Differences in tolerogenic status of NK cells between luminal A type, luminal B type, and triple-negative breast cancer.

Globally, breast cancer is the main cause of death among female cancer patients. The tumor-infiltrating lymphocytes (TILs) in breast cancer are associated with a more favorable outcome of a disease. Natural killer (NK) cells are important cytotoxic cells involved in tumor immunosurveillance, causing the direct killing of tumor cells. In solid tumors, peripheral NK cells and tumor-infiltrating NK cells display an altered phenotype characterized by reduced cytotoxicity or anergy. The goal of this study was to investigate the NK cells' phenotype and activation status in order to get into the pathological process of breast cancer subtypes. In our study, the normal tissues and tumoral breast tissue were fixed in formalin, embedded in paraffin, and the phenotypic marker CD56 and proinflammatory cytokine IL-15 were identified by immunohistology. The distribution and expression of receptors repertoire (NKG2A, NKG2C, NKp46, CD94, CD69, and CD107a) were investigated in peripheral NK cells of mononuclear cells by flow cytometry. mRNA of cytolytic mediators was determined by real-time PCR. The frequency of CD56+ and IL-15+ cells were significantly higher in triple-negative breast cancer tissue. The frequency of NK cell activating receptors was decreased in investigated breast cancer subtypes while the inhibitory NKG2A receptor was increased. Decreased percentage of CD69+/CD107a+ in NK cells could indicate lower cellular activation and cytotoxicity. In luminal B breast cancer, the mRNA of cytolytic mediators was upregulated. In conclusion, modulation of activation status in tumor-infiltration NK cells could be involved in the pathogenesis of molecular breast cancer subtypes. This highlights the importance of NK cells as an appropriate target for potent anti-tumor response in the immunosuppressive tumor microenvironment of breast cancer.

The Role of Innate Immunity in the Pathogenesis of Breast Cancer.

BACKGROUND: Breast carcinoma is the most common malignant disease in the female population and one of the leading causes of death among women worldwide. One crucial hallmark of cancer is chronic inflammation where the immunosuppressive environment is dominant. The immunosuppressive environment is largely achieved by the interaction of tumor cells and infiltrating leukocytes. SUMMARY: Usually, human macrophages and natural killer cells are involved in antitumor immunity. The therapeutic potential of this population against cancers has stimulated their study and led to the discovery of several different tumor-associated macrophages and natural killer cell subsets, each of which is endowed with different immunoregulatory functions. Both heterogeneity and plasticity of the tumor-associated macrophages and natural killer cell compartment, which are both tightly linked to the tumor microenvironment of different breast cancer types. KEY MESSAGES: The identification of specific tumor-associated macrophages and natural killer cell subsets endowed with particular functional capabilities might help monitor tumor-mediated responses in breast cancer patients. Currently, one of the most used strategies for breast cancer of newly diagnosed patients is neoadjuvant chemotherapy.

SURGICAL TREATMENT FOR BREAST CANCER AND AXILLARY METASTASES: HISTORICAL PERSPECTIVE

Breast cancer (BC) is the most common malignancy to affect females. The first suggestions of BC and its treatment date back to Ancient Egypt, 1500-1600 B.C. Throughout history, the management of BC has evolved from extensive radical mastectomy towards less invasive treatments. Radical mastectomy was introduced by W.S. Halsted in 1894, involving the resection of the breast, regional lymph nodes, pectoralis major and minor. Despite its mutilating effect, it had been the main surgical approach to BC patients until 1948, when Patey and Dyson proposed its modified form that conserved pectoralis major and minor and the level III of axillary lymph nodes. The latter was associated with less postoperative morbidity and improved quality of life. The idea of limited breast tissue resection was introduced in the 1970s by Umberto Veronesi and led to further minimizations of surgery in BC patients until breast conservation became the standard of care for early-stage disease. In the 1990s, intraoperative lymphatic mapping and the concept of sentinel lymph node (SLN) biopsy (SLNB) have been developed. SLNB has replaced axillary lymph node dissection (ALND) to be the standard procedure for axillary staging in patients with clinically node-negative BC. Many women have since been spared ALND, including those with negative SLNB or with SLNs involved with micrometastases (0.2-2 mm in size). In the last decade, evidence gathered from new clinical trials suggests that ALND may be safely omitted even in BC patients with 1 or 2 positive SLNs if adjuvant radiotherapy is delivered.

Silicone Gel Breast Implants: Past, Present, and Future.

The authors have provided an in-depth review of the history of saline and silicone gel-filled breast implants. In the history of medicine, no devices have been more scrutinized and thoroughly studied than breast implants. Although we as plastic surgeons recognize and appreciate the benefits that our patients derive from these devices, society as a whole continues to remain skeptical. The reasons for this are complex and multifactorial but appear to be fueled by the media, oppositional organizations, and several trial lawyers. Prior to 1990, when the silicone gel implant controversy began, there were only eight indexed publications that dealt with the issue of silicone gel breast implants. Since 1990, there have been more than 500 indexed publications dealing with silicone gel implants. At the time of the moratorium in 1992, we as plastic surgeons did not have a leg to stand on because there was a paucity of scientific evidence to support our observations that silicone breast implants were safe and effective devices.

The role of different lymph node staging systems in predicting prognosis and determining indications for postmastectomy radiotherapy in patients with T1-T2pN1 breast carcinoma.

PURPOSE: Based on the risk of locoregional recurrence (LRR), postmastectomy radiotherapy (PMRT) is recommended in T1-T2pN1 breast carcinoma (BC). We aimed to elucidate our institutional strategies underlying selection of these patients for PMRT. In the no-PMRT subset, we compared various lymph node (LN) staging systems' abilities to predict 5­year overall and locoregional-free survival (OS/LRFS). METHODS: We retrospectively enrolled 548 women with T1-T2pN1 BC undergoing mastectomy and axillary LN dissection. Depending on PMRT delivery, the participants were divided into the PMRT and no-PMRT groups. Predictors of OS/LRFS were calculated for the no-PMRT group only. Based on Cox regression modelling, the number of positive LNs (PLN), negative LNs (NLN), LN ratio (LNR), log odds of PLN (LODDS), and modified LNR (mLNR) were modelled, each respectively, with OS model covariates (age, grade III, lymphovascular invasion [LVI], tumor size, hormone receptor [HR] status) and LRFS model covariates (age, grade III, LVI). The C­statistic, Akaike information criterion, and likelihood ratio χ2 of the models were compared. RESULTS: Median follow-up was 60.5 (18-82), 61 (28-82), and 60 (18-80) months for the entire cohort, PMRT, and no-PMRT group, respectively. The PMRT and no-PMRT groups had comparable OS (p = 0.235). LRFS was better (p = 0.030) in the PMRT group comprising 105 subjects (19.16%) who were younger, more likely to have a higher-grade, HR-, HER2+ tumors, more PLNs, fewer NLNs, Ki-67 ≥ 20%, LVI, and extranodal extension (p ≤ 0.001). In the no-PMRT group, LNR-based OS/LRFS models exhibited superior prognostic performance. CONCLUSION: In early-stage BC patients undergoing mastectomies, LN dissections and no PMRT, we propose LNR-based multivariable models to predict OS/LRFS with superior accuracy.

Sporadic Case of Breast Angiosarcoma as a Complication of Radiotherapy Following Breast-Conserving Surgery for Invasive Ductal Breast Cancer.

BACKGROUND: Angiosarcomas are highly aggressive and malignant blood vessel tumors. Rarely, angiosarcomas develop in the breast following conservative therapy, namely radiotherapy. CASE REPORT: A 70-year-old female patient presented with dark purple discoloration of the skin of the right breast. 6 years earlier, the patient had undergone conservative surgery for invasive ductal carcinoma of the right breast. According to the breast-conserving surgery protocol, the patient had been treated with radiotherapy to the residual breast tissue. The patient's annual mammograms and ultrasound findings were normal. The skin lesion was superficially localized mostly at the border between the upper and lower medial quadrants of the breast (between 2 and 4 o'clock) and above the areola. The borders were uneven; the dimensions were 7 cm × 4 cm. The mammogram was classified as Breast Imaging Report and Data System (BI-RADS) 2. Ultrasound examination showed a well-vascularized structure, although the etiology was unclear. A tissue biopsy revealed angiosarcoma. The patient underwent radical simplex mastectomy. Following surgery, the patient underwent chemotherapy. Tests excluded metastases for a follow-up period of 5 years. CONCLUSION: Angiosarcomas that develop after radiotherapy following breast-conserving surgery are sporadic, but it is important to take this possible incident into consideration during treatment.

Secondary torsion of vermiform appendix with mesoappendiceal lipoma.

A torsion of the vermiform appendix with a mesoappendiceal lipoma is a rare condition. It is also a rare cause of acute abdomen, as such, the condition is diagnosed during surgery. This case report presents a 70-year-old male patient with lower right abdominal pain and signs of acute abdomen with an increased peripheral blood leukocyte count. An ultrasound examination revealed a mass of 9.6 cm2, which was suggested to be a perityphlitic abscess. An emergency operation was indicated, as the patient had clinical signs of acute abdomen. Laparotomy via a pararectal incision revealed the cause of the pain to be a torsion of the vermiform appendix caused by a mesoappendiceal lipoma. The apex of the appendix was perforated, which caused circumscript peritonitis. Both an appendectomy and an extirpation of the tumor were performed, and a surgical drain was placed in the wound, yielding an excellent postoperative clinical outcome.

Chronic granulomatous inflammation of the breast as a first clinical manifestation of primary sarcoidosis.

BACKGROUND: Sarcoidosis is an idiopathic multisystemic disease that affects young to middle aged adults, with higher incidence in women. Although it may involve the breast parenchyma, primary sarcoidosis of the breast is very rare. It occurs in less than 1% of cases. In a differential diagnosis it may potentially be considered a malignancy. CASE REPORT: We report a case in which breast sarcoidosis was the first clinical manifestation of systemic disease in a 54-year-old woman who presented with wide erythematous skin changes associated with palpable induration. Considering the fact that physical examination and the results of mammography, ultrasound and magnetic resonance imaging were inconclusive and unable to rule out malignancy, biopsy was performed. Pathohistological diagnosis showed a non-necrotizing granulomatous inflammation without elements of breast cancer. Sarcoidosis was confirmed with elevated level of angiotensin-converting enzyme in the sera and characteristic chest multislice computed tomography findings. The bronchoalveolar lavage was infiltrated with lymphocytes. CONCLUSION: Breast sarcoidosis has diverse and nonspecific imaging characteristics. Carcinoma must always be excluded by core needle biopsy. Achieving correct diagnosis is mandatory so that adequate corticosteroid therapy can be applied as early as possible. A multidisciplinary approach is of utmost importance in the diagnostic workup.

Metallothioneins and trace elements dyshomeostasis induced by exposure to gasoline vapor in mice.

To investigate the effects of air pollution related with the gasoline/petrochemical industry the expression of metallothionein I (MT-I) mRNA and tissue metals were analyzed in organs of mice, exposed to gasoline (G) vapor in laboratory conditions. Control groups consisted of intact mice and of those exposed in the metabolic chamber to fresh air. The data obtained by RT-PCR and inductively coupled plasma spectrometry have shown that exposure to G vapor leads to upregulation of MT-I mRNA in organs that receive a strong respiratory and olfactory input or participate in gasoline degradation and elimination (lungs, brain, kidney and liver). Besides, in the brain and in the lungs, kidney and liver a decreased tissue content of Zn²âº or Cu²âº and Mg²âº was found (p<0.001). Some of these changes were obtained also in mice closed in the metabolic chamber, pointing to the involvement of stress-induced mechanisms in the transcriptional regulation of MTs.

Metallothionein I+II expression as an early sign of chronic relapsing experimental autoimmune encephalomyelitis in rats.

Metallothioneins (MTs) are small, cysteine-rich proteins which have been implicated in various forms of stress providing cytoprotective action against oxidative injury, DNA damage and apoptosis. Owing to their high affinity for physiological metals, such as zinc and copper MTs are also critical components of regulatory proteins involved in cell growth and multiplication, as well as in the maintenance of immune homeostasis. To elucidate the role of MTs in the pathomechanisms of autoimmune CNS disorders we estimated the expression of MT I+II proteins and the content of free Zn ions in the brain, spinal cord and in the liver early in the course of chronic relapsing experimental autoimmune encephalomyelitis (CR-EAE) pathogenesis, i.e. before the onset of any clinical symptoms. Disease was induced in the genetically susceptible Dark Agouti (DA) rats by subcutaneous injection of bovine brain homogenate in CFA. Control animals were treated with CFA alone. The data, obtained by immuno-histochemistry and in situ fluorescent labeling of free zinc ions, have shown that in the presymptomatic phase of CR-EAE (on the seventh postimmunization day) MTs I+II were markedly upregulated in the cells that form blood-brain and blood-cerebrospinal fluid barriers, as well as in the cerebellar parenchyma and hippocampal dentate gyri. Furthermore, we found that the liver also becomes a site of extensive MTs I+II synthesis shortly after immunization. Simultaneously, tissue content of free zinc ions increased at the sites of MTs induction, reflecting their antioxidative activity. The data, described in this paper point to regulatory and neuroprotective role of MTs in the pathogenesis of CR-EAE.

Endoplasmic reticulum resident heat shock protein-gp96 as morphogenetic and immunoregulatory factor in syngeneic pregnancy.

The severe remodeling of endometrial stroma during blastocyst adhesion and trophoblast invasion initiates at maternal-fetal interface the reaction of evolutionary old heat shock response, in which heat shock proteins, as molecular chaperons, monitor the configurations of newly synthesized proteins and prevent the formation of functionless aggregates of misfolded proteins, targeting them to degradation by a the ubiquitin-proteasome system. In addition, the endoplasmic reticulum (ER)-resident HSPs, such as gp96/GRP94 may, after binding to CD91 and TLRs, elicit antigen-specific and antigen-unspecific immune responses, owing to its peptide-chaperoning capacity and ability to activate APCs. Considering these properties, we examined tissue expression of gp96 at the maternal-fetal interface and in the maternal liver and spleen on the 16th day of undisturbed syngeneic pregnancy and after the treatment with peptidoglycan monomer linked with zinc (PGM-Zn). The data showed that in undisturbed pregnancy the gp96, CD91 and TLR2 were markedly expressed on extravillous and villous trophoblast. PGM-Zn enhanced these findings, as well as the number of uterine natural killer cells and local NFκB immunoreactivity. Gp96 expression arose also in the maternal spleen and liver, where an accumulation of NKT cells or γδT lymphocytes was seen. The data point to roles of gp96 in maintenance of proteostasis and local and systemic immune balance in pregnancy complicated by infection.

Heat shock protein Gp96 as potential regulator of morphostasis after partial hepatectomy in mice.

Gp96 (also known as glucose-regulated protein 94, endoplasmin) is the endoplasmic reticulum (ER)-resident protein, which belongs to the heat shock protein HSP90 family. It is upregulated in response to glucose starvation and other stressful stimuli that disrupt protein synthesis in the ER. There, it is acting as a molecular chaperon involved in the correction of unfolded proteins, in the activation of proteasome-dependent ER-associated degradation of the misfolded proteins, and in activation of protein translations that modulate the polypeptide traffic into the ER. In addition, it has been implicated in antigen presentation and MHC class I and II upregulation, in the activation and maturation of dendritic cells and proinflammatory cytokine secretion, as well as in chaperoning of integrins and Toll-like receptors, acting as a "danger signal" to the innate and adaptive immunity. Moreover, owing to its specific function in Ca2+ homeostasis and in the insulin- IGF/signaling pathways, it has been proposed that gp96 might participate in mechanisms that are critical for cell growth, differentiation, and responses to ER stress. Emphasizing that gp96, as a natural adjuvant for chaperoning antigenic self peptides into the immune surveillance pathways, may also be involved in the maintenance of morphostasis and self tolerance, in this survey we show that high levels of upregulation of gp96 in regenerating liver and thymus are followed by signs of transient autoimmunity, augmented apoptosis in thymus, and the presence of autoreactive NKT and regulatory T cells that might be involved in the control of rapid liver growth induced by partial hepatectomy.

The advantages of humeral anteromedial plate osteosynthesis in the middle third shaft fractures.

BACKGROUND: Humeral shaft fractures account for 1.2% of all fractures and occur in a slightly younger population. Their causes include a fall from standing or from height, motor vehicle accident, but can be also pathological. In order to clarify which of both surgeries we performed in our Department for treating humeral shaft fractures had more advantages (anterolateral or anteromedial plating through anterolateral approach) we analyzed incidence of postoperative iatrogenic radial palsies and mean operation time required to complete each surgery. METHODS: During January 1992 to December 2009 on Department of Surgery, Division for Traumatology of Clinical Hospital Center Rijeka, 420 patients (340 males and 80 females with mean age of 38.11 ± 9.29 years) were treated for middle third humeral shaft fracture by anterolateral approach and internal fixation using AO/DCP or LCP plates that was positioned on anteromedial humeral surface in 141 patients (33.57%) and on anterolateral humeral surface in 279 patients (66.43%). RESULTS: None of the patients who had osteosynthesis by using plate on anteromedial humeral sufrace had lesions of the radial nerve. Therefore, χ(2) test revealed significantly higher frequency of postsurgical radial nerve injuries in patients who were treated by anterolateral plating than in patients where anteromedial plating was performed (χ(2) = 17.51; p< 0.05). Anterolateral plating required longer mean operation time than anteromedial plating and the difference in its duration determined by t-test for independent samples showed statistically significant difference (t= 14.57; p< 0.05). CONCLUSION: An anteromedial plating of humeral shaft fractures through anterolateral approach was determinated to be a simple, safe, effective and also fast surgical treatment and we highly recommend it as operative technique for treating humeral shaft fractures.

Kinetics of tissue iron in experimental autoimmune encephalomyelitis in rats.

To elucidate the role of iron in the pathomechanisms of autoimmune CNS disorders, we estimated the tissue concentrations of Fe(2+) in the brain, spinal cord, and liver in the chronic relapsing form of experimental autoimmune encephalomyelitis (EAE). The disease was induced in Dark Agouti (DA) strain of rats, by subcutaneous injection of bovine brain homogenate in complete Freund's adjuvant (CFA). Control rats consisted of unsensitized rats and of rats treated with CFA or saline. The data obtained by clinical assessment and by inductively coupled plasma spectrometry have shown that the attacks of disease (on the 12th and 22nd post-immunization day) were followed by high accumulation of iron in the liver. Additionally, during the second attack of disease, the decreased concentration of Fe(2+) was found in cervical spinal cord. The data point to regulatory effects of iron and hepatic trace elements regulating mechanisms in the pathogenesis of EAE.

Time-course expression of metallothioneins and tissue metals in chronic relapsing form of experimental autoimmune encephalomyelitis.

To elucidate the role of metallothioneins (MTs) in the pathomechanisms of autoimmune CNS disorders we estimated the expression of MTs I+II and the tissue concentrations of Zn²+ and Cu²+ in the brain, spinal cord (SC) and in the liver during the periods of attacks and remissions in chronic relapsing experimental autoimmune encephalomyelitis (CR-EAE). Disease was induced in the genetically susceptible Dark Agouti (DA) rats by subcutaneous injection of bovine brain homogenate in CFA. Control rats were treated with CFA. The data, obtained by clinical assessment, immunohistochemistry and inductivity coupled plasma spectrometry, have shown that during the first attack (on the 12th day) MTs I+II were markedly upregulated in subarachnoid regions and perivascular space on astrocytes, microglia and on spinal neurons. Simultaneously, the concentrations of zinc in the SC and zinc and copper in the liver have found to be increased. During the second attack (on the 22nd day) a new overexpression of MTs was found in the cerebellum, in sulcus hippocampi, in spinal neurons and particularly in hepatocytes around the central vein. Concomitantly, in the brain and SC the concentration of copper increased. The data point to a neuroprotective role of MTs and to an important regulatory role of essential metals and hepatic MTs in the pathogenesis of CR-EAE.

Dose- and time-dependent effects of luteolin on liver metallothioneins and metals in carbon tetrachloride-induced hepatotoxicity in mice.

The aim of this study was to investigate the protective effect of luteolin on liver Ca, Mg, Zn, Cu, Fe, and Mn content in mice with carbon tetrachloride (CCl4)-induced hepatotoxicity. Additionally, liver metallothionein (MT) expression was studied. Luteolin was administered intraperitoneally (i.p.) as a single 5- or 50-mg/kg dose or once daily for two consecutive days, respectively. Two hours after the last injection, the mice were treated with CCl4 (20 mg/kg, i.p.). CCl4 injection reduced hepatic level of all metals except Ca, with an intense cytoplasmic staining pattern in hepatocytes located in periportal areas, indicating induction of MTs. Pretreatment with 50 mg/kg of luteolin for 2 days remarkably elevated metal content to control values (Mg and Cu) or even above them (Zn and Fe). Luteolin pretreatment increased pericentral MTs immunopositivity and histological architecture improvement in a time- and dose-dependent manner, being the most prominent in mice pretreated with 50 mg/kg for 2 days. The liver in this group showed pronounced MT expression in almost all hepatocytes throughout the liver parenchyma. In conclusion, these results suggest the protective effect of luteolin on CCl4-induced hepatotoxicity and an enhancement of hepatocyte proliferative capabilities.

Heat shock protein-GP96 as an innate sensor of damage and activator of autoreactive NKT and regulatory T cells during liver regeneration.

Tissue disintegration after injury leads, in the endoplasmic reticulum (ER), to activation of adaptive pathways known as the ER stress response. It is directed to the correction of unfolded proteins and to the activation of proteasome-dependent ER-associated degradation of the misfolded proteins, but induces also a rapid activation of natural and adaptive immunity, since a ER resident heat shock protein-gp96 acts not only as a molecular chaperone, but also as a strong adjuvant, able to cross-present the antigenic peptides onto MHC class I or MHC class II pathways. Analyzing its potential role in processes of normal growth, in mice subjected to 1/3 partial hepatectomy (pHx) we determined the tissue expression of gp96 protein and mRNA in regenerating liver, thymus and spleen, determining simultaneously the phenotypic profile and spontaneous cytotoxic activity of intrahepatic and splenic mononuclear lymphatic cells (MNLC) against NKT- and NK-cells sensitive targets (syngeneic thymocytes and YAC-1) in wild, perforin and FasL deficient mice. The data have shown that pHx induces fast overexpression of gp96 protein and mRNA in hepatocytes, spleen and thymus, with accumulation of CD3intermediate/NK1.1+/CD69+ cells (liver) and Foxp3+CD4+CD25+ cells (liver and thymus). Simultaneously, intrahepatic MNLC acquired the FasL-dependent cytotoxic potential against NKT-sensitive targets and both, intrahepatic and splenic MNLC, acquired the perforin-dependent cytotoxic potential against NK-sensitive targets, implying that during the disturbance of morphostasis gp96 serves as a natural adjuvant for chaperoning antigenic self peptides into the immune surveillance pathways, resulting in activation of autoreactive NKT and regulatory cells, as well as NK cells. Moreover, cell cycle analysis revealed that G2+M phase of regenerating hepatocytes in PKO mice was translocated from the 1st to the 7th p. o. day, as well as that hepatocytes from FasL deficient mice were arrested in G0/G1 phase.

Metallothionein expression and tissue metal kinetics after partial hepatectomy in mice.

To better elucidate previous results showing that partial hepatectomy noticeably changes the tissue content of zinc, calcium, magnesium, and iron(II) ions in regenerating the liver, thymus, and spleen, we report on the correlation of these metal tissue kinetics in these organs with the expression of metallothionein-I+II (MT-I+II) proteins and MT-I mRNA in early postoperative period (1, 2, 6, 12, and 24 h) after one-third hepatectomy (pHx). The results showed that 2 h after pHx the regenerating liver accumulated Zn2+, Ca2+, Mg2+, and Fe2+ ions while decreasing the concentration of all these metals in the spleen and of Zn2+ in the thymus. On the 24th h, a new high accumulation of Zn2+ and Ca2+ was seen in the regenerating liver and of Zn2+, Ca2+, and Fe2+ in the spleen. Simultaneously, MT-I mRNA increased in the liver and spleen. In hepatocytes and on several spleen and thymus mononuclear lymphatic cells, the increased expression of MT proteins was found mainly in the cytoplasm and nuclei. The areas expressing MTs in regenerating liver inversely correlated with those containing apoptotic cells, suggesting that these proteins participate in tissue restoration through reduction or increase of metal ions after injury to the liver.