bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract PD03-01: EFFECT OF METFORMIN ON APOPTOSIS IN A PRESURGICAL TRIAL IN NON-DIABETIC PATIENTS WITH BREAST CANCER
Authors: Cazzaniga M , DeCensi A , Pruneri G , Puntoni M , Guerrieri-Gonzaga A , Dell'Orto P , Gentilini OD , Vingiani A , Pagani G , Puccio A , Bonanni B
Published: August 2014

BACKGROUND: metformin has been associated with antitumor activity in epidemiological and clinical studies. This effect has been related to different mechanisms of actions, including a reduction of the proliferative activity and an increase of apoptosis. We have recently shown that a 4 week pre-surgical treatment with metformin did not affect Ki-67 LI overall but reduced tumor proliferation Ki67 LI in breast cancer (BC) patients with insulin resistance (IR) (HOMA, fasting blood glucose (mmol/L)*insulin (mU/L)/22.5>2.8) or BMI>27 (Bonanni et al. JCO epub May 7, 2012). The objective of the current analysis was to determine whether metformin induced a modulation of apoptosis (TUNEL) overall and by HOMA index.

TRIAL DESIGN: After tumor biopsy we randomly allocated 200 non-diabetic women with operable breast cancer to either metformin (850 mg/bid) or placebo for 4 weeks prior to surgery. The primary outcome measure was the difference between arms in Ki-67 after 4 weeks of treatment. Here we analyzed the apoptotic cell nuclei in 88 consecutive core biopsies and their paired surgical samples from the initial 100 randomized subjects.

RESULTS: Median TUNEL levels at surgery (Metformin = 10%, IQR, 4–20, Placebo = 8%, IQR, 3–15) were significantly higher as compared with baseline (Metformin = 4%, IQR, 2–7, Placebo = 3%, IQR, 2–6, p < 0.0001), but no difference between arms was noted (p = 0.2, adjusted for age, BMI, TUNEL and Ki67 at baseline). Interestingly, Ki67 and TUNEL levels were highly and positively correlated both at baseline and at surgery (Spearman r=0.51, p < 0.0001). Furthermore, we found a trend to a different metformin effect by the HOMA index (p = 0.1). In the 59 women with HOMA <2.8 there was a higher level of TUNEL at surgery on metformin versus placebo (p = 0.05), while an opposite trend was found in the 28 women with HOMA>2.8 (p = 0.6).

CONCLUSIONS: The levels of TUNEL are significantly higher in the surgical specimens compared with baseline biopsy and are directly correlated with those of Ki-67 (TUNEL is high when Ki-67 is high). We found no significant modulation of TUNEL by metformin but a trend to a different effect according to the IR state, with a similar pattern to Ki-67: decrease by metformin in IR women and increase in non-IR women. Our findings confirm the notion that metformin has dual effects on breast cancer according to IR state. As expected, cancer apoptosis and proliferation are directly related. Our results strengthen the importance of placebo control arms in biomarker trials.

ACKNOWLEDGEMENTS: 2 Grants by AIRC and Italian Ministry of Health.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD03-01.
Abstract PD05-04: Targeted resequencing in oncogenetics: developing a new approach for molecular diagnostics
Authors: Sevenet N , Lafon D , Dupiot-Chiron J , Hubert C , Jones N , Debled M , de Lara Tunon C , Longy M , Bonnet F
Published: August 2014

Introduction: Next-generation sequencing (NGS) appears to be an accurate tool adapted for molecular oncogenetics. In contrast to certain somatic mutations, a lack of germline mutation hotspots in genes involved in cancer predisposition syndromes, especially hereditary breast and ovarian cancer (HBOC), force the molecular biologist to screen the entire coding sequence.

Material & methods: In order to screen a panel of genes predominantly involved in HBOC & Cowden disease in a molecular diagnostic setting, we captured 408 exons (and their surrounding intronic sequences) of 25 genes using the SureSelect oligonucleotide library capture (Agilent technologies). The bioinformatics resources Earray (Agilent technologies), Ensembl human genome v62 and UCSC repeat masker were used to create the capture design. This gave us 2899 unique 120-mers oligonucleotide probes which were duplicated 19 to 38 times depending on the GC content or the size of the targeted regions. Germline DNA of 190 patients (40 with previously identified mutations and 150 without previous molecular genetic analysis) was sequenced using a MiSeq bench top next-generation sequencer (Illumina) and in parallel was analyzed using our current screening method (EMMA, Enhanced Mismatch Mutation Analysis, similar to high resolution melting). Samples were prepared according the manufacturer's recommendations (Agilent technologies).

Results: All previously identified mutations along with 33 mutations in previously unscreened patients were detected. In addition, more than five hundred variants described as polymorphisms were identified. NGS seems to be more sensitive than our current screening method due to its detection and identification of homozygous variants. In order to limit the interpretation time, we restricted sequence analysis to the exon, −50 bp (including the acceptor splice site of the upstream intron) and +50 bp (including the donor splice site of the downstream intron). We have validated NGS as a technique adapted for germline mutation screening in oncogenetics. From the beginning of 2013, all germline DNA samples will be screened by NGS for oncogenetic molecular diagnostics. Sample preparation, technical organization, bioinformatics workflow and comprehensive results will be presented.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD05-04.
Abstract PD06-01: Automated computational Ki67 scoring in the GeparTrio breast cancer study cohort
Authors: Klauschen F , Wienert S , Blohmer J-U , Mueller BM , Eiermann W , Gerber B , Tesch H , Hilfrich J , Huober J , Fehm T , Barinoff J , Jackisch C , Erbstoesser E , Loibl S , Denkert C , von Minckwitz G
Published: August 2014

Background: Scoring proliferation through Ki67-immunohistochemistry is an important component in predicting therapy response to chemotherapy in breast cancer patients. Therefore, an accurate and standardized Ki67-scoring is pivotal both in routine diagnostics and larger multi-center studies aiming at improving present or establishing new cut-off values for existing or novel therapy regimens. However, recent studies have cast some doubt on the reliability of “visual” Ki67 scoring by pathologists, especially within the lower - yet clinically important - proliferation range. Here, we present and apply a novel automated image analysis approach for Ki67-quantification in breast cancer tissue.

Methods: We perform automated Ki67-scoring in 1219 breast cancer patients from the GeparTrio study cohort using a novel image analysis approach that avoids detection biases due to morphological variability by using a generic minimum-model approach. The method is capable of tumor-stroma-separation and may be used to process large data sets fully unsupervised in batch mode while allowing for efficient visual checks of the results. We compare these results with a different in-house-developed subtiling-based automated quantification method and moreover, gauge our approach with manual scoring performed by pathologists.

Results: The results show deviations of 10% (automated method 1 vs. manual), 9% (automated method 2 vs. manual) and 3% (automated method 1 vs. automated method 2) on average. The Ki67 scores show Pearson correlations between automated and manual scoring of r>0.8 (p < 0.001) for both automated methods and r>0.95 (p < 0.001) between the two tested automated methods.

Conclusion: Because of the methodological differences of the presented techniques our results suggest a high robustness of the automated methods that at the same time show a good agreement with manual Ki67 scoring. Our approach therefore offers an automated and standardized means of Ki67 quantification applicable in routine diagnostics as well as larger clinical study settings, such as in the GeparTrio cohort shown here.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD06-01.
Abstract PD06-05: St. Gallen 2011 clinico-pathological subtypes of breast cancer: concordance of core biopsies and related surgical specimens
Authors: Decker T , Focke CM
Published: August 2014

Rationale: Whereas the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2011 considered molecular typing as the adequate model representing the heterogeneity of breast cancers, it did not generally accept gene expression array criteria for clinical decision making. When the classification of tumours by gene expression array criteria and immunohistochemical analysis of ER, PR and HER2 are discrepant, patients should be managed according to the current immunohistochemical markers. Therefore, for systemic therapy decision the St Gallen consensus Conference 2011 did recommend clinicopathologically defined breast cancer subtypes (cpBCST) to guide therapeutic choices. There are many reasons to provide patients and doctors these information already preoperatively. To evaluate relevance of St. Gallen 2011 cpBCST core biopsy (CB) results we estimated their concordance with postoperative cpBCSTs.

Methods: cpBCSTs of CB and related surgical specimen (SSP) of 379breast cancers (BC) (62 Grade 1, 157Grade 2, 160 grade 3) were assessed according to the St Gallen definition using the prospectively estimated results for Estrogen, Progesteron, and Her2-status. To differentiate between Luminal A and the Her2 negative subgroup of Luminal B we retrospectively measured the mitotic activity index (MAI) with a cut-off of ≥10 for high versus low as evaluated by Baak et al. 2008. Concordance between cpBCST results of CB and SSP and PPV of cpBCST of CB were calculated.

Results:

None of the Luminal A BCs was overestimated in CB, whereas 49% (53/108) of all Luminal B or 66% (55/83) of the Luminal B (Her2−) BCs were underestimated as Luminal A, for all other subtypes, the agreement was 100%. In general, there was no overestimation as a more unfavourable CPBCST in CB. The overall underestimation rate came out with 14%. Whereas the PPV in CB is 100% for Luminal B, Her2 positive, and Triple negative CPBCSTs, it is only 78% for Luminal A (198/254). The reason is underestimation of proliferation in CB.

Conclusions: BC subtypes classified according to the St. Gallen clinicopathological definitions on CB show a high agreement with corresponding SSP results. The respective PPVs are also generally high. This means that clinicopathological subtyping on CB can be used for preoperative decision making in the vast majority of cases. However, for the Her2 negative subgroup of Luminal B subtype in CB the agreement with SSP is lower due to underestimation of proliferation in CB.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD06-05.
Abstract PD06-08: Strong prognostic concordance between Ki67 and binary, but not multi-level gene expression signatures
Authors: Tobin NP , Lindström LS , Carlson JW , Bergh J , Wennmalm K
Published: August 2014

Background: Several proliferation-related gene signatures have been proposed to aid breast cancer management by providing better prognostic and therapy predictive information on a patient-by-patient basis. It is unclear however, whether a less demanding assessment of cell division rate (as determined by Ki67 expression) can function in place of gene profiling.

Methods: Agreement between literature-, distribution-based, as well as signature-derived threshold values for Ki67, relative to the genomic grade index (GGI), the 70-gene signature, the p53 signature, the recurrence score (RS), and the molecular subtype models of Sorlie, Hu, and Parker was investigated in a representative set of 253 breast cancers with 25 years follow up. Relevance for breast cancer specific survival was assessed for contrast groups, and in uni- and multivariate Cox models.

Results: Our broad approach identified Ki67 cutoffs in the range of 10%–20%. With optimum signature-reproducing cutoffs, similarity in classification of individual tumors was high for GGI (81%), the 70-gene (78%), and the p53 (82%) signatures, but lower for the recurrence score (68%), Sorlie (68%), Parker (67%) and Hu (68%) signatures. Consistent with strong agreement, no prognostic superiority was noted for Ki67 vs. the binary GGI, 70-gene and p53 signatures respectively, in multivariate analyses. In contrast, Ki67-independent prognostic capacity could be demonstrated for RS and molecular subtypes according to Sorlie, Parker and Hu (Table 1).

Conclusions: The added prognostic value of binary proliferation-related gene signatures appears limited for Ki67-assessed breast cancers. More complex, multi-level descriptions seem to have a greater potential in pinpointing the outcome heterogeneity in breast cancer. We aim to validate our findings in a second cohort of 159 breast cancer patients with over 15 years of clinical follow up.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD06-08.
Abstract PD08-06: Significant Clinical impact of recurrent BRCA1 and BRCA2 (BRCA) mutations in Mexico
Authors: Villarreal-Garza C , Herrera LA , Herzog J , Port D , Mohar A , Perez-Plasencia C , Clague J , Alvarez RMa , Santibanez M , Blazer KR , Weitzel JN
Published: August 2014

Background: Breast cancer (BC) is the most commonly diagnosed cancer and the leading cancer cause of death in Hispanic women. Although the incidence of breast cancer in Hispanics is less than that for non-Hispanic white women, our studies on the prevalence of deleterious mutations in the BRCA genes among high-risk Hispanics in the US suggest that BRCA mutations may account for a higher proportion of BC in this population. However, a lack of research on BRCA mutations in Hispanics has limited the implementation of prevention efforts and the scope of comparative studies of genetic factors that influence BC and ovarian cancer (OC) risk within Hispanic populations – this is especially true of Mexico where there has been little access to clinical BRCA gene analyses.

Objective/Methods: We used an economic panel assay (HISPANEL) on a mass spectroscopy platform (Sequenom) to analyze DNA from 189 cancer cases (92 unselected OC; 97 BC) from the National Cancer Institute in Mexico City for recurrent BRCA mutations, including a large rearrangement (BRCA1 ex9-12del) that we hypothesize is a Mexican founder mutation.

Results: Overall, 14% (27/189) harbored a germline BRCA mutation (25 BRCA1, 2 BRCA2) detected by the HISPANEL (17% in OC; 11% in BC). BRCA1 ex9-12del was detected in 9.8% (9/92) of unselected OC cases, representing 56% of the 16 BRCA mutations. It also represented 36% (4/11) of the BRCA mutations detected in the BC cases. Mean age at onset of BC for BRCA-associated cases (n = 11) was 46 years old (range 31–63); 8/11 were triple negative BC (TNBC) – a BRCA mutation was detected in 24% (8/34) of all TNBC cases.

Conclusions: The remarkable frequency of the BRCA1 ex9-12del mutation, accounting for 56% of BRCA mutations in the OC cases and 36% of BC cases, supports our hypothesis of regional origin of this Mexican founder mutation approximately 1,474 years ago. Similar to our experience in the Mexican American population, the HISPANEL, which includes recurrent BRCA mutations found in women of Hispanic ancestry, appears to have high sensitivity and thus is likely to have clinical utility while reducing overall genotyping cost among underserved women in Mexico. Both in the US Hispanic populations and in Mexico, the prevalence of the Mexican founder mutation make it a significant public health issue, and presents an opportunity for cost effective in BC and OC prevention.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD08-06.
Abstract PD09-04: Homologous Recombination Deficiency (HRD) score predicts pathologic response following neoadjuvant platinum-based therapy in triple-negative and BRCA1/2 mutation-associated breast cancer (BC)
Authors: Telli ML , Jensen KC , Abkevich V , Hartman A-R , Vinayak S , Lanchbury J , Gutin A , Timms K , Ford JM
Published: August 2014

Background: BC that arises in BRCA1/2 mutation carriers is characterized by defective homologous recombination DNA repair. Given the clinical potential for DNA repair-targeted therapeutics, Myriad Genetics has developed a tumor DNA-based assay that can identify underlying defects in the homologous recombination pathway, regardless of etiology, including identification of BRCA1/2 mutation carriers with high sensitivity. This study was designed to assess ability of the HRD score to predict pathologic response to neoadjuvant platinum-based therapy in early-stage triple-negative and BRCA1/2 mutation-associated BC.

Methods: The HRD score was assessed in a cohort of 55 fresh frozen tumors from pts with clinical stage I-IIIA triple-negative and BRCA1/2 mutation-associated BC enrolled onto a single-arm, phase II study of neoadjuvant gemcitabine, carboplatin and iniparib. Following neoadjuvant therapy (4 cycles=11; 6 cycles=44), pathologic response was assessed using the residual cancer burden (RCB) index by a central pathologist. Twenty-nine tumors were obtained from responders (RCB 0/1) and 26 tumors were from non-responders (RCB 2/3). The HRD score was derived by count of the number of LOH regions (>15 Mb and < whole chromosome) observed in the tumor genome. Association of response to treatment and HRD score was performed by the Mann-Whitney U test.

Results: Germline BRCA1/2 mutation status was known in all pts and 13/55 tumors were from carriers of deleterious BRCA1 (n = 9), BRCA2 (n = 3) or BRCA1&2 (n = 1) mutations. Two mutation carriers had ER+/PR+(>5%) BC. The mean HRD score for responders is 16.5 and no differences were noted between germline BRCA1/2 mutants vs. non-mutants. The mean HRD score for non-responders is 11.4. Among carriers of BRCA1/2 mutations, 12/13 achieved a favorable response. The one BRCA1 mutation carrier non-responder with TNBC had a low HRD score of 8. This pt was previously treated with chemotherapy twice 12 years prior for primary and locally recurrent contralateral TNBC. The p-value for association between response to treatment and HRD score by the Mann-Whitney U test is 0.004. If BRCA1/2 deficient samples are excluded, the association between response to treatment and HRD score remains significant (p = 0.02). Multivariate analysis that includes HRD score, BRCA1/2 genotype, age, stage, tumor grade, PAM50 subtype, ER/PR status, and cycles of therapy will be presented together with data from an additional 35 pts. Enrollment to the therapeutic trial is complete and final clinical results will be separately presented.

Conclusion: The HRD score is significantly correlated with pathologic response to platinum-based chemotherapy in early-stage triple-negative and BRCA1/2 mutation-associated BC.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD09-04.
Abstract PD09-09: The Akt inhibitor MK-2206 is an effective radio-sensitizer of p53 deficient triple negative breast cancer (TNBC) cells.
Authors: Connolly EP , Sun Y , Chao KC , Hei TK
Published: August 2014

Purpose: Triple negative breast cancer (TNBC) is an aggressive tumor with a higher locoregional recurrence compared to estrogen receptor (ER) positive breast cancer. Mutations in the PI3K/Akt/mTOR pathway leading to up-regulation of Akt occur with high frequency in TNBC. Hyperactive Akt is associated with increase radiation resistance, mediated through inhibition of apoptosis and up-regulation of DNA damage-induced G2 arrest. p53 plays a key role in mediating G1 cell cycle arrest following genotoxic stress such as radiation; p53-deficient cells however must rely on alternate mechanisms for cell cycle arrest in S- and G2-phases. Inhibition of Akt therefore would be expected to act in a synthetic lethal fashion to radiosensitize p53 deficient TNBC cells by decreasing their ability to arrest in G2. Given that p53 mutations occur in 44% of TNBC this may be an effective strategy for radiosensitizing TNBC.

Methods: Experiments were conducted using MDA-MB-468, MDA-MB-231 and SUM 149 cells, all well established models for p53-deficient TNBC. Cells were treated with MK-2206, a potent allosteric Akt inhibitor, alone or in combination with increasing doses of radiation from 0–8 Gy. In vitro studies preformed included; cell survival assays, MTT assay, immunoblot analysis of key proteins, FACS analysis for cell cycle, apoptosis, and gH2AX staining.

Results: We found that the combination of IR and Akt inhibition by MK-2206 is synergistic. MK-2206 inhibited both endogenous and radiation-induced Akt activation and phosphorylation of its down-stream targets. Decreased clonogenic survival was seen after 2 or 24 hours pretreatment with MK-2206 as well as decreased viability by MTT assay. Cell cycle analysis demonstrates MK-2206 decreases the proportion of cells in G2/M arrest following irradiation, as well as induced a greater proportion of apoptosis. Evaluation of the DNA damage response pathway demonstrated decreased levels of total DNA-PK, as well as a delayed DNA damage response.

Conclusions: These studies demonstrate that targeted inhibition of Akt effectively radiosensitizes p53 deficient TNBC cells lines, possibly through a synthetic lethal effect on the DNA damage response.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD09-09.
Abstract PL-3: Breast Radiotherapy: Fractionation and Other Fashions
Authors: Yarnold J
Published: August 2014

Hypofractionation, defined as the use of fraction sizes >2.0 Gy, requires a reduction in the total dose delivered in 1.8–2.0 Gy fractions that takes account of the greater effect per Gy of larger fractional doses. Generations of radiation oncologists have been taught that small (≤2.0 Gy) daily fractions are always gentler on the dose-limiting healthy tissues than on the cancer, thereby optimising clinical benefit. This relationship applies at many tumour sites, but breast cancer is different. Well-designed randomised trials involving >7000 women confirm that there are no advantages to using ≤2.0 Gy fractions, which spare breast cancer as much as the normal tissues. The limits of hypofractionation for whole breast/chest wall radiotherapy are under evaluation in the UK FAST Forward trial, testing 2 dose levels of a 5-fraction regimen given in 1 week against the 3-week UK standard. Hypofractionation can also be employed to match dose intensity more effectively to the spatial pattern of tumour relapse by modulating fraction size across the breast in preference to fraction number, an approach under test in the UK IMPORT HIGH trial. In marked contrast to conservative attitudes towards whole breast hypofractionation, there has been a dash to accelerated hypofractionation schedules among practitioners of partial breast radiotherapy.

The mean fractionation sensitivity of breast cancer, expressed as an α/β value, is approximately 3 Gy. The distribution around this point estimate could be wide or narrow; we don't know. The fractionation sensitivities of early responding normal tissues and cancers are postulated to reflect the responses of a limited number of target stem cell populations. Late-responding normal tissues are more complex in that multiple parenchymal and stromal cell lineages and interactions need to be considered. Despite potential complexity, a strong association between the proliferative indices of normal tissue parenchymal cells and fractionation sensitivity support the notion that the latter has a cellular basis, justifying a focus on classical cellular recovery and DNA double strand break (DSB) repair. Differences between healthy and malignant tissues in how they handle DSB are but one of several potential modulators of fractionation sensitivity. The processes are likely to be strongly affected by mutational and epigenetic alternations in tumours, but they foretell a future when predictive biomarkers replace historical dogma in determining fractionation regimens for cancer patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PL-3.
Abstract S3-8: Identification of Novel Synthetic-Lethal Targets for MYC-Driven Triple-Negative Breast Cancer
Authors: Goga A , Samson S , Horiuchi D
Published: August 2014

Currently, the greatest clinical challenge in treating breast cancer occurs in those patients whose tumors lack expression of the estrogen and progesterone receptors and the HER2 oncoprotein. No targeted agents currently exist against this aggressive type of receptor ‘triple negative’ breast cancer that disproportionately affects young African American women and also a substantial number of white American women. We have discovered that triple-negative tumors frequently express high levels of the MYC proto-oncogene. We sought to identify new “synthetic-lethal” strategies to selectively kill triple-negative breast tumors with MYC overexpression. Synthetic lethality arises when a combination of mutations in two or more genes leads to cell death, whereas a mutation in only one of these genes has little effect. Using this strategy, we can take advantage of the elevated MYC signaling in triple-negative tumors to selectively kill them, while sparing normal tissues in which MYC is expressed at much lower levels.

RESULTS: We performed a shRNA synthetic-lethal screen to identify new molecules, such as cell cycle kinases, which when inhibited can preferentially kill triple-negative breast tumor cells. The unbiased shRNA-based screening approach was performed in human mammary epithelial cells (HMECs) that have inducible MYC over-expression. A high-throughput screen of ∼2000 shRNAs, that target the human kinome (∼ 600 kinases) was performed, and identified 13 kinases whose inhibition by >1 shRNAs gave rise to >50% inhibition of cell growth. Two of the kinases identified in our screen, ARK5 and GSK3A, were also recently identified by other studies and shown to have a synthetic-lethal interaction with MYC. These results validated our ability to identify synthetic-lethal targets. We are currently characterizing and validating the 11 novel targets identified in this screen, using human cancer cell lines as well as mouse cancer models to determine the impact of inhibiting these targets on triple-negative breast cancer development and proliferation. Additional synthetic-lethal interactions with MYC over-expression in triple-negative breast cancers will be presented.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S3-8.
Abstract ES06-2: The impact of biological age
Authors: Ring A
Published: August 2014

The prognosis of a woman with early breast cancer is dependent on both tumor and patient characteristics. Tumor-related prognostic factors, such as stage, grade, and biomarker expression are well-described in the breast cancer literature and remain the focus of considerable ongoing research efforts. However patient-related factors which may influence risks of death from competing causes of mortality or tolerance of adjuvant therapies receive less attention. Risks of death from other causes and likely tolerance of treatment are particularly important considerations in the management of the increasing number of older women who are now presenting with early breast cancer. Chronological age itself may be a useful predictor of these outcomes. However older patients represent a heterogeneous population in terms of co-morbidities, fitness, life expectancy, social situation, cognitive function as well as desire for treatment. Therefore an objective definition of “biological age” might be a more accurate predictor. Those involved in the care of older patients have therefore developed “Comprehensive Geriatric Assessments” (CGAs) which are based on questionnaires or simple physical measurements which may describe “biological age”. Furthermore blood-based biomarkers of biological age have also been developed. Co-morbidity is one component of a holistic patient assessment which has been shown to be a useful predictor of risk of death before recurrence in women with breast cancer (1). In addition questionnaires derived from CGAs may be good predictors of treatment tolerance in patients receiving chemotherapy (2). Ongoing studies are evaluating whether more extensive assessments, incorporating more domains of a CGA, such as functional status, cognitive function and nutrition add to the predictive model. Any incorporation of such measures into routine clinical practice will require further validation and confirmation of clinical utility. Nonetheless such tools assessing biological age do offer the promise to improve further on the advances made in personalising adjuvant therapies that pathological and molecular tumor characterisation have already achieved. As such it seems likely that assessment of these factors in order to more objectively take into account the risks of death from competing causes of mortality and likely tolerance of treatment will become core components to informed adjuvant treatment decisions in the future.

1. Ring A et al. J Clin Onc 2011; 29:4266-4272

2. Hurria A et al. J Clin Onc 2011;29:3457-3465.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr ES06-2.
Abstract MS01-1: Using T cell receptor engineered T cells for the treatment of cancer
Authors: Morgan RA
Published: August 2014

Adoptive cellular immunotherapy involves the administration of autologous or allogenic tumor reactive T cells into patients to achieve tumor regression and has been successful in transplant-related malignancies, leukemia, and melanoma. The molecule responsible for the recognition of tumor antigens is the T cell receptor (TCR). Best studied in melanoma, this process involves the identification of lymphocytes with high affinity for tumor antigens that can be selected in vitro and expanded and administered to patients. The administration of naturally occurring T cells has been shown to have an objective response rate ranging from 50-70% in metastatic melanoma patients; including bulky invasive tumors at multiple sites including liver, lung, soft tissue and brain. A major limitation to the widespread application of adoptive cell therapy is the difficulty in generating human T cells with anti-tumor reactivity. To overcome this limitation, we can now insert highly active TCR genes into T cells that can recognize tumor antigens. Genetic engineering of TCR genes into normal T cells is a powerful new strategy to generate large numbers of defined antigen-specific cells for therapeutic application. This approach has evolved beyond experimental stage into a clinical reality. The feasibility of TCR engineered T cells has been shown to be an effective clinical strategy resulting in the regression of established tumors in recent clinical trials. Ultimately it may be possible to establish a collection of defined TCR genes that could be used to treat a diverse set of cancers tailored to each patient depending on the expression pattern of their tumor antigens.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr MS01-1.
Abstract MS02-1: HER2+ breast cancer: Unresolved challenges
Authors: Winer EP
Published: August 2014

Dramatic advances have been made in the treatment of HER2+ breast cancer over the past 15 years. As a result of HER2-directed therapy, survival in the both the early stage and metastatic settings has improved substantially. This improvement in survival has been accompanied by decreases in treatment-associated toxicity and improvements in quality of life. In spite of these advances, numerous challenges remain. Metastatic HER2+ disease remains incurable, and the vast majority of women with HER2+ metastatic disease ultimately succumb to their illness. In the setting of early stage disease, there is a need to identify which patients require more treatment than the present standard, which would do equally well with less, and which patients need an entirely different treatment program. Clinical data strongly suggest that HER2+ breast cancer is not a monolithic force. A better understanding of the underlying heterogeneity of HER2+ breast cancer is needed, and this understanding will assist in answering many of the unresolved questions. The most critical clinical challenges include: 1) What approaches can be used to delay and ultimately avoid drug resistance? 2) How can we treat and/or prevent brain metastases? 3) Which patients can be treated with adjuvant regimens that minimize or entirely avoid chemotherapy? 4) What is the optimal treatment for patients with small tumors and negative lymph nodes? 5) What trial designs are needed the vast majority of patients are doing well and recurrence rates are very low, but there is still some room for improvement. If we are going to eliminate mortality from HER2+ breast cancer, creative, collaborative, and multidisciplinary, approaches will be needed.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr MS02-1.
Abstract OT2-6-14: Phase 2, single arm study of a steroid-based mouthwash to prevent stomatitis in women with hormone receptor–positive advanced breast cancer treated with everolimus plus exemestane
Authors: Rugo HS , Chambers MS , Litton J , Mayer I , Rogerio J , Demars L , Geronimo J , Warsi G , Meiller TF
Published: August 2014

BACKGROUND: Stomatitis, the inflammation of mucous membranes lining the mouth and throat, is a frequent adverse event that is associated with the oral mTOR inhibitor everolimus and can significantly impact treatment adherence. Specific strategies to prevent and/or lessen the severity of everolimus-associated stomatitis are not well documented. Steroid mouthwashes and steroid gels or pastes used to treat recurrent aphthous stomatitis may be effective for stomatitis associated with everolimus. This phase 2, single-arm study will evaluate a steroid-based therapeutic intervention to prevent stomatitis (Grade ≥2) in breast cancer patients taking everolimus + exemestane.

METHODS: Eligible participants will be patients with HR-positive, HER2-negative advanced breast cancer with no evidence of oral stomatitis or other oral pathology who have been prescribed everolimus + exemestane but have not yet started treatment. A baseline oral assessment will be conducted, and patients will be provided instructions on how to self-monitor for stomatitis, along with instructions to contact the study site at the first sign of oral pain or changes to the oral mucosa. All patients will be instructed to perform routine good oral care. Eligible patients will receive a steroid-based mouthwash (alcohol-free 0.5mg/5ml dexamethasone solution) prophylactically. Patients will be instructed to perform the mouthwash regimen four times per day and swish the mouthwash in mouth for a minimum of 120 seconds before spitting it out. Patients will be instructed to abstain from eating or drinking for at least an hour after taking the mouthwash. Mouthwash regimen will begin on the first day of everolimus after administration of the dose and patients will continue the regimen for the first 4 months of everolimus therapy.

Primary endpoint is the incidence of stomatitis (Grade ≥2) at 2 months defined as meeting at least one of the following criteria: ≤50 on Normalcy of Diet Scale to assess oral intake and a rating of 7 on two consecutive days or a rating of 8, 9 or 10 on any one day using Visual Analog Scale to assess oral pain. Evidence of stomatitis must be confirmed by investigator on physical exam and/or phone call assessment. Secondary endpoints include average number of times per day the mouthwash regimen was performed and time to resolution of stomatitis (Grade ≥2) that occurs during the trial. Assuming a 13% absolute reduction in the rate of grade ≥ stomatitis from the historical control rate of 33% and one sided Type 1 error = 0.05 and power = 80%,73 evaluable patients will be needed. To account for 25% of the total patient population being non-evaluable, 97 patients will be enrolled for this study.

Supported by funding from Novartis Pharmaceuticals Corporation.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-6-14.
Abstract P1-01-07: Pre-operative selection of patients with limited disease of the axilla using ultrasonography of the axilla: Might additional lymph node dissection (ALND) be safely omitted in the future?
Authors: Moorman AM , Bourez R , Heijmans HJ , Kouwenhoven EA
Published: August 2014

Background: The sentinel lymph node biopsy (SLNB) procedure is the method of choice for the identification and monitoring of regional lymph node metastases in patients with breast cancer. In the case of a positive sentinel node additional lymph node dissection is still warranted for regional control, though 40-65% have no additional axillary disease. Recent studies showed that after breast-conserving surgery, SLNB and adjuvant systemic therapy there is no significant difference between recurrence-free interval and overall survival if there are 2 or less positive axillary nodes.

Purpose: Preoperative identification of patients with limited axillary disease (≤ 2 macrometastases) using ultrasonography (US).

Method: Between January 2007 and August 2011, data from 1103 consecutive primary breast cancer patients who underwent surgery in our hospital were collected into a single database. Patients were selected by clinical tumours smaller than 50mm (cT1-2), no palpable adenopathy (cN0) and a maximum of 2 SLNs containing macrometastases. The variable of interest was ultrasonography of the axilla. The population was divided into two groups: the group with 2 or fewer positive nodes and the group with more than 2 positive nodes in the axilla after ALND.

Results: After selection, 1060 patients remained of which 102 (9.6%) had more than 2 positive axillary nodes on SLNB or ALND. Selected by unsuspected US, the chance of having more than 2 positive lymph nodes is substantially lower (4.2%). This is significant on univariate and multivariate analysis. The chance of more than 2 positive lymph nodes was 12.8 times as big in case of a positive axillary US. When we select this subgroup even further by excluding the patients with extra capsular extension (ECE) on SLN, the chance of more than 2 positive lymph nodes is only 2.6%. Subdivided by clinical tumour size the chances are 0.96% in case of cT1 tumour and 7.0% in case of a cT2 tumour. For pathological T-status the numbers are respectively 0.87% en 5.0%. For pT1-2 this is 2.2%.

Conclusion: The risk of more than 2 positive axillary nodes is relatively small in patients with cT1-2 breast cancer. Ultrasonography of the axilla helps in further identifying patients with a minimal risk of additional axillary disease, putting ALND up for discussion.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-07.
Abstract P1-01-22: Which cytologically proven node-positive breast cancer patients can avoid axillary lymph dissection after neaodjuvant chemotherapy?
Authors: Karanlik H , Ilhan B , Fayda M , Yavuz E , Mudun A , Saip P , Eralp Y , Kurul S , Aydiner A
Published: August 2014

BACKGROUND:

It is still controversial whether axillary lymph node dissection can be omitted after negative sentinel lymph node biopsy in breast cancer patients with clinically positive axilla at presentation treated with neoadjuvant chemotherapy (NAC). The aim of this study was to analyze whether SLN biopsy could be useful in these patients.

METHODS:

After NAC of 112 patients with cytology-proven axillary node metastasis at the time of diagnosis, SLNB using radioisotope and blue dye was performed including completion node dissection between 2008 and 2012. The results of SLNB and clinicopathological characteristics were analyzed for correlation with pathological axillary lymph node status.

RESULTS:

SLN was successfully identified in 107 (95.5%) patients. Tumor nonresponse and extensive residual nodal disease were found to be significantly associated with detection failure of sentinel nodes. Axillary status was predicted with 94% accuracy and a false negative rate of 8.7%. Axillary nodal status before NAC (cN2 versus cN12) was associated with higher false-negative rates (p = 0.02). Conversion to node-negative disease was achieved in 38 (35%) patients: 23% of patients with the luminal A subtype, 12% of patients with the luminal B, 39% of patients with the HER2-enriched, and 26% of patients with the triple-negative breast cancer subtype. The tripple negative and HER2-enriched breast cancer subtypes had a significantly better false negative rate and accuracy.

CONCLUSIONS:

SLNB was found to be technically feasible, but its routine use was not recommended for LABCs after NAC. However, acceptable performance was noted for tripple negative and HER2-enriched breast cancer patients presented with N1 axillary status in the beginning of NAC, and thus SLNB might be safely considered in these selected patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-22.
Abstract P1-01-24: Preoperative ultrasound staging of the axilla superfluous peroperative examination of the sentinel node
Authors: Tjalma W , Van Berckelaer C , Van Goethem M , Verslegers I , Van Dam P
Published: August 2014

Background:

Axillary surgery in breast cancer is tailored. The current standard is to perform a frozen section or dep examination of the sentinel node during surgery. If the sentinel node is found positive (≥ macrometastases) a complete axilliary resection is recommended. Preoperative identification of positive nodes will lead to a further improvement of the tailored therapy.

Hypothesis:

A percentage of less than 5% of patients who would needed an additional operation is considered acceptable.

Material and Method:

From 2010 – 2012 all breast cancer patients of the Multidisciplinary Breast Clinic Antwerpen had an ultrasound evaluation of the axilla as part of their staging.

Fine needle aspiration cytology was performed of suspicious lymph nodes. If this showed to be positive, sentinel node biopsy was bypassed. Patients with normal nodes or benign/non diagnostic biopsy had removal of the sentinel node(s) without peroperative pathological examinations.

Results:

A total of 275 breast patients had an ultrasound staging (table 1). The sensitivity, specificity, positive predictive value and negative predictive value was respectively 90%, 85%, 77% and 94%.

Table 1: Ultrasound stagingEchoLN +LN -N1 (n = 117)9027N0 (n = 158)10148

Ten of the 275 patients (3.6%) needed an axillary clearance as a second procedure.

Discussion

Preoperative detection of invaded lymph nodes has several advantages. First of all it will allow you to identify patients with positive nodes, who can participate in neoadjuvant trial. Secondly it will save operating time and avoid overloading of the system for direct examination and reduces tissue loss. This approach will reduce costs for the health system and anesthetic time for the patient, with an acceptable reoperation rate.

Conclusion

Preoperative evaluation ultrasound staging of the axillare lymph nodes will avoid peroperative examination of the sentinel node at an acceptable reoperation rate. It is better for the patient, the physicians and the health care system.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-24.
Abstract P1-01-25: Predictive factors of micrometastases in the sentinel node of patients affected by invasive early breast cancer
Authors: Livi L , Meattini I , Bertocci S , Zei G , Cecchini S , Francolini G , Scotti V , De Luca Cardillo C , Orzalesi L , Casella D , Simoncini R , Nori J , Bianchi S , Biti G
Published: August 2014

Aim: nodal metastatic involvement is the most important prognostic indicator in breast cancer. Sentinel node biopsy led to an increase in the detection of micrometastases. The aim of our analysis was to identify predictive factors of micrometastases and macrometastases of sentinel node.

Materials and Methods: between January 2000 and December 2006, 675 patients were treated with breast surgery and sentinel node evaluation at University of Florence (Florence, Italy). Estrogen receptor status, progesterone receptor status, and Ki-67 labeling index determined with the MIB1 monoclonal antibody were assessed. HER2 immunohistochemistry (IHC) expression was scored as follows: 0, no staining or faint membrane staining; 1+, faint membrane staining in >10% of tumor cells, incomplete membrane staining; 2+, weak to moderate membrane staining in >10% of tumor cells; and 3+, intense circumferential membrane staining in >10% of tumor cells. HER2 scores of 0 and 1+ were considered negative. HER2 IHC 3+ and fluorescent in situ hybridization (FISH) – amplified tumors were considered positive. All IHC 2+ tumors and indeterminate tumors were tested for gene amplification by FISH. The sentinel node was examined by hematoxylin and eosin. The patients were divided into three groups based on AJCC TNM staging: sentinel node negative (n = 601); micrometastases if tumor deposit more than 0.2 mm but <2 mm (n = 20), and macrometastases if tumor deposit more than 2 mm (n = 53).

Results: at the logistic regression with polytomous analyses (outcome micrometastases or macrometastases), age (p = 0.048), menopausal state (p = 0.013), breast quadrant (p = 0.005), lymph vascular invasion (p = 0.0001), post-surgical T stage (p = 0.0001), histotypes (p = 0.023), HER2 status (p = 0.02), Ki-67 proliferative index (p = 0.001) and nuclear grade (p = 0.024) were significantly correlated with sentinel node macrometastases. Sentinel node biopsy technique (cytological aspiration versus histological biopsy) was not associated with micrometastases (p = 0.89) or macrometastases (p = 0.48) occurrence. The only feature significantly associated with micrometastases in sentinel node was the lymph vascular invasion (p = 0.0001).

Conclusion: the presence of micrometastases remained fairly constant over time if compared to macrometastases. In our experience the only feature significantly associated with micrometastases in sentinel node is the lymph vascular invasion.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-25.
Abstract P1-04-10: Assessment of circulating tumor cells (CTC) by RT/PCR as a surrogate marker for PFS in metastatic breast cancer (MBC)
Authors: Saber MM , Bahnasy AA , El-Zawahry HM , Allahloubi NM , El-Moetii MA , Abd El Fatah RM , Aid S , Ghareeb M
Published: August 2014

Background: Despite significant improvements in the treatment of metastatic breast cancer (MBC), it remains an incurable disease. The presence of circulating tumor cells (CTC) predicts for progression free survival (PFS) in (MBC) patients. We hypothesized that the change in level of CTCs can be a good surrogate marker for PFS.

Methods: CTC level was determined by flow cytometry (FCM) in the blood of MBC female patients with measurable or non-measurable evaluable disease excluding CNS metastasis 1) before starting taxanes (Docetaxel or Paclitaxel) regimen, 2) after the first cycle, and 3) at assessment of the disease after 3-4 cycles. The breast origin was further confirmed through assessment of CK19, mammaglobin, prolactin inducible peptide (PIP), aldehyde dehydrogenase 1 (ALDH1) and human chorionic gonadotropin (hCG) in the separated CTCs by quantitative real time PCR (QRT-PCR). CTC level and level of these markers were correlated with the clinical features of the patients, response to treatment and PFS.

Results: Sixty-six female patients were enrolled between May 2010 and Jan. 2011. The median age was 48.9 years and duct carcinoma was the main pathologic subtype. After a median follow up period of 20 months, median PFS was 6 months. There was a very strong relation between the selection marker CK-19 and the breast cancer markers (p value = 0.0001). Patients with baseline CTC < 4 had significantly higher median, 6 months and 1 year PFS when compared with those with CTC ≥ 4 (p value = 0.03) while CTC levels did not correlate with PFS in the 2nd & 3rd samples respectively (p value = 0.28). Also patients whose CTC level decreased after treatment had significantly prolonged median PFS compared to patients whose CTC level increased (10 versus 4 months, p = 0.007).

Conclusions: CTCs; measured by RT-PCR were strongly predictive of PFS in MBC. CTC also could be of a great potential value in early assessment of response to chemotherapy after the 1st cycle especially in non-measurable lesions.

Key Words: Circulating tumor cells, metastatic breast cancer, progression free survival and RT-PCR.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-04-10.