ONCOLOGY LETTERS 14: , China Medical University, Shenyang, Liaoning , P.R. China

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1 4890 Expression of vsculr endothelil growth fctor nd cspse 3 in mucinous brest crcinom nd infiltrting ductl crcinom not otherwise specified, nd the correltion with disese free survivl QIULI WANG 1, LISHA SUN 1, JICI YAN 1, SHUO WANG 1, JUNCHENG ZHANG 1 nd XINYU ZHENG 1,2 1 Deprtment of Brest Surgery, First Affilited Hospitl; 2 Lbortory 1, Cncer Institute, First Affilited Hospitl, Chin Medicl University, Shenyng, Lioning , P.R. Chin Received Jnury 22, 2016; Accepted June 2, 2017 DOI: /ol Abstrct. Mucinous brest crcinom (MBC) is rre type of brest cncer, but it hs been infrequently studied due to its ssocited good prognosis. Vsculr endothelil growth fctor (VEGF) nd cspse 3 hve been identified to be prognostic fctors of infiltrting ductl crcinom not otherwise specified (IDC NOS), but their expression in MBC hs not been reported. In the present study, the expression of cspse 3 nd VEGF in MBC nd IDC NOS were ssessed by immunohistochemistry. Scoring ws conducted bsed on stining intensity nd percentge of positive cells. Bsed on the scores of cspse 3 nd VEGF expression, ll ptient smples were divided into two groups: Low expression (score of 0 5) or high expression (score of 6 12). In totl, 42.59% of MBC ptients exhibited high VEGF score compred with 61.67% of the IDC NOS group (P<0.05). Furthermore, 57.41% of MBC ptients exhibited high cspse 3 expression compred with only 33.33% of IDC NOS ptients (P<0.05). VEGF expression in MBC ws ssocited with ge, nodl sttus nd tumor node metstsis (TNM) stge. Cox univrite nlysis showed tht higher VEGF expression, positive nodl sttus nd higher TNM stge were ssocited with shorter disese free survivl (DFS). The Kpln Meier method showed tht higher VEGF expression in MBC ws ssocited with worse DFS times, while Cox multivrite nlysis showed tht only TNM stge ws significntly ssocited with DFS. VEGF nd cspse 3 expression vried in the MBC nd IDC NOS smples, but neither ws directly correlted with DFS in the MBC ptients. Correspondence to: Dr Xinyu Zheng, Deprtment of Brest Surgery, First Affilited Hospitl, Chin Medicl University, 155 North Nnjing Street, Shenyng, Lioning , P.R. Chin E mil: xyzheng@cmu.edu.cn Key words: mucinous brest crcinom, infiltrting ductl crcinom not otherwise specified, vsculr endothelil growth fctor, cspse 3, disese free survivl Introduction Mucinous brest crcinom (MBC), lso known s colloid crcinom, is rre subtype of brest tumors tht ccounts for 1 7% of ll brest cncer cses. MBC is chrcterized by the presence of extrcellulr mucin (MUC) (1). MBC includes mixed MBC, consisting of other cncer types such s invsive ductl crcinom, nd pure MBC (PMBC), in which the entire mss is lmost occupied by mucinous cncer cells nd is without conventionl invsive ductl crcinom cells (2). PMBC is represented by mss with >90% mucinous component (3). MBC is linked with more fvorble prognosis, longer disese free intervl nd lower incidence of xillry node metstsis compred with infiltrting ductl crcinom not otherwise specified (IDC NOS) (1,2,4). However, recurrence nd metstsis of MBC re frequently present in clinicl prctice. Angiogenesis is prerequisite for tumor development; there is close ssocition between the formtion of blood vessels in the vicinity of tumor cells nd the potentil for tumor formtion, invsion nd metstsis. Angiogenesis is induced nd developed in response to two sets of extrcellulr signls: soluble ngiogenic fctors nd the extrcellulr mtrix (5). Brest crcinom hs been shown to be n ngiogenesisdependent tumor through experimentl nd clinicl dt. Vsculr endothelil growth fctor (VEGF) is the most potent endothelil cell mitogen (6) nd regultor of vsculr permebility, therefore, VEGF hs been considered s powerful novel prognostic tool (7). However, the ssocitions between VEGF expression in MBC nd IDC NOS nd the morphology, behvior nd prognosis of tumors, nd the differences between MBC nd IDC NOS, re uncler. The good prognosis of MBC is closely ssocited with the formtion of MUC round the cells (8). Previous studies hve reveled the expression of the MUC1, MUC2, MUC3, MUC4, MUC5A nd MUC6 proteins in PMBC, nd this expression hs been suggested to be prognostic fctor (9). Gel forming secretory MUCs, including MUC2 nd MUC6, exhibit high expression rte in mucinous crcinom, indicting tht high production of these types of MUCs my ct s brrier to the extension of cncer, resulting in less ggressive biologicl behvior. However, the expression of

2 WANG et l: VEGF AND CASPASE 3 IN MUCINOUS BREAST CARCINOMA 4891 MUC1, which is ssocited with poor prognosis in gstric nd colorectl cncer types, is low in MBC (9). A study by Ahmed (10) highlighted tht the MUC of MBC is derived from cell brekdown. We hypothesize tht significnt cell poptosis my exist in the MBC tissues nd produce lrge mount of mucus. The most well known biochemicl hllmrk of erly nd lte stge poptosis is cysteine protese ctivtion. Arginine glycine sprtte synthetic peptides induce poptosis by direct cspse 3 ctivtion (11). Cspse 3 is lso required for the DNA frgmenttion nd morphologicl chnges ssocited with poptosis (12). A high level of ctive cspse 3 in cells nd tissues is n importnt biomrker for poptosis induced by wide vriety of poptotic signls (13). Thus, detection of cspse 3 expression cn reflect the poptotic sttus of tumor cells, which my id in explining the differences in prognosis nd survivl between MBC nd IDC NOS. In the present study, the expression of VEGF nd cspse 3 in MBC nd IDC NOS ws investigted using immunohistochemicl stining, nd the ssocition between the expression levels of VEGF nd cspse 3 nd clinicopthologicl fetures were further investigted. Mterils nd methods Ptients nd tissues. A totl of 54 ptients with MBC nd 60 rndomly selected ptients with IDC NOS who underwent surgery t the First Affilited Hospitl of Chin Medicl University (Shenyng, Lioning, Chin) between My 2009 nd June 2011 were included in the present study. MBC is rre type of brest cncer, so the 54 ptients with MBC included ll the MBC in ccordnce with the set of conditions between My 2009 nd June 2011 who underwent surgery t the First Affilited Hospitl of Chin Medicl University. Cses in which complete clinicopthologicl informtion nd formlin fixed, prffin embedded brest tissues could not be obtined were excluded. All ptients hd not received rdiotherpy or chemotherpy prior to surgery. The dignosis of ll cses ws confirmed ccording to the criteri of the World Helth Orgniztion (14), s ssessed by the Deprtment of Pthology (First Affilited Hospitl). Archivl formlin fixed prffin embedded brest tissues were retrieved. Ptients were followed up for medin period of 47 months (rnge, months) subsequent to the initil cncer surgery. Follow up consisted of regulr clinic visits nd ultrsound of the brest nd xillry node, suprclviculr re nd infrclviculr region, with or without mmmogrphy, lung computed tomogrphy, liver ultrsound, bone emission computed tomogrphy nd blood tests t the discretion of the treting specilist. Relevnt clinicl nd pthologicl informtion re described in Tble I. Immunohistochemicl stining. Immunohistochemicl exmintion ws performed on 4 µm thick, formlin fixed, prffin embedded sections using UltrSensitive SP IHC kit (MXB Co., Ltd., Fuzhou, Chin). Briefly, following deprffiniztion (with xylene) nd rehydrtion (with lcohol), the endogenous peroxidse ctivity ws blocked with 3% H 2 O 2. Antigen retrievl ws performed with high pressure cooker nd norml serum (prt of the UltrSensitive SP IHC kit) ws pplied to the sections t room temperture for 30 min to block non specific ntibody binding. The sections were then incubted overnight t 4 C with the primry ntibodies, including monoclonl mouse nti humn cspse 3 (1:50 dilution; ctlog no. b2171; Abcm, Cmbridge, MA, USA) nd monoclonl mouse nti humn VEGF (1:300 dilution; ctlog no. sc 7269; Snt Cruz Biotechnology, Inc., Dlls, TX, USA). Sections were further incubted with the biotin lbeled IgG secondry ntibody solution from the UltrSensitive SP IHC kit t room temperture for 15 min, followed by streptvidin peroxidse incubtion t room temperture for 15 min. Finlly, sections were stined with 3,3 diminobenzidine, counterstined with hemtoxylin for 5 min nd mounted. Negtive controls were processed with PBS insted of the primry ntibody. Immunohistochemicl scoring. The immunostined sections were ssessed with n opticl microscope t x400 mgnifiction, bsed on mnul counting of positive cells in ech tissue by two observers blinded to clinicl outcomes. Cses of disgreement were reviewed jointly to obtin consensus score. The percentge of positive cells nd stining intensity of VEGF nd cspse 3 were scored. Intensity ws grded s negtive (score 0), wek (score 1), moderte (score 2) or strong (score 3), nd percentge of positive cells ws grded s <5% (score 0), 5 25% (score 1), 26 50% (score 2), 51 75% (score 3) nd >75% (score 4). The finl score of VEGF nd cspse 3 expression ws determined by multiplying the intensity score nd percentge score, with rnge of According to the scoring results, ll ptients were divided to two groups: Low (score of 0 5) nd high (score of 6 12) expression. Sttisticl nlysis. Sttisticl nlysis ws performed using SPSS version 19.0 sttisticl softwre (IBM Corp., Armonk, New York, USA). A χ² test nd Fisher's exct test were used to identify the differences between MBC nd IDC NOS with regrd to clinicopthologicl fetures, nd for the ssocitions between VEGF or cspse 3 nd clinicopthologicl vribles. Disese free survivl (DFS) ws recorded from the dte of surgery to the relpse dte or the lst follow up dte, nd ws estimted using the Kpln Meier nlysis. The sttisticl significnce of differentil survivl ws ssessed using the log rnk test. Cox regression nlysis for DFS ws used. P<0.05 ws used to indicte sttisticlly significnt difference. Vribles with univrite p vlue of <0.1 were included in the multivrite model. Results Chrcteristics of the study popultion. A totl of 54 femle ptients with MBC (medin ge yers; rnge, yers) nd 60 IDC NOS (medin ge yers; rnge, yers) were included. The cohort consisted of 94.5% pthologicl tumor stge 1 2 (pt 1 2 ) ptients, 5.6% pt 3 4 ptients nd 16.8% node positive ptients in the MBC group, nd 98.4% pt 1 2 ptients, 1.7% pt 3 4 ptients nd 45.0% node positive ptients in the IDC NOS group. No metstsis ws observed in either group prior to surgery. In the MBC group, 92.6% of ptients chose to undergo mstectomy nd 7.4% of ptients chose brest conserving

3 4892 Tble I. Clinicl nd pthologicl fetures of the ptients (n=114). MBC IDC Chrcteristics (n=54) (n=60) P vlue Age, yers Men , n (%) 26 (48.15) 35 (58.33) >50, n (%) 28 (51.85) 25 (41.67) T stge, n (%) pt1 23 (42.59) 19 (31.67) pt2 28 (51.85) 40 (66.67) pt3 4 3 (5.56) 1 (1.67) N stge, n (%) N0 45 (83.33) 33 (55.00) N1 5 (9.26) 15 (25.00) N2 3 (5.56) 7 (11.67) N3 1 (1.85) 5 (8.33) TNM stge, n (%) I 23 (42.59) 13 (21.67) II 27 (50.00) 35 (58.33) III 4 (7.41) 12 (20.00) ER sttus, n (%) Negtive 6 (11.11) 23 (38.33) Positive 48 (88.89) 37 (61.67) PR sttus, n (%) Negtive 18 (33.33) 28 (46.67) Positive 36 (66.67) 32 (53.33) Hormone receptor sttus, n (%) Negtive 5 (9.26) 22 (36.67) Positive 49 (90.74) 38 (63.33) HER 2 sttus, n (%) Negtive 1 (1.85) 35 (58.33) Positive 43 (79.63) 10 (16.67) Unknown 10 (18.52) 15 (25.00) Ki 67, n (%) 20% 41 (75.93) 30 (50.00) >20% 13 (24.07) 30 (50.00) p53, n (%) Negtive 19 (35.19) 22 (36.37) Positive 28 (51.85) 32 (53.33) Unknown 7 (12.96) 6 (10.00) Surgery Mstectomy 50 (92.59) 58 (96.67) BCS 4 (7.41) 2 (3.33) Axillry opertion Sentinel lymph 8 (14.81) 2 (3.33) node biopsy Axillry clernce 46 (85.19) 58 (96.67) Chemotherpy No 12 (22.22) 2 (3.33) Yes 42 (77.78) 58 (96.67) <0.001 Tble I. Continued. MBC IDC Chrcteristics (n=54) (n=60) P vlue Anthrcycline 31 (57.41) 13 (21.67) included Txne included 4 (7.41) 3 (5.00) Anthrcycline nd 6 (11.11) 41 (68.33) txne included Other 1 (1.85) 1 (1.67) Rdiotherpy 0.12 No 54 (100.00) 56 (93.33) Yes 0 (0.00) 4 (6.67) Significnt difference between MBC nd IDC NOS (P<0.05). MBC, mucinous brest crcinom; IDC NOS, infiltrting ductl crcinom not otherwise specified; ER, estrogen receptor; PR, progesterone receptor; TNM, tumor node Metstsis; BCS, brest conserving surgery; HER2, humn epiderml growth fctor receptor 2; p53, cellulr tumor ntigen p53. Tble II. VEGF nd cspse 3 expression in MBC nd IDC NOS. MBC, IDC NOS, Expression n (%) n (%) P vlue VEGF high 23 (42.59) 37 (61.67) Cspse 3 high 31 (57.41) 20 (33.33) Significnt difference between MBC nd IDC NOS (P<0.05). MBC, mucinous brest crcinom; IDC NOS, infiltrting ductl crcinom not otherwise specified; VEGF, vsculr endothelil growth fctor. surgery. Furthermore, 14.8% of ptients underwent sentinel lymph node biopsy nd 85.2% of ptients received xillry clernce. In the MBC group, 22.2% of ptients did not ccept djuvnt chemotherpy nd no ptients ccepted djuvnt rdiotherpy following surgery. There were no significnt differences in terms of ge, T stge, brest surgery nd djuvnt rdiotherpy between the two groups. In contrst to IDC NOS, the MBC ptients showed higher rte of positive ER nd hormone receptor, nd lrger popultion of which expression Ki 67 ws 20%. MBC ptients tended to hve significntly less lymph node metstsis nd lower tumor node metstsis (TNM) stge (15) compred with IDC NOS ptients (P=0.010 nd P=0.023, respectively) (Tble I). VEGF nd cspse 3 expression in MBC nd IDC NOS ptients. The positive stining of VEGF nd cspse 3 ws minly observed in the cytoplsm (Fig. 1). The expression of VEGF nd cspse 3 ws significntly different between the MBC nd IDC NOS ptients. In totl, 42.59% of MBC ptients exhibited high VEGF score ( 6), with this

4 WANG et l: VEGF AND CASPASE 3 IN MUCINOUS BREAST CARCINOMA 4893 Figure 1. Expression of VEGF nd cspse 3 in MBC nd IDC NOS. (A) The high expression of VEGF in MBC. (B) High expression of VEGF in IDC NOS. (C) The high expression of cspse 3 in MBC. (D) The low expression of cspse 3 in IDC NOS. Scle br, 50 µm; originl mgnifiction, x400. VEGF, vsculr endothelil growth fctor; MBC, mucinous brest crcinom. Figure 2. Kpln Meier survivl nlysis of DFS in MBC. (A) The high expression of VEGF ws found to be significntly ssocited with poor 5 yer DFS rte in MBC (P<0.05). (B) The expression of cspse 3 exhibited no significnt ssocition with DFS in MBC. DFS, disese free survivl; VEGF, vsculr endothelil growth fctor; MBC, mucinous brest crcinom. percentge being 61.67% in the IDC NOS group (P=0.042). Furthermore, 31 cses (57.4%) of MBC ptients exhibited high cspse 3 expression ( 6), but only 20 cses (33.33%) in the IDC NOS group exhibited high cspse 3 expression (P=0.028) (Tble II). Assocition between VEGF nd cspse 3 expression nd DFS in MBC ptients. Since the expression, function nd mechnism of IDC NOS is lredy cler, the present study shows the ssocitions between them in MBC. Kpln Meier log rnk test showed tht the ptients with high VEGF expression tended to experience shorter DFS times (P=0.006) compred with those with low expression in MBC. However, there ws no ssocition between cspse 3 expression nd DFS time in MBC ptients (Fig. 2). Assocition between VEGF nd cspse 3 expression nd clinicopthologicl vribles in MBC ptients. There ws significnt ssocition between VEGF expression nd ge, nodl sttus nd TNM stge in the MBC ptients, but there ws no significnt ssocition between cspse 3 expression nd ge, tumor stge, nodl sttus, TNM stge, estrogen

5 4894 Tble III. Assocition between VEGF, cspse 3 nd other vribles in MBC. Vribles VEGF ( ) VEGF (+) P vlue Cspse 3 ( ) Cspse 3 (+) P vlue Age, yers > Tumor stge pt pt Nodl sttus Negtive Positive TNM stge I II IIb IIIc ER Negtive Positive PR Low b High c Ki 67, % > Significnt difference between MBC nd IDC NOS (P<0.05); b PR <20%; c PR 20%. MBC, mucinous brest crcinom; VEGF, vsculr endothelil growth fctor; ER, estrogen receptor; PR, progesterone receptor. receptor (ER) sttus, progesterone receptor (PR) sttus or Ki 67 expression (Tble III). Cox nlysis in MBC. Univrite Cox regression nlyses showed higher VEGF score, positive nodl sttus nd higher TNM stge were significnt predictors of worse DFS. Cspse 3 expression hd no significnt predictive vlue in terms of DFS. Moreover, multivrite nlysis nlyzed the correltion between DFS nd VEGF expression, nodl sttus nd TNM stge, nd found tht TNM stge ws significntly ssocited with worse DFS (Tble IV). Ki 67 expression ws lso nlyzed. The rte of Ki 67 ( 20%) expression ws 75.93% in the MBC ptients compred with 50% in the IDC NOS ptients (P<0.05), suggesting tht MBC tumors my hve lower prolifertive bility thn IDC NOS tumors. However, Cox survivl nlysis showed tht Ki 67 expression ws not significntly ssocited with DFS in the MBC ptients. Discussion The mjority of previous MBC clinicl studies found tht MBC showed higher ER nd PR positive rtes, less lymph node metstsis, lower TNM stge nd notbly higher OS nd DFS rtes (16 20). The present study nlyzed the bsic informtion of MBC ptients nd compred it with tht from IDC NOS ptients treted in the sme period. The results were consistent with those of the previous studies, in which the ptients with MBCs hd better prognosis thn those with IDC NOS. Jo et l (21) studied 7 cses of MBC using electron microscopy nd found tht in ddition to the bundnt production of mucosubstnce, MBC lso fetured the bsence of myoepithelil differentition nd bsl lmin deposition, the presence of notbly developed cytoplsmic filmentous systems, reltively scrcity of lysosomes, pprently nd frequently well developed intercellulr junctions nd mrked pucity of stroml vessels. These dt suggest tht the fvorble clinicl prognosis of MBC my be the result of multiple complicted fctors (21). Tumor growth requires constnt vsculr growth nd remodeling so tht solid tumors cn exceed 1 2 mm 3 in size. VEGF nd its receptors re key regultors of ngiogenesis, mening tht they re ttrctive therpeutic trgets (22). Microvessel density nd tumor VEGF expression in heptocellulr crcinom hve previously been ssessed, nd the results indicted tht upregultion of VEGF promoted ngiogenesis, tumor growth nd intrheptic metstsis (23). VEGF C producing cncer cells my induce lymphtic vessel prolifertion nd diltion, resulting in cncer cell invsion into the lymphtic vessels nd lymph node metstsis (24). Cncer tretment using number of VEGF trgeted inhibitory gents is currently being ssessed. VEGF trgeted therpy hs been pproved for the clinicl tretment of metsttic triple negtive brest cncer (25). The pucity of stroml vessels in MBC my

6 WANG et l: VEGF AND CASPASE 3 IN MUCINOUS BREAST CARCINOMA 4895 Tble IV. Cox univrite nlysis nd multivrite nlysis of clinicopthologicl vribles, including VEGF, for DFS in MBC. Univrite nlysis Multivrite nlysis Vribles HR 95% CI P vlue HR 95% CI P vlue VEGF High ( ) ( ) Low Cspse 3 High ( ) Low Age, yers ( ) >50 Tumor stge pt2/pt ( ) pt1 Nodl sttus Positive ( ) ( ) Negtive TNM II/III ( ) ( ) I ER Positive ( ) Negtive PR High b ( ) Low c Ki 67, % > ( ) Significnt difference between MBC nd IDC NOS (P<0.05). b PR 20%; c PR <20%. DFS, disese free survivl; MBC, mucinous brest crcinom; VEGF, vsculr endothelil growth fctor; ER, estrogen receptor; PR, progesterone receptor; HR, hzrd rtio; CI, confidence intervl. be n importnt dverse fctor for ngiogenesis (21). In the present study, VEGF expression ws ssessed in MBC nd IDC NOS smples, nd VEGF expression in MBC ws found to be lower thn tht in IDC NOS. It ws concluded tht low VEGF expression in MBC my be ssocited with the pucity of tumor vessels nd result in better prognosis. In the MBC ptients, high VEGF expression ws significntly ssocited with primry lymph node metstsis nd high TNM stge. Kpln Meier curves showed tht VEGF ws ssocited with DFS in the MBC ptients, while in the Cox multivrite nlysis model, only TNM stge ws the independent prognostic fctor. A lrge mount of mucus is typicl feture of MBC smples. Norris nd Tylor (8) found tht the mucus in the tumor tissues plys n importnt role in the prognosis of the ptients nd the whole clinicl course of the disese. Ahmed (10) noted tht the formtion of mucus is cused by the brekdown of cncer cells, followed by the degenertion of mitochondri, nd tht it leds to mrked decrese in tumor invsion. In ddition to necrosis, poptosis is lrge prt of cell disintegrtion. The cspses re fmily of genes tht re importnt for the mintennce of homeostsis vi the regultion of cell deth nd inflmmtion (26). Cspse 3 is the key moleculr fctor in vrious poptotic pthwys (27,28). The present study exmined cspse 3 expression in ech group. MBC smples showed high cspse 3 expression, suggesting tht cspse 3 medited poptosis my hinder tumor progression in MBC ptients. Unexpectedly, cspse 3 expression ws not ssocited with DFS or other clinicopthologicl prmeters in the MBC ptients. The Ki 67 index hs potentil prognostic nd predictive vlue in brest cncer, nd hs become n importnt, routinely used prolifertion biomrker (29). The present study nlyzed the expression of Ki 67 nd found tht the rte of Ki 67 ( 20%) expression in MBC ws 75.93% compred with 50% in IDC NOS. A significnt difference exists between MBC nd

7 4896 IDC NOS, which suggests tht tumor cells of MBC my hve lower prolifertion bility thn those of IDC NOS. However, Cox survivl nlysis showed tht Ki 67 expression ws not directly ssocited with DFS in MBC ptients. In conclusion, the present study reveled tht high rte of hormone receptor nd cspse 3, low expression of VEGF nd Ki 67 nd erlier TNM stge my contribute to improved prognosis of MBC compred with IDC NOS. VEGF nd cspse 3 my serve role in mucus production, which is importnt in MBC progression. However, neither high expression of VEGF nor cspse 3 hd significnt direct ssocition with the DFS of ptients with MBC. The mucinous brest cncer cell lines my need to be cultured in the future to explore the prolifertion, invsion nd migrtion bility of cncer cells nd the exct role of mucus in tumor progression. Acknowledgements The present study ws supported by grnts from the Ntionl Nturl Science Foundtion of Chin (grnt no ). References 1. Dumitru A, Procop A, Iliesiu A, Tmp M, Mitrche L, Costche M, Sjin M, Lzroiu A nd Cirstoiu M: Mucinous brest cncer: A review study of 5 yer experience from hospitl bsed series of cses. Medic (Buchr) 10: 14 18, Rnde A, Btr R, Sndhu G, Chitle RA nd Bldercchi J: Clinicopthologicl evlution of 100 cses of mucinous crcinom of brest with emphsis on xillry stging nd specil reference to microppillry pttern. J Clin Pthol 63: , Komki K, Skmoto G, Sugno H, Morimoto T nd Monden Y: Mucinous crcinom of the brest in Jpn. A prognostic nlysis bsed on morphologic fetures. Cncer 61: , H KY, Deleon P nd Deleon W: Invsive mucinous crcinom of the brest. Proc (Byl Univ Med Cent) 26: , Le Querrec A, Duvl D nd Tobelem G: Tumour ngiogenesis. Billieres Clin Hemtol 6: , Yncopoulos GD, Dvis S, Gle NW, Rudge JS, Wiegnd SJ nd Holsh J: Vsculr specific growth fctors nd blood vessel formtion. Nture 407: , Gsprini G: Prognostic vlue of vsculr endothelil growth fctor in brest cncer. The oncologist 5 Suppl 1: 37 44, Norris HJ nd Tylor HB: Prognosis of mucinous (Geltinous) crcinom of the brest. Cncer 18: , Mtsukit S, Nomoto M, Kitjim S, Tnk S, Goto M, Irimur T, Kim YS, Sto E nd Yonezw S: Expression of mucins (MUC1, MUC2, MUC5AC nd MUC6) in mucinous crcinom of the brest: Comprison with invsive ductl crcinom. Histopthology 42: 26 36, Ahmed A: The myoepithelium in humn brest crcinom. J Pthol 113: , Buckley CD, Pilling D, Henriquez NV, Prsonge G, Threlfll K, Scheel Toellner D, Simmons DL, Akbr AN, Lord JM nd Slmon M: RGD peptides induce poptosis by direct cspse 3 ctivtion. Nture 397: , Jänicke RU, Sprengrt ML, Wti MR nd Porter AG: Cspse 3 is required for DNA frgmenttion nd morphologicl chnges ssocited with poptosis. J Biol Chem 273: , Mzumder S, Plesc D nd Almsn A: Cspse 3 ctivtion is criticl determinnt of genotoxic stress induced poptosis. Methods Mol Biol 414: 13 21, Frnk GA, Dnilov NV, Andreev IuIu nd Nefedov NA: WHO clssifiction of tumors of the brest, Arkh Ptol 75: 53 63, 2013 (In Russin). 15. Edge SB, Byrd DR nd Compton CC (eds): AJCC Cncer Stging Mnul. 7th edition. Springer, New York, NY, Kshiwgi S, Onod N, Asno Y, Nod S, Kwjiri H, Tkshim T, Ohsw M, Kitgw S nd Hirkw K: Clinicl significnce of the sub clssifiction of 71 cses mucinous brest crcinom. Springerplus 2: 481, Zekioglu O, Erhn Y, Ciris M nd Byrmoglu H: Neuroendocrine differentited crcinoms of the brest: A distinct entity. Brest 12: , Be SY, Choi MY, Cho DH, Lee JE, Nm SJ nd Yng JH: Mucinous crcinom of the brest in comprison with invsive ductl crcinom: Clinicopthologic chrcteristics nd prognosis. J Brest Cncer 14: , Prk S, Koo J, Kim JH, Yng WI, Prk BW nd Lee KS: Clinicopthologicl chrcteristics of mucinous crcinom of the brest in Kore: Comprison with invsive ductl crcinom not otherwise specified. J Koren Med Sci 25: , Tseng HS, Lin C, Chn SE, Chien SY, Kuo SJ, Chen ST, Chng TW nd Chen DR: Pure mucinous crcinom of the brest: Clinicopthologic chrcteristics nd long term outcome mong Tiwnese women. World J Surg Oncol 11: 139, Jo W, Lo IO, Chowdhury LN nd Gould VE: Ultrstructurl spects of mucinous (colloid) brest crcinom. Dign Gynecol Obstet 2: 83 92, Rosen LS: VEGF trgeted therpy: Therpeutic potentil nd recent dvnces. Oncologist 10: , Ng IO, Poon RT, Lee JM, Fn ST, Ng M nd Tso WK: Microvessel density, vsculr endothelil growth fctor nd its receptors Flt 1 nd Flk 1/KDR in heptocellulr crcinom. Am J Clin Pthol 116: , Yonemur Y, Endo Y, Fujit H, Fushid S, Ninomiy I, Bndou E, Tniguchi K, Miw K, Ohoym S, Sugiym K nd Sski T: Role of vsculr endothelil growth fctor C expression in the development of lymph node metstsis in gstric cncer. Clin Cncer Res 5: , Hein A, Lmbrechts D, von Minckwitz G, Häberle L, Eidtmnn H, Tesch H, Untch M, Hilfrich J, Schem C, Rezi M et l: Genetic vrints in VEGF pthwy genes in neodjuvnt brest cncer ptients receiving bevcizumb: Results from the rndomized phse III GeprQuinto study. Int J Cncer 137: , McIlwin DR, Berger T nd Mk TW: Cspse functions in cell deth nd disese. Cold Spring Hrb Perspect Biol 5: , Fuchs Y nd Steller H: Progrmmed cell deth in niml development nd disese. Cell 147: , Hung Q, Li F, Liu X, Li W, Shi W, Liu FF, O'Sullivn B, He Z, Peng Y, Tn AC, et l: Cspse 3 medited stimultion of tumor cell repopultion during cncer rdiotherpy. Nt Med 17: , Kontzoglou K, Pll V, Krolnis G, Kriskos I, Alexiou I, Pters I, Konstntoudkis K nd Stmtkos M: Correltion between Ki67 nd brest cncer prognosis. Oncology 84: , 2013.