case_images: PMC11004348_01
case_images: (A) Initial clinical presentation. (B) Initial chest CT. (C) Initial breast MRI. (D) Whole body on PET/CT with 18F-FDG at initial staging.
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case_images: At physical examination, she presented an enlarged right breast with lower-quadrant edema and an infiltrative ulcerated mass with a multinodular aspect in the intermammary cleft ( Figure 1A ). The chest CT revealed a solid mass with irregular borders in the medial area of the right breast measuring 53 x 82 x 86 mm with posterior involvement of the sternum and chondrosternal joints ( Figure 1B ) and multiple enlarged nodes in the right axillary region. The breast MRI revealed a lesion of 90 x 55 x 76 mm occupying the totality of the lower-inner quadrant of the right breast, with a necrotic component that invaded and ulcerated the overlying skin, upper anterior abdominal wall, chest wall, and the lower-inner quadrant of the left breast ( Figure 1C ). The exam was positive for right axillary, left parasternal, and right supraclavicular lymph nodes, without evident bone involvement or other images suggesting distant metastases ( Figure 1D ).
case_images: (A) Clinical response following 6 months of systemic therapy. (B) Breast MRI following 6 months of systemic therapy. (C) Whole body on PET/CT with 18F-FDG following 6 months of systemic therapy. (D) Right breast lesion on PET/CT with 18F-FDG prior to (upper image) and following 6 months of systemic therapy (lower image). (E) Lymph node involvement on PET/CT with 18F-FDG prior to (upper image) and following 6 months of systemic therapy (lower image).
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case_images: The patient had a good local response from as early as the first cycle of ribociclib, and the lesion's regression was very evident following six months of systemic therapy ( Figure 2A ). The breast MRI confirmed a favorable response, with a tumor size reduction from 90 x 55 x 76 mm to 72 x 39 x 73 mm, the disappearance of the vegetation in the intermammary cleft, and suggested tumor necrosis ( Figure 2B ). There was a marked decrease in both metabolic expression (SUVmax 10.95 to 2.30) and tumor's dimensions of the right breast neoplasm, as well as a complete extinction of the lymph node hypermetabolism previously documented ( Figures 2C-E ).
case_images: (A) Surgical resection of the tumor, pre- and latersternal skin, medial portions of both pectoralis muscles and part of the inner quadrants of both breasts. (B) Surgical reconstruction using internal mammary flaps. (C) Surgical specimen. (D) Pathological results of the surgical specimen showing tumoral infiltration of the muscular tissue.
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case_images: She underwent a resection of the previously clip-marked tumor, including pre- and latersternal skin, medial portions of both pectoralis muscles, as well as part of the inner quadrants of both breasts ( Figure 3A ). The resection was followed by an immediate reconstruction using internal mammary flaps ( Figure 3B ). The pathological results evidenced a tumor bed of 77 x 55 x 26 mm of invasive breast carcinoma NST, moderately differentiated, with infiltration of surrounding muscular tissue, adipose tissue, and superficial and deep dermis ( Figures 3C, D ).
case_images: (A) Firmicutes/Bacteroidetes (F/B) ratio in gut microbiota across timepoints. The F/B ratio decreases from 2.73 at the initial timepoint (diagnosis) to 0.13 at the intermediate timepoint (following 6 months of systemic therapy) and 0.15 at the final timepoint (following surgery), reflecting a major shift from a Firmicutes-dominant profile at the initial timepoint to a Bacteroidetes-dominant profile in the subsequent timepoints. (B) alpha-diversity indices in gut microbiota across timepoints. At diagnosis, Shannon's and Simpson's diversity indices were 2.58 and 0.89, respectively, indicating a high diversity at this stage. There is a significant decrease in both indices at the intermediate timepoint (0.58 and 0.20), followed by a partial recovery by the final timepoint (1.17 and 0.53). (C) Relative abundance of microbial species in gut microbiota across timepoints.
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case_images: The dynamic evolution of the gut microbiota across the three timepoints was analyzed ( Figures 4A, B ). At the species level, there is a clear dominance of Prevotella copri in the intermediate and final timepoints ( Figure 4C ).
case_images: (A) Bray-Curtis distance matrix for tissue samples. The Bray-Curtis distance matrix shows a very high dissimilarity (approximately 0.995) between the two samples, suggesting that the microbial compositions of the residual tumor and respective margins are markedly different. (B) Relative abundance of microbial species in tissue samples (residual tumor and respective margins).
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case_images: The analysis from the microbiota samples of the surgical specimen revealed an interestingly high dissimilarity between the residual tumor and respective margins, with statistical significance (p<0.001), suggesting markedly different microbial compositions ( Figure 5A ). While the margins revealed a more diverse distribution of microbial species, the tumor's microbial composition was dominated by fewer species, particularly Streptococcus pneumoniae and Atopobium vaginae ( Figure 5B ).