P4-11-03: Prognosis of Pregnancy-Associated Breast Cancer: A Meta-Analysis Involving 39,415 Patients

Background

Pregnancy-associated breast cancer (PABC), defined as breast cancer diagnosed during pregnancy or one year after is a relatively rare disease and hence considerable controversy exists regarding its prognosis compared to non-pregnancy-related breast cancer.

Methods: Two of the authors independently performed a literature search on MEDLINE and Cochrane Library with no date or language restrictions. Eligible studies were control-matched, population-based and hospital-based studies that have addressed the outcome of patients diagnosed during pregnancy or one-year afterwards. The control group was defined as patients diagnosed with breast cancer not related to pregnancy. The primary and secondary end-points were overall and disease-free survival respectively. Pooling of data was done using the random effect model. To control for potential differences between the two groups in systemic treatment and clinico-pathological features (e.g. tumor size, nodal status, ER, etc …) that could affect prognosis, we performed a sensitivity analysis by pooling the hazard ratios (HRs) of the adjusted multivariate models within each study. We also analyzed differences according to time of diagnosis (during pregnancy or post-partum), type of study and year of reporting the study. Finally, we communicated with the authors of the eligible studies to collect unpublished statistics relevant to our analysis to further refine our findings.

Results: 29 studies were included in this meta-analysis (2903 cases and 36, 512 controls). Women diagnosed with PABC had a significantly higher risk of death compared to those diagnosed with non-pregnancy-related breast cancer (pooled hazard ratio (pHR): 1.47 [95% CI: 1.30−1.65]). A sensitivity analysis including 11 studies (1222 PABC cases, 19231 controls) adjusted for differences in tumor size, nodal status and systemic treatment showed the same result (pHR: 1.44 [95% CI: 1.17−1.77]). These findings were consistent in patients diagnosed either during pregnancy (pHR: 1.30 [95% CI: 1.01−1.67]) or in the post-partum period (pHR: 1.56 [95% CI: 1.08−2.26]) with no heterogeneity observed (p=0.43). Sensitivity analyses according to the type and year of study showed the same findings. Regarding the secondary end-point, only ten studies (531 cases, 1842 controls) provided sufficient information to estimate disease-free survival, and indeed PABC patients had a higher risk of relapse compared to breast cancer controls [pHR: 1.59 (95%CI: 1.23−2.07)]. Collection of unpublished data is currently ongoing and further analyses will be presented at the meeting.

Conclusion: To the best of our knowledge, this is the largest analysis addressing the prognosis of PABC. Our results confirm that PABC is independently associated with a worse prognosis whether diagnosis is made during pregnancy or in the post-partum period. This underscores the possible impact of pregnancy on breast cancer biology. In this regard, we are currently interrogating potential biological differences between PABC patients and matched breast cancer controls at the gene expression level to elucidate the biology of this relatively rare, yet very challenging disease.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-03.

Prognostic significance of UBE2C mRNA expression in high-risk early breast cancer. A Hellenic Cooperative Oncology Group (HeCOG) Study

BACKGROUND

The ubiquitin-proteasome system (UPS) plays a pivotal role in tumorigenesis. Components of the UPS have recently been implicated in breast cancer progression. In the present study, we sought to explore the prognostic and/or predictive significance of UBE2C messenger RNA (mRNA) expression on disease-free survival (DFS) and overall survival (OS) in high-risk operable breast cancer patients.

METHODS

Five hundred and ninety-five high-risk breast cancer patients were treated in a two-arm trial evaluating postoperative, dose-dense sequential chemotherapy with epirubicin followed by CMF (cyclophosphamide, methotrexate and 5-fluorouracil) with or without paclitaxel (Taxol). RNA was extracted from 313 formalin-fixed primary tumor tissue samples followed by one-step quantitative RT-PCR for assessment of mRNA expression of UBE2C.

RESULTS

High UBE2C mRNA expression was associated with poor DFS (Wald's P = 0.003) and OS (Wald's P = 0.005). High tumor grade, as well as high Ki67 protein expression, was more frequent in the high-expression group of UBE2C. Results of the Cox multivariate regression analysis revealed that high UBE2C mRNA expression remained an independent adverse prognostic factor for relapse (P = 0.037) and death (P = 0.05).

CONCLUSIONS

High UBE2C mRNA expression was found to be of adverse prognostic significance in high-risk breast cancer patients. These findings need to be validated in larger cohorts.

Cancer of unknown primary site: 20 questions to be answered

Cancer of unknown primary (CUP) is a common, well-recognized and heterogeneous clinical syndrome. Patients with CUP present with metastatic disease in the absence of an identifiable primary tumour despite a diagnostic work-up. Aetiologically, CUP might either harbor primaries that cannot be detected by the standardized diagnostic investigations or carry distinct genetic and epigenetic aberrations. In this article we try to clarify the clinical and pathological enigma of CUP by answering 20 important questions related to this entity.

The diagnosis and management of gastric cancer: expert discussion and recommendations from the 12th ESMO/World Congress on Gastrointestinal Cancer, Barcelona, 2010

Well-recognized experts in the field of gastric cancer discussed during the 12th European Society Medical Oncology (ESMO)/World Congress Gastrointestinal Cancer (WCGIC) in Barcelona many important and controversial topics on the diagnosis and management of patients with gastric cancer. This article summarizes the recommendations and expert opinion on gastric cancer. It discusses and reflects on the regional differences in the incidence and care of gastric cancer, the definition of gastro-esophageal junction and its implication for treatment strategies and presents the latest recommendations in the staging and treatment of primary and metastatic gastric cancer. Recognition is given to the need for larger and well-designed clinical trials to answer many open questions.

Cancer and pregnancy: a comprehensive review

BACKGROUND

Pregnancy complicated by cancer is relatively rare but, as women in western societies tend to delay childbearing to the third and fourth decade of life, this phenomenon is going to be encountered more often in the future.

MATERIAL AND METHODS

Review of the literature and description of the different diagnostic and therapeutic approaches which are required to diagnose and treat pregnant mothers with cancer.

RESULTS

As in non-pregnant patients, every effort should be made to provide the maximal benefit and best prognosis to the pregnant patient. In most cases, in order to avoid any harm to the fetus, different diagnostic approach should be incorporated and treatment should be tailored to each pregnant woman. Cooperation of multidisciplinary teams, incorporating medical and radiation oncologists, surgeons, obstetricians, neonatologists and experienced nursing staff, is required to provide optimal care for the patient. The benefits from use of surgery, chemotherapy and/or radiotherapy as well as the mother's wishes and beliefs need to be factored into recommendations and treatment planning.

CONCLUSIONS

With the experience gained, the developments in clinical and radiation oncology and the cooperation of multidisciplinary teams, treatment of cancer during pregnancy with normal fetal outcome is feasible.

Abstract P2-09-15: TOP2A and DARPP32 Are Associated with Response to Trastuzumab-Based Treatment of HER2-Positive Advanced Breast Cancer (ABC)

Background: HER2 status (gene amplification, protein overexpression) is the hallmark for the selection of patients who will benefit from trastuzumab-based treatment. Except for HER2, however, the status of additional genes located at chromosome 17q seems to have an impact on disease biology and patients’ outcome. In this retrospective study, we investigated the impact of TOP2A (chr 17q21-q22, telomerically to ERBB2) and PPP1R1B (DARPP32, chr 17q12, centromerically to ERBB2) status on the outcome of patients with ABC treated with trastuzumab-based regimens. Materials and Methods: In a cohort of 199 patients with ABC treated with 1st or 2nd line trastuzumab-containing regimens, tumor tissues were assessed for HER2 and TOP2A gene amplification (by FISH), HER2, TOP2A and DARPP32 mRNA expression (by RTQ-PCR), and Her2 and TopoIIa protein expression (by IHC). Tumors were HER2 positive (FISH amplified and/or 3+ by IHC) (n= 137) or negative (n=62). Disease outcome was assessed as time to progression (TTP), survival from trastuzumab administration (survivalT) and survival from 1st metastasis (survivalM). Results: In comparison to patients with HER2-negative tumors, those with HER2-positive tumors exhibited a longer TTP (Median [95% CI] = 13.7 [10.7-16.7] vs 9.2 [7.5-10.9], p=0.037) and survivalT (Median [95% CI] = 47.4 [37.9-56.9] vs 34.8 [24.3-45.4], p=0.008), as expected. HER2 positivity was strongly associated with relatively high HER2 mRNA and protein expression (P<0.001 for both) and with TOP2A amplification (P<0.001), but not with relatively high TOP2A mRNA and protein expression. DARPP32 mRNA strongly correlated with HER2 mRNA (P<0.001) and was associated with HER2 and TOP2A gene status (P<0.001), it was not however related to TOP2A mRNA, and TopoIIa and Her2 protein expression. The relative expression of DARPP32 to HER2 mRNA was occasionally very high, with ratios of DARPP32/HER2 >1 equally distributed among HER2-positive and negative tumors. In patients with HER2-positive tumors, TOP2A gene amplification was associated with longer survival, irrespectively of the chemotherapy regimen administered in addition to trastuzumab (survivalT: p=0.004, survivalM: p=0.003). Interestingly, in patients with HER2-negative tumors, DARPP32/HER2 ratios of >1 were associated with a favorable outcome (survivalT: p=0.008 and survivalM: p=0.043). No association with disease outcome was observed for high DARPP32 expression or for DARPP32/HER2 ratios in HER2-positive tumors.

Discussion: This study shows that genes located peripherally to HER2 on the same chromosome arm, such as TOP2A and DARPP32, may be concomitantly altered in the same breast tumor, but may have a different impact on the course of the disease. A favorable outcome may be predicted for HER2-positive tumors with amplified TOP2A and for HER2-negative tumors expressing higher DARPP32 mRNA in comparison to HER2.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-09-15.

Undergraduate training in oncology: an ESO continuing challenge for medical students

During the last six years the European School of Oncology (ESO) opened an undergraduate programme for European medical students, aiming to further improve their oncology knowledge and clinical skills. In this endeavour a 5-day course is organized every summer at the University of Ioannina, Greece, where distinguished European oncologists introduce preselected medical students to cancer medicine. The programme includes teaching of several oncological topic regarding diagnosis and treatment of the most common tumours; interactive case presentations and discussions were also incorporated. An overall of 229 medical students, mostly from European medical schools, have been taking part to this intensive summer course, from 2004 to 2009. This article presents the detailed educational programme, the evaluation results and the outcome of the last six ESO courses; an assessment of the oncological curricula available across European faculties is also presented.

A twisted kiss: in vitro and in vivo evidence of genetic variation and suppressed transcription of the metastasis-suppressor gene KiSS1 in early breast cancer

KiSS-1 is ametastasis suppressor gene, its inactivation linked to advanced tumor stage and dismal prognosis. We studied its mutational status ,transcription and protein expression in human cancer cell lines and patients with early breast cancer.<br />Tumor tissue DNA and messenger RNA (mRNA) of KiSS1 exons III and IV from the human cancer cell lines Hela, Jurkat, A549, W138t, MCF-7 and from formalin-fixed resected breast adenocarcinomas from 50 women were analysed by means of PCR-SSCP, RT-PCR and sequencing. Tumor tissue was stained for KiSS1 protein expression by means of the streptavidin-biotin complex immunoperoxidase assay. Presence of KiSS1 mutation, mRNA levels and protein staining were examined for correlations with patient/tumor characteristics. <br />A transversion in exon IVa replacing cytosine with guanine was identified 242 base pairs from the translation start site (242C>G) in the cell lines MCF-7, A549 and in 5/50 tumors (10%), resulting in substitution of proline by arginine (P81R) and alteration of the protein tertiary structure. As the substitution was present in germ-line DNA in 3/5 breast cancer patients harbouring the polymorphism in their tumor, the incidence of tumour-specific somatic mutation was 4% among the 50 patiens with early breast cancer. Although the P81R substitution was associated with reduced KiSS1 protein immunoreactivity (56% in wild-type tumors versus 20% in KiSS1-variant tumours) and with axillary nodal involvement (55% in wild-type versus 80% in KiSS1-variant tumors), the correlations did not reach statistical significance. KiSS1 mRNA was detected in only 15/48 tumours (31%) and showed no correlation with mutation or protein expression. Twenty-six tumors stained for KiSS1 protein, in contrast to the universal strong staining seen in normal breast parenchyma and placental tissues. At amedian follow-up of 38 months, relapses occurred in 20% of women with non wild-type tumors versus 13% of women with wild-type KiSS1 tumors (p=0.7). Presence of KiSS1 mutation, mRNA levels and protein expression did not have prognostic significance for relapse-free survival.<br />In conclusion, altered nucleotide sequence and repression of transcription are two potential mechanisms of suppression of the anti-metastatic effects of KiSS1 in early breast cancer: Confirmation in larger cohorts and study of functional effects of the 242C>G exon IVa mutation are warranted.

KEYWORDS

KiSS1, metastasis-suppressor gene, breast cancer, mutation, transcription.

Malignant melanoma of unknown primary site. To make the long story short. A systematic review of the literature

INTRODUCTION

Although more than 90% of melanomas have a cutaneous origin, occasionally it is discovered as a secondary deposit without evident primary site. The aim of this study was to systematically review published literature and analyse data on incidence, presentation, therapeutic interventions, survival and prognostic factors.

METHODS

We searched MEDLINE, (search terms Melanom*, unknown origin, unknown primary, indolent, occult) and the abstracts from major congresses of the last 4 years and perused the references of the retrieved relevant articles.

RESULTS

4348 patients with MUP were reported along with 132,643 patients with Melanoma of Known Primary (MKP). The incidence of MUP was 3.2%. The male to female ratio was 2:1 while the age peak was in the 4th and 5th decades. MUP patients harbouring nodal disease had a median overall survival ranging between 24 and 127 months, 5-year survival rate between 28.6% and 75.6% and 10-year survival rate between 18.8% and 62.9%. MUP patients with visceral disease had median survival times between 3 and 16 months, and 5-year survival rates between 5.9% and 18%. Presence of tumour regression in metastatic sites and low nodal burden were associated with favourable outcome. Potentially curative surgical treatment offered survival advantage in comparison to patients with residual metastatic foci. MUP patients who received adjuvant chemotherapy or radiotherapy paradoxically seemed to fare worse compared to patients observed.

CONCLUSIONS

This is the first review to bring together the information of 89 years and to analyze all the potential information accumulated. Although a well know entity no consensus is reached in order to describe MUP presentation, management or prognosis.