questioned in the past. More recent reports however, do find in situ melanoma or radial growth phase in a substantial number of cases, which has helped to establish the diagnosis of primary esophageal melanoma. Because metastatic melanoma is more common, before the diagnosis of *Correspondence to: Fang Fan, MD, Ph.D, Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160-7417. E-mail: ffan@kumc.edu Received 29 December 2010; Accepted 2 February 2011 DOI 10.1002/dc.21674 Published online 17 March 2011 in Wiley Online Library (wileyonlinelibrary.com).

Thoracic spinal metastasis of merkel cell carcinoma in an immunocompromised patient: case report.

Study Design Case report. Objective Merkel cell carcinoma (MCC), an uncommon cutaneous neuroendocrine malignancy, is a rare cause of spinal metastasis, with only five cases previously reported. We report a rare case of MCC metastatic to the spine in an immunocompromised patient. Methods A 55-year-old male with previously resected MCC, immunocompromised due to cardiac transplant, presented with sharp mid-thoracic back pain radiating around the trunk to the midline. Computed tomography of the thoracic spine showed a dorsal epidural mass from T6 to T8 with compression of the spinal cord. Laminectomy and subtotal tumor resection were performed, and pathology confirmed Merkel cell tumor through immunohistochemistry staining positive for cytokeratin 20 and negative for thyroid transcription factor-1. Results Further treatment with radiation therapy was initiated, and the patient did well for 4 months after surgery, but returned with a lesion in the cervical spine. He then opted for hospice care. Conclusions With an increasing number of immunocompromised patients presenting with back pain, MCC should be considered in the differential diagnosis of spinal metastatic disease.

Benign Conditions Associated with a Risk for the Subsequent Development of Cancer

The vast majority of breast conditions that are biopsied (sampled) are benign [1]. Some of these benign conditions are associated with the increased risk for the subsequent development of cancer and some are not 1–5 Those that are associated with an elevated risk can be placed into a spectrum of changes referred to as proliferative breast disease (with or without atypia). They are considered marker lesions in contrast to precursor lesions, which will be described in Chap. 4. Marker lesions are associated with risk for cancers in both breasts. If cancer develops in the same breast as a marker lesion, it is likely to arise at a location in that breast other than where the marker lesion was found, in contrast to precursor lesions, for which subsequent cancers are usually found in close proximity to where the precursor lesion was located.

CD44s expression is reduced in endometriotic lesions compared to eutopic endometrium in women with endometriosis.

Immunohistochemical expression of the standard form of CD44 (CD44s) was examined in archival formalin-fixed endometriotic and matching eutopic endometrial tissue obtained from 25 patients in proliferative (N = 16) and secretory (N = 9) stages of the cycle. CD44s was expressed in most eutopic endometria and endometriotic tissue. Its expression was significantly higher in secretory than in proliferative phase endometrium. It was low but detectable in 13 of 16 proliferative phase biopsies. The majority of these endometria exhibited both glandular and stromal staining (63%). In the secretory phase, glandular cells exhibited a significantly greater intensity of staining compared to stromal cells. In endometriotic tissue, stromal cell CD44s expression did not differ between tissue types in either stage of the cycle. In contrast, glandular expression in endometriotic tissue during the secretory phase was reduced (p < 0.05) compared to eutopic endometrium. It was absent in 66% of cases and reduced in the remaining cases. Our results indicate a correlation between CD44s expression and secretory differentiation of endometrial glands in the cycle, suggesting hormonal regulation of its expression. This cyclic pattern of CD44s expression was lost in corresponding endometriotic tissue. Reduced expression of CD44s in endometriotic tissue may provide insight into the pathophysiology of endometriosis.

W1955 Pancreatic Endocrine Neoplasms: Predictive Cytomorphologic Features and Diagnostic Accuracy of Endoscopic Ultrasound-Guided Fine Needle Aspiration

Introduction: Pancreatic endocrine neoplasms (PENs) are rare lesions with an estimated frequency of 1 per 100,000. An accurate diagnosis of PEN depends on characteristic cytomorphologic criteria in combination with clinical and radiologic findings, including the use of Endoscopic ultrasonography-guided fine needle aspiration cytology (EUS-FNA). Aims: To evaluate the diagnostic reliability of for PENs at our institution and attempt to identify cytomorphologic features that predict aggressive clinical behavior. Methods: A total of 774 EUS-FNA pancreatic cases were retrieved from the files at KU Medical Center for the years 2002 to 2008. Of these, 34 cases (4%) were diagnosed as positive or suspicious for PENs. The cytologic features used as diagnostic criteria included clusters of monotonous small uniform cells, singly dispersed or loosely cohesive plasmacytoid cells (on Diff-Quik stained smears), scant to moderate granular cytoplasm, and stripped nuclei in a granular background. Of these, thirteen cases (8 females) had surgical or clinical follow-up in our institution. Cytomorphologic features were correlated with the clinical behavior of each tumor. The cytomorphologic features evaluated included cellularity, nuclear pleomorphism, macronucleoli, mitotic activity and tumor diathesis. Results: Mean age of the patients in this cohort was 56 years (range: 9-79). Cytology samples obtained by EUS showed PEN in all 13 patients and were subsequently confirmed by surgical pathology in 10. The mean size of the PENs was 3.1 cm (range: 0.5-8.3cm) and were distributed in the head (n=4), body (n=4), tail (n= 4), and neck (n=1) of the pancreas. Eight patients (62%) had the lesions resected with tumor free margins, 5 lesions were found to be unresectable2 secondary to invasion of portal vein (n=1) or superior mesenteric vein (n=1); 2 due to evidence of hepatic metastasis (these patients underwent palliative surgery); and 1 because of a coexisting locally advanced adenocarcinoma of unknown primary. In the surgically resected PENs, 4 were benign (3 insulinomas, 1 PPoma), and 4 were malignant islet cell tumors. The presence of tumor diathesis and mitoses correlated with malignancy, however other features such as cellularity, nuclear pleomorphism, and macronucleoli did not. Conclusion: EUS-FNA is a reliable diagnostic tool for evaluating PENs. Identification of mitoses and tumor diathesis in the smears may predict a more aggressive clinical behavior.