Conditions: Ductal Carcinoma in Situ
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 9
Healthy volunteers: yes

Brief summary:
This will be a proof of principle clinical trial to evaluate the use of pasireotide (SOM230) in women with ductal carcinoma in situ (DCIS) of the breast. Surgery and radiotherapy are used as treatment for DCIS and subsequent treatment with antiestrogens has been effective in reducing the occurrence of invasive breast cancer. Unfortunately, treatment with antiestrogens carries potential serious side effects and toxicities that are intolerable to some patients. Preliminary data suggest that inhibition of IGF-1 action in the breast will be at least as effective as tamoxifen. Pasireotide is a somatostatin analog that prevents mammary development by inhibiting IGF-1 action directly in the mammary gland and also indirectly without causing menopausal symptoms. This study is an expansion of work that we have previously done in women with atypical hyperplasia of the breast, which showed that treatment with pasireotide for 10 days caused a reduction in the cellularity of these precancerous lesions. In our present study, women with DCIS will be treated with pasireotide for 20 days prior to surgical excision. Endpoints will be as follows:

1. To determine whether pasireotide will inhibit cell proliferation and angiogenesis (signs of tumor growth), and stimulate apoptosis (cell death) in surgically excised tissue in comparison to core biopsies from women with estrogen receptor (ER) positive DCIS. Both the core biopsy and surgical excision are standard of care procedures that women with DCIS have regardless of participation in this trial.
2. To use dynamic contrast enhanced MRI to assess patients before and after treatment with pasireotide and evaluate for changes in tumor volume and other tumor related features
3. In our previous study we found that many women experienced a slight elevation in blood sugar with 10 days of treatment with pasireotide. Other work has shown that this effect often resolves with greater duration of treatment. We are therefore expanding the duration of treatment in this study to 20 days to assess if the initial hyperglycemia seen with pasireotide improves as treatment duration progresses.

Detailed description:
Ductal carcinoma in situ (DCIS) is a direct precursor of invasive breast cancer and is also a marker of an increased chance of developing invasive cancer in the ipsilateral and contralateral breast. Surgery and radiotherapy are used as treatment for DCIS and subsequent treatment with antiestrogens has been effective in reducing the occurrence of invasive breast cancer in DCIS patients. Unfortunately, treatment with antiestrogens carries potential side effects and toxicities. The investigators have data to suggest that inhibition of IGF-I action in the breast will be more effective than antiestrogens, raising hopes it might be effective enough to stand alone as a treatment. Pasireotide is a somatostatin analog that prevents mammary development by inhibiting IGF-I action directly in the mammary gland and also indirectly, without causing menopausal symptoms and signs. As both estrogen (E2) and progesterone (P) require IGF-I in order to act, part of the inhibitory effect of pasireotide is on prevention of estrogen action. The investigators have data that indicate that IGF-I also has direct actions on the breast that are independent of steroid hormones. One example is that IGF-I has a direct stimulatory effect on mammary development in the absence of E2. Additionally, IGF-I has effects on ER-negative tumor cell lines that can be reversed by IGF-I inhibition. If pasireotide inhibited both E2 related and E2 unrelated effects of IGF-I it would likely be more effective than antiestrogens. Preliminary data in rats show that pasireotide, at minimum, can entirely substitute for tamoxifen. To determine whether pasireotide had activities in women at high risk for breast cancer, similar to those observed in rats, the investigators were awarded a DOD Synergistic Idea grant. Those data are expected to be reported soon.

The investigators plan to expand this work to determine in principle whether pasireotide has the potential to treat DCIS. The investigators plan on treating 24 women, with low grade (8), intermediate grade (8) and high grade (8) ER-positive DCIS tumors. The investigators will assess its effect on apoptosis, cell proliferation, angiogenesis, ER and PR and phosphorylation of IGF-IR and IRS-1 before and after 20 days of treatment with pasireotide in core biopsy vs. surgical excision specimens. These endpoints will be measured by specific immunohistochemistry. Simultaneously, the investigators will determine whether IGF-I inhibition will reduce angiogenesis in DCIS using dynamic contrast enhanced MRI (DCE-MRI) at 3.0 Tesla, in addition to mammography. This MRI technique is able to detect early changes of neo-angiogenesis associated with invasive breast cancers and DCIS. Pasireotide should theoretically inhibit angiogenesis in these women, as it does in mice. The DCE-MRI may also show changes in tumor volume, morphologic and kinetic features. Imaging will serve as an additional measure to monitor response to treatment. Results will be correlated with pathology and immunohistochemical endpoints.

In our previous work the investigators noted that there was an increase in blood glucose early after starting pasireotide, but the work of others has indicated that this side effect lasts only several weeks. The investigators found that suppressed levels of insulin (due to pasireotide effect on β cells) began to rise by day 10 of treatment. Therefore, extending the treatment period from 10 to 20 days with daily monitoring of patients will enable us to make certain that the early elevated glucose associated with pasireotide is only temporary. Another side effect is reduction in circulating levels of IGF-I. Theoretically, this could lead to body changes associated with growth hormone deficiency (GHD). Although, tamoxifen and raloxifene also lower serum IGF-I, and women taking it do not usually complain of symptoms of GHD, this is an issue that must be further investigated. However, if pasireotide is found to be effective in the treatment of DCIS, the benefit would likely outweigh the risk.

Arms:
arm 1: Treatment with SOM230 600mcg twice daily for 20 days.

Interventions: intervention 1: SOM 230 / Pasireotide
Intervention descriptions: intervention 1: SOM230/Pasireotide is a multi-receptor targeted somatostatin analogue. In this trial, 600 mcg of SOM230/Pasireotide are taken twice daily subcutaneously.

Protocol document: