Age interacts with the expression of steroid and HER-2 receptors in operable invasive breast cancer

BACKGROUND

The negative association between the oestrogen receptor (ER) and the human epidermal growth factor receptor 2 (HER-2) in breast cancer travels in both directions. ER+ tumours are less likely HER-2+ and HER-2+ tumours are less likely ER+.

METHODS

We studied the age-related immunohistochemical (IHC) expression of ER, progesterone receptor (PR) and HER-2 in 2,227 tumours using age as a continuous variable. Steroid receptors were considered positive for any nuclear staining of invasive cancer cells and for HER-2, either for strong expression by IHC (score 3+) or gene amplification by fluorescence in situ hybridisation (FISH). Based on nonparametric regression, the age-related association between steroid receptors and HER-2 was presented as likelihood curves.

RESULTS

The association between ER or PR and HER-2 is age-related. The age-related expression of ER and PR is HER-2 dependent. In HER-2(-) cases, the odds ratio (OR) for being ER+ was 2.594 (95% CI = 1.874-3.591) up to age 50 and age-independent thereafter; for PR-expression the OR was 2.687 (95% CI = 1.780-4.057) up to age 45 and 0.847 (95% CI = 0.761-0.942) thereafter. In HER-2+ cases, the OR was 0.806 (95% CI = 0.656-0.991) to be ER+ and 0.722 (95% CI = 0.589-0.886) to be PR+. The age-related OR for breast cancers to be HER-2+ is steroid receptor dependent. Taking together, ER+PR+HER-2+ breast cancers appear on average 5.4 years earlier than breast cancers of any other ER/PR/HER-2 phenotype (95% CI = 3.3-7.5; P < 0.0001).

CONCLUSION

There is a qualitative interaction between age and expression of steroid and HER-2 receptors. Our findings suggest a strong age-related selective growth advantage for breast tumour cells belonging to the ER+PR+HER-2+ subgroup.

Upregulation of Wilms’ tumour gene 1 (WT1) in uterine sarcomas

AIM

Overexpression of Wilms' tumour gene (WT1) has been proven in several tumours. Previous research of our group on the cell cycle of uterine leiomyosarcoma (LMS) and carcinosarcoma (CS) suggested a possible role for WT1. We therefore intended to further explore the expression pattern of WT1 in uterine sarcomas.

METHODS

27 CS, 38 LMS, 15 endometrial stromal sarcomas (ESS) and seven undifferentiated sarcomas (US) were collected. WT1 expression was evaluated by immunohistochemistry (IHC) in 87 samples, by RT-PCR (m-RNA expression) in 23 random selected samples and by Western blotting in 12 samples, separating cytoplasmic and nuclear proteins. A pilot study to detect mutations (exons 7-10) was performed on eight samples.

RESULTS

IHC showed WT1 positivity in 12/27 CS, 29/38 LMS, 7/15 ESS and 4/7 US. All-but-one sample had a positive RT-PCR. All Western blottings were positive with more cytoplasmic expression in 9/12 cases. No mutations were found.

CONCLUSIONS

WT1 is overexpressed in uterine sarcomas. Since increased levels of mRNA determine the biological role, WT1 might contribute to uterine sarcoma tumour biology.

Natural course and clinical features of myxoid and round cell liposarcoma (MRCL) - a retrospective single center analysis

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Background and methods: MRCL, the 2nd most common type liposarcoma, represents ∼10 % of adult soft tissue sarcomas. In most pts the karyotypic hallmark is t(12;16)(q13;p11), leading to fusion of CHOP and FUS genes and generation of a hybrid protein. MRCL has unique sensitivity to antineoplastic agent ET-743 (Yondelis, Trabectidin), which induces specific morphological change and long-lasting response. We made a retrospective analysis of MRCL cases in our center. Results: 33 pts had histological diagnosis of MRCL with a mean (mn) follow-up of 45 mo (range, 2–214). By karyotyping or FISH analysis CHOP-FUS fusion was present in 12 and CHOP-EWS in 2 pts. The mn age at diagnosis was 45 yrs (range, 18–71), male:female ratio 1:0.8. Frequent primary sites: lower limb (25), abdomen (5), retroperitoneum (2), neck (2). Stage grouping at diagnosis: IA (2), IB (6), IIA (5), III (14), IV (2), not known (NK) (4). 2 had distant spread, 9 metachronous metastasis with a mn interval of 24 mo (range, 5–84). Main sites involved: abdomen (5), lung (3), bone (3). Surgery was performed with curative intent in 26/28 pts (5 NK), R0 resection in 23. 17/28 pts are alive without disease (16 previously R0-resected). 6/28 are alive with disease, 5 died due to MRCL. Relapse after R0 resection occurred after a mn of 24 mo (range, 5–84). Radiotherapy was used in 15/28 (5NK) with neoadjuvant (1), adjuvant (13) or palliative (3) intent (total doses 50–66 Gy). Chemotherapy (CT) was given in palliative (11) or neoadjuvant (1) fashion, after a mn of 1.3 surgical interventions (range, 0–3). 1st-line CT: doxorubicin- based combinations (7), single-agent doxorubicin (3), ET-743 (1). Best response: PR (5), NC (4), PD (1), NE (1). Mn duration of response was 6.3 mo (range, 1–15). 2nd-line CT: ET-743 (3), other agents (4). Best response: CR (1), PR (1), NC (3), PD (1), NE (1), with mn response duration of 7 mo (range, 1–13). 2 had further CT (PR 1, SD 1). Conclusions: MRCL is a chemosensitive sarcoma with variable clinical course. Local treatment can be curative, but systemic spread is frequent. Pts may respond to conventional CT or new agents such as ET-743. To evaluate the relative value of systemic treatment we need randomized trials in this unique clinical setting.

No significant financial relationships to disclose.

Docetaxel (T) + capecitabine (X) with or without trastuzumab (H) neoadjuvant therapy for locally advanced breast cancer (BC): Phase II study

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Background: In MBC, adding X to T improves RR, TTP and OS; adding X to TH improves TTP. XT±H is appealing in early BC because H serum concentrations fall during the peri-operative period, potentially reducing the risk of overlapping cardiac toxicity with adjuvant anthracyclines. Methods: Pts with newly diagnosed invasive stage III inoperable BC (cT4 and/or cN2–3) received six 21d cycles of oral X 900 mg/m2 bid d1–14 + iv T 36 mg/m2 d1&8 (+ H on d1 in pts with HER2+ [IHC 3+/FISH+] tumors: 8 mg/kg cycle 1, 6 mg/kg cycles 2–6). After surgery, pts received 4–6 cycles of FEC100 and radiotherapy (+ hormone therapy and H when indicated). Clinical response was assessed after cycles 3 and 6, safety after each cycle, and pathological complete response (pCR: no residual invasive tumor in breast and axilla) after surgery. Results: 71 of 89 planned pts have completed XT±H (Table); 64 have undergone surgery (53 mastectomies, 9 wide excisions, 2 axillary lymph node dissections only). 51 pts are evaluable for safety. The most common treatment-related adverse events (AEs; G1- 2/G3) were stomatitis (61%/8%), nausea (61%/6%), diarrhea (41%/22%), fatigue (57%/4%), neuropathy (59%/0), lacrimation (57%/0) and hand- foot syndrome (33%/16%). Other G3 AEs were anorexia (14%) and vomiting (10%); neutropenic fever occurred in 4 pts (8%). 24 pts had a dose reduction for G2–3 AEs (X 47%, T 27%). 7 pts stopped therapy prematurely for AEs. No unexpected AEs occurred with anthracycline-based adjuvant therapy. Conclusions: Although all pts experienced at least one AE, toxicity was predictable and manageable with dose reduction. Based on the encouraging efficacy of XT+H in HER2+ pts, we are expanding this arm.

[Table: see text]

No significant financial relationships to disclose.

A thin and regular endometrium on ultrasound is very unlikely in patients with endometrial malignancy

OBJECTIVE

To evaluate the clinical and sonographic features in patients with endometrial malignancy in whom endometrial thickness on ultrasound examination had been recorded in our database to be < 5 mm.

METHODS

This was a retrospective observational study on 187 consecutive patients diagnosed with endometrial malignancy in whom an ultrasound evaluation of the endometrium had been performed in our institution. The characteristics of those patients presenting with an endometrial thickness < 5 mm were analyzed.

RESULTS

The median endometrial thickness was 15 mm: 12 mm for the women who underwent endometrial sampling before ultrasound examination vs. 17 mm in those who did not (P = 0.0086). In 13 women (6.9%), the endometrial thickness recorded in our database was < 5 mm. In 12 of these the measurement was compromised in some way: nine of these patients had undergone endometrial sampling (Pipelle biopsy in one and dilatation and curettage in eight patients) before the ultrasound examination, in two cases, focal malignant lesions were not included in the recorded endometrial thickness and in one, the endometrial thickness was visualized poorly due to myometrial distortion. In only one case was was the endometrium correctly measured to be < 5 mm; this woman had diffuse uterine and endometrial metastases of a breast cancer.

CONCLUSIONS

A thin and regular endometrial line is very reliable for the exclusion of endometrial carcinoma. The suspicion of focal lesions as well as incomplete visualization of the endometrium on sonography should be considered abnormal. Recently performed endometrial sampling makes measurement of the endometrial thickness unreliable.

Preoperative diagnosis of ovarian tumors using Bayesian kernel-based methods

OBJECTIVES

To develop flexible classifiers that predict malignancy in adnexal masses using a large database from nine centers.

METHODS

The database consisted of 1066 patients with at least one persistent adnexal mass for which a large amount of clinical and ultrasound data were recorded. The outcome of interest was the histological classification of the adnexal mass as benign or malignant. The outcome was predicted using Bayesian least squares support vector machines in comparison with relevance vector machines. The models were developed on a training set (n=754) and tested on a test set (n=312).

RESULTS

Twenty-five percent of the patients (n=266) had a malignant tumor. Variable selection resulted in a set of 12 variables for the models: age, maximal diameter of the ovary, maximal diameter of the solid component, personal history of ovarian cancer, hormonal therapy, very strong intratumoral blood flow (i.e. color score 4), ascites, presumed ovarian origin of tumor, multilocular-solid tumor, blood flow within papillary projections, irregular internal cyst wall and acoustic shadows. Test set area under the receiver-operating characteristics curve (AUC) for all models exceeded 0.940, with a sensitivity above 90% and a specificity above 80% for all models. The least squares support vector machine model with linear kernel performed very well, with an AUC of 0.946, 91% sensitivity and 84% specificity. The models performed well in the test sets of all the centers.

CONCLUSIONS

Bayesian kernel-based methods can accurately separate malignant from benign masses. The robustness of the models will be investigated in future studies.

Intravascular large B-cell lymphoma of the uterus presenting as fever of unknown origin (FUO) and revealed by FDG-PET

Non-Hodgkin's lymphoma (NHL) is a common cause of Fever of Unknown Origin (FUO) but the presentation as a gynaecologic malignancy is exceedingly rare. To our knowledge, this represents the first report of an intravascular large B-cell lymphoma of the uterus presenting with fever of unknown origin. After a standard clinical work-up for FUO, the endometrial curettage directed by the finding of a localized fluoro-deoxyglucose Positron Emission Tomography (FDG-PET) hot spot in the pelvic area, yielded material revealing an intr avascular B-cell lymphoma. A total abdominal hysterectomy confirmed the presence of an intravascular large B-cell lymphoma in the lumina of small blood vessels of the uterus.

Metastatic breast cancer: sequencing hormonal therapy and positioning of fulvestrant

Fulvestrant, a novel estrogen receptor (ER) antagonist with no agonist effects, binds, blocks, and degrades the ER, thereby downregulating cellular ER levels, which in turn leads to reduced expression of the progesterone receptor. Due to this specific working mechanism, fulvestrant is an important addition to the armamentarium of endocrine agents in advanced breast cancer (ABC). Fulvestrant has been shown to be equally effective as the third-generation aromatase inhibitor (AI) anastrozole in postmenopausal patients with hormone-sensitive ABC progressing prior to tamoxifen. In another randomized phase III trial, it was shown that fulvestrant had similar efficacy to tamoxifen in the first-line treatment of postmenopausal women with hormone receptor-positive ABC. When comparing the side effects of fulvestrant with tamoxifen and anastrozole, it was shown that fulvestrant is well tolerated compared with these agents and is associated with a lower incidence of joint disorders. Clinical benefit on fulvestrant treatment after AI therapy has been reported in a substantial number of patients (28-46%). On the other hand, it was also shown that sensitivity to further endocrine therapy is retained following progression on first-line or second-line fulvestrant (57% and 46% clinical benefit, respectively). In conclusion, fulvestrant provides us with an additional endocrine treatment option making it possible to prolong the time that patients with ABC can be treated with endocrine therapy.

HPV induced ovarian squamous cell carcinoma: case report and review of the literature

BACKGROUND

Ovarian squamous cell carcinoma is usually derived from a teratoma, a Brenner tumour or endometriosis. Association with an HPV infection is rare.

CASE

A fourth case of ovarian squamous cell cancer associated with HR-HPV is presented. Debulking for stage IIIc ovarian squamous cell cancer was performed and she received adjuvant combination chemotherapy. She developed bone metastases and received radiotherapy. The Progression of these metastases and the newly developed metastases did not respond to an oral tyrosine kinase inhibitor (gefitinib).

CONCLUSION

The development of bone metastases in association with an ovarian squamous cell carcinoma is a rare finding, and it did not respond to treatment with a tyrosine kinase. A review of literature is presented.

Body mass index and HER-2 overexpression in breast cancer patients over 50 years of age

PURPOSE

In breast cancer, in vitro as well as in vivo experiments have shown an inverse relationship between HER-2 and steroid hormone receptors. It is unknown whether circulating estrogens affect HER-2 expression. We hypothesize that the postmenopausal body mass index (BMI) as a surrogate marker for bio-available estrogens, is inversely associated with HER-2 over-expression.

PATIENTS AND METHODS

A total of 535 women over age 50 or with known postmenopausal status, with a unilateral, not previously treated, operable breast cancer were evaluated the evening prior to surgery for body weight, height, abdominal and hip circumference over a 3 years period. Waist-to-hip ratio (WHR) and BMI were calculated. HER-2, estrogen receptor and progesterone receptor staining was done by immunohistochemistry. All tumours with DAKO 2+ staining were submitted for HER-2 detection by FISH analysis. HER-2 was defined as positive if DAKO 3+ or FISH positive. We assessed the frequency of HER-2 positivity in each of 6 quantiles for all parameters of body composition and tested for a trend in HER-2 expression across the 6 quantiles. Furthermore, we investigated whether BMI contributed, together with other known predictors for HER-2, in a standard multivariate logistic regression model that predicts HER-2 over-expression.

RESULTS

There is a decrease in HER-2 over-expression per increasing quantile of BMI. In a multivariate model-including both steroid receptors-BMI remains an independent predictor for HER-2 over-expression.

CONCLUSION

In women over age 50 or with known postmenopausal status with an operable breast cancer, there is an inverse association between BMI and HER-2 over-expression.

Effectiveness of weekly topotecan in patients with recurrent epithelial ovarian cancer

The objective of this study was to investigate the effectiveness and toxicity of weekly topotecan in patients with recurrent epithelial ovarian cancer. Twenty patients were treated with topotecan at a dose of 4 mg/m2weekly. Efficacy was determined according to the Response Criteria in Solid Tumors (RECIST) Gynecologic Cancer Inter Group criteria. Median age was 62 years (45–78). Patients had received 1–7 (median 3) prior chemotherapy lines. A total of 203 weekly treatments were administered. In 13 patients (65%) treatment delay was necessary due to bone marrow toxicity. Grade 3/4 neutropenia occurred in 11 patients (55%) and grade 3/4 thrombocytopenia in four patients (20%). Six patients (30%) needed a dose reduction, and 42 cycles (21%) were given with dose reduction. No neutropenia, fever, or sepsis was observed. There was one complete response and one partial response (response rate 10%). All patients with response had platin-sensitive disease (three out of eight). Six patients needed blood transfusion. None of the patients required granulocyte/granulocyte-macrophage colony-stimulating factor. The median duration of response was 13 months. In addition, there were four patients (20%) with a stable disease lasting at least for 4 months. Based on the results of this Phase II study, the toxicity of weekly topotecan seems to be lower than with the 3-weekly topotecan. The response rate of 10% is low but was not expected to be higher as these patients were heavily pretreated.

The position of neoadjuvant chemotherapy within the treatment of ovarian cancer

It is clear that primary debulking remains the standard of care within the treatment of advanced ovarian cancer (International Federation of Gynaecology and Obstetrics, FIGO, stage III and IV). Debulking surgery should be performed by a gynaecologic oncologist without any residual tumour load, or so called optimal debulking'. Over the last decades, interest in the use of neoadjuvant chemotherapy together with an interval debulking has increased. Open laparoscopy is probably the most valuable tool for evaluating the operability primarily or at the time of interval debulking surgery. Neoadjuvant therapy can be used for patients that are primarily suboptimally debulked due to an extensive tumor load. In this situation, based on the randomized EORTC-GCG trial, interval debulking by an experienced surgeon improves survival in some patients who did not undergo optimal primary debulking surgery. Based on the GOG 152 data, interval debulking surgery does not seem to be indicated in patients who underwent primarily a maximal surgical effort by a gynecological oncologist. Neoadjuvant chemotherapy can also be used as an alternative to primary debulking. In retrospective analyses neoadjuvant chemotherapy followed by interval debulking surgery does not seem to worsen prognosis compared to primary debulking surgery followed by chemotherapy. However, we will have to wait for the results of future randomized trials to know whether neoadjuvant chemotherapy followed by interval debulking surgery is a good alternative to primary debulking surgery in stage IIIc and IV patients.

Role of lymphadenectomy and pelvic radiotherapy in patients with clinical FIGO stage I endometrial adenocarcinoma: an analysis of 208 patients

Two hundred and eight patients with a clinical stage I endometrial carcinoma were studied (164 fulfilled the inclusion criteria). High risk was defined as nonendometrioid, or endometrioid tumors grade 3 (G3), or G2 with any or G1 with deep (>1/2) myometrial infiltration. The low-risk group consisted of the remaining patients. Surgical staging in the high-risk group included pelvic lymphadenectomy with para-aortic lymphadenectomy in selected cases. Twelve percent of the high-risk patients had nodal metastasis. Patients with low-risk (group A, n = 85) and high-risk disease confined to the uterus (group B, n = 57) did not receive adjuvant radiotherapy. Patients with nodal metastases (group C, n = 10) received postoperative irradiation. The total recurrence rate of the entire population was 12.5%, and the actuarial overall survival, disease-specific survival, and disease-free survival were 90%, 94%, and 88%, respectively. All patients with only vaginal relapse (n = 9) were cured locally with salvage radiotherapy until the date of analysis. The pelvic relapse rate was low as only one patient of group B recurred in the pelvis. In conclusion, lymphadenectomy remains indicated to better select patients at high risk of pelvic recurrence that may benefit from postoperative radiotherapy.

New models to predict depth of infiltration in endometrial carcinoma based on transvaginal sonography

OBJECTIVES

Preoperative knowledge of the depth of myometrial infiltration is important in patients with endometrial carcinoma. This study aimed at assessing the value of histopathological parameters obtained from an endometrial biopsy (Pipelle de Cornier; results available preoperatively) and ultrasound measurements obtained after transvaginal sonography with color Doppler imaging in the preoperative prediction of the depth of myometrial invasion, as determined by the final histopathological examination of the hysterectomy specimen (the gold standard).

METHODS

We first collected ultrasound and histopathological data from 97 consecutive women with endometrial carcinoma and divided them into two groups according to surgical stage (Stages Ia and Ib vs. Stages Ic and higher). The areas (AUC) under the receiver-operating characteristics curves of the subjective assessment of depth of invasion by an experienced gynecologist and of the individual ultrasound parameters were calculated. Subsequently, we used these variables to train a logistic regression model and least squares support vector machines (LS-SVM) with linear and RBF (radial basis function) kernels. Finally, these models were validated prospectively on data from 76 new patients in order to make a preoperative prediction of the depth of invasion.

RESULTS

Of all ultrasound parameters, the ratio of the endometrial and uterine volumes had the largest AUC (78%), while that of the subjective assessment was 79%. The AUCs of the blood flow indices were low (range, 51-64%). Stepwise logistic regression selected the degree of differentiation, the number of fibroids, the endometrial thickness and the volume of the tumor. Compared with the AUC of the subjective assessment (72%), prospective evaluation of the mathematical models resulted in a higher AUC for the LS-SVM model with an RBF kernel (77%), but this difference was not significant.

CONCLUSIONS

Single morphological parameters do not improve the predictive power when compared with the subjective assessment of depth of myometrial invasion of endometrial cancer, and blood flow indices do not contribute to the prediction of stage. In this study an LS-SVM model with an RBF kernel gave the best prediction; while this might be more reliable than subjective assessment, confirmation by larger prospective studies is required.

Second case of uterine mesonephric adenocarcinoma

A second report of an intramural mesonephric adenocarcinoma of the uterus is presented. The histogenesis and clinicopathologic outcome of a surgically staged malignancy add to the insights and experience of this uncommon disorder.

Neoadjuvant chemotherapy followed by radical hysterectomy for invasive cervical cancer diagnosed during pregnancy: report of a case and review of the literature

Although cervical carcinoma is among the most frequently encountered malignancies during pregnancy, only four cases of neoadjuvant chemotherapy during pregnancy have been reported. A 28-year-old A0P1G2M0 was diagnosed at 15 weeks with stage Ib1 invasive squamous cervical cancer. Because she strongly desired the continuation of this pregnancy, after extensive counseling she was treated with 75 mg/m(2) cisplatin every 10 days starting at 17 weeks. After six cycles, clinically and radiologically stable disease with normalization of the squamous cell carcinoma tumor marker was obtained. An elective cesarean delivery followed by radical hysterectomy and lymphadenectomy was performed at 32 weeks gestation. The pathology report revealed a moderately differentiated squamous cell carcinoma of 3.5 cm, and all 33 lymph nodes were free of disease. Neonatal examination of the baby could not reveal any abnormalities, and this was confirmed at 6 months. The use of neoadjuvant chemotherapy enabled us to continue this pregnancy until the fetus was viable. Cisplatin did not influence the short-term outcome, but only a long-term follow-up will inform us on its safety during pregnancy.