The clinical significance of breast MRI in the management of ductal carcinoma in situ diagnosed on needle biopsy.

OBJECTIVE: To identify the factors associated with invasive disease in ductal carcinoma in situ diagnosed on needle biopsy by analyzing breast magnetic resonance imaging findings with the histopathological factors of biopsy specimens. METHODS: This was an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study. Seventy-five ductal carcinoma in situ patients diagnosed by needle biopsy who underwent preoperative magnetic resonance imaging were retrospectively reviewed. The magnetic resonance imaging and histopathological variables were assessed between pure ductal carcinoma in situ and invasive breast cancer diagnosed on surgical specimens. Multivariable analyses were performed to determine the independent factors for invasion using a logistic-regression model. RESULTS: The median age of patients was 55 (34-76) years. On dynamic magnetic resonance imaging, 60 cases out of 75 (80%) were classified as non-mass-like enhancement type and 15/75 (20%) were Mass type. In non-mass-like enhancement, 11/60 (18%) were ultimately diagnosed as invasive breast cancer. Lesion size (P = 0.027), signal intensity ratios (calculated as the signal intensity of detected lesions divided by the signal intensity of surrounding normal breast tissue; P = 0.032) on magnetic resonance imaging and the number of biopsy-cores containing cancer nests (P = 0.012) were each independently associated with invasion. Furthermore, each signal intensity ratio of invasive and non-invasive components of invasive breast cancer represented a value significantly higher than that of 49 pure ductal carcinoma in situ classified as non-mass-like enhancement (P = 0.001 and P = 0.034, respectively). Conversely, there were no significant magnetic resonance imaging findings to distinguish seven invasive breast cancer from among Mass type. CONCLUSIONS: Needle-biopsy-proven ductal carcinoma in situ cases with non-mass-like enhancement type might be sufficiently managed using breast magnetic resonance imaging features such as enhanced lesion size and signal intensity, incorporating the number of cancer-cores at needle biopsy specimen in the clinical setting.

Reversible methotrexate-associated lymphoproliferative disorder resembling advanced gastric cancer in a patient with rheumatoid arthritis.

A 73-year-old woman with rheumatoid arthritis had been treated with weekly low-dose methotrexate (MTX) for 5 years. She suffered from epigastric discomfort. Endoscopic examination revealed a tumor resembling advanced gastric cancer. Biopsy specimens showed atypical lymphoid cell infiltration. Immunohistological studies showed that these cells were positive for CD30 and CD79a, but not for CD15 or CD20. In situ hybridization identified Epstein-Barr virus latency-associated RNA expression in these cells. Clonally rearranged immunoglobulin heavy chain JH gene was not detected by Southern blot analysis. She was diagnosed with Epstein-Barr virus-associated polymorphic lymphoproliferative disorder (LPD) due to immunodeficiency caused by MTX administration. Cessation of MTX therapy led to complete regression of the tumor. To our knowledge, this is the first case of spontaneous remission of MTX-associated gastric LPD after discontinuation of MTX therapy. Increased awareness is needed on the possible occurrence of LPD resembling gastric cancer in rheumatoid arthritis patients treated with MTX.

MRI accurately depicts underlying DCIS in a patient with Paget's disease of the breast without palpable mass and mammography findings.

Breast-conserving therapy must be carefully indicated among patients with Paget's disease of the breast, because the disease is often associated with an underlying in situ or invasive carcinoma, even when there are no palpable mass or mammography findings. We report a 52-year-old woman who complained of skin color change of her right nipple for 11 months. No mass was palpable in her breasts, and mammography did not show any density or calcification. Nipple biopsy revealed Paget's disease of the breast with ductal carcinoma in situ (DCIS) in the breast epithelium just beneath the nipple. Magnetic resonance imaging (MRI) of the breast demonstrated diffuse segmental enhancement in two different quadrants. According to the pattern of enhancement, the lesions depicted by MRI were diagnosed as an extensively spreading type of DCIS. Based on informed consent, the patient received a total mastectomy. The histopathological examination demonstrated non-invasive ductal carcinoma with comedo-necrosis. The histological mapping with subserial sectioning demonstrated an extent of the lesions that corresponded accurately to the lesions defined by MRI. We conclude that MRI may play an important role in selecting candidates for breast-conserving therapy out of those patients with mammary Paget's disease with no clinical evidence of an underlying breast carcinoma.

Apoptosis regulation differs between ulcerative colitis-associated and sporadic colonic tumors. Association with survivin and bcl-2.

To clarify kinetics in ulcerative colitis (UC)-associated lesions, cell proliferation, apoptosis, and expression of apoptosis-inhibitory proteins were studied. Ki-67 labeling and survivin and bcl-2 expression were examined immunohistochemically in 22 low-grade dysplasias (LGDs), 25 high-grade dysplasias (HGDs), and 13 adenocarcinomas associated with UC, and for comparison in 21 sporadic adenomas with LGD, 22 sporadic adenomas with HGD, and 21 invasive adenocarcinomas. Apoptosis was studied with nick-end labeling and immunohistochemical analysis of single-stranded DNA. In UC-associated LGDs, Ki-67--positive cells were more frequent in the lower than the upper half of the crypt, related to bcl-2 expression, while in sporadic adenomas such cells were more common in the upper half. No difference in apoptosis was found between UC-associated LGDs and sporadic adenomas with LGD or between UC-associated HGDs and sporadic adenomas with HGD. However, UC-associated carcinomas exhibited a lower apoptotic count than their sporadic invasive counterparts. This seemed related to higher survivin expression without a significant difference between the 2 types of invasive lesions regarding bcl-2 levels. Apoptosis is less frequent in UC-associated than in sporadic invasive colon carcinomas, this being linked to elevated survivin expression. The control of apoptosis may be different in the 2 types of tumorigenesis.