The clinical impact and outcomes of immunohistochemistry-only metastases in breast cancer

613

Background: Modern surgical and pathologic techniques can detect small volume axillary metastases in breast cancer. The clinical significance of these metastases was evaluated in comparison to patients with negative sentinel lymph nodes (Neg-SN). Methods: Retrospective database review from 1997 through 2003 for eligible patients with unilateral breast cancer and no history of significant non-breast malignancy identified 232 patients with sentinel lymph node (SLN) metastases identified only by immunohistochemical stains (IHC-SN). They were compared to 252 Neg-SN controls selected at random from the same database population. Statistical analysis was performed with 2-sample tests, Kaplan-Meier, and Cox regression methods. Results: IHC-SN patients had worse prognostic features and received more systemic therapy than controls (Table). Age and ER status were similar. In 123 IHC-SN patients treated with axillary dissection (ALND), 16% had macrometastases in the non-SLNs. Only one axillary recurrence occurred in the group of IHC-SN patients without ANLD (n=109). With median follow up of 5 years (range 0.01–12.0), 28 recurrences and 25 deaths occurred. There were no differences between cases and controls for recurrence-free survival (RFS) or overall survival (OS) both by univariate and multivariate models that included variables such as age, tumor size, chemotherapy and hormone therapy [HR 0.99 (95%CI 0.43–2.28, p=0.99) for RFS, HR 2.06 (95%CI 0.79–5.35) p=0.14 for OS]. In IHC-SN patients treated with ALND, patients with positive non-SLNs (n=20) tended to have worse RFS than those with negative non-SLNs (n=103) [RFS 89% vs. 97% at 5 yrs (p=0.06)]. Conclusions: A significant number of IHC-SN patients had a macrometastasis identified at ALND. In patients not undergoing dissection, axillary recurrence was a rare event. However, failure to identify additional metastases by omitting ALND may result in understaging and inadequate systemic treatment in some patients.

[Table: see text]

No significant financial relationships to disclose.

Integrating cancer care: Patient and practice management processes among surgeons who treat breast cancer

6526

Background: The Institute of Medicine has called for cancer care models that parallel those underway to integrate the management of patients with chronic conditions. The objective of this study was to evaluate patterns and correlates of such initiatives in the practices of surgeons treating women with breast cancer. Methods: We developed 5 multi-item scales to describe breast cancer patient and practice management processes based on the Chronic Care Model (multidisciplinary clinician communication; availability of clinical information; patient decision support; access to information technology; and practice management initiatives). We then performed a survey among attending surgeons of a population-based sample of patients diagnosed with breast cancer during a period from June 2005-February 2007 in metropolitan Los Angeles and Detroit (N = 312, response rate 76.1%). We evaluated the distribution of management process measures across selected characteristics of providers and practices. Results: About half of the surgeons devoted 15% or less of their total practice to breast cancer; while 16.2% of surgeons devoted 50% or more. The deployment of management processes varied markedly with most surgeons reporting low use. For example, only about 10% of surgeons indicated that half or more of their patients were exposed to multidisciplinary physician communication; while only 5% indicated that half or more of their patients were provided decision and care support services such as attending a presentation or viewing a video about breast cancer prior to surgery or attended a patient support group. Management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status (NCI center, ACS cancer program, neither) was weakly associated with any of the management process measures. Conclusions: The low uptake of patient and practice management processes observed in this study suggests that breast surgeons are not convinced that these processes matter or that there are logistical and cost barriers to implementation. More research is needed to understand how variation in patient and practice management processes may affect the quality of care for patients with breast cancer.

No significant financial relationships to disclose.

Impact of molecular subtype on presenting characteristics of T1a,b tumors

11111

Background: Gene expression profiling of breast cancers has identified molecular subtypes (Lum A and B, basal, HER2) which impact upon the risk of both local and distant recurrence. There is interest in the impact of molecular subtype on outcome in T1a,bN0M0 tumors, a group thought to have good prognosis and to be amenable to breast conservation. The purpose of this study was to determine if presenting features of T1a,b tumors differ among molecular subtypes. Methods: Subtypes were classified using IHC as Lum A (ER±PR pos, HER2 neg); Lum B: (ER±PR pos, HER2 pos); HER2: (ER+PR neg, HER2 pos); or Basal: ER, PR, and HER2 neg. Data was obtained from a registered database which included patients treated in our institution between 1/98 and 6/07. Of 7906 eligible patients, 6016 were classifiable into molecular subtypes and 1974 tumors (32.8%) measured 10 mm or less. The Chi square test and ANOVA were used for statistical analysis. Results: Data are shown in Table 1 . Patients overexpressing HER2 were significantly younger, had more nodal involvement, multicentric/multifocal (Multi) disease, extensive intraductal component (EIC), and lymphovascular invasion (LVI) (all p<0.0001). On multivariate analysis the HER2 subtype had an odds ratio of 2.5 for Multi versus Lum A/B, but HER 2 was not predictive of nodal status. Conclusions: Even in small breast cancers, presenting features vary with molecular subtype. Unlike Multi, the higher incidence of positive nodes in HER2 patients is explained by traditional prognostic features such as grade, age, and size rather than subtype, suggesting that evaluation of traditional prognostic factors remains valuable in the molecular era. [Table: see text]

No significant financial relationships to disclose.

Determinants of outcome in elderly patients with positive sentinel lymph nodes

614

Background: Older women are less likely to receive standard of care treatment for breast cancer. This undertreatment may be linked to the perception that elderly patients (pts) may not tolerate or derive benefit from treatment that is often viewed as “too toxic.” Methods: From July 1997 to July 2003, 1,470 pts with invasive cancer with positive sentinel lymph nodes (PSLN) by intraoperative frozen section or final pathologic exam by hematoxylin-eosin and/or immunohistochemistry (IHC). We examined sociodemographic, pathologic, and therapeutic variables that affected the outcome of elderly pts ≥70 years old. A comorbidity score was assigned using Adult Comorbidity Evaluation-27 system. Chi-square, Fisher's exact Wilcoxon tests, and multivariate logistic regression analysis were used. Results: The median age was 53 years (range 21–89) and median tumor size 1.6 cm (range 0.1–11). 1,265 (86.1%) pts were <70 years old and 205 (13.9%) pts were ≥70 years old. 183 (12.5%) pts had IHC only PSLN, 1,021 (69.5%) had 1–3 PSLN, and 266 (18%) ≥4 PSLN. Breast conservation therapy (BCT) was performed in 59.7% of pts. Elderly pts were more likely to have moderate to severe comorbidities (46% vs. 11%, p < 0.0001) and BCT (67% vs. 59%, p = 0.026), compared to pts <70 years old. Elderly pts were less likely to undergo completion ALND (73% vs. 89%, p < 0.0001), adjuvant chemotherapy (43% vs. 90%, p < 0.0001) and radiotherapy following BCT (82% vs. 90%) compared to pts <70 years old. The 5-year disease-free survival (DFS) was not significantly different for elderly pts compared to non-elderly pts (87.7% vs. 91.9%, p = 0.21), on the other hand the 5-year overall survival was significantly worse for elderly pts (80.4% vs. 93.2%, p < 0.0001), a difference that was mainly due to a significantly higher 5-year cumulative incidence of death due to other causes (13.2% vs. 1.9%, p < 0.0001). On multivariate analysis, ER or PR positive status, IHC only PSLN and T1 tumors were the only factors independently associated with improved odds of 5-year DFS. Conclusions: Tumor rather than patient factors were the primary determinants of breast cancer outcomes in our cohort of node positive breast cancer pts. Elderly breast cancer pts with an estimated life expectancy beyond 5 years should receive the same standard of care therapy as their younger counterparts.

No significant financial relationships to disclose.

Prophylactic mastectomy and the timing of breast reconstruction

Immediate reconstruction advocated

Vulnerable but feeling safe: HIV risk among male rural-to-urban migrant workers in Chengdu, China

HIV prevalence is increasing in China. The proportion of infection attributable to heterosexual sex in China is also on the rise. The scale of internal migration for work is likely to be one of the factors contributing to these changing patterns, but little is known about HIV-related knowledge, perceptions and risk behaviours of China's migrant workers. This study aimed to investigate HIV-related knowledge, attitudes and risk behaviours of male rural-to-urban migrant workers in Chengdu and to identify factors associated with risk behaviours. In 2005, a cross-sectional questionnaire survey was completed by 163 male construction- and factory-based migrant workers aged 18-35 years. With a mean age of 26 years, just 30% had completed senior middle school and 47% were currently married. Respondents were highly mobile, worked long hours and were relatively poorly paid. As migrants, their access to urban services and benefits was restricted, making it difficult for family members to join them. Knowledge of HIV transmission was generally poor and discriminatory attitudes towards people with HIV were commonplace. Seventy-five percent were sexually experienced, among whom 88% had had sexual relations in the last 12 months. Of these, 30% had had two or more partners and 20% had paid for sex. Just 36% had used a condom during the most recent sexual encounter with a sex worker. Around 70% thought it was 'impossible' for them to become infected, yet a significant sub-group were engaging in sexual behaviours that place them at risk of infection with HIV and sexually transmitted infections (STIs). Logistic Regression found a significant association between having multiple sexual partners and both education level and marital status. Education was also found to be significantly associated with purchasing sex. Targeted HIV-prevention programs for male migrant workers in Chengdu, especially for those who are single and less educated, are urgently needed.

Occurrence of multidrug resistant Salmonella in antimicrobial-free (ABF) swine production systems

This cross-sectional study was conducted to determine the prevalence and antimicrobial resistance of Salmonella species in swine reared in the intensive (indoor) and extensive (outdoor) ABF production systems at farm and slaughter in North Carolina, U.S.A. We sampled a total of 279 pigs at farm (extensive 107; intensive 172) and collected 274 carcass swabs (extensive 124; intensive 150) at slaughter. Salmonella species were tested for their susceptibility against 12 antimicrobial agents using the Kirby-Bauer disk diffusion method. Serogrouping was done using polyvalent and group specific antisera. A total of 400 salmonellae were isolated in this study with a significantly higher Salmonella prevalence from the intensive (30%) than the extensive farms (0.9%) (P<0.001). At slaughter, significantly higher Salmonella was isolated at the pre- and post-evisceration stages from extensively (29% pre-evisceration and 33.3% post-evisceration) than the intensively (2% pre-evisceration and 6% post-evisceration) reared swine (P<0.001). The isolates were clustered in six serogroups including B, C, E1, E4, G and R. Highest frequency of antimicrobial resistance was observed against tetracycline (78.5%) and streptomycin (31.5%). A total of 13 antimicrobial resistance patterns were observed including the pentaresistant strains with ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, tetracycline resistance pattern observed only among isolates from the intensive farms (n=28) and all were serotype Salmonella typhimurium var. Copenhagen. In conclusion, this study shows that multidrug resistant Salmonella are prevalent in ABF production systems despite the absence of antimicrobial selection pressure. In addition, it also highlights the possible role played by slaughterhouse and other environmental factors in the contamination and dissemination of antimicrobial resistant Salmonella in ABF production systems.

Assessment of the biological and pharmacological effects of the ανβ3 and ανβ5 integrin receptor antagonist, cilengitide (EMD 121974), in patients with advanced solid tumors

BACKGROUND

Cilengitide, an antiangiogenic agent that inhibits the binding of integrins alpha(nu)beta(3) and alpha(nu)beta(5) to the extracellular matrix, was studied at two dose levels in cancer patients to determine the optimal biological dose.

PATIENTS AND METHODS

The doses of cilengitide were 600 or 1200 mg/m(2) as a 1-h infusion twice weekly every 28 days. A novel dose escalation scheme was utilized that relied upon the biological activity rate.

RESULTS

Twenty patients received 50 courses of cilengitide with no dose-limiting toxic effects. The pharmacokinetic (PK) profile revealed a short elimination half-life of 4 h, supporting twice weekly dosing. Of the six soluble angiogenic molecules assessed, only E-selectin increased significantly from baseline. Analysis of tumor microvessel density and gene expression was not informative due to intrapatient tumor heterogeneity. Although several patients with evaluable tumor biopsy pairs did reveal posttreatment increases in tumor and endothelial cell apoptosis, these results did not reach statistical significance due to the aforementioned heterogeneity.

CONCLUSIONS

Cilengitide is a well-tolerated antiangiogenic agent. The biomarkers chosen in this study underscore the difficulty in assessing the biological activity of antiangiogenic agents in the absence of validated biological assays.

The Effect of Multiple Reexcisions on the Risk of Local Recurrence After Breast Conserving Surgery

BACKGROUND

Guidelines for breast conserving surgery (BCS) advise mastectomy if negative margins cannot be obtained after reasonable surgical attempts. This study examined the effect of multiple reexcisions on local recurrence (LR) and identified factors predictive of the need for multiple reexcisions.

METHODS

2,770 patients undergoing BCS over 25 years were analyzed; 137 patients (group A) with two or more reexcisions, 1514 patients with one reexcision (group B), and 1119 patients who had no reexcision (group C). The median follow-up was 73 months.

RESULTS

The five and ten-year actuarial LR rates for groups A, B, and C were 5.5%, 1.9%, 2.5%, and 10%, 5.7%, and 5.6%, respectively. The number of reexcisions did not predict for LR on multivariate analysis. Women <40 years underwent reexcision more frequently than other age groups. Patients with tumors detected by palpation alone made up 14% of the reexcision group versus 8% of the no reexcision group (p < 0.001). Patients with ductal carcinoma in situ and lobular carcinoma were more likely to require reexcision than those with ductal carcinoma. On multivariate analysis, younger age, detection by physical exam only, lobular histology, smaller tumor size, and the presence of extensive intraductal component (EIC) were highly significant predictors of the need for reexcision.

CONCLUSIONS

Multiple reexcisions do not impact on LR rates if negative margins are ultimately obtained. Conversion to mastectomy based solely on the number of excisions performed is not indicated. Subsets of patients more likely to require reexcision, who may be candidates for a larger initial resection, can be identified.

TEL-AML1 preleukemic activity requires the DNA binding domain of AML1 and the dimerization and corepressor binding domains of TEL

The t(12;21)(p13;q22) translocation generates the TEL-AML1 (TEL, translocation-Ets-leukemia; AML1, acute myeloid leukemia-1) (ETV6-RUNX1) fusion product and is the most common chromosomal abnormality in pediatric leukemia. Our previous studies using a murine fetal liver transplantation model demonstrated that TEL-AML1 promotes the self-renewal of B-cell precursors in vitro and enhances the expansion of hematopoietic stem cells (HSCs) in vivo. This is consistent with the hypothesis that TEL-AML1 induces expansion of a preleukemic clone. Several studies have described domains within TEL-AML1 involved in the transcriptional regulation of specific target genes. However, it is unclear which of these domains is important for the activity of TEL-AML1 in preleukemic hematopoiesis. In order to examine this, we have generated a panel of deletion mutants and expressed them in HSCs. These experiments demonstrate that TEL-AML1 requires multiple domains from both TEL and AML1 to alter hematopoiesis. Furthermore, mutation of a single amino-acid residue within the runt homology domain of AML1, required for DNA binding, was sufficient to abrogate TEL-AML1 activity. These data suggest that TEL-AML1 acts as an aberrant transcription factor to perturb multiple pathways during hematopoiesis.

Why do women get mastectomy? Results from a population-based study

605

Background: Persistently high rates of mastectomy (M) use for breast cancer have motivated lingering concerns about over-treatment. Yet, little information exists about the etiology of current rates of M. Methods: 2,030 women with non- metastatic breast cancer diagnosed from August 2005 to May 2006 and reported to the LA County SEER registry were identified and mailed a survey shortly after receipt of surgical treatment. Latina and African American women were over-sampled. Survey data were merged to SEER data. We report results on a 50% respondent sample (n=736) which will be updated based on a final respondent sample of 1400 patients (projected response rate, 72%). Results: M was ultimately performed in 279 women (37.9%): 47.3% (n=132) received initial M based on surgeon recommendation and most (80.8%) reported a clinical contraindication to breast conserving surgery (BCS); 69 patients (24.7%) chose M despite a surgeon recommendation for BCS or no recommendation favoring either procedure; and 28.0% (n=78) received M after initial attempts at BCS. This latter group included 16 of 22 patients who attempted BCS in spite of a surgeon recommendation for M. The failure rate of BCS in patients thought to be candidates for the procedure was 12.6%. One quarter of patients who received an initial recommendation for M sought a second opinion, and 80.6% reported concordance in recommendation for M between their first and second surgeons. Conclusions: Receipt of M in this large population sample was the result of clinical contraindications to BCS and, to a lesser extent, patient preference. The infrequent discordance in surgical opinions about the need for M and infrequent conversion to M in patients selected for BCS suggest that surgeons have accepted BCS and recognize standard contraindications to the procedure. Initiatives to improve surgical treatment decision-making should focus on patient perspectives about risk and benefits of surgical options and clinicopathologic features predictive of the success of re-excision after initial attempt at BCS.

[Table: see text]

No significant financial relationships to disclose.

The effect of margin status on local recurrence following breast conservation and radiation therapy for DCIS

597

Background: There is no consensus on what constitutes an adequate surgical margin in patients receiving breast conserving surgery (BCS) and postoperative irradiation (RT) for ductal carcinoma in situ (DCIS). Inadequate margins may result in high local recurrence, and excessively large resections may lead to poor cosmetic outcome without oncological benefit. Methods: A comprehensive search for published trials which examined outcomes after adjuvant RT following BCS for DCIS was performed using medline and cross referencing available data. Reviews of each study were conducted, and data were extracted. Fixed and random effects methods were used to combine data. Primary outcomes were in breast tumour recurrence (IBTR) related to surgical margins. Results: Analysis of 3,606 patients from randomized trials confirms that patients with negative margins are significantly less likely to recur than those with positive margins after RT (RR 0.53, 95% CI= 0.42 to 0.66, p<0.01). Combined data from randomized and non randomized trials, of 5,500 patients, demonstrates that where the margin status is close or unknown there is significant risk of IBTR compared to a negative margin (RR=1.68, 95% CI= 1.22–2.33, p<0.01). When specific margin thresholds are examined a 2 mm margin is superior to less than 2 mm (OR=0.67, 95% CI 0.51 -0.89, p<0.01), however we saw no significant difference in the rate of IBTR between a 2 mm margin and >5 mm (OR=1.49, 95% CI 0.54 to 4.9, p>0.05). Conclusions: Surgical margins negative for DCIS should be obtained following BCS for DCIS. A margin threshold of 2mm appears be as good as a larger margin when BCS for DCIS is combined with RT.

No significant financial relationships to disclose.

Surgeon specialization and patient satisfaction with breast cancer treatment

11012

Background: Experience and practice setting vary greatly among surgeons who treat patients with breast cancer. Yet, little is known about how these factors influence patient outcomes such as patient satisfaction with aspects of care. Methods: All women with DCIS and a 20% random sample of women with invasive breast cancer diagnosed in 2002 and reported to the Detroit and Los Angeles metropolitan SEER registries were identified and surveyed shortly after receipt of surgical treatment. Attending surgeons were identified primarily using pathology reports and mailed a survey. The final sample contained complete dyad information for 64.6% of patients (n=1,539) and 69.7% of surgeons (n=318). Logistic regression was used to examine the associations between surgeon specialization (% of practice devoted to breast disease) and treating hospital cancer program status (no program, American College of Surgeons approved cancer program, or NCI cancer center) with four domains of patient satisfaction: 1) the surgical decision, 2) decision-making process, 3) surgeon-patient relationship, and 4) surgeon-patient communication, adjusting for patient and surgeon demographics and disease stage. Results: 34.5%, 32.5% and 33.0% of patients were treated by surgeons who devoted <30% (low volume), 30%-60% (medium volume), and >60% (high volume) of their practice to breast disease. Compared to patients who were treated by low volume surgeons, patients treated by medium or high volume surgeons were more satisfied with the decision making process (medium volume: OR=1.2, 95%CI 0.8–1.7, high volume: OR=1.8, 95% CI 1.1- 2.8, p=0.036) and more satisfied with the surgeon-patient relationship (medium volume: OR=1.1, 95% CI 0.7 - 1.7, high volume: OR=2.1, 95% CI 1.1–3.7, p=0.053). Similar trends were observed for the other domains of satisfaction. Treatment setting was not associated with patient satisfaction after controlling for other factors. Conclusions: Surgeon specialization, but not treatment setting, was associated with patient satisfaction. Examining the processes underlying these associations could inform strategies to improve the quality of breast cancer care.

No significant financial relationships to disclose.

The farnesyl transferase inhibitor, tipifarnib, is a potent inhibitor of the MDR1 gene product, P-glycoprotein, and demonstrates significant cytotoxic synergism against human leukemia cell lines

Farnesyl transferase inhibitors (FTIs) target signal-transduction pathways responsible for the proliferation and survival of hematologic malignancies, including acute myelogenous leukemias (AML). Lonafarnib has been shown to be a potent inhibitor of Pgp-mediated drug efflux. On the basis of these findings, we examined the Pgp-inhibitory properties of tipifarnib and assessed its activity when combined with anthracyclines. The effects of tipifarnib on cell proliferation, induction of apoptosis and inhibition of Pgp-mediated anthracycline efflux were analyzed in two human leukemia cell lines overexpressing Pgp (CCRF-CEM and KG1a). Measurement of residual daunorubicin (DNR)-mediated fluorescence after incubation with DNR and tipifarnib demonstrated that tipifarnib significantly inhibited DNR efflux in CCRF-CEM with an IC(50) value less than 0.5 microM. Proliferation and apoptosis assays after exposure to DNR in the presence or absence of tipifarnib demonstrated synergistic inhibition of cellular proliferation, and induction of apoptosis with the combination of tipifarnib and DNR. Similar data was obtained with an enantiomer of tipifarnib that possesses no FTI activity. Incubation with tipifarnib and DNR did not interfere with inhibition of the post-translational processing of HDJ-2. These data suggest that tipifarnib possesses Pgp-inhibitory activity in addition to its FTI activity. In high risk and refractory patients these properties may be exploited as a dual targeting mechanism in the therapy of AML.

A phase I safety, pharmacological and biological study of the farnesyl protein transferase inhibitor, tipifarnib and capecitabine in advanced solid tumors

BACKGROUND

To evaluate the toxicity and pharmacological and biological properties of the farnesyl protein transferase (FPTase) inhibitor, tipifarnib (R115777, ZARNESTRAtrade mark) and capecitabine administered for 14 days every 3 weeks.

PATIENTS AND METHODS

Patients with advanced cancers received twice daily tipifarnib (100-500 mg) and capecitabine (1000-1125 mg/m(2)) for 14 days every 3 weeks. Pharmacokinetics of tipifarnib, capecitabine and 5-fluorouracil (5-FU) were determined. Peripheral blood mononuclear cells were analyzed for farnesylation of the HDJ2 chaperone protein and FPTase activity.

RESULTS

Forty-one patients received 185 courses of treatment. Diarrhea and palmar-plantar erythrodysesthesia were dose limiting at 300 mg tipifarnib/1125 mg/m(2) capecitabine b.i.d. When the capecitabine dose was fixed at 1000 mg/m(2) b.i.d., neutropenia was dose limiting at 400 and 500 mg b.i.d. of tipifarnib. Capecitabine did not affect the pharmacology of tipifarnib at 100-300 mg b.i.d., although tipifarnib significantly increased the C(max) of 5-FU at 400 mg b.i.d. HDJ2 farnesylation and FPTase activity decreased between 200 and 400 mg b.i.d. doses of tipifarnib, without a dose-response relationship. Five patients demonstrated partial remissions and 11 patients maintained prolonged stable disease.

CONCLUSIONS

Tipifarnib and capecitabine are well tolerated at 300 mg/1000 mg/m(2) b.i.d., respectively, resulting in biologically relevant plasma concentrations and antitumor activity. The recommended dose for further disease-focused studies is 300 mg b.i.d. tipifarnib and 1000 mg/m(2) b.i.d. capecitabine, given for 14 days every 3 weeks.