The importance of surgical margins in breast cancer

Achieving negative margins with "no tumor on ink" is an appropriate goal in breast conserving therapy (BCT). Wider margins do not decrease recurrence rates, and re-excision in patients with microscopic positive margins is warranted. Several strategies exist to increase rates of negative margins, including techniques to improve tumor localization, intraoperative assessment of margins and oncoplastic techniques. Negative margins should be the goal of BCT, as this will improve both local control and long-term survival.

Malignancy rates after surgical excision of discordant breast biopsies

BACKGROUND

Vacuum-assisted core-needle biopsy (VAB) is increasingly used to perform breast biopsies instead of automated-gun core-needle biopsy (CNB). The significance of discordance between radiologic and pathologic findings has not been well established in the era of VAB predominance. This retrospective study was conducted to determine the rate of malignancy after surgical excisional biopsy (EXB) of these lesions at our two institutions.

MATERIALS AND METHODS

We reviewed medical records from January 2008-June 2013 to identify female patients who underwent EXB for a Breast Imaging-Reporting and Data System (BI-RADS) 4 or 5 lesions found to be benign and discordant on CNB. Clinicopathologic data were gathered, and analysis was performed using descriptive statistics.

RESULTS

A total of 8081 core biopsies were performed in the study timeframe. Six of 81 (7.4%) patients who had an EXB for a benign discordant breast lesion were found to have malignant pathology (two invasive, four in situ). Four of 63 (6.3%) lesions originally biopsied by VAB were upgraded, compared with 2 of 17 (11.8%) originally biopsied by CNB. There were no statistically significant differences in the rates of upgrade to malignancy when data were stratified by BI-RADS score or method of biopsy.

CONCLUSIONS

The overall rate of malignancy after EXB of benign discordant lesions was 7.4%. Despite the widespread adoption of VAB, EXB is still warranted for clarification of discordant radiologic-pathologic findings.

Abstract P5-12-04: De-escalating doses of letrozole in post menopausal women at high risk for breast cancer

Background: Although breast cancer (BC) may occur at any age, its prevalence is greater postmenopause. Greater than 75 % of postmenopausal BCs are hormone dependent. Aromatase inhibitors suppress postmenopausal estrogen biosynthesis. Letrozole has demonstrated efficacy against BC in the adjuvant and metastatic setting at the treatment dose of 2.5 mg daily. Its potential role in BC prevention has been inferred from reductions in contralateral BCs. Its side effect profile, similar to other AIs, includes exacerbation of menopausal symptoms that negatively impact quality of life (QOL) and may result in discontinuation of the drug. Both anastrazole and exemestane have been demonstrated to reduce BC in high-risk women.

Hypothesis: Lower and intermittent doses of letrozole effectively suppress estrogen in the high-risk postmenopausal woman and provide a better side effect profile.

Methods: A randomized, double-blind study comparing the impact of varying letrozole doses (2.5 mg daily, 2.5 mg MWF, 1.0 mg MWF, or 0.25 mg MWF) on estrogen suppression and side effects--lipids, bone resorption, menopause, and QOL-- was conducted. Participants randomized to intermittent dosing received placebo on nontreatment days.

Results: 112 participants were enrolled at 2 clinical sites. Mean patient age was 62.8 years, and average BMI was 29.8. Analysis of available data after 24 weeks of therapy revealed statistically significant increase in triglycerides (N=94): 114.67±48.39 to 125.79±54.31 (p<0.01); vasomotor symptoms (N=95): 2.25±1.26 to 2.74±1.67 (p<0.01); and C-telopeptide (N=75): 0.39±0.23 to 0.55±0.28 (p<0.0001). Statistically significant decrease in estradiol (N=68): 5.57±5.19 to 1.26±1.41 (p<0.0001) and estrone (N=68): 22.39±13.02 to 1.64±2.66 (p<0.0001) were observed. No differences in QOL (SF 36) were noted after letrozole treatment. P-values were derived from paired t-test (signed rank test) for the difference between baseline and after 24 weeks of study drug.

Conclusions: De-escalating doses of letrozole suppress postmenopausal estrogen effectively and result in statistically significant increases in triglycerides, C-telopeptide and vasomotor symptoms without impact on QOL. Presentation will include unblinded intervention arm outcomes.

Citation Format: Ana Maria Lopez, Hsiao Hui Sherry Chow, Denise Frank, Sandhya Puthi, Judy Boughey, Paul Hsu, Jose Guillen, Marjorie Perloff, Michelle Ley, Julie E Lang. De-escalating doses of letrozole in post menopausal women at high risk for breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-12-04.

Targeting matriptase in breast cancer abrogates tumour progression via impairment of stromal-epithelial growth factor signalling

Matriptase is an epithelia-specific membrane-anchored serine protease that has received considerable attention in recent years due to its consistent dysregulation in human epithelial tumors, including breast cancer. Mice with reduced levels of matriptase display a significant delay in oncogene-induced mammary tumor formation and blunted tumor growth. The abated tumor growth is associated with a decrease in cancer cell proliferation. Here we demonstrate by genetic deletion and silencing that the proliferation impairment in matriptase deficient breast cancer cells is caused by their inability to initiate activation of the c-Met signaling pathway in response to fibroblast-secreted pro-HGF. Similarly, inhibition of matriptase catalytic activity using a selective small-molecule inhibitor abrogates the activation of c-Met, Gab1 and AKT, in response to pro-HGF, which functionally leads to attenuated proliferation in breast carcinoma cells. We conclude that matriptase is critically involved in breast cancer progression and represents a potential therapeutic target in breast cancer.

Lymph node status in inflammatory breast cancer

Positive lymph node status in breast cancer is known to be an adverse prognostic factor, but the effect of lymph node (LN) status in inflammatory breast cancer (IBC) has not been evaluated. This study was designed to investigate the association between lymph node status and overall survival (OS) in individuals with IBC. Using the Surveillance, Epidemiology, and End Results (SEER) 18 registry, we collected data on 761 patients diagnosed with non-metastatic IBC from 2004 to 2008. Survival analysis was performed using the Kaplan-Meier method. Cox proportional hazard regression was performed to evaluate univariate and multivariate associations between estrogen and progesterone receptor (ER/PR) status, treatment, and OS. Positive nodal status was associated with a significant decrease in OS (p < 0.001). Five-year survival for LN-positive and LN-negative patients was 49 and 66 %, respectively. In node-positive patients, ER or PR positivity was associated with improved OS, (p = 0.025, p = 0.007). In node-positive patients, the combination of surgery and radiation therapy improved OS when compared with surgery alone (p = 0.002). Nearly 80 % of the patients in this study had nodal metastasis. Positive nodal status was found to be an adverse prognostic factor. ER/PR positivity and treatment with surgery and radiation in node-positive patients was found to improve outcomes. Further studies are required to characterize the biology of IBC and guide the optimal treatment of this disease.

Plasma metabolomic profiles of breast cancer patients after short-term limonene intervention

Limonene is a lipophilic monoterpene found in high levels in citrus peel. Limonene demonstrates anticancer properties in preclinical models with effects on multiple cellular targets at varying potency. While of interest as a cancer chemopreventive, the biologic activity of limonene in humans is poorly understood. We conducted metabolite profiling in 39 paired (pre/postintervention) plasma samples from early-stage breast cancer patients receiving limonene treatment (2 g QD) before surgical resection of their tumor. Metabolite profiling was conducted using ultra-performance liquid chromatography coupled to a linear trap quadrupole system and gas chromatography-mass spectrometry. Metabolites were identified by comparison of ion features in samples to a standard reference library. Pathway-based interpretation was conducted using the human metabolome database and the MetaCyc database. Of the 397 named metabolites identified, 72 changed significantly with limonene intervention. Class-based changes included significant decreases in adrenal steroids (P < 0.01), and significant increases in bile acids (P ≤ 0.05) and multiple collagen breakdown products (P < 0.001). The pattern of changes also suggested alterations in glucose metabolism. There were 47 metabolites whose change with intervention was significantly correlated to a decrease in cyclin D1, a cell-cycle regulatory protein, in patient tumor tissues (P ≤ 0.05). Here, oral administration of limonene resulted in significant changes in several metabolic pathways. Furthermore, pathway-based changes were related to the change in tissue level cyclin D1 expression. Future controlled clinical trials with limonene are necessary to determine the potential role and mechanisms of limonene in the breast cancer prevention setting.

Breast reconstruction satisfaction rates at a large county hospital

BACKGROUND

It has been previously reported that the indigent patient population is less likely to seek breast reconstruction. It has also been reported that lower income women who do chose to undergo reconstruction are less satisfied with the results. This study assesses the level of breast reconstruction satisfaction in women treated at Los Angeles County Medical Center (LAC). For those women with lower satisfaction, we seek to identify the root source of this dissatisfaction.

METHODS

Patients who underwent breast reconstruction at LAC from 2007 to 2012 were identified by Current Procedural Terminology codes. Eligible participants were administered the BREAST-Q postreconstruction module. Demographic data were obtained from the patient and/or their medical records.

RESULTS

A total of 65 patients completed the surveys. The satisfaction scores for the appearance of the breast were 61 (24) and satisfaction with overall outcome was 80 (26). The occurrence of major complications was associated with lower satisfaction scores with respect to the appearance of the breast (P<0.0001) and overall outcome (P=0.02). In addition, patients with delayed reconstruction were also noted to be more satisfied with respect to appearance of the breast (P=0.03).

CONCLUSIONS

Despite suggestions that the indigent and the underserved patient population are less satisfied with the results of their breast reconstruction procedures, patients at LAC demonstrated comparable satisfaction levels to other published reports. The occurrence of major complications and immediate reconstruction were significantly associated with lower levels of satisfaction.

Expression profiling of circulating tumor cells in metastatic breast cancer

Circulating tumor cells (CTCs) are prognostic in all stages of breast cancer. However, since they are extremely rare, little is known about the molecular nature of these cells. We report a novel strategy for the isolation and expression profiling of pure populations of CTCs derived from peripheral blood. We developed a method to isolate CTCs based on immunomagnetic capture followed by fluorescence-activated cell sorting (IE/FACS). After assay validation using the BT474 cell line spiked into blood samples in vitro, RNA from CTCs isolated from the blood of five metastatic breast cancer (MBC) patients was linearly amplified and subjected to gene expression profiling via cDNA microarrays. We isolated a range of 9-993 captured CTCs from five MBC patients' blood and profiled their RNA in comparison to a diverse panel of primary breast tumors (n = 55). Unsupervised hierarchical clustering revealed that CTC profiles clustered with more aggressive subtypes of primary breast tumors and were readily distinguishable from peripheral blood (PB) and normal epithelium. Differential expression analysis revealed CTCs to have downregulated apoptosis, and they were distinguishable from PB by the relative absence of immune-related signals. As expected, CTCs from MBC had significantly higher risk of recurrence scores than primary tumors (p = 0.0073). This study demonstrates that it is feasible to isolate CTCs from PB with high purity through IE/FACS and profile them via gene expression analysis. Our approach may inform the discovery of therapeutic predictors and be useful for real-time identification of emerging resistance mechanisms in MBC patients.

Abstract 1200: Characterization of a novel radiation-induced sarcoma cell line

Background: Radiation-induced sarcoma (RIS) is a potential complication of cancer treatment. No widely available cell line models currently exist to facilitate studies of RIS. Methods: We derived a primary human cell line, UACC-SARC1, from a RIS. Short tandem repeat (STR) genotyping was used to confirm that this cell line was propagated from the tumor. Further characterization of this cell line involved comparing 24 markers using immunocytochemistry (ICC) to immunohistochemistry (IHC) of the tumor, a Matrigel invasion assay, karyotyping of the cell line, comparative genomic hybridization (CGH), DNA sequencing using the Ion AmpliSeq Cancer panel and in vivo mouse xenografts after subcutaneous injection of UACC-SARC1 in immunodeficient mice. Results: STR profiling of UACC-SARC1 was virtually identical to its parental tumor. IHC analysis of the tumor and ICC analysis of UACC-SARC1 revealed shared expression of vimentin, osteonectin, CD68, Ki67 and PTEN but tumor-restricted expression of the histiocyte markers α1-antitrypsin and α1-antichymotrypsin. Karyotyping of the tumor demonstrated aneuploidy. CGH provided direct genetic comparison between the tumor and UACC-SARC1. Sequencing of 740 mutation hotspots revealed no mutations in UACC-SARC1 nor in the tumor. SCID mice xenografts exhibited tumor formation but resulting tumors failed to metastasize. Further xenografts with NOD SCID gamma (NSG) mice are planned. The doubling time of UACC-SARC1 was 28.3 hours. Conclusion: Our novel RIS strain constitutes a useful tool for pre-clinical studies of this rare, aggressive disease.

Citation Format: Julie E. Lang, Brandon Nokes, Grishma Sheth, Petr Novak, Laura Fuchs, George S. Watts, Bernard W. Futscher, Neal Mineyev, Weizhu Zhu, Lauren LeBeau, Ray Nagle, Lee Cranmer. Characterization of a novel radiation-induced sarcoma cell line. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1200. doi:10.1158/1538-7445.AM2014-1200

Value of routine staging imaging studies (RSIS) for patients with stage III breast cancer (BC)

122

Background: RSIS (CT, bone and PET scan) in pts with stage I or II BC is not recommended by NCCN and is considered optional in stage III BC. 10-15% of pts with stage III BC have occult metastases by RSIS, but it is unclear if this finding affects pt management or outcome. The addition of PET scans to conventional imaging (CT and bone scans) is of little added value (Niikura, et al. Oncologist 2011; 16: 772-82). We hypothesized that the use of RSIS in pts with stage III BC does not lead to changes in treatment or pt outcomes. Methods: After IRB approval, we retrospectively identified 875 women with stage III or stage IV BC from 2000-2010 through the Los Angeles County-University of Southern California and Norris Comprehensive Cancer Center cancer registries. Pts with clinically apparent stage IV disease, pregnancy at time of diagnosis, a history of prior malignancy, or incomplete medical records were excluded. Pts who underwent RSIS prior to planned treatment (before surgery, neoadjuvant or adjuvant therapy) were identified. RSIS results and the treatment plan in response to the results were recorded. Results: 424 pts were identified with clinical or pathologic stage III BC: 197 pts (46%) were < 50 years old, 224 (53%) had ER+ or PR+/HER2- tumors, 111 (26%) had ER-/PR-/HER2+ tumors, 74 (17%) had triple negative tumors, 15 (4%) had missing biomarker data, and 61 (14%) had inflammatory BC. 365 pts (86%) underwent RSIS. RSIS were negative for metastatic disease in 266 (73%), indeterminate in 75 (21%), and positive in 24 (7%). Treatment was altered in 21 pts (6%) based on RSIS (20 with metastatic disease, 1 with indeterminate disease). Median follow-up was 3.8 years (range: 0.1 to 13.3). When controlled for age, stage, or biomarker status, no differences in progression-free survival (PFS) were observed between the pts who underwent RSIS compared to those that did not. Conclusions: Most pts with stage III BC undergo RSIS. However, the results of RSIS infrequently affect treatment decisions. We did not observe a difference in PFS between pts who underwent RSIS and those who did not. Our findings suggest RSIS in stage III BC has limited value. A prospective study of this research question is warranted.

Molecular markers for breast cancer diagnosis, prognosis and targeted therapy

Precision medicine involves understanding the molecular drivers unique to an individual patient's cancer so that specific factors may be targeted with the goal of improved patient outcomes. The purpose of this article is to review standard of care and research grade (non-standard of care) biomarkers in breast cancer that may be useful for diagnosis, prognosis and targeted therapy.

Abstract P1-04-11: Recovery rates of circulating tumor cells in breast cancer cell lines spiked into peripheral blood

Background: Circulating tumor cells (CTCs) have been demonstrated to be prognostic in all stages of breast cancer. Immunomagnetic enrichment followed by fluorescence activated cell sorting (IE/FACS) isolates enriched populations of CTCs derived from peripheral blood without the need for background subtraction of leukocytes. We previously reported IE/FACS as a strategy for gene expression profiling of CTCs. We hypothesized that variable expression of the epithelial cell adhesion marker (EpCAM) may bias IE/FACS recovery rates and composition.

Patients and Methods: 10 breast cancer cell lines were acquired from the ATCC, authenticated by short tandem repeat profiling, and stratified according to subtype: HER2 positive (SKBR3, MDA-MB-453, SUM190), luminal A (T47D, MCF7, ZR751), luminal B (BT474) and basal-like (SUM149, MDA-MB-231, Hs578T). Unknown quantities of cell lines were spiked into PBS or peripheral blood (PB) from healthy female donors. IE/FACS was performed using EpCAM (MJ37) ferrofluid particles via a magnetic separator followed by incubation with Thioflavin T, CD45 PE-Cy7, and EpCAM (EBA-1) mAb conjugated to phycoerythrin. FACS sorting was performed using a FACS Aria II (BD Biosciences) and a gating strategy devised based on negative controls (n = 23). Absolute cell counts and recovery rates were determined using the TruCOUNT method (BD Biosciences) with acquisition of 35,000 beads. Two-way ANOVA was used to analyze variation in recovery rates between groups (Prism GraphPad 6.0).

Results: Overall mean recovery rates for the 10 cell lines were 51.4% from PBS and 39.5% from PB. The specific cell type being analyzed was a more significant source of variation (p = 0.03) than was whether measurements were made from PBS or PB (p = 0.2). However, analysis by molecular subtype did not show differences between intrinsic groups (p = 0.23) nor did it show differences in recovery rates from PBS or PB (p = 0.26). The two inflammatory breast cancer cell lines (SUM 149 and SUM190) showed no differences in recovery rates compared to other cell lines (p = 0.41) nor in recovery rates from PBS versus PB (p = 0.75). Recovery rates for the 10 cell lines are shown in Table 1.

Recovery Rate Recovery from PBS (%)Recovery from PB (%)SKBR368.051MDA-MB-45361.270.6T47D28.911.4MCF794.024.4BT47497.147.6ZR75152.850.8SUM1496372.9SUM19048.358.3MDA-MB-2310.927.04Hs578T0.250.84Recovery rate of immunomagnetic enrichment/fluorescence activated cell sorting of cell lines spiked into saline (PBS) or peripheral blood (PB)

Conclusions: Significant variation occurred in recovery rates of spiked, sorted cells depending on cell line type. Negative control PB specimens from healthy individuals could successfully define a consistent gating strategy that captured zero CTCs from healthy individuals and permitted acquiring a portion of CTCs from each of the 10 cell lines. Further experiments will characterize the gene expression of the sorted cells compared to bulk RNA for each cell line. Better biomarkers are needed to improve upon the recovery rates of CTCs while minimizing selection bias. Future studies are required to determine if expression profiling of CTCs is an informative biomarker that may be applied clinically as a prognostic or predictive tool.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-04-11.

Abstract P1-04-07: Isolation and expression profiling of EpCAM-negative circulating tumor cells in human and xenograft models of breast cancer

Background: While several assays currently exist to enumerate circulating tumor cells (CTCs), limitations to existing assays include reliance on the expression of the cell surface marker epithelial cell adhesion molecule (EpCAM) and difficulty isolating pure populations of rare CTC RNA from peripheral blood without background subtraction of leukocytes. We evaluated the biomarkers CD146 and CD49f as a strategy to isolate CTCs that underwent epithelial to mesenchymal transition (EMT). We hypothesized that using immunomagnetic separation and fluorescence activated cell sorting (IE/FACS) it is possible to isolate RNA derived from EpCAM-negative CTCs.

Methods: 10 breast cancer cell lines were acquired from the ATCC, authenticated by short tandem repeat profiling, and stratified according to subtype: HER2 positive (SKBR3, MDA-MB-453, SUM190), luminal A (T47D, MCF7, ZR751), luminal B (BT474) and basal-like (SUM149, MDA-MB-231, Hs578T). IE/FACS with EMT gates was performed using CD146 ferrofluid particles via a magnetic separator followed by incubation with Thioflavin T, CD 31 and CD45 PE-Cy7 (for human or mouse blood), CD146-V450, and CD49f-A647. FACS sorting was performed using a FACS Aria II (BD Biosciences). Known quantities of cells were spiked into PBS or peripheral blood (PB) from healthy female donors and subjected to IE/FACS with EMT gates. Absolute cell counts and recovery rates were determined using the TruCOUNT method (BD Biosciences) with acquisition of 35,000 beads. MDA-MB-231 xenografts were established in 4 male NOD/SCID/IL2 gamma chain deficient mice; cardiac punctures were performed to acquire a complete xenograft PB volume for IE/FACS. Sorted xenograft CTCs, human PB and MDA-MB-231 were used to isolate RNA, amplify and profile via Affymetrix human gene ST 1.0 arrays. The effect of sample processing with IE/FACS was assessed using our EpCAM gates (EpCAM ferrofluid, EpCAM-PE, thioflavin, CD45 PE-Cy7) to sort BT474 and profiled via next generation sequencing (NGS) using the Helicos Single Molecule sequencing approach.

Results: MDA-MB-231 spiked into PB from an unaffected mouse and negative mouse PB controls were used to establish gating thresholds. This gating strategy recovered 14% of MDA-MB-231 cells from spiked human PB via the TruCOUNT method, which represented a 200% yield versus EpCAM based IE/FACS. CTCs were successfully isolated from 4/4 mice bearing xenografts (ranging from 193-6352 cells captured per ∼1mL mouse blood). Principal component analysis demonstrated that gene expression may differentiate xenograft CTCs from PB and MDA-MB-231. Recovery rates using the EMT gates for 10 cell lines spiked into PBS and human PB will be reported and compared to our typical EpCAM gating strategy. Pearson's correlation coefficient of BT474 spiked into PB and recovered via IE/FACS using an EpCAM gating strategy was 92% by NGS.

Conclusions: We have established a method for the isolation and expression profiling of EpCAM-negative CTCs as well as EpCAM-positive CTCs. Future studies are required to determine if expression profiling of CTCs can be used as prognostic, predictive and discovery tools.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-04-07.

ALOX5 polymorphism associates with increased leukotriene production and reduced lung function and asthma control in children with poorly controlled asthma

BACKGROUND

Identification of risk factors for reduced asthma control could improve the understanding and treatment of asthma. A promoter polymorphism in the 5-lipoxygenase gene affects gene expression and response to asthma therapy, but its impact on disease control remains unclear.

OBJECTIVE

We sought to determine if the ALOX5 promoter SP1 tandem repeat polymorphism was associated with changes in cysteinyl leukotriene production, lung function, airway inflammation and asthma control score.

METHODS

We analysed 270 children, 6- to 17-years old, with poorly controlled asthma enrolled in a 6-month clinical trial (NCT00604851). In secondary analysis, we associated the ALOX5 promoter SP1 tandem repeat polymorphism genotype (rs59439148) with asthma outcomes using both additive and recessive genetic models. We evaluated FEV1 percent predicted, symptom control, exhaled nitric oxide and urinary LTE4 levels.

RESULTS

Of all children, 14.8% (40/270) (and 28% (38/135) of African Americans) carried two non-5-repeat variant alleles of rs59439148. Children who were homozygous for variant alleles had significantly higher urinary LTE4 levels (38 vs. 30 nmol/mol creatinine, P = 0.0134), significantly worse FEV1% predicted (84 vs. 91, P = 0.017) and a trend towards worse asthma control. FEV1% predicted values were significantly negatively correlated with urinary LTE4 (r = -0.192, P = 0.009).

CONCLUSION AND CLINICAL RELEVANCE

Carrying two copies of a minor variant ALOX5 promoter SP1 tandem repeat allele contributes to increased cysLT exposure as determined by urinary LTE4 levels, reduced lung function and potentially worse asthma control. ALOX5 promoter SP1 tandem repeat genotype may be a risk factor for worse asthma outcomes.

Trends in post-mastectomy reconstruction: a SEER database analysis

BACKGROUND AND OBJECTIVES

This study was performed to investigate recent trends and factors associated with immediate breast reconstruction (IBR) using a large population-based registry. We hypothesized that rates of IBR have increased since passage of the Women's Health and Cancer Rights Act of 1998.

METHODS

The SEER (surveillance, epidemiology and end results) database was used to evaluate Stage I-III breast cancer (BC) patients who underwent total mastectomy from 1998 to 2008. Univariate and multivariate analyses were performed to study predictors of IBR.

RESULTS

Of 112,348 patients with BC treated by mastectomy 18,001 (16%) had IBR. Rates of IBR increased significantly from 1998 to 2008 (P < 0.0001). Use of IBR significantly decreased as patient age increased (P < 0.0001), as stage increased (P < 0.0001), and as the number of positive lymph nodes increased (P < 0.0001). Estrogen receptor+/progesterone receptor+ (ER+/PR+) patients had significantly higher IBR rates than ER-/PR-patients (P < 0.0001). IBR was used in 3,615 of 25,823 (14.0%) of patients having post-mastectomy radiation (XRT) and in 14,188 of 86,513 (16.4%) of those not having XRT (P < 0.0001).

CONCLUSIONS

The utilization of IBR has increased significantly over the last decade. IBR was found to be significantly associated with age, race, geographical region, stage, ER, grade, LN status, and XRT (P < 0.0001).

Abstract 160: Modulation of the serum metabolomic profiles of breast cancer patients after receiving limonene intervention

Background. Limonene is a bioactive food component found in citrus peel oil that has demonstrated chemopreventive and chemotherapeutic activities in preclinical studies. To better characterize its mechanism of action in the clinical setting, we measured the serum metabolomic profiles of breast cancer patients before and after receiving a short-term limonene intervention.

Methods. Forty women with stage 0 - II breast cancer received 2 g QD limonene daily for 2 - 6 weeks (21.5 ± 8.8 days) before surgical resection of their tumor. Pre/post intervention blood draws were taken to assess serum metabolomic profiles. Metabolomic analysis was performed on the gas chromatography mass spectrometry and liquid chromatography mass spectrometry platforms established at Metabolon, Inc.

Results. Of the 397 identified biochemicals, 71 changed significantly (p&lt;0.05) from baseline to post limonene intervention. Pathway analysis revealed several key metabolic changes. Significant increases were noted in eight bile acid conjugates following limonene intervention, including a 3-fold elevation in taurocholate, taurodeoxycholate, and glycoursodeoxycholate. There were also significant decreases in a number of steroid hormones including dehydroisoandrosterone sulfate (DHEA-S), 4-androsten-3beta, 17beta-diol disulfate, epiandrosterone sulfate, androsterone sulfate, and pregnen-diol disulfate. In addition, markers of collagen remodeling or degradation were elevated following limonene intervention. Increased circulating vitamin C, improved insulin sensitivity and glycemic control, and reduced inflammatory potential were also noted following limonene treatment. An increase in plasma levels of ten different glycerophosphocholines and four carnitines were all significantly correlated to a decrease in cyclinD1 (all p's&lt;0.01 and Rˆ2&gt;0.4) in an exploratory analysis.

Conclusions. This global metabolomic profiling study revealed several novel mechanistic insights into the potential clinical activities of limonene. Efforts are ongoing to correlate these metabolic changes to carcinogenesis, clinical characteristics, and risk markers measured in breast tissue and serum.

Citation Format: Jessica A. Miller, Kirk Pappan, Chengcheng Hu, Elizabeth J. Want, Hector Keun, Julie E. Lang, H-H Sherry Chow. Modulation of the serum metabolomic profiles of breast cancer patients after receiving limonene intervention. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 160. doi:10.1158/1538-7445.AM2013-160

Human breast tissue disposition and bioactivity of limonene in women with early-stage breast cancer

Limonene is a bioactive food component found in citrus peel oil that has shown chemopreventive and chemotherapeutic activities in preclinical studies. We conducted an open-label pilot clinical study to determine the human breast tissue disposition of limonene and its associated bioactivity. We recruited 43 women with newly diagnosed operable breast cancer electing to undergo surgical excision to take 2 grams of limonene daily for two to six weeks before surgery. Blood and breast tissue were collected to determine drug/metabolite concentrations and limonene-induced changes in systemic and tissue biomarkers of breast cancer risk or carcinogenesis. Limonene was found to preferentially concentrate in the breast tissue, reaching high tissue concentration (mean = 41.3 μg/g tissue), whereas the major active circulating metabolite, perillic acid, did not concentrate in the breast tissue. Limonene intervention resulted in a 22% reduction in cyclin D1 expression (P = 0.002) in tumor tissue but minimal changes in tissue Ki67 and cleaved caspase-3 expression. No significant changes in serum leptin, adiponectin, TGF-β1, insulin-like growth factor binding protein-3 (IGFBP-3), and interleukin-6 (IL-6) levels were observed following limonene intervention. There was a small but statistically significant postintervention increase in insulin-like growth factor I (IGF-I) levels. We conclude that limonene distributed extensively to human breast tissue and reduced breast tumor cyclin D1 expression that may lead to cell-cycle arrest and reduced cell proliferation. Furthermore, placebo-controlled clinical trials and translational research are warranted to establish limonene's role for breast cancer prevention or treatment.

Aminolevulinic acid (ALA): photodynamic detection and potential therapeutic applications

Aminolevulinic acid (ALA) is a heme precursor that may have potential applications for photodynamic detection and photodynamic therapy-based treatment of solid tumors in a variety of malignancies. ALA may have a role in other applications in surgical oncology based on its ability to discriminate neoplastic tissue from adjacent normal tissue. In this review, we provide a comprehensive summary of the published studies of ALA in noncutaneous solid malignancies.

Primary tumor extirpation in breast cancer patients who present with stage IV disease is associated with improved survival

PURPOSE

Previous evaluation of our institutional experience with stage IV breast cancer patients with an intact primary tumor (IPT) did not reveal an overall survival (OS) benefit for surgery at 32.1 months median follow-up. We assessed the impact of surgery after 74.2 months median follow-up, and the effect of systemic therapy and local radiotherapy (RT).

METHODS

We reviewed the records of all patients presenting from 1997 to 2002 with stage IV disease with an IPT. Cox proportional hazards modeling was used to assess differences in survival between treatment groups.

RESULTS

Seventy-four (35.6 %) of 208 patients underwent resection of the IPT. After adjustment for covariates, surgery was associated with improved OS (p = 0.04). Multivariable analysis revealed that estrogen receptor (ER) positivity (p = 0.002) and having only a single focus of metastatic disease (p = 0.05) were also associated with improved OS. Surgery was highly associated with receipt of RT (p = 0.0003). RT was significantly associated with improved survival (p = 0.015) in an exploratory analysis.

CONCLUSIONS

Stage IV breast cancer patients with an IPT treated surgically had significantly improved OS. Radiation to the primary was also associated with improved survival, but this was evident only with adjustment for the effect of surgery. These findings may be limited by selection bias. Completion of ongoing prospective randomized trials is needed to conclusively determine whether stage IV patients with an IPT should be offered aggressive locoregional therapy.

In Vitro Assessment of the Inflammatory Breast Cancer Cell Line SUM 149: Discovery of 2 Single Nucleotide Polymorphisms in the RNase L Gene

Background: Inflammatory breast cancer (IBC) is a rare, highly aggressive form of breast cancer. The mechanism of IBC carcinogenesis remains unknown. We sought to evaluate potential genetic risk factors for IBC and whether or not the IBC cell lines SUM149 and SUM190 demonstrated evidence of viral infection.

Methods: We performed single nucleotide polymorphism (SNP) genotyping for 2 variants of the ribonuclease (RNase) L gene that have been correlated with the risk of prostate cancer due to a possible viral etiology. We evaluated dose-response to treatment with interferon-alpha (IFN-α); and assayed for evidence of the putative human mammary tumor virus (HMTV, which has been implicated in IBC) in SUM149 cells. A bioinformatic analysis was performed to evaluate expression of RNase L in IBC and non-IBC.

Results: 2 of 2 IBC cell lines were homozygous for RNase L common missense variants 462 and 541; whereas 2 of 10 non-IBC cell lines were homozygous positive for the 462 variant (p= 0.09) and 0 of 10 non-IBC cell lines were homozygous positive for the 541 variant (p = 0.015). Our real-time polymerase chain reaction (RT-PCR) and Southern blot analysis for sequences of HMTV revealed no evidence of the putative viral genome.

Conclusion: We discovered 2 SNPs in the RNase L gene that were homozygously present in IBC cell lines. The 462 variant was absent in non-IBC lines. Our discovery of these SNPs present in IBC cell lines suggests a possible biomarker for risk of IBC. We found no evidence of HMTV in SUM149 cells. A query of a panel of human IBC and non-IBC samples showed no difference in RNase L expression. Further studies of the RNase L 462 and 541 variants in IBC tissues are warranted to validate our in vitro findings.

Abstract P3-10-07: Lymph node status and survival in inflammatory breast cancer

Objectives: Positive lymph node status in breast cancer is known to be associated with poor outcomes when compared with node-negative disease, but the effect of lymph node status on outcomes in inflammatory breast cancer (IBC) has not been evaluated. This study was designed to investigate the association between lymph-node status and overall survival (OS) in individuals with inflammatory breast cancer using prospective data from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods: We identified 750 patients in the April 2012 edition of the SEER 17 registry who had non-metastatic IBC diagnosed from 1973–2008. Patients were included only if they met a stringent definition of IBC (ICD-O-2 morphology code 8503) and their pathologic nodal status was known. Patients who did not receive mastectomy as part of their local therapy were excluded, to minimize the likelihood of inadvertently including patients with metastatic disease at or shortly after diagnosis. A total of 711 patients were deemed evaluable for analysis (145 node-negative, 566 node-positive). Survival analysis was performed using the Kaplan–Meier method. Cox proportional hazard regression was performed to evaluate univariate and multivariate associations between treatment and OS. Information regarding receipt of systemic therapy and human epidermal growth factor receptor 2 (HER2) status was not available in this version of the SEER database.

Results: Positive lymph node status was associated with a significant decrease in OS (p = 0.01) when compared with node negative status. In lymph node-positive patients, ER or PR positivity was associated with better OS than ER or PR negativity (adjusted HR 0.56 (p = 0.005) for ER+ vs. ER−, and adjusted HR 0.55 (p = 0.009) for PR+vs. PR−). In patients with positive lymph nodes, the combination of surgery and radiation therapy improved overall survival when compared with surgery alone (adjusted HR 0.56, p = 0.003). In node-negative patients, the combination of surgery and radiation therapy was not clearly superior to surgery alone, possibly due to the rarity of node-negative IBC (adjusted HR 0.53, 95% CI 0.23–1.19, p = 0.13).

Conclusions: Our findings provide a better understanding of the characteristics of inflammatory breast cancer, and creates the opportunity for future studies to evaluate the prognostic significance and treatment implications of lymph node status in inflammatory breast cancer. Our study is limited by lack of knowledge of use of systemic therapy, the HER2 status for each patient, and information regarding locoregional recurrence. However, institutions participating in the SEER registry are likely to follow guidelines set forth by the National Comprehensive Cancer Network, recommending induction chemotherapy followed by surgery followed by radiation for IBC. Nearly 80% of the IBC patients included in this study had nodal metastasis, reflecting the inherently aggressive biology of this disease. Further studies are required to characterize the biology of IBC and guide the optimal treatment of this disease.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-10-07.

Abstract 3560: Application of metabolomics to assess serum profiles in limonene-treated breast cancer patients

Background. Limonene is a highly lipophilic monoterpene found in citrus peel that has demonstrated anticancer effects in preclinical models. Limonene likely affects multiple targets with varying potency. Advanced techniques to obtain metabolomic profiles from biofluids have the potential to provide a non-invasive means to assess these multiple effects. This strategy was applied to a clinical trial with women with early stage breast cancer receiving limonene treatment. Methods. Forty women with stage 0 - 2 breast cancer received 2 g QD limonene daily for 2 - 6 weeks (21.5 + 8.8 days) before scheduled surgical resection of their tumor. Pre/post intervention blood draws were taken for metabolomics analysis. Metabolomics profiling was conducted using ultra performance liquid chromatography tandem time-of-flight mass spectrometry (UPLC-QToF). Chromatographic separation was achieved using a gradient of two mobile phases; A: 0.1% formic acid in water, and B: 0.1% formic acid in methanol with a flow rate of 0.4 mL/min. A Waters Aquity UltraPerformance LC HSS T3 column was used. Metabolomics data was preprocessed with XCMS. Preliminary metabolite identification was conducted by mining the Human Metabolome Database (HMDB). Results. Over 1,000 metabolite features were identified by metabolomic profiling. In negative ion mode, three metabolites exhibited a 48-fold change or higher from pre to post-intervention; 183.1 m/z at 9.4 min, 177.0 m/z at 10.0 min, and 345.1 m/z 8.9 min (P's&lt;0.001). Two distinct peaks with m/z of 103.0 elute at 1.9 and 2.25 minutes respectively and changed &gt;20% (P's&lt;0.05). Twenty potential metabolites were identified in positive ion mode with &gt;20% change by the intervention (P's&lt; 0.05), of these, two exhibited 10-fold change or higher; 312.2 m/z at 8.7 min, and 369.2 m/z at 9.0 min (P's&lt;0.001). Discussion. This study demonstrates that 2 g QD daily oral limonene results in significant changes in approximately 20 metabolites in serum. Candidate compounds include limonene metabolites, carnitines and end products of arachindonic acid metabolism. Efforts are ongoing to identify these metabolites for analyte specific verification and quantitation. Further clinical trials with limonene are necessary to establish its potential role as a chemopreventive agent in breast cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3560. doi:1538-7445.AM2012-3560

Abstract 3558: A pilot clinical study of limonene in women with early stage breast cancer: Effects of short-term treatment on tissue limonene disposition and serum markers

Background: Limonene is a highly lipophilic monoterpene found in citrus peel oil that has demonstrated anticancer properties in preclinical studies. The purpose of this study was to evaluate whether limonene and its primary metabolite perillic acid (PA) would distribute extensively to the breast tissue and reach an effective drug concentration. Secondary endpoints included evaluation of changes in cancer-related biomarkers in plasma and tissue. Methods: Participants (N = 40) with newly diagnosed stage 0 - 2 breast cancer took 2 grams daily of oral limonene for 2 - 6 weeks (21.5 ± 8.8 days) prior to planned surgical tumor resection. Blood was drawn pre/post intervention for measurement of serum concentration of limonene, PA, and protein biomarkers, as well as to assess toxicity profiles. A small piece of breast tissue adjacent to the tumor mass was also collected for analysis of limonene and PA levels. Limonene and PA levels in tissue and serum were analyzed using specific chromatography-based assays. Results: Limonene was found to preferentially concentrate in breast tissue (332.3 + 336.1 uM) versus plasma (0.49 + 0.67 uM) with tissue-to-plasma concentration ratio (TPCR) of 1,667 + 312.5 (P&lt;0.001). PA did not concentrate in breast tissue (5.73 + 10.28 uM) versus plasma (3.89 + 6.81 uM) with TPCR of 1.4 + 0.56. Post-intervention serum levels of leptin, adiponectin, TGF-beta1, IGFBP-3 and IL-6 were unchanged from baseline. There was a small but statistically significant post-intervention increase in IGF-1, however the change was no longer significant after adjustment for number of days on agent. Possibly or probably related adverse events were primarily GI-related and were not dose-limiting. No clinically significant changes in complete blood count, renal, hepatic or other blood chemistry studies were noted. Analysis of the intervention effects on tissue biomarkers of proliferation, apoptosis, and cell cycle regulation is ongoing. Discussion: Oral limonene preferentially concentrates in the breast tissue and has a favorable side effect profile. PA does not readily concentrate in breast tissue when administered as oral limonene. Short-term limonene intervention resulted in minimal changes in systemic biomarkers. Further clinical trials with a longer intervention are necessary to establish limonene's potential role as a chemopreventive agent in breast cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3558. doi:1538-7445.AM2012-3558