Quantification of Regional Breast Density in Four Quadrants Using 3D MRI—A Pilot Study

PURPOSE: This study presented a three-dimensional magnetic resonance (MR)–based method to separate a breast into four quadrants for quantitative measurements of the quadrant breast volume (BV) and density. METHODS: Breast MR images from 58 healthy women were studied. The breast and the fibroglandular tissue were segmented by using a computer-based algorithm. A breast was divided into four quadrants using two perpendicular planes intersecting at the nipple or the nipple-centroid line. After the separation, the BV, the fibroglandular tissue volume, and the percent density (PD) were calculated. The symmetry of the quadrant BV in the left and right breasts separated by using the nipple alone, or the nipple-centroid line, was compared. RESULTS: The quadrant separation made on the basis of the nipple-centroid line showed closer BVs in four quadrants than using the nipple alone. The correlation and agreement for the BV in corresponding quadrants of the left and the right breasts were improved after the nipple-centroid reorientation. Among the four quadrants, PD was the highest in the lower outer and the lowest in the upper outer (significant than the other three) quadrants (P < .05). CONCLUSIONS: We presented a quantitative method to divide a breast into four quadrants. The reorientation based on the nipple-centroid line improved the left to right quadrant symmetry, and this may provide a better standardized method to measure quantitative quadrant density. The cancer occurrence rates are known to vary in different sites of a breast, and our method may provide a tool for investigating its association with the quantitative breast density.     

Fine needle aspiration cytology of invasive micropapillary carcinoma of the breast. A case report

BACKGROUND: Invasive micropapillary carcinoma of the breast is uncommon and was characterized only recently. Awareness of this entity and its cytologic appearance is important to allow early diagnosis by fine needle aspiration cytology (FNAC). To our knowledge, only two cases of FNAC of this lesion have been reported in the English-language literature. CASE: An 80-year-old female presented with a firm, nontender mass in the upper outer quadrant of the left breast. FNAC showed ductal carcinoma, and mastectomy showed invasive micropapillary carcinoma. The patient had axillary metastases and received tamoxifen. CONCLUSION: The cytologic features of invasive micropapillary carcinoma are distinctive, with clusters of cells showing hyperchromatic, irregular and crowded nuclei and peripherally located cytoplasm with a rare central lumen. Fibrovascular cores are absent. Although FNAC experience with this lesion is limited, the characteristic cytologic features, including "inside-out" cell clusters, should raise the suspicion of this variant of ductal carcinoma. Differentiation from other papillary lesions and malignancies may be possible, but more experience is needed as the number of reported cases remains limited.     

Fine needle aspiration cytology of metastatic choriocarcinoma presenting as a breast lump. A case report

BACKGROUND: While choriocarcinoma is a rapidly invasive, widely metastasizing malignancy, it responds well to chemotherapy, so it is important to obtain an early diagnosis. We report the fine needle aspiration cytology (FNAC) of a case of choriocarcinoma metastatic to the breast. CASE: A 48-year-old female presented with a cough, hemoptysis and epistaxis. Chest computed tomography revealed multiple nodules in both lung fields. Also, a firm, slightly tender mass in the lower outer quadrant of the left breast was palpated. The breast mass was clinically suspected to be a metastatic lung cancer. FNAC of the breast showed a malignant tumor that had been misdiagnosed as a metastatic non-small cell carcinoma of the lung. Histologic examination of a nasal biopsy revealed metastatic choriocarcinoma. CONCLUSION: The cytologic features of choriocarcinoma are quite characteristic, with side-by-side, malignant, mononucleated cells and multinucleated giant cells corresponding to cytotrophoblasts and syncytiotrophoblasts, respectively. The disease is possible to diagnose by a careful examination of FNAC samples.     

乳腺错构瘤X线及病理特征分析

目的：探讨乳腺错构瘤的病理及影像学特征。方法：对11例乳腺错构瘤患者的临床特征、X线征象及病理表现进行回顾性分析。结果：患者平均年龄为46岁（26-58岁）,10例可触及肿块（9例患者自己发现,1例体检摄片时发现）,还有1例未能触及肿块。左乳7例,右乳4例,5／11（45．5％）肿块位于外上象限。11例钼靶X线平片均发现乳腺肿块,多数肿块呈卵圆形,边界清楚。肿块平均最大直径为6．Ocm（2．5-13．0cm）,6／11（54．5％）肿块呈混合密度影。4／11例（36．4％）术前X线确诊。镜下：肿瘤由数量不等、杂乱无章的乳腺导管、小叶和成熟的脂肪细胞及纤维纽织混杂组成。结论：混合密度影是其特异性X线表现,不同个体肿瘤各成分比例的不同导致X线表现差异较大。     

The Effect of Laterality and Primary Tumor Site on Cancer-Specific Mortality in Breast Cancer: A SEER Population-Based Study

Background

Reduced overall survival has been observed in patients with left-sided versus right-sided breast cancer due to cardiac toxicity after radiotherapy. However, the effect of laterality and primary tumor site on breast cancer-specific mortality (BCSM) remains unclear.

Patients and Methods

We analyzed data from 305,443 women ages 20- to 79-years-old diagnosed with breast cancer between 1990 and 2009. The data were obtained from the population-based Surveillance, Epidemiology, and End Results (SEER) program of the U.S. National Cancer Institute. The survival outcomes with regard to laterality and primary tumor site were compared using univariate and multivariate (Cox proportional hazards regression model) methods.

Results

In the multivariate analysis, BCSM was affected by the primary tumor site (P<0.0001) but not laterality (P = 0.331). The combined effect was piecewise: using the left upper-outer quadrant as the reference, the BCSM hazard ratio (HR) was not significant in the right upper quadrant (P = 0.755) and the right central portion (P = 0.329). The BCSM HR was slightly increased in the left central portion as well as the left and right lower-outer quadrants (HRs from 1.136 to 1.145; P<0.0001). The BCSM HR was significantly increased in the upper-inner and lower-inner quadrants (HRs from 1.242 to 1.372; P<0.0001) on both sides. Laterality only impacted BCSM in patients with breast cancer located in the central portion (HR, 1.100; P = 0.013, using the right side as the reference).

Conclusion

Patients with tumors in the upper-outer quadrant of both sides and the right central portion have a better prognosis than patients with tumors at other locations. Laterality is not regarded as a prognostic factor in breast cancer.     

Breast Tumor Laterality in the United States Depends Upon the Country of Birth,but Not Race

More breast cancers are diagnosed in the left breast than the right. The ratio (l/r) is called the laterality ratio. We analyzed 1.2 million cases of breast cancer diagnosed in the US between 1973 and 2010 and recorded by the Surveillance, Epidemiology, and End Results (SEER) program. We found that the laterality ratio depends upon the country of birth, but not race of the patient. We identified five countries of birth that had p-values larger than 0.995, while we expected to see less than 1. Those born in Japan (l/r = 1.14, p = 0.997), the Ryukyu Islands (l/r = 2.6, p = 0.998), Laos (l/r = 1.62, p = 0.9999) and Algeria (l/r = 2.1 p = 0.9959) had significantly larger laterality ratios compared to the overall SEER population (l/r = 1.04). Those born in Poland (l/r = 0.92, p = 0.997) had a laterality ratio significantly less than expected. We compared the laterality ratio calculated for tumors occurring in each quadrant of the breast for two immigrant populations: those born in Japan and those born in Poland. We found the only significant difference was in the laterality ratio of the upper outer quadrant. Thus, the birthplace effect appears to only occur in the upper outer quadrant of the breast. Finally, we found a small, but statistically significant, increase in the breast cancer laterality ratio with age, and decrease with birth year and year of diagnosis.     

Spindle cell malignant melanoma metastatic to the breast from a pigmented lesion on the back. A case report

BACKGROUND: Tumors metastatic to the breast are quite unusual (1.2% of all tumors). Malignant melanoma is an exception and is one of the principal metastasizing tumors, described mainly as a primary tumor. There are 5 different cytologic patterns; the spindled pattern is very uncommon, more difficult to diagnose and can be confused with a wide range of sarcomatous lesions. Nevertheless, there are some cytologic features that allow differentiation from similar tumors. CASE: A 30-year-old woman presented with a firm, deep, nontender mass in the upper outer quadrant of the right breast. Fine needle aspiration cytology was performed, and the aspiration smears showed spindle-shaped neoplastic cells arranged singly or in clusters with marked nuclear atypia. Melanin pigment was sometimes seen in the cytoplasm of some cells. Pathologic study of the breast tumor corroborated the diagnosis, and later study revealed lymph node metastases and relapse in the breast area and on a scar on the back. Two years earlier, biopsy of a pigmented lesion on the back was diagnosed as a cellular blue nevus. CONCLUSION: The cytologic features of spindle cell melanoma are distinctive. The presence of atypical fusiform cells with elongated cytoplasm; enlarged nuclei, some of them binucleated or multinucleated; prominent nucleoli; intranuclear cytoplasmic inclusions; and melanin pigment can help to diagnose these unusual metastases to the breast. This case was the first of malignant metastatic melanoma with the spindled pattern in which the diagnosis was made by fine needle aspiration cytology.     

Analysis of the recurrence risk factors for the patients with hepatocellular carcinoma meeting University of California San Francisco criteria after curative hepatectomy

We report a rare male case of an undifferentiated carcinoma with osteoclast-like giant cells originating in an indeterminate mucin-producing cystic neoplasm of the pancreas. A 59-year-old Japanese man with diabetes visited our hospital, complaining of fullness in the upper abdomen. A laboratory analysis revealed anemia (Hemoglobin; 9.7 g/dl) and elevated C-reactive protein (3.01 mg/dl). Carbohydrate antigen 19-9 was 274 U/ml and Carcinoembryonic antigen was 29.6 ng/ml. A computed tomography scan of the abdomen revealed a 14-cm cystic mass in the upper left quadrant of the abdomen that appeared to originate from the pancreatic tail. The patient underwent distal pancreatectomy/splenectomy/total gastrectomy/cholecystectomy. The mass consisted of a multilocular cystic lesion. Microscopically, the cyst was lined by cuboidal or columnar epithelium, including mucinous epithelium. Sarcomatous mononuclear cells and multinucleated osteoclast-like giant cells were found in the stroma. Ovarian-type stroma was not seen. We made a diagnosis of osteoclast-like giant cell tumor originating in an indeterminate mucin-producing cystic neoplasm of the pancreas. All surgical margins were negative, however, two peripancreatic lymph nodes were positive. The patient recovered uneventfully. Two months after the operation, multiple metastases occurred in the liver. He died 4 months after the operation.     

A case of colonic lymphoid tissue invasion by Gymnophalloides seoi in a Korean man

A 65-year old Korean man, living in Mokpo-city, Jeollanam-do, Republic of Korea, visited a local clinic complaining of right upper quadrant pain and indigestion. At colonoscopy, he was diagnosed as having a carcinoma of the ascending colon, and thus, a palliative right hemicolectomy was performed. Subsequently, an adult fluke of Gymnophalloides seoi was incidentally found in a surgical pathology specimen of the lymph node around the colon. The worm was found to have invaded gut lymphoid tissue, with characteristic morphologies of a large oral sucker, a small ventral sucker, and a ventral pit surrounded by strong muscle fibers. This is the first reported case of mucosal tissue invasion by G. seoi in the human intestinal tract.     

A case of human breast sparganosis diagnosed as Spirometra Type I by molecular analysis in Japan

A 92-year-old Japanese woman presented with a mass in the left breast, and sparganosis was suspected by biopsy of the mass. The mass disappeared once, but it reappeared at the same site one year later. For a definitive diagnosis, the mass was surgically removed, and a sparganum-like worm was detected. The causative agent was confirmed as Spirometra Type I (most probably Spirometra mansoni) by mitochondrial DNA analysis. The serological examination also proved the case as sparganosis. Considering the presence of two Spirometra species (Type I and II) in Asia, particularly Japan, molecular analysis of the causative agents is highly recommended to understand the epidemiology, infection sources, and pathogenicity in humans in both species, if the parasite specimens are available.     

The effectiveness of prophylactic subcutaneous mastectomy in Sprague-Dawley rats induced with 7,12-dimethylbenzanthracene

Fifty-day-old female, albino Sprague-Dawley rats were induced with DMBA, a potent carcinogen that reliably causes multiple breast tumors. Prophylactic subcutaneous mastectomy was performed 2 weeks after injection. Control animals had no breast tissue removed and developed 5.14 tumors per animal, or 1.3 tumors per quadrant. Animals subjected to 50 percent (unilateral) mastectomy developed 5.4 tumors per animal, with 0.72 tumors per surgical quadrant. Animals that underwent 75 percent (three quadrant) mastectomy developed 4.33 tumors per animal, or 0.48 tumors per surgical quadrant. The incidence of tumors was significantly reduced in the surgical areas. However, the risk of any animal developing a breast neoplasm was not reduced in direct proportion to the percentage of breast tissue removed. We believe that this model may prove valuable in evaluating prophylactic subcutaneous mastectomy.     

Breast metastasis from squamous cell carcinoma of the oropharynx: a case report

Background

Breast metastases from extramammary tumors are extremely rare, the most common primary tumors being contralateral breast carcinoma, followed by lung, gynecological, gastrointestinal, melanoma, and hematological cancers. Only a few cases deriving from head and neck squamous cell carcinoma have been reported in the literature to date.

Case presentation

We report a case of a 47-year-old Caucasian woman who presented to our hospital with a solitary breast lesion in the right upper external quadrant associated with multiple bone and visceral metastases. Two years before, she had undergone radical resection of a squamous cell carcinoma of the oropharynx (stage pT2, pN1), which was followed by adjuvant radiotherapy. Breast ultrasound showed a hypoechogenic tumor lesion of 4 cm in the right upper external quadrant that was associated with multiple axillary and infra-/supraclavicular adenopathies. A positron emission tomographic scan documented multiple visceral and bone metastases with a single hypermetabolic lesion of the right breast. The results of histology and immunohistochemistry were consistent with a metastasis from a squamous cell carcinoma. The patient died of acute respiratory insufficiency 1 month after her breast metastasis diagnosis and before starting any systemic antitumoral treatment.

Conclusions

Although breast metastases are extremely rare, they should be considered in any patient with a history of cancer and confirmed by histology and immunohistochemistry because they are very difficult to distinguish from other primary breast tumors based only on clinical and radiological features. There are no standardized treatment guidelines for breast metastasis management. Surgery and radiotherapy can play a role in symptom palliation, but they do not have any relevant impact on survival, the prognosis being poor, with an estimated overall survival less than 1 year from diagnosis.

     

Interaction of central subgerminal ooplasm with the elementary tissues (endophyll, Rauber's sickle and upper layer) of unincubated avian blastoderms in culture

By placing a central subgerminal ooplasmic mass over isolated parts (alone or in association) of unincubated avian blastoderms and culture, we obtained an improvement in, or in some cases restoration of normal development. The evolution of small rectangular fragments (isolates) excised from different regions of the unincubated blastoderm was observed in association or not with subgerminal ooplasm. The only type of differentiation that was clearly distinguished in these isolates (taken from the caudocentral area centralis region) was a so-called 'primary neurula' formed by the endophyll and an associated thickened upper layer. In the present study, we also demonstrate that after removal of the area centralis from an unincubated caudal blastoderm quadrant, the upper layer (UL) and endophyll can no longer be restored from the associated subgerminal ooplasm (and form a miniature embryo), as is the case after removal of the endophyll alone. A deep layer (containing the endophyll) reformed during the migration of Rauber's sickle-derived cells into the neighbouring central subgerminal ooplasm only in the presence of the upper layer. This suggests that the upper layer has an early influence on the cells containing the original central deep ooplasm (delta ooplasm) to form the endophyll. The present study offers supplementary arguments in favour of the hypothesis that the endophyll is an inductor of preneurulation.     

THE SYNDROME OF PROXIMAL JEJUNAL LOOP OBSTRUCTION FOLLOWING ANTERIOR GASTRIC RESECTION

An occasional complication following subtotal gastric resection of the antiperistaltic, antecolic type is closed loop obstruction high in the intestine. Unless recognized and treated early, it causes death rather quickly. Prompt surgical intervention is life-saving.Symptoms which characterize the complication and distinguish it from other forms of high intestinal obstruction or stomal edema are (1) unrelenting epigastric or left upper quadrant pain and tenderness attended by clinical indication of shock, and (2) rather limited vomiting with absence of bile and small bowel contents in the vomitus.Five cases occurred in a series of some 500 anterior long loop anastomoses. In three cases the complication was not immediately recognized and the patients died. In the other two cases, recovery followed surgical intervention.     

Pelvic abscess from enterobius vermicularis. Report of a case with cytologic detection of eggs and worms

BACKGROUND: Enterobius vermicularis is known to produce perianal and ischioanal abscesses and invade the peritoneal cavity via the female reproductive system, causing pelvic peritonitis. However, there are only rare case reports on the cytodiagnosis of these parasitic lesions. CASE: A 28-year-old woman was admitted with a tender left iliac fossa mass and greenish vaginal discharge. Ultrasonogram and computed tomography scan confirmed the presence of a mass lesion suggestive of a tuboovarian abscess. Cytologic examination of the pus obtained during left salpingo-oophorectomy revealed the presence of ova of E vermicularis and fragments of the adult worm in an inflammatory exudate consisting predominantly of neutrophils, eosinophils and occasional epithelioid cell granulomas. Paraffin sections of the tuboovarian mass showed necrotizing epithelioid cell granulomas, but neither ova nor any worm section was identified. Although the possibility of tuberculosis was considered histologically, Ziehl-Neelsen (Z-N) stain for acid-fast bacilli was negative. Z-N staining of the smear and mycobacterial culture of the pus also did not yield positive results. CONCLUSION: E vermicularis may cause tuboovarian abscess with necrotizing epithelioid granulomas mimicking tuberculosis. Cytologic examination of the pus is helpful in the diagnosis.     

A case of ovarian enterobiasis

A 36-year old Korean woman consulted a clinic for a regular gynecological examination, and a mass was noticed in her pelvis. She was referred to the Asan Medical Center, Seoul where transvaginal ultrasonography confirmed a pelvic mass exceeding 10 cm in diameter. She received total abdominal hysterectomy and bilateral salpingoophorectomy, and a borderline serous neoplasm with micropapillary features involving the left ovary and right ovarian serosa was histopathologically confirmed. In addition, a section of a nematode with numerous eggs was found in the parenchyma of the left ovary. The worm had degenerated but the eggs were well-preserved and were identified as those of Enterobius vermicularis. She is an incidentally recognized case of ovarian enterobiasis.     

Terminal hinge axis--Hobo point--Frankfurt horizontal relations

Aim of this investigation was to determine the spatial relations of the terminal hinge axis of the temporomandibular joints toward Frankfurt horizontal. The sample consisted of 50 examinees. Terminal hinge axis was located, using Lauritzen's technique, on the left side of face for each examinee. Arbitrary point, as proposed by Sumiya Hobo, was measured and point Orbital was defined by palpation. On designated points steel pellets 0.25 mm in diameter were stocked. Lathero--latheral cephalogram was obtained for each examinee. Cephalograms were traced down on a transparent foil and points Orbital, THA--terminal hinge axis, Hobo and Porion--as the uppermost point of the metal ear rod of the cephalostat, were designated. Connecting points Orbital and Porion, Frankfurt horizontal was defined, and shortest distance toward points THA and Hobo, as well as between them were measured. Lines parallel and perpendicular to Frankfurt horizontal were drawn through point THA. In a co-ordinate system defined in such a way, upper left quadrant was first, upper right second, lower right third, and lower left was fourth. Observation was made in which quadrant Hobo point was located. Measured values were statistically evaluated. Results revealed that Hobo point is located in first quadrant in 5 cases, in second in 7, third quadrant in 18, and in fourth in 20 cases. That means that Hobo point is located lower to the THA point in majority of our population. Points THA and Hobo were not identical in any case. Mean values of variables showed that investigated points were inferior to the FH. Measures of variability revealed great variability of both points toward FH, as well as for their mutual distance. It could be pointed out that THA point should be defined kinematically during prosthodontic procedures, and that orientation in articulator's space should not be according to the FH.     

Outward migration of Gnathostoma spinigerum in interferon alpha treated hepatitis C patient

After the first dose injection of pegylated interferon alpha-2b (Peg-IFN alpha-2b) to a HCV infected Thai woman, she developed cyclic painful swelling nodules on right upper quadrant of abdomen and right anterior lower chest wall. The nodules subsided spontaneously within 1-2 days but were recurrent after every Peg-IFN alpha-2b injection. She also experienced acute urticaria. After nine months of therapy, an immature male of G. spinigerum migrated out from the skin nodule shortly after a Peg-IFN alpha-2b injection as scheduled. The worm showed a head-bulb bearing 8 transverse rows of spines which indicated immature stage. It had well defined four pairs of caudal papillae on posterior body part which were used to identify male gender. Painful migratory swelling and urticaria disappeared after the parasite was removed. She was continually treated and had sustained both virological and biochemical responses to HCV treatment. This case demonstrates that the outward migration of G. spinigerum may be stimulated by the injection of Peg-IFN alpha-2b.     

A case of breast sparganosis

A 29-year-old Korean woman visited the Department of Surgery in MizMedi Hospital with a palpable itching mass on the right breast that had existed for the past 7 months. She had no history to eat either frogs or snakes, but had the history of drinking impure water. Sonography revealed a serpiginous hypoechoic tubular structure associated with partial fat necrosis in breast parenchymal layer and subcutaneous fat layer. It also revealed oval cystic lesions. At operation, an ivory white opaque ribbon-like worm that measured 16.5 cm in length and 0.5 cm in width was extracted. Anti-sparganum specific serum IgG level in the patient's serum (absorbance = 0.71), measured by ELISA, was found to be significantly higher than those of normal controls (cut off point = 0.21). Sonography and ELISA appear to be helpful to diagnose sparganosis. Breast sparganosis is rarely found throughout the world.     

Aluminium in human breast tissue

Aluminium is omnipresent in everyday life and increased exposure is resulting in a burgeoning body burden of this non-essential metal. Personal care products are potential contributors to the body burden of aluminium and recent evidence has linked breast cancer with aluminium-based antiperspirants. We have used graphite furnace atomic absorption spectrometry (GFAAS) to measure the aluminium content in breast biopsies obtained following mastectomies. The aluminium content of breast tissue and breast tissue fat were in the range 4-437 nmol/g dry wt. and 3-192 nmol/g oil, respectively. The aluminium content of breast tissue in the outer regions (axilla and lateral) was significantly higher (P=0.033) than the inner regions (middle and medial) of the breast. Whether differences in the regional distribution of aluminium in the breast are related to the known higher incidence of tumours in the outer upper quadrant of the breast remains to be ascertained.