Takashi Hojo

Evaluation of sentinel node biopsy by combined fluorescent and dye method and lymph flow for breast cancer.

BACKGROUND Conservative breast resection with subsequent sentinel lymph node biopsy (SNB) is an increasingly popular initial approach for the treatment of breast cancer due to decreased invasiveness. SNB is a shorter procedure with fewer side effects than more substantial surgical procedures, but it sometimes fails to identify metastatic disease. Therefore, a highly sensitive and convenient method is needed to identify sentinel lymph nodes (SLN) with a high probability of containing disease in SNB. We compared the combination of radioisotope or dye with a fluorescence compound to analyze lymph flow to identify targets for SNB. MATERIALS AND METHODS We examined patients with breast cancer lacking metastases in the axillary lymph node (ALN). Two methods for targeted SNB were developed: (1) Indocyanine Green (ICG) and Patent blue were injected into the skin overlying the tumor and sub-areolar region just before the surgical procedure. (2) ICG and radiocolloid were injected into the skin overlying the tumor and sub-areolar region. The draining fluorescent lymphatic duct was visualized using a Photodynamic Eye (PDE). We removed the SLNs that were identified by the dye and fluorescence imaging methods. Method 1 was applied to 113 patients undergoing SNB, and 29 patients were treated with Method 2. In our study, patients were grouped by lymph flow into two types: Type C demonstrated convergence to one lymph duct. Type S demonstrated separate lymph ducts. RESULTS Using the fluorescence imaging method, 99.3% of SLNs were identified, and 3.8 SLNs per patient were seen. The SLN identification rates for Patent blue dye and radiocolloid were 92.9% and 100%, respectively, while 1.9 and 2.0 SLNs per patient, respectively, were seen with these methods. We classified two types of lymph flow based on the pattern of lymphatic drainage. Type C converged to a single lymph duct, while Type S drained to separate ducts. Type S lymph drainage was seen in 29/142 patients (20.4%), and Type C drainage was found in 113/141 patients (79.6%). Of the patients with Type S drainage, there were 4.1 SLNs per patient, but only 3.4 SLNs per patient were seen in individuals with Type C drainage. Forty cases had metastases found in the ALNs, and five of these cases were dye-negative and fluorescence-positive. Among these cases, the average number of SLNs identified was one. CONCLUSION The combination of fluorescence with a visible dye is a highly sensitive method for SLN identification. When SNB is guided by only the dye method, there is a risk of missing appropriate SLNs in patients with Type S lymph drainage or weak dye staining. The use of a fluorescence method together with dye could increase sensitivity of detection in these cases. Furthermore, fluorescent methods are ideal for hospitals that cannot use conventional radioactive measures.

Down regulation of the tumor suppressor gene maspin in breast carcinoma is associated with a higher risk of distant metastasis

BACKGROUND Maspin (mammary serpin) is a relatively novel serine protease inhibitor with tumor suppressing function in breast cancer. Maspin expression was found in normal breast epithelial cells, but was decreased during tumor progression. Only a few systematic analyses of this phenomenon have been undertaken so far. In this study we developed specific nested reverse transcription polymerase chain reaction (RT-PCR) conditions for the detection of maspin expression in human breast carcinoma and assessed maspins association with the clinical behavior of primary breast cancers. METHODS Tumor specimens obtained from 45 primary breast cancer patients were analyzed for maspin expression by a nested RT-PCR assay. Recurrence free survival was evaluated and correlated to maspin expression. RESULTS The maspin transcript was detected in 29 (64%) breast cancer specimens whereas no expression was found in 16 (36%) cancer specimens. This expression was unrelated to any of the established prognostic factors. However, 6 out of 8 patients who developed distant metastasis (lymph nodes, lung, liver, bone, pleura) within 3 yr after their initial diagnosis showed no maspin expression of the primary breast cancer (p < 0.05). CONCLUSIONS The lack of maspin expression in breast cancer seems to be associated with a short disease free survival and supports maspins function as an indicator of tumor aggressiveness and metastatic potential. Nested RT-PCR is a sensitive method to determine maspin expression in human breast cancer tissue.

Long-term prognostic study of carcinoembryonic antigen (CEA) and carbohydrate antigen 15-3 (CA 15-3) in breast cancer

BackgroundTumor markers are frequently used for screening and monitoring in oncology. We investigated the use of preoperative tumor marker (carcinoembryonic antigen [CEA] and carbohydrate antigen [CA] 15-3) levels in estimating the prognosis of breast cancer patients.MethodsWe conducted a retrospective study in patients who underwent breast cancer surgery at National Cancer Center Hospital between 1975 and 1994 and whose serum CEA (n = 1663) and CA 15-3 (n = 1500) levels were measured prior to operation. When we excluded patients with stage IV disease from the study, the CEA level was within the normal range in 1470 patients, while 150 patients had an elevated CEA level. For CA 15-3, 1395 patients were within the normal range, while 70 patients exhibited an elevated level.ResultsThe 5-year and 10-year survival rates for patients with normal CEA levels were 87% and 76%, respectively. However, the 5-year and 10-year survival rates for patients with elevated CEA levels were 76% and 65%, respectively. At both time points, patients with normal CEA levels had higher survival rates (P < 0.05). The 5-year and 10-year survival rates for the patients with normal CA 15-3 levels were 86% and 76%, respectively, while only 71% and 52% patients with elevated CA 15-3 levels survived at 5 and 10 years, respectively. These differences were also significant (P < 0.05). However, there were no significant differences in disease-free survival (DFS) according to CEA or CA 15-3 levels.ConclusionThere was a positive correlation between CEA levels and CA 15-3 levels and patient prognosis. Thus, the levels of these tumor markers may help to determine prognosis in breast cancer patients.

Association of maspin expression with the malignancy grade and tumor vascularization in breast cancer tissues.

Maspin belongs to a tumor suppressing protein which is usually expressed highly in myoepithelial cells, and is significantly downregulated in breast cancer cells. We focused on identifying the correlation between maspin expression and the clinicopathological features of human breast cancer tissues using immunohistochemistry. There was a significant correlation in that maspin-positive tumor specimens showed a low pathological grade of malignancy, such as a lower infiltration of the tumor into the surrounding tissue and a downregulation of c-erbB2 expression. Moreover, maspin-positive cases showed a significant decrease in tumor vessels positively stained with anti-factor VIII-related antigen antibody. These results suggest that maspin production in myoepithelial cells could downregulate the malignant phenotype of breast cancer.

The differences in the histological types of breast cancer and the response to neoadjuvant chemotherapy: The relationship between the outcome and the clinicopathological characteristics

UNLABELLED Although effective regimens have been established for invasive ductal carcinoma-not otherwise specified (IDC), the efficacy and prognosis of other minor types of breast cancer are unknown because of their rareness. The clinicopathological features and prognosis of other minor types concerning the response to neoadjuvant chemotherapy (NAC) were evaluated in this study. A total of 562 patients were classified according to the Japanese and the World Health Organization (WHO) classifications, and the number of IDC and other special types (SP) was 500 and 62. The SP patients had a significantly poorer clinicopathological response to NAC and less breast-conservative therapy than those with IDC. According to the WHO classification, mucinous carcinoma, metaplastic carcinomas and apocrine carcinoma also responded poorly, and patients with metaplastic carcinomas and invasive lobular carcinoma had a significantly poorer prognosis. Despite the poor response to chemotherapy, patients with mucinous carcinoma and apocrine carcinoma had a good prognosis. The response to NAC and the prognosis vary for each histological type. For some types, the prognosis was not related to the clinicopathological response to NAC. BACKGROUND In the treatment of breast cancer, neoadjuvant chemotherapy (NAC) has become the standard treatment modality for downstaging purposes. Although effective regimens have been established for the treatment of invasive ductal carcinoma-not otherwise specified (IDC), the data about the efficacy and prognosis for patients with other minor types of breast cancer are insufficient because of the rareness of these tumors. Defining the relationship between each histological type and the clinicopathological response to NAC is essential to optimizing individualized treatment. METHODS We retrospectively evaluated the clinicopathological features and classification of the histological types based on the Japanese and the World Health Organization (WHO) classifications before and after NAC in 562 patients with primary breast cancer who underwent curative treatment after NAC between 1998 and 2008. The prognosis was estimated for each histological type. RESULTS Of the 562 patients, the number of cases of IDC and other special types (SP) was 500 and 62. In the SP group, the clinicopathological response to NAC was significantly poorer, and the patients underwent breast-conservative therapy less frequently than did the IDC patients. According to the WHO classification, mucinous carcinoma, metaplastic carcinomas and apocrine carcinoma responded poorly to NAC. The disease-free survival and overall survival were significantly worse for patients with metaplastic carcinomas (p<0.001 and p<0.001) and with invasive lobular carcinoma (p=0.03 and p<0.001) than other cancers. Despite their poor response to treatment, patients with mucinous carcinoma and apocrine carcinoma had a good prognosis. CONCLUSIONS The response to standardized NAC and prognosis varies for each histological type. For some types, the prognosis was not associated with the clinicopathological response to NAC. Innovative regimens should therefore be investigated for each histological type to achieve the best response.

Metaplastic carcinoma of the breast

The purposes of this study were to investigate whether the biological characteristics or outcomes of patients with metaplastic carcinoma, invasive ductal carcinoma, or invasive lobular carcinoma of the breast differ; to determine whether the metaplastic carcinoma subtypes have similar malignant potentials; and to identify accurate predictors of outcome in patients with metaplastic carcinoma. The subject comprised 6137 invasive ductal carcinoma patients, 301 invasive lobular carcinoma patients, and 46 metaplastic carcinoma patients of the breast. The metaplastic carcinomas were classified according to the World Health Organization classification. Multivariate analyses clearly demonstrated that the metaplastic carcinoma patients had a significantly poorer outcome than the invasive ductal carcinoma patients or the invasive lobular carcinoma patients independent of the nodal status or age not exceeding 39 years, whereas patients with triple-negative metaplastic carcinomas or triple-negative invasive lobular carcinomas had a poorer outcome than those with triple-negative invasive ductal carcinomas. Although no significant differences in clinical outcome were observed among the metaplastic carcinoma subtypes in multivariate analyses, an age not exceeding 39 years, the presence of skin invasion, and the presence of a squamous cell carcinoma component in nodal tumors were significant outcome predictors for metaplastic carcinoma patients. In conclusion, the results of this study clearly demonstrated that metaplastic carcinoma is more aggressive than invasive ductal carcinoma or invasive lobular carcinoma. Although the metaplastic carcinoma subtypes had no prognostic significance, an age not exceeding 39 years, the presence of skin invasion, and the presence of a squamous cell carcinoma component in nodal tumors were significant predictors of outcome among metaplastic carcinoma patients.

21-Gene expression profile assay on core needle biopsies predicts responses to neoadjuvant endocrine therapy in breast cancer patients.

This study examined postmenopausal estrogen receptor-positive breast cancer patients who received prospective neoadjuvant endocrine therapy (NAET) with tamoxifen or anastrozole to determine if the 21-gene recurrence score (RS) predicts NAET responses. RS scores were determined from pretreatment core biopsy specimens. Although half of the specimens yielded insufficient RNA, the remaining samples were highly representative. Patients with a low RS tended to respond better than those with an intermediate or high RS (n=43). Response rates by RS were similar between the tamoxifen and anastrozole groups. Patients with a low RS tended to have better relapse-free survival (RFS) than those with an intermediate or high RS (5y-RFS; 100% vs. 84% and 73%, respectively). These results suggest that RS predicts responses to NAET with tamoxifen or anastrozole. Because this pilot study examined a small sample size, these results should be validated in larger studies.

Antitumor effects induced by dendritic cell-based immunotherapy against established pancreatic cancer in hamsters.

Because the prognosis of patients with pancreatic cancer is very poor, development of a novel approach for treatment of this disease is vital. In the present study, we investigated the effect of dendritic cell (DC)-based immunotherapy against established syngeneic hamster pancreatic cancer named HPD1NR. Hamster enriched DCs were prepared from bone marrow (BM) by a culture for 7 days in the presence of mouse GM-CSF and mouse IL-4, and characterized by the expression of specific DC markers (DEC205, DC-SIGN) mRNA using in situ hybridization (ISH). DCs pulsed with tumor lysate and N-[1-(2,3-dioleoyloxy)propyl]-N,N,N-trimethylammonium methylsulfate (DOTAP) or DCs alone were injected s.c. weekly into HPD1NR-bearing hamsters three times. Tumor growth was significantly inhibited by 82% in hamsters treated with tumor lysate and DOTAP-pulsed DCs when compared with the PBS vehicle-treated group. These findings suggest that DC-based immunotherapy may be a useful approach for the treatment of pancreatic cancers.

Adenovirus-Mediated MUC1 gene transduction into human blood-derived dendritic cells.

MUC1 protein is widely expressed on various human cancer cells and has a specific highly glycosylated core structure with multiple tandem repeats, which may include an immunogenic peptide sequence. The potency of MUC1 protein to induce human histocompatibility leukocyte antigen–class I–restricted cytotoxic T-lymphocyte (CTL) induction remains to be fully clarified in human beings. In the current study, we made MUC1-expressing human dendritic cells (DCs) using recombinant adenovirus vector. Adenovirus vector plasmid containing human MUC1 cDNA, pAdHM4-MUC1 was constructed using in vitro ligation with a shuttle vector, pHMCMV5. Adenovirus vector expressing MUC1 was generated by the transfection of Pac I-digested recombinant vector plasmid into 293 cells. Human blood DCs were obtained from 7-day culture of monocytes with recombinant human (rh) granulocyte-macrophage (GM) colony-stimulating factor (CSF) and (rh)interleukin (IL)-4. Then, 1 × 10 6 DCs were incubated with viral supernatant at a multiplicity of infection of 200 for 24 h in the presence of rhGM-CSF and rhIL-4. Flow cytometric analysis showed that 30% to 40% of the transduced DCs expressed MUC1 protein; by contrast, nontransduced or transduced DCs with mock virus expressed only small amounts of MUC1 protein. Adenovirus-mediated MUC1 gene transduction into DCs had no significant effect on DC surface marker expressions or functions such as mixed leukocyte reaction. Furthermore, MUC1-specific CD8 + CTLs could be induced from healthy donor blood lymphocytes using MUC1-expressing DCs as stimulators. These results suggested that MUC1 gene-transduced DCs are a functional and potent tool for triggering a CTL response against MUC1 + cancer cells.

Clinical and pathological features of intracystic papillary carcinoma of the breast.

PurposeTo evaluate the clinicopathological features of intracystic papillary carcinoma (ICPC), which have not been established given its rarity and lack of standard diagnostic criteria.MethodsWe reviewed the clinicopathological findings and treatment outcomes of 14 patients with ICPC diagnosed between 2002 and 2006.ResultsIntracystic papillary carcinoma was diagnosed by fine-needle aspiration biopsy in three patients and by core-needle biopsy in six patients. A preoperative diagnosis was not made in five patients. Three patients underwent magnetic resonance imaging preoperatively, which helped to differentiate benign tumors and maintain free surgical margins. The final pathological diagnosis was invasive carcinoma in 2 (14.2%) of the 14 patients. The patients were followed up for 1–72 months, during which time only one died, of a cancer-unrelated cause.ConclusionOur results show that ICPC is more difficult to diagnose than common breast cancer preoperatively. Excisional biopsy was necessary when fine-needle aspiration and core-needle biopsy could not provide a diagnosis. Magnetic resonance imaging is helpful to differentiate a benign tumor from invasive disease.