bluuebunny/crossref_metadata_2025 huggingface dataset:
Molecular markers for circulating tumor cells in breast cancer.
Authors: Zeillinger R. , Obermayr E. , Fink-Retter A. , Heinze G. , Reinthaller A. , Horvat R. , Castillo-Tong D. C.
Published: February 2017

223

Background: Recently, we identified a six gene panel (CCNE2, DKFZp762E1312, EMP2, MAL2, PPIC, and SLC6A8) for the RT-qPCR based detection of circulating tumor cells (CTC) in breast cancer patients. The aim of the present study was to evaluate the gene panel in further blood samples.

Methods: Blood samples were taken from breast cancer patients with metastatic disease (MBC, N=10) or with no evidence of disease (NED, N=30). Putative CTC were enriched by Oncoquick density gradient centrifugation. Total RNA was isolated with RNeasy Micro Kit (QIAgen). Template cDNA was generated with M-MLV Reverse Transcriptase, RNase H Minus (Promega) and random nonamers as primers. RT-qPCR was performed in duplicate reactions using TaqMan Assays (Applied Biosystems) with default thermal cycling parameters. Raw data were analyzed with the AB7900 Sequence Detection Software version 2.2.2 using automatic baseline correction and manual cycle threshold setting. Gene expression was normalized to GAPDH expression. A threshold value TX for each gene X was set at two standard deviations above the mean dCtX value in the healthy control group. A patient was defined as CTC-positive, if at least one gene marker was over-expressed compared to the defined threshold.

Results: The gene panel consisting of CCNE2, DKFZp762E1312, EMP2, MAL2, PPIC, and SLC6A8 identified 4/11 MBC but only 5/27 NED patients as CTC positive (p=0.163). By adding known CTC markers (SCGB2A2, TFF1, FXYD3, AGR2, S100A18, and EPCAM) to the panel, 7/11 MBC but only 6/27 NED patients were CTC positive (p=0.018). The presence of CTC in NED patients correlated with pN staging (p=0.026). Only one out of the six CTC positive NED patients relapsed within the observation period (median 35 months, range 25-39 months from blood sampling). We observed no correlation of CTC positivity and recurrence in NED patients.

Conclusions: The sensitivity of the RT-qPCR based CTC detection in breast cancer patients may be enhanced by adding known CTC markers (SCGB2A2, TFF1, FXYD3, AGR2, S100A18, and EPCAM) to the six gene panel (CCNE2, DKFZp762E1312, EMP2, MAL2, PPIC, and SLC6A8). Longer follow-up times are needed to evaluate the predictive value of the gene markers on survival.
Factors affecting lymphovascular invasion in node-positive breast cancer patients.
Authors: Cornwell L. B. , McMasters K. , Chagpar A. B.
Published: February 2017

24

Background: Lymphatic and/or vascular invasion (LVI) is not uniformly reported in breast cancer tumors, and may be absent even in LN+ patients. The purpose of this study was to define factors associated with (a) the non-reporting of LVI, and (b) the finding of no LVI in LN+ patients.

Methods: Data from 400 LN+ patients from a cohort of patients in a prospective multicenter study were reviewed. Institutional and clinicopathologic factors correlating with the reporting and finding of LVI were assessed using non-parametric statistical analysis.

Results: Of the 400 LN+ patients in this cohort, LVI was not reported in 98 (24.5%) patients. Of the remaining 302 patients, LVI was reported as negative in 147 (48.7%). LVI was more often reported in later years (84.9% in 2001-2004 vs. 67.9% in 1997-2000, p<0.001). The reporting of LVI did not vary significantly by region, teaching affiliation, community size, or the surgeon’s proportion of breast practice or number of cases. Further, reporting of LVI was not associated with surgery type, patient age, number of positive nodes, size of largest metastasis, nor extracapsular extension. LVI was, however, more frequently reported in larger tumors (median tumor size 2.0 cm vs. 1.8 cm, p=0.030). Despite the finding that LVI was more frequently reported in later years, the proportion of patients found to have LVI did not vary by year (53.3% in 2001-2004 vs. 49.3% in 1997-2000, p=0.565), region, teaching affiliation, community size, or surgeon practice. LVI positivity was associated with younger age (median age 53 vs. 60, p=0.001), larger tumors (median size 2.5 vs. 1.8 cm, p<0.001), more positive lymph nodes (median 2.5 vs. 1, p<0.001), more macrometastases (58.7% vs. 36.5%, p=0.002), and more extracapsular extension (70.3% vs. 46.0%, p=0.001).

Conclusions: Reporting of LVI has improved in recent years, and while the rate of LVI positivity has not changed in LN+ patients, it remains associated with poor prognostic factors in this cohort. Therefore, reporting of LVI should be encouraged as a standard part of synoptic pathology reports for breast cancer patients, regardless of lymph node status.
The INFORM HER2 Dual ISH assay compared with FISH to determine HER2 gene status in invasive breast carcinoma.
Authors: Loftin I. R. , McElhinny A. , Miller R. , Garcia C. , Bai I. , Ranger-Moore J. , Ostrem J. , Padilla M. , Grogan T. M.
Published: February 2017

25

Background: The HER2 gene, located on chromosome 17 (Chr17), is amplified in 15-25% of patients with invasive breast carcinoma. Amplification and/or HER2 overexpression is associated with poor clinical outcome for these patients; however prognosis is improved if HER2 status indicates eligibility of patients for trastuzumab therapy. Thus, accurate diagnosis of HER2 status through a companion diagnostic is essential. Here we validated the INFORM HER2 Dual ISH Probe Cocktail (Dual ISH) assay as an alternative to FISH, the current gold standard for HER2 testing. The Dual ISH assay is fully automated and is scored using light microscopy.

Methods: A multi-site method comparison and inter-laboratory reproducibility study were performed. 5 sites were used to compare Dual ISH results with FISH (Vysis PathVysion). 510 invasive breast carcinoma cases were stained at 3 clinical sites, FISH staining was performed at a fourth site (central laboratory). IHC status was determined at a fifth site (second central laboratory). In addition, 6 cases were evaluated for inter-site (3 sites), inter-reader (6 readers), inter-run (15 runs) and intra-run (duplicate slides) reproducibility. All assay steps were fully automated on a VENTANA BenchMark XT automated slide stainer, using a HER2 repeat-reduced, dinitrophenyl-labeled probe targeting the HER2 gene, detected with silver metallographic detection, and a digoxigenin-labeled Chr 17 probe, detected by an alkaline phosphatase-driven red chromogenic detection. HER2 and CHR17 signals were enumerated using conventional light microscopy allowing interpretation within the morphological context of the specimen. HER2 status was determined as the ratio of HER2/Chr17, where a ratio <2 is non-amplified and a ratio ≥2 is amplified.

Results: The positive and negative agreement rates with FISH (95% CI) were 96% (92.6-97.9) and 92.3% (88.6-94.8), respectively. The HER2 Dual ISH assay also was highly reproducible in determining HER2/Chr17 ratio across sites, days, readers and runs.

Conclusions: The fully automated INFORM HER2 Dual ISH assay is reproducible and concordant with the manual FISH assay in determining HER2 status in invasive breast carcinoma.
Risk of breast cancer (BC) relapse after 5 years of adjuvant tamoxifen (AT) in estrogen/progestrone-positive (ERP) patients (pts).
Authors: Barzi A. , Sisk B. A. , Yu C. , Budd G. T. , Kattan M. W.
Published: February 2017

253

Background: Current standard of care for pts with ERP BC is 5 years of AT or aromatase inhibitors (AIs). Based on MA17 data, practitioners offer extended adjuvant therapy with AIs to post menopausal women. Extended therapy is costly and has side effects. Identifying pts with higher risk of relapse will allow practitioners to offer extended therapy to selected pts.

Methods: Among 334 pts from the Cleveland Clinic BC surgery dataset, 38 had relapsed (local and systemic) and 39 had died of other causes. The 5 year absolute risk of late recurrence was calculated by cumulative incidence. We used a multivariable competing risks regression (CRR) analysis to determine the association of clinical parameters with late recurrence and treat death from other causes as competing risk. The predictor variables we tried to include are age at surgery, stage, pathology, progesterone receptor status and Charlson Comorbidity Index (CCI). Due to the limited number of recurrences, a parsimonious model with 3 predictors was desired. The model with the highest discrimination accuracy (quantified by Concordance index (CI)) selected as the basis of the final nomogram (ng). The ng was internally validated using ten fold cross-validation. The calibration of the ng prediction was checked visually by plotting the ng predicted risk of 5 year recurrence against the observed cumulative incidence from the data.

Results: The 5-year risk of late recurrence or death from other causes were 0.066 (0.039 – 0.093) or 0.050 (0.026 – 0.073) respectively. The model that included age (<=60 vs > 60), stage (I vs others) and CCI had the highest discrimination (CI = 0.551), on which a final ng was constructed for predicting the 5-year probabilities of late recurrence. In our previous work we showed that CI in Adjuvnat Online (AO) is 0.569. Our calibration curve after ten-fold cross-validation looks comparable to AO model.

Conclusions: We built and internally validated a ng for predicting the absolute probability of late recurrence for pts who completed five-year AT. Given the small size of our data set and the low number of recurrences our ng has fair discrimination and good calibration; however we were unable to outperform AO.
An algorithm for screening and treatment of breast cancer-related lymphedema.
Authors: Lopez Penha T. R. , Heuts E. M. , Tuinder S. , van der Hulst R. , von Meyenfeldt M. F.
Published: February 2017

256

Background: Currently, there is no clear-cut regimen for the treatment of breast cancer related lymphedema. There is evidence advocating both conservative and micro surgical therapy, with treatment effectiveness being dependent on the lymphedema stage. We propose a multidisciplinary screening program with the aim of preventing breast cancer related lymphedema progression and ensure disease regression by early identification and treatment initiation. This approach would ultimately reduce the negative functional, psychosocial and cosmetic consequences resulting from (chronic) lymphedema.

Methods: All women with early stage breast cancer are included in this screening program. We use preoperative and sequential postoperative bilateral upper limb circumference measurements and patient perception to identify lymphedema. A difference of > 2cm between post-operative and baseline circumference and patient perception of (refractory) swelling constitutes a diagnosis of lymphedema. Upon lymphedema diagnosis, patients are referred to a lymph therapist for initiation of conservative therapy in the form of complex decongestive physiotherapy. Therapy effect is evaluated after 1 month. In case of unsatisfactory symptom or limb circumference reduction, the patient is considered for surgical treatment. A plastic surgeon evaluates the possibility of microsurgical lymph vessel repair in the form of lymphatic-venous anastomoses or lymphatic-venous-lymphatic anastomoses. This minimal invasive surgery can improve lymph flow in the affected limb. If despite this, symptom improvement and patient satisfaction remains minimal, autologous lymph node transplantation is considered.

Results: The aimed outcome parameters are 1) limb circumference reduction, 2) perceived symptom improvement: (refractory) swelling, 3) quality of life improvement, 4) limb range of motion improvement, 5) strength and sensory improvement, 6) restoration/improvement of lymph flow visualized by lymphoscintigraphy.

Conclusions: A structured approach for a multidisciplinary treatment of breast cancer related lymphedema is proposed to reduce the negative functional, psychosocial and cosmetic consequences resulting from (chronic) lymphedema.
A study of atherosclerosis in patients after radiation for early breast cancer.
Authors: Kirtani V. G. , Chang M. , Dobrescu A. M. , Zeldis S. , Haas J. A. , Hindenburg A. A.
Published: February 2017

260

Background: Radiation therapy (RT) is widely used as part of curative treatment of breast cancer. However, older studies have shown increased cardiac morbidity and mortality from breast RT. A screening method is needed to detect early cardiac damage in this population. Recent data have shown that Electron beam computed tomography (EBCT) can detect early atherosclerosis in coronary arteries by identifying the amount of calcification in the coronaries. In our study we employed this tool to detect occult atherosclerosis caused by breast RT.

Methods: We evaluated 20 asymptomatic patients, less than 60 years of age, treated with RT at least 5 years prior to enrollment. Nine received RT to the left and 11 to the right hemithorax. Average interval between RT and CT was 7.7 years (5-14). All patients were treated with external beam RT using tangential technique. The breast was treated to a dose of 4500-5040 cGy and the tumor bed was boosted to a total dose of 6000-6600 cGy. All patients underwent EBCT to compute the volumetric and agatston calcium scores in the coronary arteries and the aorta.

Results: Of the 11 patients who had RT to right hemithorax, 8 had calcium score of 0, 2 had very minimally elevated scores and 1 had significantly elevated score (patient 19, interval -14 years). Of the 9 patients who had RT to left hemithorax, 7 had calcium score of 0. None had significantly elevated scores. In the aorta, 11 patients had score of 0 and 8 had minimally elevated scores.

Conclusions: Occult atherosclerosis was not detected using EBCT calcium scores in coronaries and aorta in a significant number of patients treated with RT for breast cancer. However, the study is limited by a small sample size.

[Table: see text]
PTEN expression in Palestinian women with breast cancer, particularly in triple-negative subtype.
Authors: Khatib A. A. , AL Abed M. N.
Published: February 2017

27

Background: According to data from the Palestinian Ministry of Health, breast cancer is the most common malignancy affecting Palestinian women, being 30% of all cancers affecting female patients, 60% of them present with metastasis, very few studies were conducted to explore characteristics of this cancer in this population. Triple-negative breast cancer (TNBC) has distinct clinical and pathologic features. The fact that this type is more aggressive despite lacking the expression of growth promotion receptors, suggest other players, as defect in tumor suppressors such as PTEN gene. To our knowledge this is the first study in English literature correlating TNBC to loss of PTEN protein expression. The aim of this study is to establish data about the clinicopathological characteristics of breast cancer in Palestinian women, and to study the status of PTEN protein expression by immunohistochemistry in breast cancer and specifically in TNBC.

Methods: 100 confirmed cases of breast cancer, were collected from different pathology centers, clinicopathological data; age, grade, stage for each case were specified. Each case was evaluated for the expression of hormone receptors, Her-2 status, and for PTEN protein expression by immunohistochemistry (IHC) to see if a certain pattern is noted.

Results: Out of the 100 cases, the mean age at presentation was 53.3 years, 69.84% of the cases presented with advanced stage and 53% were high grade, 58% were ER positive and 46% were PR positive. HER-2 positive breast cancer were 26%. 30% of all breast cancer cases were TNBC subtype. Loss of PTEN expression was seen in 44% of cases. 60% of TNBC cases lost PTEN expression, which was statistically significant (p + 0.035), no significant correlation between PTEN loss and ER, PR, HER-2, grade or stage.

Conclusions: Palestinian women have high incidence of TNBC in comparison to White population, and presented with high grade, and advanced stage tumors. There is a significant correlation between PTEN loss and TNBC that needs more research and study.
Relationship between taxane-induced neuropathy and clinical outcomes after adjuvant chemotherapy.
Authors: Schneider B. P. , Wang M. , Stearns V. , Martino S. , Jones V. E. , Perez E. A. , Saphner T. J. , Wolff A. C. , Sledge G. W. , Wood W. , Davidson N. E. , Sparano J. A.
Published: February 2017

270

Background: Neuropathy is a common and potentially enduring and disabling complication of adjuvant taxane therapy. Recent studies have identified candidate host single nucleotide polymorphisms (SNPs) associated with taxane-induced neuropathy (Schneider et al. ASCO 2011, abstr. 1000). We therefore sought to determine whether neuropathy was associated with breast cancer recurrence.

Methods: This study included 4,950 eligible women with axillary lymph node positive or high-risk node-negative breast cancer who received up to 4 cycles of AC (doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2) every 3 weeks, followed by either: (1) paclitaxel 175 mg/m2 every 3 weeks x 4 (P3), (2) paclitaxel 80 mg/m2 weekly x 12 (P1), (3) docetaxel 100 mg/m2 every 3 weeks x 4 (D3), or (4) docetaxel 35 mg/m2 weekly x 12 (D1). Chemotherapy doses were based on actual body weight. Cox proportional hazards model were used to determine the relationship between neuropathy and disease free survival (DFS) and overall survival (OS) treating neuropathy status as a time dependent covariate and using a landmark analysis.

Results: Of 4,702 patients who received at least 1 taxane dose, grade 2-4 neuropathy developed in 20%, 27%, 16%, and 16% in the P3, P1, D3, and D1 arms, respectively. In a model including age, tumor size, nodal status, treatment arm, neuropathy, and the neuropathy- treatment interaction, there was no relationship between neuropathy and DFS and OS in the entire population, for any of the individual treatment arms, or for any breast cancer subtypes, whether analyzed as a time-dependent covariate or using a landmark analysis. Baseline covariates associated with an increase rate of neuropathy included black race (25% vs. 19% grade 2-4, p=0.02) and obesity (21% vs. 19%, p=0.04), but not age.

Conclusions: There was no association between taxane-induced neuropathy and DFS or OS in patients treated with contemporary AC-taxane therapy, including weekly paclitaxel. These findings show that taxane-induced neuropathy is not associated with outcome, thus suggesting that validation of SNPs predictive of neuropathy may be useful in identifying patients at higher risk for neuropathy but not taxane benefit and thereby improve therapeutic individualization.
Effect of denosumab versus zoledronic acid on health-related quality of life in patients with metastatic breast cancer.
Authors: Fallowfield L. , Patrick D. , Body J. , Lipton A. , Tonkin K. S. , Qian Y. , Jiang Q. , Braun A. H. , Dansey R. D. , Chung K.
Published: February 2017

272

Background: Patients with breast cancer and bone metastases often experience skeletal-related events (SREs) and pain, which can impact health-related quality of life (HRQoL). Denosumab is superior to zoledronic acid (ZA) in preventing SREs and more effective in delaying moderate or severe pain in patients with advanced breast cancer. We now describe the effect of denosumab or ZA treatment on HRQoL in these patients.

Methods: Patients enrolled in this double-blind, double-dummy study were randomized to receive denosumab (120 mg SC) or ZA (4 mg IV) every 4 weeks. Patients completed the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire at baseline (BL), day 8, and each monthly visit to assess overall HRQoL. Higher scores (range 0 to 108) reflect a better HRQoL. Changes in HRQoL were summarized through month 18, when 30% of patients had died or dropped out due to disease progression or withdrawal of consent. Increases or decreases of ≥ 5 points in the FACT-G total score were considered clinically meaningful. Pain was evaluated by the Brief Pain Inventory–Short Form (BPI-SF). HRQoL was assessed in subgroups with no/mild pain or moderate/severe pain at BL.

Results: The BL mean (SD) FACT-G score was similar for denosumab (n = 956) 72.7 (16.4) and ZA (n = 952) 73.6 (16.5) groups and increased from BL to month18 for both groups reflecting improved HRQoL. An average of 3.2% more (range 0.9% to 6.8%) denosumab-treated patients than ZA-treated patients experienced a ≥ 5-point increase in HRQoL from months 1 to 18. Fewer denosumab than ZA-treated patients reported a ≥ 5-point decrease in HRQoL (average 2.7% fewer; range 0.6% to 5.8%). Among patients with no/mild pain at BL, an average of 4.1% more (range -0.6% to 9.3%) denosumab-treated patients had a ≥ 5-point increase in FACT-G score from month 4 to 18. In this same subgroup, fewer denosumab-treated patients had a ≥ 5-point decrease in HRQoL over 18 months (average 2.4% fewer; range -4.4% to 6.3%). Similar patterns in FACT-G scores were noted for the subgroup with moderate/severe pain at BL.

Conclusions: In patients with advanced breast cancer, a greater proportion treated with denosumab than ZA had a meaningful improvement in HRQoL regardless of BL pain level.
Antiestrogenic effects of the natural fetal estrogen estetrol (E4) in women with estrogen-receptor-positive early breast cancer.
Authors: Singer C. F. , Natter C. , Steurer S. , Moinfar F. , Visser M. , Appels N. , Kubista E. , Coelingh Bennink H.
Published: February 2017

280

Background: Estetrol (E4) is a fetal estrogen which exerts estrogenic effects on vaginal epithelium, hot flushes and bone, but has estrogen-antagonistic effects on breast cancer cell lines in vitro and in the rat DMBA model. Therefore E4 may be suitable for Hormone Replacement Therapy (HRT) in women with breast cancer including women treated with aromatase inhibitors.

Methods: We have investigated the effect of 14 days pre-operative treatment with 20 mg E4 per day on proliferation, apoptosis, ER-receptors and sex steroid levels in a prospective, randomised, double-blind, placebo-controlled, neo-adjuvant study in 15 pre- and 15 postmenopausal women with estrogen-receptor positive early breast cancer.

Results: Estetrol induced a significant increase of SHBG, a significant decrease of FSH in postmenopausal women and no increase of gonadotrophins in premenopausal women. Estetrol had no effect on Ki67 expression and on apoptosis-related Bax and Bcl-2, but the apoptosis index in tumor tissue increased significantly. Systemic IGF-1 levels decreased significantly. Surprisingly the intratumoral epithelial ER-alpha expression decreased significantly, whereas the ER-beta expression showed a trend to increase.

Conclusions: This data show that E4 has estrogenic endocrine effects. The data support the hypothesis that E4, may be suitable and safe for HRT in women with spontaneous or induced menopausal symptoms, since apoptosis increases, IGF-1 decreases and no unfavourable effects are observed on Ki67, Bax and Bcl-2. The decrease of ER-alpha and the increase of ER-beta suggest a mechanism of action, explaining why the natural fetal estrogen E4 has estrogen-antagonistic effects on breast cancer tissue.
Safety of adjuvant trastuzumab (T) in elderly patients with breast cancer.
Authors: Militello L. , Carli P. , Spazzapan S. , Lestuzzi C. , Miolo G. , Scalone S. , Veronesi A. , Crivellari D.
Published: February 2017

282

Background: T is a mainstay in adjuvant therapy for HER2+ breast cancer (BC) patients (pts). Safety and efficacy of T in elderly patients are largely unknown. In HERA trial, NSABP B-31, NCCTG N9831 only 16% of pts were older than 60 years. Risk factors for T related cardiotoxicity are age (>50 y/o), hypertension, baseline LVEF (left ventricular ejection fraction <55%), previous antracycline therapy and BMI.

Methods: Charts of pts >65 y/o with early HER2+ BC treated with T as adjuvant or neoadjuvant therapy at our institution were retrospectively reviewed. Primary endpoint was the evaluation of T cardiac toxicity and safety.

Results: 22 elderly out of 172 pts (12%) were identified: 19 pts were treated only with surgery and adjuvant chemotherapy with concomitant or sequential T, 3 more pts also received neoadjuvant chemotherapy concomitant with T. According to Balducci’s criteria, fit, vulnerable and frail pts were 20, 2, 0 respectively. Median age was 69 y/o (range 65-76). Hormonal status was negative in 10/22 (45%). 21/22 were histologic grade 3. Median follow-up was 33 months. Baseline comorbidities were the following: hypertension (G2-3) in 17 pts, diabetes mellitus in 1, supra/infraventricular arrhythmia (G1-2) in 3 and 1 pts. Antracyclines were administered in 16 pts (liposomal-doxorubicin in 5 pts), a sequential taxane-regimen was used in 3 more pts. Neoadjuvant weekly Paclitaxel and concomitant T was used in 3 pts. Median basal LVEF was 65% (range 59-74%). 2 pts developed an asymptomatic 10% LVEF drop from baseline (left ventricular systolic dysfunction G1) during T treatment. Known cardiac risk factors were hypertension in 1 pt and previous antracycline based chemotherapy in both. They recovered within 9 months. One minor adverse event was atrial fibrillation (G2) during T treatment.

Conclusions: T was well tolerated in elderly pts. More data are needed in order to understand the correlations between T related toxicity and cardiovascular risk factors. Long term safety of T treatment should verify the reversibility of cardiac T related toxicity on elderly pts.
Standardized uptake value (SUV) by positron emission tomography/computed tomography (PET/CT) as a prognostic variable in metastatic breast cancer (MBC).
Authors: Jhaveri K. L. , Ulaner G. , Fazio M. , Eaton A. , Patil S. , Evangelista L. , Serna-Tamayo C. , McArthur H. L. , Hudis C. , Morris P. G.
Published: February 2017

3

Background: The accurate prediction of outcome from MBC could be useful if it could guide more effective therapies. Because PET/CT combines anatomical with functional imaging it could enable greater individualization of treatment. However, there is substantial SUV variation by anatomic site. In this retrospective, single-institution study, we examine baseline SUV on PET/CT as a predictor of outcome from MBC.

Methods: Patients (Pts) with ≥1 metastatic lesion on PET/CT performed ≤60 days of diagnosis of MBC from 01/01/2001-12/31/2008 were identified through institutional databases. Pts who rcvd chemotherapy within 30 days prior to PET/CT were excluded. Electronic medical record reports were reviewed and maximum SUV (SUV-MAX) by site for lesions in bone, liver, lung and lymph node (LN) was recorded. In a secondary analysis, PET/CT scans were reviewed and SUV-MAX recalculated. Relationships between SUV-MAX and OS were assessed using Cox regression by site.

Results: We identified 285 pts, median (med) age 57 yrs (range 27-90) who had PET/CT at med of 2.3 yrs (range 0–41) from primary BC (67% ER+ and 21% HER2+). Med time between PET/CT and MBC diagnosis was -9 days (range -58–59). At med follow-up of 53 mths, 163 pts have died. Med OS is 41 mths (95%CI 34-48). The SUV-MAX by site was; bone (N=159) med 7.0 (range 2.1–29.6); liver (N=55) med 8.2 (range 2.9–51.2); lung (N=89) med 4.7 (range 1.1–24.0); LN (N=180) med 6.9 (range 1.2–34.0). On univariate analysis, higher SUV in bone was associated with shorter survival (p<0.001; table). This was maintained in multivariate analyses after adjusting for known prognostic variables (p=0.02). A similar trend for shorter survival for higher SUV was noted in liver (p=0.07). However, no relationship between SUV and OS was noted in lung (p =0.34) and LN (p=0.6).

Conclusions: This large retrospective study of pts with chemotherapy-naïve MBC suggests that SUV-MAX in bone strongly correlates with prognosis.

[Table: see text]
HOXB9, a gene promoting tumor angiogenesis and proliferation, as a prognostic factor in breast cancer.
Authors: Seki H. , Hayashida T. , Jinno H. , Hirose S. , Takahashi M. , Mukai M. , Kitagawa Y.
Published: February 2017

33

Background: We demonstrated that HOXB9, a member of homeobox genes, expression promoted tumor neovascularization and metastasis in vitro and in vivo assay. These findings imply that overexpression of HOXB9 contributes to tumor progression through activation of signaling pathways that alter both tumor-specific cell fates and tumor-stromal microenvironment, leading to increased invasion and metastasis. (Hayashida et al., PNAS 2010) We sought to determine whether these results could be extended to the clinical application. In this study, we evaluated the correlation between HOXB9 expression, clinical outcomes, and the clinicopathological variables in breast cancer patients, and the contribution of HOXB9 expression to tumor cell proliferation and angiogenesis.

Methods: A consecutive series of 141 patients with invasive ductal carcinoma who underwent surgical treatment were examined. HOXB9 protein expression was analyzed immunohistochemically using the anti-human HOXB9 polyclonal antibody. Immunostaining of Ki-67, CD31, and CD34 were performed to evaluate the association of proliferation and tumor angiogenesis with HOXB9 expression.

Results: Of 141 tumor specimens immunostained for HOXB9, 69 specimens (48.9%) were positive staining. Univariate logistic regression revealed ER and PgR negativity, HER2 positivity, high nuclear grade, and large pathological tumor size as significant variables associated with HOXB9 expression. Moreover, 12 (92.3%) out of 13 triple negative breast cancer showed HOXB9 expression. The disease-free survival (DFS) and the overall survival were significantly different between the HOXB9 positive and negative group; HR=20.714, p=0.001, HR 9.206, p=0.003, respectively. A Multivariate analysis indicated that HOXB9 expression was the only independent prognostic factor for DFS (HR=15.532, p=0.009). In subgroup analysis, HOXB9 positive tumors showed a significant increase in the number of vasculature and the Ki-67 ratio in comparison with HOXB9 negative.

Conclusions: Our results suggest that HOXB9 expression promoting the tumor proliferation and the angiogenesis is a significant prognostic factor in breast cancer.
The effect of statins on overall survival of breast cancer.
Authors: Mozayen M. , Omaira M. , Kanaan M. , Ahmad A. , Katato K.
Published: February 2017

34

Background: Observational studies have raised the possibility that use of statins may reduce the incidence and overall risk of cancer. In contrast, some randomized trials have consistently shown no effect of statins at cancer incidence or mortality. However, data about the potential effect of statins on overall survival of breast cancer are limited. We intend to examine the role of statins at overall survival of women diagnosed with breast cancer.

Methods: A retrospective observational study was conducted from 1993 to 2007, using data from McLaren Regional Medical Center in Flint, Michigan on women diagnosed with breast cancer. Patient's characteristics including age at diagnosis, race, stage and use of statin with dosage were recorded. Patients with coronary artery disease were excluded to eliminate the confounding effect. The three-year overall survival was considered the primary outcome. Results:s A total of 392 women diagnosed with breast cancer were identified. 146 patients were on statins therapy prior to diagnosis (group 1), and 246 patients were not on statins (group 2). African American percentage was 7%. Mean age at diagnosis was 65 for both groups. Atorvastatin was the most used treatment with a dose of 20 mg daily. Patients were classified according to the TNM staging system of breast cancer as stage I, II, III, IV (58%, 31%, 8%, 3%) for group 1, and (62%, 32%, 4%, 2%) for group 2 respectively. The 3-year stage-specific survivals were calculated and compared between the two groups using Fisher's exact test (Table). Overall survival was not statistically significant between the two groups.

Conclusions: Our study did show that statins do not affect the three-year overall survival of breast cancer at early stages, but it may improve the outcome at advanced stages. A larger national data review is warranted.

[Table: see text]
Frequency distribution of SPARC in triple-negative breast cancer patients.
Authors: Basu G. , Van Vickle G. , Ghazalpour A. , Ashfaq R. , Gatalica Z. , Blevins R. , Arguello D. , Brisbin L. , Roberts C. , Loesch D. , Bender R.
Published: February 2017

37

Background: SPARC (secreted protein acid rich in cysteine) belongs to a group of extracellular matrix proteins and promotes adhesion of cells from the matrix. It plays an important role in tumor development in breast cancer and has a significant bearing on patient prognosis and long term survival. It is also known to predict response to nab-paclitaxel in certain tumor types including breast cancer. In 2005, FDA approved a solvent free formulation of paclitaxel for the treatment of metastatic breast cancer that utilizes albumin bound (nab) technology (nab-paclitaxel). Clinical studies have shown that nab-paclitaxel is significantly more effective than paclitaxel. Our study evaluated the frequency distribution of SPARC among triple negative breast cancer patients in which identification of a novel therapeutic target is warranted.

Methods: In a total of 951 breast cancer patients, we analyzed tumor SPARC expression by immunohistochemistry (IHC) using a monoclonal (R&D Systems) and a polyclonal antibody (Exalpha Biologicals). Immunoreactivity was assessed by scoring the percentage of cells stained in each field and by the intensity of staining. A cutoff point of 2+ and >30% stained tumor cells were considered as positive.

Results: From our analysis of 951 breast cancer patients profiled, a total of 165 patients (17%) were triple negative for ER, PR and HER2. Within this pathologic subtype, 29% patients stained positive with SPARC monoclonal antibody and 21% stained positive with SPARC polyclonal antibody. The correlation of SPARC tumor staining with hormone receptor status will be presented in detail.

Conclusions: We conclude that SPARC over-expression is a functionally important feature of a subset of triple negative breast cancer patients. The triple negative subset of tumors generally has a more aggressive clinical course and does not benefit from conventional targeted therapies. Our study suggests that nab-paclitaxel may serve as a therapeutic agent for the subset of triple negative patients that over-express SPARC. To the best of our knowledge, this is the first study involving a large patient pool in which SPARC has been investigated in a single clinical laboratory using standardized IHC with two different SPARC antibodies.
Re-evaluating the efficacy of axillary ultrasound in the detection of nodal metastasis and its impact on clinical practice.
Authors: Lee B. , Lim A. , Krell J. , Satchithananda K. , Lewis J. S. , Stebbing J. , Meric-Bernstam F.
Published: February 2017

4

Background: Recent reports have indicated a lack of overall survival benefit for axillary node dissection versus sentinel lymph node biopsy in early breast cancer. To study this further, we wished to assess the accuracy and effectiveness of ultrasound guided fine needle aspiration (FNA) cytology in detecting lymph node involvement in breast cancer patients, in order to refine and evaluate our current clinical pathways as newly diagnosed invasive breast cancer patients routinely undergo pre-surgical axillary ultrasound.

Methods: An FNA was taken from nodes of consecutive patients, which appeared abnormal on ultrasonography based on size, morphology, fatty hilum and cortical thickness measurements. Ultrasound and FNA cytological findings were correlated with histology following axillary node dissection. Of 260 cases, 123 (47.3%) had metastatic nodal involvement. Of these cases, only 66 (53.7%) were reported as positive on US findings.

Results: The overall positive predictive value (PPV) of ultrasound for detecting metastatic nodal involvement measured 0.82, and the negative predictive value (NPV) was 0.60. The sensitivity was 0.54, specificity measured 0.85 and the accuracy was 0.68. The ultrasound morphological nodal features with the greatest correlation with malignancy were absence of a fatty hilum (p=0.003) and an increased cortical thickness (p=0.03). Cases with a metastatic nodal burden density of a least 20% were also more likely to be detected as abnormal on axillary ultrasound. (p=0.009).

Conclusions: Axillary ultrasound has a low NPV and negative sonographic results do not exclude node metastases with sufficient sensitivity in most cases, to justify its routine clinical use.

[Table: see text]
Combined use of MammaPrint and molecular subtyping profile (BluePrint) to identify subgroups with marked differences in response to neoadjuvant treatment.
Authors: Stork-Sloots L. , De Snoo F. , Roepman P. , Krijgsman O. , Bernards R. , Glas A.
Published: February 2017

42

Background: Concordance between the IHC receptor status and the molecular subtype suggests that molecular profiles represent oncogenic processes that are driven by pathways in which ER, PR and HER2 play pivotal roles. It is, therefore, likely that the use of gene expression arrays will enable the identification of previously unappreciated subtypes of breast cancer that differ in clinical outcomes.

Methods: The cohort consists of 133 (T1-4, N0-3) breast cancer patients treated with T/FAC neoadjuvant chemotherapy. Genome wide expression data was publicly available and downloaded from bioinformatics.mdanderson.org/pubdata.html. The data was used to determine the response to T/FAC neoadjuvant chemotherapy for patients stratified by MammaPrint and molecular subtype (BluePrint). The MammaPrint and BluePrint result were used to subtype the patients into 4 groups: MammaPrint Low-risk/Luminal-type, MammaPrint High-risk/Luminal-type, Basal-type and ERBB2-type.

Results: Within this patient cohort, 20% (n=27) were classified as Basal-type, 62% (n=82) as Luminal-type, and 18% (n=24) as ERBB2-type. The overall pCR of this patient cohort was 26% and differed substantially among the subgroups. pCR was observed in 9% of all Luminal-type samples (i.e. 3% of MammaPrint Low Risk/Luminal-type and 11% of MammaPrint High Risk/Luminal-type), in 50% of the ERBB2-type samples and in 56% of the Basal-type samples. The pCR rates observed for the ERBB2-type and Basal-type patient groups were higher compared to classification based on IHC/CISH assessed ER and HER2 receptor status: 50% for ERBB2-type versus 39% for HER2+ and 56% for Basal-type versus 47% for ER-/HER2- samples.

Conclusions: We observed marked differences in response to neo-adjuvant treatment in groups stratified by MammaPrint and BluePrint. These findings confirm differences in chemotherapy response among molecular subgroups and indicate that the BluePrint profile described here will help to further establish a clinical correlation between molecular subtyping and treatment response.
Does mammography affect the nodal status at presentation in 40- to 49-year-old breast cancer patients?
Authors: Hopkins L. , Chang S. H. , Kirstein L. J. , Fulop T. , Malamud S. C. , Chadha M. , Boolbol S. K.
Published: February 2017

55

Background: It has previously been demonstrated that mammographically-detected breast cancers present as earlier stage disease than those detected as a palpable finding. In addition, it is well known that the single most important prognostic indicator in breast cancer is lymph node status. The benefit of screening mammography in women age 40-49 has been questioned recently, and has led to a change in the recommendations by the United States Preventative Services Task Force (USPSTF) to begin screening mammography in the average risk woman at age 50, rather than 40. In this study, we sought to determine whether detection of breast cancer in 40-49 year old women by screening mammography is associated with negative nodal status at presentation.

Methods: A prospectively collected database was reviewed to identify 460 women ages 40-49 diagnosed with invasive breast cancer from 2003-2008. The method of detection of the breast cancer was noted, and the lymph node status at presentation was identified.

Results: There were 460 eligible patients with invasive breast cancer for whom information regarding nodal status was available. Of these, 205 patients were diagnosed with a mammographic finding, and 255 patients presented with a palpable abnormality. In the group whose cancers were detected on mammography, 18% presented with lymph node metastases. This is significantly lower than the 41% who presented with a palpable finding (p<0.0001). For 40-49 year old women with invasive breast cancer, the likelihood of having a positive lymph node at presentation is 3.2 times higher if her cancer is detected as a palpable abnormality rather than on mammography (odds ratio) (CI: 2.1-5.0) (Table).

Conclusions: Our analysis demonstrates that a patient diagnosed with invasive breast cancer in her 40s is more likely to present with lymph node metastases if her cancer is detected as a palpable mass, compared to those detected on mammography. This has certain prognostic importance, and provides an additional rationale for performing screening mammography in women of this age group.

[Table: see text]
Responsiveness of adjacent ductal carcinoma in situ and changes in HER2 status after neoadjuvant chemotherapy/trastuzumab treatment in early breast cancer: Results from the GeparQuattro study (GBG 40).
Authors: Von Minckwitz G. , Darb-Esfahani S. , Loibl S. , Huober J. B. , Tesch H. , Solbach C. , Holms F. , Eidtmann H. , Diedrich K. , Just M. , Clemens M. , Hanusch C. , Schrader I. , Henschen S. , Hoffmann G. , Tiemann K. , Diebold K. , Untch M. , Denkert C.
Published: February 2017

6

Background: Adjacent ductal carcinoma in situ (DCIS) is in found in approximately 45% of invasive ductal carcinomas (IDC) of the breast. Pure DCIS overexpresses HER2 in approximately 45%. There is uncertainty whether adjacent DCIS impacts on the response to neoadjuvant chemotherapy and trastuzumab as well as whether HER2 expression in IDC component or adjacent DCIS changes throughout treatment.

Methods: Core biopsies and surgical tissue from participants of the GeparQuattro study with HER2-positive IDC were centrally examined for the area of invasive ductal component and adjacent DCIS before and after receiving neoadjuvant anthracycline-taxane-trastuzumab containing chemotherapy. HER2 overexpression in IDC and adjacent DCIS was quantified separately by immunohistochemistry using the Ventana automated staining system. Pathological complete response (pCR) was defined as no residual invasive or non-invasive tumor tissue.

Results: Fifty nine (37.3%) of 158 IDCs presented with adjacent DCIS at diagnosis. These tumors showed lower regression grades than pure IDC (p=0.033). Presence of adjacent DCIS was an independent negative predictor of pCR (odds ratio 0.42 [95% CI 0.2-0.9], p=0.027). Adjacent DCIS area decreased from pre-treatment to surgery (r=0.205) with 30 (50.8%) IDCs with adjacent DCIS showing complete eradication of adjacent DCIS. HER2 status of adjacent DCIS was highly correlated with HER2 status of IDC component before (r=0.892) and after treatment (r=0.676). Degree of HER2 overexpression of the IDC component decreased in 16 (33.3%) out of 49 patients without a pCR. These 16 IDCs showed lower RGs compared to the 33 IDCs with unchanged HER2 expression (p=0.055).

Conclusions: HER2-positive IDCs with adjacent DCIS is less responsive to neoadjuvant chemotherapy and trastuzumab compared to pure IDC. However, complete eradication of adjacent DCIS is frequently observed. HER2-overexpression of the invasive ductal component decreases in a subset of tumors, which showed less tumor regression.
Loss of B-cell translocation gene 2 in estrogen receptor–positive breast cancer and tamoxifen resistance.
Authors: Hayashida T. , Jinno H. , Takahashi M. , Kitagawa Y.
Published: February 2017

63

Background: The expression analysis in ER positive human breast cancer already demonstrated the loss of nuclear expression of BTG2, the cell cycle regulator, in 46% of tumors and showed a significant inverse correlation with cyclinD1 expression. Our analysis of Oncomine database suggested that BTG2 expression might be related to the clinical outcome in patients with tamoxifen treatment.

Methods: The examinations to evaluate whether BTG2 expression affects the sensitivity against tamoxifen were conducted both in vitro and in vivo.

Results: In vitro cellular proliferation assay using tamoxifen against ER positive cell lines revealed that T47D expressing high level of endogenous BTG2 showed more drug sensitivity than MCF7 expressing low level of BTG2. (MCF7; IC50=4.48uM, T47D; =1.31uM) Tetracycline-inducible BTG2 expression model was developed in MCF7 and the cellular proliferation was strongly inhibited by the concomitant administration of tetracyclin and tamoxifen in vitro. Then, the cell line was injected into the mammary fat pad of immunodeficient mice. After the tumors grew more than 125mm3, these tumor bearing mice were administered the water including tetracyclin and/or tamoxifen pellet for 3 weeks. Tumor growth ratio was significantly suppressed in the concomitant administration of tetracyclin and tamoxifen in comparison with the animal treated with single agent. (p=0.044) Consistently, tumor weight and Ki67 expression were also significantly suppressed in the mice administered both tamoxifen and tetracyclin. (BW; p=0.034, Ki67; p=0.039) The cohort of 60 patients treated with adjuvant tamoxifen monotherapy was available online. Comparison of disease-free survival (DFS) of patients with positive BTG2 expression versus patients with loss of BTG2 expression revealed an univariate association in the dataset (log-rank probability, p=0.029). Multivariate analysis indicated that BTG2 expression resulted an independent prognostic factor for DFS (HR, 0.69; 95% CI, 0.495 to 0.963; p=0.029).

Conclusions: Despite further validation studies need to be conducted, BTG2 expression may be useful biomarker to identify patients appropriate for tamoxifen treatment.
A noninvasive multimodal sono-contrast NIR spectroscopy system for breast cancer diagnosis: Clinical trial.
Authors: Yan K. , Yu Y. , Liao L.
Published: February 2017

68

Background: A noninvasive multimodal sono-constrast spectroscopy system was developed to detect breast cancer from benign mass. An IRB approved clinical study has been carried out to evaluate its diagnostic power. Fourteen patients with histologically-proven cancer and 26 with benign mass were enrolled with informed consent.

Methods: This system combines three modules: diffuse reflectance spectroscopy, ultrasonography and low intensity focused ultrasound (LIFU). It reports the optical functional difference in cancer and benign mass after transient LIFU interaction with vascular flow. The optical intensity and LIFU signals were collected during each study. The ratio of optical intensities at wavelengths 685 nm and 830 nm was decomposed into low frequency and high frequency components using wavelet analysis.

Results: Comparison of the high frequency component showed that LIFU stimulated transitory fluctuation in benign mass, but not in malignant tissue, as quantified by mean absolute deviation (MAD). The ratios of MAD during LIFU vs. baseline in cancer and benign mass are [mean (max/min/std)] 2.04 (3.27/1.41/0.43) and 3.00 (4.29/1.86/0.62). This suggests that high frequency fluctuation was amplified in benign mass during LIFU stimulation. There are a few outliers due to poor patient setup or patient movement during procedure. The MAD ratios are significantly different in cancer vs. benign mass (p<<0.01). An ROC curve was generated by varying threshold MAD values. The area under ROC curve (AUC) was calculated to be 0.91. With threshold 2.3, sensitivity of 92.8% and specificity of 80.8% can be achieved. Backward stepwise regression study reveals that system performance is not affected by patient age (hormone status), tumor depth and tumor size.

Conclusions: Current results demonstrate the effectiveness of the multimodal system in characterizing breast cancer vs. benign mass. LIFU appears to exert more pronounced influence on blood flow in benign mass than in tumor. This lack of response to LIFU in breast cancer is possibly due to its abnormal blood vasculature. The analysis is ongoing to incorporate ultrasound imaging parameters with spectroscopy to further improve the diagnostic power.