The HERe2Cure project, which involved a group of breast cancer experts, members of multidisciplinary tumor boards (MTB) from health-care institutions in Bosnia and Herzegovina, was initiated with the aim of defining an optimal approach to the diagnosis and treatment of HER2 positive breast cancer. After individual multidisciplinary consensus meetings were held in all oncology centers in Bosnia and Herzegovina, a final consensus meeting was held to reconcile the final conclusions discussed in individual meetings. Guidelines were adopted by consensus, based on the presentations and suggestions of experts, which were first discussed in a panel discussion and then agreed electronically between all the authors mentioned. The conclusions of the panel discussion represent the consensus of experts in the field of breast cancer diagnosis and treatment in Bosnia and Herzegovina. The objectives of the guidelines include the standardization, harmonization, and optimization of the procedures for the diagnosis, treatment, and monitoring of patients with HER2-positive breast cancer, all of which should lead to an improvement in the quality of health care of mentioned patients. The initial treatment plan for patients with HER2-positive breast cancer must be made by a MTB comprised of at least: A medical oncologist, a pathologist, a radiologist, a surgeon, and a radiation oncologist/radiotherapist.

Glycogen-rich clear cell carcinoma (GRCC) is a very rare form of primary breast cancer (<0.1% of all breast cancers). It is characterized by the presence of neoplastic cells with a glycogen-abundant clear cytoplasm (the Periodic Acid Schiff–positive, diastase-sensitive). The expression of steroid receptors (estrogen and progesterone receptors) has been variably reported (35% to 100% of the cases), whereas most studies reported low human epidermal growth factor receptor 2 positivity in GRCC. High androgen receptor positivity without androgen receptor splice variant-7 was reported in one recent study. Although sparse, the preliminary theranostic data on GRCC indicate the potential of targeted treatments in selected cases (antiandrogen, PIK3CA, and immune checkpoint inhibitors). Because of its rarity, the prognosis for GRCC patients remains controversial. Herein, we comprehensively appraise the epidemiological, morphologic, molecular, and clinical characteristics of this rare mammary malignancy.

Dear Editor, We highly appreciate Dr Altundag's feedback regarding our recently published manuscript in The Breast Journal.1 We are also thankful to the editor in chief (Dr S. Masood) for giving us the opportunity to address Dr Altundag's comments. Neo‐adjuvant chemotherapy has been widely used for breast cancer treatment due to the effective pathologic responses seen with newer therapeutic agents.2 Recently, it has also been introduced for the treatment of early breast cancer.3 Despite this, there is ongoing debate and controversies related to the use of neo‐adjuvant chemotherapy in breast cancer (critically appraised in a recent review by Vaidya et al2). We find Dr Altundag's point regarding our neo‐adjuvant cohort quite valid. In our study, ~43% of patients with invasive apocrine carcinoma (IAC) presented at the advanced stage (III or IV) with only 19% of the patients having the tumor size ≤2 cm at presentation. This is mainly due to the lack of organized screening program at the national level. In this regard, our small IAC cohort treated in neo‐adjuvant setting is somehow biased but it essentially reflected the previous and current overall breast cancer presentation in Bosnia and Herzegovina. Consequently, the response rates to neo‐adjuvant therapy in our study may be different from the previously published data. Noteworthy, IAC is a rare breast cancer subtype (~1%‐2% of all breast cancers)4,5 and future larger and multi‐institutional studies are required to validate the effectiveness of (neo)adjuvant chemotherapy in patients with IAC.

School of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina Department of Pathology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina Department of Radiology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina Department of Oncology, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina College of Medicine, Qatar University, Doha, Qatar

Treatment of symptoms and signs beyond the expanded disability status scale remains a major target in multiple sclerosis. QualiCOP was an observational, noninterventional, open-label study conducted at 170 sites in Germany. Of the 754 enrolled patients, 96 % had relapsing-remitting multiple sclerosis (MS) and were either disease-modifying therapy naı̈ve (de novo, n = 481) or previously treated (n = 237) with once-daily, subcutaneous 20-mg/mL glatiramer acetate (GA). Assessments of relapse rate, disease progression, overall functioning, quality of life (QoL), cognition, fatigue, and depression were performed over 24 months. GA treatment over 24 months was associated with reduced annual relapse rate for previously treated (from 0.98 to 0.54 relapses) and de novo (from 0.81 to 0.48 relapses) patients. Multiple Sclerosis Functional Composite scores showed slight improvement in both cohorts (all p\ 0.01). Paced Auditory Serial Addition Test and Multiple Sclerosis Inventory Cognition scale scores showed robust improvement in cognition among previously treated and de novo cohorts (all p\ 0.001). General Depression Scale scores showed significantly reduced depressive symptoms (p\ 0.001). Disease severity, fatigue, and QoL were stable over the observational period. These real-world findings suggest that patients with MS show benefit from GA treatment in important QoL parameters beyond standard measures of relapse and disease severity.

To the Editor A 65-year-old woman with a positive family history for breast cancer presented with the palpable mass in the upper outer quadrant of the left breast. Ultrasonography and mammography revealed an oval, hypoechogenic, sharply demarcated mass, measuring 23 9 14 mm, classified as Bi-RADS 4 (Fig. 1A). A core needle biopsy revealed a cellular spindle cell lesion (AE1/AE3 negative) without prominent atypia and mitotic activity (B3 category, Fig. 1B). The multidisciplinary breast meeting discussed the case and recommended a wide local excision of the mass. Grossly, the 20-mm tumor was well-circumscribed, grayish-white on cut section, without necrosis and hemorrhage (Fig. 1C). Histopathologic examination revealed a well circumscribed, spindle cell neoplasm composed of the cells with mild to moderate atypia and sporadic mitotic activity (up to 5/10 hpf mitotic figures, Fig. 1D,E). An extensive immunohistochemical (IHC) examination revealed only convincing S-100 positivity in about 20% of neoplastic cells (Fig. 1F). All other markers were negative (AE1/AE3, Cam5.2, p63, GFAP, SMA, desmin, CD34, HMB-45, SOX-10) while beta-catenin retained cytoplasmic/membranous expression without nuclear positivity. Morphologic and immunohistochemical findings were consistent with a low-grade malignant peripheral nerve sheath tumor (MPNST). Due to the tumor size, clean margins, and the tumor grade, a close follow-up without further treatment of the patient was recommended (1–3). Additional clinical

Medical findings of 210 patients with bronchogenic cancer in the four years period of time were elaborated retrospectively. Bone metastases were found with 27 (13.8%) patients. Diagnostic radiologic procedure were plain radiography and CT. The frequency, the localization and the distribution of bone metastases depending on pathohistological diagnosis were presented. The bone metastases were the most frequent (27 patients or 13.8%) compared to metastases of abdomen (23 patients or 10.9%) and brain (20 patients or 9.5%). Out of the total number of 27 (100%) patients with bone metastases, 9 (33.3%) of them have got solitary metastases, and 18 (66.7%) patients have got multiple metastases. Large number of bone metastases were located at spine, and very rarely at radius, ulna and scapula. It was shown that the small cell carcinoma with the most malignant potential was found with 3 (11.1%) patients only. It can be explained by the fact that a large number of patients hadn't got pathohistological diagnosis (13 patients or 48.2%). As a conclusion, the high percentage of patients without final diagnosis is a result of insufficient diagnostic procedures, the radiological ones due to a lack of technical means and not performing biopsy and autopsy.