[Survival of patients with advanced HER2+ breast cancer. Analysis of a cancer center database]

BACKGROUND

HER2+ breast cancer (BC) subtype overexpresses the Human Epidermal growth factor Receptor type-2 (HER2) and is characterized by its aggressiveness and its high sensitivity to monoclonal antibody-based HER2-targeted therapies.

AIM

To assess the prognosis and evaluate the impact of novel anti-HER2 therapies on advanced HER2+ BC patients treated at our institution over the last decades.

MATERIAL AND METHODS

Analysis of the patient database at a cancer center of a university hospital. Information about the subtype of cancer was obtained in 2,149 of 2,724 patients in the database. Eighteen percent of the latter were HER2+. We analyzed data of 83 of these patients with advanced disease.

RESULTS

Median overall survival (OS) was 24 months. For patients treated between 1997-2006 median OS was 17 months and for those treated in the period 2007-2017 median OS was 32 months (p = 0.09).

CONCLUSIONS

A non-significant trend towards better survival in the last decade was observed. HER2+ BC overall survival has improved in our center. This can be probably attributed to the use of novel more effective anti-HER2 therapies.

Prenatal prediction of postnatal large-for-dates neonates using a simplified MRI method: comparison with conventional 2D ultrasound estimates

OBJECTIVE

To evaluate the performance of a simple semi-automated method for estimation of fetal weight (EFW) using magnetic resonance imaging (MRI) as compared with two-dimensional (2D) ultrasound (US) for the prediction of large-for-dates neonates.

METHODS

Data of two groups of women with singleton pregnancy between March 2011 and May 2016 were retrieved from our database and evaluated retrospectively: the first group included women who underwent US-EFW and MRI-EFW within 48 h before delivery and the second group included women who had these evaluations between 35 + 0 weeks and 37 + 6 weeks of gestation, more than 48 h before delivery. US-EFW was based on Hadlock et al. and MRI-EFW on the formula described by Baker et al. For MRI-EFW, planimetric measurement of the fetal body volume (FBV) was performed using a semi-automated method and the time required for measurement was noted. Outcome measure was the performance of MRI-EFW vs US-EFW in the prediction of large-for-dates neonates, both ≤ 48 h and > 48 h before delivery. Receiver-operating characteristics (ROC) curves for each method were compared using the DeLong method.

RESULTS

Of the 270 women included in the first group, 48 (17.8%) newborns had birth weight ≥ 90^th centile and 30 (11.1%) ≥ 95^th centile. The second group included 83 women, and nine (10.8%) newborns had birth weight ≥ 95^th centile. Median time needed for FBV planimetric measurements in all 353 fetuses was 3.5 (range, 1.5-5.5) min. The area under the ROC curve (AUC) for prediction of large-for-dates neonates by prenatal MRI performed within 48 h before delivery was significantly higher than that by US (for birth weight ≥ 90^th centile, difference between AUCs = 0.085, standard error (SE) = 0.020, P < 0.001; for birth weight ≥ 95^th centile, difference between AUCs = 0.036, SE = 0.014, P = 0.01). Similarly, MRI-EFW was better than US-EFW in predicting birth weight ≥ 95^th centile when both examinations were performed > 48 h prior to delivery (difference between AUCs = 0.077, SE = 0.039, P = 0.045).

CONCLUSION

MRI planimetry using our purpose-designed semi-automated method is not time-consuming. The predictive performance of MRI-EFW performed immediately prior to or remote from delivery is significantly better than that of US-EFW for the prediction of large-for-dates neonates. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Risk factors for loco-regional recurrence in breast cancer patients: a retrospective study

Background

Although fairly uncommon, loco-regional recurrence in breast cancer (BC) has major consequences for the patient. Several predictors for locoregional have been previously reported from large randomized clinical trials mainly from Europe & North America; data from other geographical areas are somewhat scarce. Here we performed a retrospective review of medical records in a single academic center in Chile, searching for predictors of breast tumor recurrence.

Results

Median patient follow up was 61 months, 5 year overall survival (OS) rate was 94.2% (95% CI 93-95.3). We found that 108 out of 2,754 (5.3%) patients had loco-regional recurrence. The 2-year loco-regional control was 98% (95% CI 97.3-98.7) and 5-year was 94% (95% CI 92.6-95.4). Univariate analysis showed a correlation between recurrence and being <50 year-old, positive surgical margins, advanced stage, subtype, and presence of LVI and omission of adjuvant radiotherapy. Only the absence of adjuvant RT was predictor of locoregional recurrence in multivariable (p< 0.001).

Conclusions

Our study population presents high local control of BC. Age, surgical margins, stage, molecular subtype and absence of adjuvant radiotherapy were associated with loco-regional recurrence. Prospective trials and long-term follow up are required in order to confirm these results.

Materials and Methods

We analyzed medical records from 2,201 BC patients at the Pontificia Universidad Católica de Chile from 1997 to 2016. Collected data included: age at diagnosis, tumor size, axillary involvement, molecular subtype, margin status, histological grade, lympho-vascular invasion (LVI) and ipsilateral recurrence.

Prophylactic mastectomy versus surveillance for the prevention of breast cancer in women's BRCA carriers

INTRODUCTION

Women who have mutations in BRCA genes have a high risk of developing breast cancer. Therefore, multiple preventive strategies have been proposed, within which is prophylactic mastectomy. Considering physical and psychological effects of surgery, the controversy is established as to whether the preventive effect exceeds that of active vigilance.

METHODS

To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified 13 systematic reviews including 50 studies overall. We concluded prophylactic mastectomy is associated with frequent adverse effects, but probably reduces the incidence of breast cancer and decreases mortality, in addition to being associated with high levels of satisfaction.

Extension of the thermal porosimetry method to high gas pressure for nanoporosimetry estimation

Standard pore size determination methods like mercury porosimetry, nitrogen sorption, microscopy, or X-ray tomography are not suited to highly porous, low density, and thus very fragile materials. For this kind of materials, a method based on thermal characterization has been developed in a previous study. This method has been used with air pressure varying from 10^-1 to 10⁵ Pa for materials having a thermal conductivity less than 0.05 W m^-1 K^-1 at atmospheric pressure. It enables the estimation of pore size distribution between 100 nm and 1 mm. In this paper, we present a new experimental device enabling thermal conductivity measurement under gas pressure up to 10⁶ Pa, enabling the estimation of the volume fraction of pores having a 10 nm diameter. It is also demonstrated that the main thermal conductivity models (parallel, series, Maxwell, Bruggeman, self-consistent) lead to the same estimation of the pore size distribution as the extended parallel model (EPM) presented in this paper and then used to process the experimental data. Three materials with thermal conductivities at atmospheric pressure ranging from 0.014 W m^-1 K^-1 to 0.04 W m^-1 K^-1 are studied. The thermal conductivity measurement results obtained with the three materials are presented, and the corresponding pore size distributions between 10 nm and 1 mm are presented and discussed.

Can Histological Grade and Mitotic Index Replace Ki67 to Determine Luminal Breast Cancer Subtypes?

Introduction: Breast cancer can be classified into subtypes based on immunohistochemical markers, with Ki67 expression levels being used to divide luminal BC tumors in luminal A and B subtypes; however, Ki67 is not routinely determined due to a lack of standardization. Objective: To evaluate histological grade and Eliminate: the mitotic index to determine if they can be used as an alternative method to Ki67 staining for luminal subtype definition. Methods: We evaluated estrogen receptor positive breast cancer tissue samples. Pathological analysis included determination of Ki67. A low level of Ki67 was defined as <14% positive cells. Results: We evaluated 151 breast cancer samples; 24 (15,9%) were classified as I; 74 as HG II (49%), and 53 (35,1%) as HG III. The median value for Ki67 was 13% (range: <1% - 82%) and for MI was 2 (0-12). Histological grade I tumors exhibited Ki67 values significantly lower than HG II and III tumors (Anova, Tamhane test p=0,001). A higher Ki67 value was related to a higher MI (Rho Sperman p=0,336; R2= 0,0273). ROC curve analysis determined that a MI ≥ 3 had a sensibility of 61.9% and specificity of 66.7% in predicting a high Ki67 value (≥14%) (area under the curve: 0,691; p =0,0001). A HG I tumor or HG II-III with MI ≤2, had a high probability of corresponding to a LA tumor (76,3%), as defined using Ki67 expression, while the probability of a LB subtype was higher with HG II-III and a MI ≥3 (57.4%). Global discrimination was 68.1%. Conclusions: For the LA subtype, our predictive model showed a good correlation of HG and MI with the classification based on Ki67<14%. In the LB subtype, the model showed a weak correlation; therefore Ki67 determination seems to be needed for this group of patients.

Diagnosis of acute overt gastrointestinal bleeding with CT-angiography: Comparison of the diagnostic performance of individual acquisition phases

PURPOSE

To compare the respective values of arterial phase, portal venous phase and combination of phases using 64-section multidetector computed tomography (MDCT) for diagnosing acute overt gastrointestinal bleeding (AOGIB).

PATIENTS AND METHODS

Forty-nine patients with AOGIB were included. There were 30 men and 19 women, with a mean age of 65.4±15.6 (SD) years [range, 34-91years]. Two observers reviewed MDCT examinations in consensus for presence of active bleeding, location of bleeding site and nature of causative lesion. The different acquisition phases were reviewed independently.

RESULTS

AOGIB was identified in 28/49 patients (57%) with the multiphasic set, in 26/49 patients (53%) with arterial phase and in 25/49 patients (51%) with portal venous phase. Multiphasic set helped locate the bleeding site in 40/49 patients (82%). The cause was elucidated in 23/49 patients (47%) with multiphasic set. The differences between set performances were not statistically significant. Sensitivity for depicting AOGIB with the multiphasic set was 92% and specificity was 76%.

CONCLUSION

Multiphasic 64-section MDCT has high diagnostic performances in patients with AOGIB. Further studies with a larger population are needed to reach statistical significance and demonstrate better diagnostic performance of multiphasic MDCT in comparison with the arterial or portal phase alone.

[Neutrophil/lymphocyte ratio in complete blood count as a mortality predictor in breast cancer]

The white blood cell count is one of the most sensitive markers associated with inflammation. The neutrophil/lymphocyte count ratio may be an independent factor for breast cancer mortality.

AIM

To assess the predictive value of the neutrophil/lymphocyte ratio for mortality in breast cancer.

MATERIAL AND METHODS

Review of the database of a cancer center of a University hospital. Patients with infiltrating breast cancer treated between 1997 and 2012 were selected. The pathology type and lymph node involvement were obtained from the pathology report. The expression of estrogen, progesterone and Human Epidermal Growth Factor Receptor 2 (HER2) was determined by immunohistochemistry or in situ fluorescent hybridization (FISH). The absolute peripheral neutrophil and lymphocyte counts were obtained from a complete blood count obtained at least three months before treatment. Patients were followed for a median of 61 months (range 1-171).

RESULTS

From 323 eligible patients, after excluding those in stage IV and those without an available complete blood count, 131 patients were analyzed (81 with negative receptors and 117 HER2 enriched). The neutrophil/lymphocyte ratio was similar in both types of tumors (2.1 and 1.91 respectively). Twenty two patients died during follow-up. Surviving patients with HER2 enriched tumors had a lower neutrophil/lymphocyte ratio than those who died (1.79 and 3.21 respectively, p < 0.01). In a multivariate analysis, including age, tumor stage and lymph node involvement as confounding factors, the neutrophil/lymphocyte ratio was still significantly associated with a risk of death with a hazard ratio of 2.56.

CONCLUSIONS

A high neutrophil/lymphocyte ratio in the complete blood count can be a predictor of death in breast cancer.

BRCA1 and BRCA2 founder mutations account for 78% of germline carriers among hereditary breast cancer families in Chile

Identifying founder mutations in BRCA1 and BRCA2 in specific populations constitute a valuable opportunity for genetic screening. Several studies from different populations have reported recurrent and/or founder mutations representing a relevant proportion of BRCA mutation carriers. In Latin America, only few founder mutations have been described. We screened 453 Chilean patients with hereditary breast cancer for mutations in BRCA1 and BRCA2. For recurrent mutations, we genotyped 11 microsatellite markers in BRCA1 and BRCA2 in order to determine a founder effect through haplotype analysis. We found a total of 25 mutations (6 novel) in 71 index patients among which, nine are present exclusively in Chilean patients. Our analysis revealed the presence of nine founder mutations, 4 in BRCA1 and 5 in BRCA2, shared by 2 to 10 unrelated families and spread in different regions of Chile. Our panel contains the highest amount of founder mutations until today and represents the highest percentage (78%) of BRCA1 and BRCA2 mutation carriers. We suggest that the dramatic reduction of Amerindian population due to smallpox and wars with Spanish conquerors, a scarce population increase during 300 years, and the geographic position of Chile constituted a favorable scenario to establish founder genetic markers in our population.

Self-assembling peptide matrix for the prevention of esophageal stricture after endoscopic resection: a randomized controlled trial in a porcine model

Esophageal stricture formation after extensive endoscopic resection remains a major limitation of endoscopic therapy for early esophageal neoplasia. This study assessed a recently developed self-assembling peptide (SAP) matrix as a wound dressing after endoscopic resection for the prevention of esophageal stricture. Ten pigs were randomly assigned to the SAP or the control group after undergoing a 5-cm-long circumferential endoscopic submucosal dissection of the lower esophagus. Esophageal diameter on endoscopy and esophagogram, weight variation, and histological measurements of fibrosis, granulation tissue, and neoepithelium were assessed in each animal. The rate of esophageal stricture at day 14 was 40% in the SAP-treated group versus 100% in the control group (P = 0.2). Median interquartile range (IQR) esophageal diameter at day 14 was 8 mm (2.5-9) in the SAP-treated group versus 4 mm (3-4) in the control group (P = 0.13). The median (IQR) stricture indexes on esophagograms at day 14 were 0.32 (0.14-0.48) and 0.26 (0.14-0.33) in the SAP-treated and control groups, respectively (P = 0.42). Median (IQR) weight variation during the study was +0.2 (-7.4; +1.8) and -3.8 (-5.4; +0.6) in the SAP-treated and control groups, respectively (P = 0.9). Fibrosis, granulation tissue, and neoepithelium were not significantly different between the groups. The application of SAP matrix on esophageal wounds after a circumferential endoscopic submucosal dissection delayed the onset of esophageal stricture in a porcine model.

Clinico-Pathologic Subtypes of Breast Cancer Primary Tumors Are Related to Prognosis after Recurrence

Background: Pathological factors, based mainly on immunohistochemistry (IHC) and histological differentiation, are mostly used to differentiate breast cancer (BC) subtypes. Our present aim was to describe the characteristics and survival of a relapsing BC patient cohort based on clinico-pathologic subtypes determined for the primary tumors. Methods: We used a clinico- pathological definition of BC subtypes based on histological grade (HG), estrogen receptor (ER), progesterone receptor (PgR),and epidermal growth factor receptor type 2 (HER2) expression assessed by IHC. We determined variables associated with loco-regional recurrence (LRR), second primaries (SP), systemic recurrence (SR) and post-recurrence survival (PRS). Results: Out of 1,702 patients, 240 (14%) had an event defined as recurrence. Those with recurrent disease were significantly younger than those without,and were initially diagnosed at more advanced stages, with larger tumors, greater lymph nodal involvement and higher HG. With a median follow up of 61 months (1-250), 4.6% of patients without recurrence and 56.6% of patients with an event defined as recurrence had died. The median PRS for the LRR group was 77 months; 75 months for those who developed a SP and 22 months for patients with an SR (p <0.0001). In SR cases, the median PRS was shorter for ER- tumors than for ER+ tumors (15 vs. 26 months, respectively; p = 0.0019, HR 0.44; CI: 0.25-0.44). Conclusions: Subtype, defined through classic histopathologic parameters determined for primary tumors, was found to eb related to type of recurrence and also to prognosis after relapse.

miR-146a and miR-638 in BRCA1-deficient triple negative breast cancer tumors, as potential biomarkers for improved overall survival

BACKGROUND

Mechanisms that lead to the reduced expression of BRCA1 in triple-negative breast cancer (TNBC) tumors are not fully understood. A possible cause is overexpression of miR-146a and miR-638, which regulate BRCA1 expression in other cancers.

OBJECTIVE

To evaluate the expression of these microRNAs in relation to BRCA1 expression in TNBC tumors.

METHODS

Expression of both microRNAs was assessed by real time qPCR using Taqman microRNA assays in TNBC tumors. Results were related to protein expression of BRCA1 and patient's survival.

RESULTS

miR-146a and miR-638 were overexpressed in 36% and 59% of TNBC tumors, respectively. Overexpression was preeminent in BRCA1-deficient tumors and significantly associated to a better overall survival.

CONCLUSION

Both miRNAs are potential biomarkers for improved overall survival in patients with BRCA1-deficient TNBC tumors.

Different Array CGH profiles within hereditary breast cancer tumors associated to BRCA1 expression and overall survival

Background

Array CGH analysis of breast tumors has contributed to the identification of different genomic profiles in these tumors. Loss of DNA repair by BRCA1 functional deficiency in breast cancer has been proposed as a relevant contribution to breast cancer progression for tumors with no germline mutation. Identifying the genomic alterations taking place in BRCA1 not expressing tumors will lead us to a better understanding of the cellular functions affected in this heterogeneous disease. Moreover, specific genomic alterations may contribute to the identification of potential therapeutic targets and offer a more personalized treatment to breast cancer patients.

Methods

Forty seven tumors from hereditary breast cancer cases, previously analyzed for BRCA1 expression, and screened for germline BRCA1 and 2 mutations, were analyzed by Array based Comparative Genomic Hybridization (aCGH) using Agilent 4x44K arrays. Overall survival was established for tumors in different clusters using Log-rank (Mantel-Cox) Test. Gene lists obtained from aCGH analysis were analyzed for Gene Ontology enrichment using GOrilla and DAVID tools.

Results

Genomic profiling of the tumors showed specific alterations associated to BRCA1 or 2 mutation status, and BRCA1 expression in the tumors, affecting relevant cellular processes. Similar cellular functions were found affected in BRCA1 not expressing and BRCA1 or 2 mutated tumors. Hierarchical clustering classified hereditary breast tumors in four major, groups according to the type and amount of genomic alterations, showing one group with a significantly poor overall survival (p = 0.0221). Within this cluster, deletion of PLEKHO1, GDF11, DARC, DAG1 and CD63 may be associated to the worse outcome of the patients.

Conclusions

These results support the fact that BRCA1 lack of expression in tumors should be used as a marker for BRCAness and to select these patients for synthetic lethality approaches such as treatment with PARP inhibitors. In addition, the identification of specific alterations in breast tumors associated with poor survival, immune response or with a BRCAness phenotype will allow the use of a more personalized treatment in these patients.

[Predictive value of conventional immuno-histochemical biomarkers in breast cancer]

BACKGROUND

Pathological complete response (pCR) after neoadjuvant chemotherapy (NCT) in breast cancer (BC) identifies patients with good prognosis.

AIM

To assess if the clinico-pathological subtype, determined by classic immunohistochemical (IHC) markers, is able to predict pCR and prognosis in BC patients treated with NCT.

MATERIAL AND METHODS

One hundred thirty three BC patients aged 24-80 years, were treated with NCT. Clinico-pathological subtype was defined based on classic IHC markers. pCR was defined as the absence of invasive neoplastic cells in the breast and lymph nodes, on final breast surgery.

RESULTS

pCR was achieved in 8.2% of patients, 3.5 and 19.5% in luminal and hormonal receptor (HR) negative tumors respectively (p < 0.01). Median follow-up was 72.6 months (3.5-190). Patients who achieved pCR had higher overall survival (OS) (p = 0.04). A univariate analysis revealed that size of the tumor, ratio of metastatic to examined lymph nodes and absence of HR were significant predictors of pCR. These findings were not replicated in the multivariate analyses.

CONCLUSIONS

Clinico-pathological subtypes were independent prognostic factors for pCR and OS in BC patients in our cohort. These findings support using classic and cheap biomarkers as a predictive tool for NCT in BC.

Breast cancer at extreme ages--a comparative analysis in Chile

BACKGROUND

Young onset breast cancer (BC) has a worse outcome as compared to in the elderly. However, some studies have shown that BC in the elderly, despite indolent features, does also cause increase in mortality. In an attempt to compare clinic-pathological characteristics, BC subtypes and survival in patients with BC presenting at extremes of age, we performed a retrospective study.

MATERIALS AND METHODS

Patients were either ≤40 or ≥70 years old. Subtypes were defined using immunohistochemistry and histological grade. Chi-Square test was used for evaluation of categorical variables, and Kaplan-meier and log-rank for disease-specific survival (DSS) and disease free survival (DFS) .

RESULTS

We analyzed 256 patients ≤40 and 366 patients ≥70. Younger patients presented with more aggressive disease, with less luminal A but more luminal B and triple negative (TN) subtype. With a median follow-up of 57.5 months, DFS at 5 years in younger patients was 72.3% vs 84.6% in the elderly (p=0.007). Luminal A and B disease presented with worse DFS in younger patients. The opposite was seen in the TN subgroup. Although we found no significant differences in DSS, older patients with TN tumors died of BC more frequently. This group also received less chemotherapy.

CONCLUSIONS

Young patients present with more aggressive disease, this translating into worse DFS. However, elderly patients with TN disease represent a particular subpopulation with worse DFS and DSS, suggesting that chemotherapy should not be withheld only because of age.