Reduction of breast cancer relapses with perioperative non-steroidal anti-inflammatory drugs: new findings and a review

Ovarian Tumor Microenvironment Signaling: Convergence on the Rac1 GTPase

The tumor microenvironment for epithelial ovarian cancer is complex and rich in bioactive molecules that modulate cell-cell interactions and stimulate numerous signal transduction cascades. These signals ultimately modulate all aspects of tumor behavior including progression, metastasis and therapeutic response. Many of the signaling pathways converge on the small GTPase Ras-related C3 botulinum toxin substrate (Rac)1. In addition to regulating actin cytoskeleton remodeling necessary for tumor cell adhesion, migration and invasion, Rac1 through its downstream effectors, regulates cancer cell survival, tumor angiogenesis, phenotypic plasticity, quiescence, and resistance to therapeutics. In this review we discuss evidence for Rac1 activation within the ovarian tumor microenvironment, mechanisms of Rac1 dysregulation as they apply to ovarian cancer, and the potential benefits of targeting aberrant Rac1 activity in this disease. The potential for Rac1 contribution to extraperitoneal dissemination of ovarian cancer is addressed.

Effects of anesthetic interventions on breast cancer behavior, cancer-related patient outcomes, and postoperative recovery

This narrative review will summarize our current understanding of the effects of perioperative interventions on patients undergoing surgical removal of breast malignancies. It will focus on how different anesthetic agents and perioperative interventions might affect both breast cancer behavior and/or tumor recurrence as well as postoperative recovery. The main objective of this study will be to describe the evidence and critically analyze preclinical and clinical studies on the use of intravenous versus inhaled anesthetic agents, opioids, regional anesthetics, and anesthetic adjuncts in patients undergoing breast cancer resection. We will look both at the evidence regarding cancer-related outcomes and postoperative recovery. A search of PubMed, from inception to May 2017 was performed using Mesh terms Breast Neoplasms [Mesh] OR cancer AND breast AND Anesthesia [Mesh]; "Anesthetics"[Mesh] AND "Breast Neoplasms/surgery"[Mesh]. Although no optimal anesthetic combination has been identified for patients undergoing breast cancer resection, it should be noted that based on the available evidence, an ideal anesthetic in this patient population would involve a combination of TIVA (propofol), regional anesthesia (paravertebral block)), non opioid sedatives (clonidine or dexmedetomidine), and COX-2 inhibition (ketorolac). Based on the current evidence, this combination of anesthetic and analgesic agents has the best chance of improving cancer-related outcomes and postoperative recovery.

Suppression of Metastasis by Primary Tumor and Acceleration of Metastasis Following Primary Tumor Resection: A Natural Law?

We study metastatic cancer progression through an extremely general individual-patient mathematical model that is rooted in the contemporary understanding of the underlying biomedical processes yet is essentially free of specific biological assumptions of mechanistic nature. The model accounts for primary tumor growth and resection, shedding of metastases off the primary tumor and their selection, dormancy and growth in a given secondary site. However, functional parameters descriptive of these processes are assumed to be essentially arbitrary. In spite of such generality, the model allows for computing the distribution of site-specific sizes of detectable metastases in closed form. Under the assumption of exponential growth of metastases before and after primary tumor resection, we showed that, regardless of other model parameters and for every set of site-specific volumes of detected metastases, the model-based likelihood-maximizing scenario is always the same: complete suppression of metastatic growth before primary tumor resection followed by an abrupt growth acceleration after surgery. This scenario is commonly observed in clinical practice and is supported by a wealth of experimental and clinical studies conducted over the last 110 years. Furthermore, several biological mechanisms have been identified that could bring about suppression of metastasis by the primary tumor and accelerated vascularization and growth of metastases after primary tumor resection. To the best of our knowledge, the methodology for uncovering general biomedical principles developed in this work is new.

Breast conserving surgery versus mastectomy: overall and relative survival-a population based study by the Danish Breast Cancer Cooperative Group (DBCG)

BACKGROUND

Observational studies have pointed at a better survival after breast conserving surgery (BCS) compared with mastectomy. The aim of the present study was to evaluate whether this remains true when more extensive tumor characteristics and treatment data were included.

METHODS

The cohort included patients registered after primary surgery for early invasive breast cancer in the database of the Danish Breast Cancer Cooperative Group, in the period 1995-2012. The cohort was divided into three groups: (i) patients who primarily had a mastectomy, (ii) patients treated by BCS, and (iii) patients who primarily had BCS and then mastectomy [intention to treat (ITT) by BCS]. The association between overall mortality and standard mortality ratio (SMR) and risk factors was analyzed in univariate and multivariate Poisson regression models.

RESULTS

A total of 58,331 patients were included: 27,143 in the mastectomy group, 26,958 in the BCS group, and 4230 in the BCS-ITT group. After adjusting for patient and treatment characteristics, the relative risk (RR) was 1.20 (95% CI: 1.15-1.25) after mastectomy and 1.08 (95% CI: 1.01-1.15) after BCS first and then mastectomy, as compared to BCS. Statistically significant interactions were not observed for age, period of treatment, and nodal status, but patients with Charlson's Comorbidity Index (CCI) score 2+ had no increased mortality after mastectomy, as opposed to patients with CCI 0-1. Loco-regional radiation therapy (RT) in node positive patients did not reduce the increased risk associated with mastectomy [RR = 1.28 (95% CI 1.19-1.38)].

CONCLUSION

Patients assigned to BCS have a better survival than patients assigned to mastectomy. Residual confounding after adjustment for registered characteristics presumably explained the different outcomes, thus consistent with selection bias. Diversities in RT did not appear to explain the observed difference in survival after BCS and mastectomy.

Perioperative events influence cancer recurrence risk after surgery

Surgery is a mainstay treatment for patients with solid tumours. However, despite surgical resection with a curative intent and numerous advances in the effectiveness of (neo)adjuvant therapies, metastatic disease remains common and carries a high risk of mortality. The biological perturbations that accompany the surgical stress response and the pharmacological effects of anaesthetic drugs, paradoxically, might also promote disease recurrence or the progression of metastatic disease. When cancer cells persist after surgery, either locally or at undiagnosed distant sites, neuroendocrine, immune, and metabolic pathways activated in response to surgery and/or anaesthesia might promote their survival and proliferation. A consequence of this effect is that minimal residual disease might then escape equilibrium and progress to metastatic disease. Herein, we discuss the most promising proposals for the refinement of perioperative care that might address these challenges. We outline the rationale and early evidence for the adaptation of anaesthetic techniques and the strategic use of anti-adrenergic, anti-inflammatory, and/or antithrombotic therapies. Many of these strategies are currently under evaluation in large-cohort trials and hold promise as affordable, readily available interventions that will improve the postoperative recurrence-free survival of patients with cancer.

The R-Enantiomer of Ketorolac Delays Mammary Tumor Development in Mouse Mammary Tumor Virus-Polyoma Middle T Antigen (MMTV-PyMT) Mice

Epidemiologic studies report improved breast cancer survival in women who receive ketorolac (Toradol) for postoperative pain relief compared with other analgesic agents. Ketorolac is a racemic drug. The S-enantiomer inhibits cyclooxygenases; R-ketorolac is a selective inhibitor of the small GTPases Ras-related C3 botulinum toxin substrate 1 (Rac1) and cell division control protein 42 (Cdc42), which are signaling molecules up-regulated during breast cancer progression and metastasis. The goal of this study was to determine whether R-ketorolac altered breast cancer development in the mouse mammary tumor virus-polyoma middle T-antigen model. Mice were administered ketorolac orally at 1 mg/kg twice daily to approximate the typical human dose. Mammary glands were analyzed for tumor number and immunohistochemical markers of proliferation and differentiation. R-ketorolac treatment significantly reduced mammary epithelial proliferation, based on Ki67 staining, and suppressed tumor development. Proliferative mammary epithelium from R-ketorolac-treated mice displayed greater differentiation, based on significantly higher total E-cadherin and decreased keratin 5 staining than epithelium of placebo-treated mice. No differences were detected in estrogen receptor, progesterone receptor, β-catenin, or vimentin expression between placebo and R-ketorolac treatment groups. These findings indicate that R-ketorolac treatment slows tumor progression in an aggressive model of breast cancer. R-ketorolac may thus represent a novel therapeutic approach for breast cancer prevention or treatment based on its pharmacologic activity as a Rac1 and Cdc42 inhibitor.

Does the type of anesthesia really affect the recurrence-free survival after breast cancer surgery?

Background

Although previous studies have suggested that propofol inhibits cancer recurrence and metastasis, the association between anesthetic agents and the recurrence of breast cancer has not been clearly investigated. We compared total intravenous anesthesia and balanced anesthesia with volatile agents to investigate the differences in their effects on recurrence-free survival and overall survival after breast cancer surgery.

Materials and Methods

The electronic medical records of 2,729 patients who underwent breast cancer surgery between November 2005 and December 2010 were retrospectively reviewed to analyze the factors associated with recurrence-free survival after surgery. Cox proportional hazards models were used to identify the risk factors for cancer recurrence and overall mortality after breast cancer surgery.

Results

Data from 2,645 patients were finally analyzed. The recurrence-free survival rate in this study was 91.2%. Tumor-node-metastasis staging exhibited the strongest association with breast cancer recurrence. However, we were unable to identify significant differences between the preventive effects of total intravenous anesthesia and those of volatile agents on postoperative breast cancer recurrence using Cox regression analyses and propensity score matching. Furthermore, the survival probability with regard to postoperative recurrence and mortality showed no significant differences among anesthetic agents.

Conclusions

Our findings suggest that the effects of total intravenous anesthesia are comparable with those of volatile agents with regard to postoperative recurrence-free survival and overall survival in patients with breast cancer.

Metastasis 'systems' biology: how are macro-environmental signals transmitted into microenvironmental cues for disseminated tumor cells?

Disseminated breast tumor cells reside on or near stable microvascular endothelium. Currently, the cues that disrupt DTC dormancy and facilitate outgrowth are largely unknown. This article explores the hypothesis that specific patient lifestyle exposures (e.g., alcohol abuse) may disrupt the microenvironments that maintain disseminated tumor cell (DTC) dormancy in a tissue-specific fashion. We suggest that such exposures are 'transmitted' to the dormant niche in the form of injury. Thus, we discuss the relationship between wound healing and metastasis using liver as an example to illustrate how injury steers the phenotype of liver endothelium and perivascular hepatic stellate cells to a potentially pro-metastatic one. We posit further that non-steroidal anti-inflammatory drugs (NSAIDs) - recently shown to prevent metastatic relapse - may act by preserving the dormant niche. We conclude by suggesting that maintenance of the dormant niche - either through patient lifestyle or via development of therapeutics that mimic local molecular cues/responses that coincide with a healthy lifestyle - is a means to prevent metastatic relapse, and should be the subject of far greater research.

Pre-metastatic niches: organ-specific homes for metastases

It is well established that organs of future metastasis are not passive receivers of circulating tumour cells, but are instead selectively and actively modified by the primary tumour before metastatic spread has even occurred. Sowing the 'seeds' of metastasis requires the action of tumour-secreted factors and tumour-shed extracellular vesicles that enable the 'soil' at distant metastatic sites to encourage the outgrowth of incoming cancer cells. In this Review, we summarize the main processes and new mechanisms involved in the formation of the pre-metastatic niche.

The Impact of Paravertebral Block Analgesia on Breast Cancer Survival After Surgery

BACKGROUND AND OBJECTIVES

The impact of regional anesthesia on breast cancer recurrence is controversial. We tested the hypothesis that the use of paravertebral block (PVB) analgesia during breast cancer surgery prolongs the recurrence-free survival (RFS) and overall survival (OS) of women with breast cancer.

METHODS

Seven hundred ninety-two women with nonmetastatic breast cancer were included in this retrospective study. Patients were divided based on the administration of PVB analgesia for mastectomy surgeries. One hundred ninety-eight (25%) were given a PVB, the remainder were treated with opioid-based analgesia. Propensity score matching was developed using several variables. Univariate and multivariate analyses were used to assess the impact of PVB analgesia on RFS and OS.

RESULTS

The median follow-up times for RFS and OS were 5.8 and 6 years, respectively. In the propensity score matching model, a total of 396 women were included in each group of treatment (non-PVB group, n = 198 vs PVB group, n = 198). As expected, the fentanyl consumption was significantly lower in PVB (122.8 ± 77.85 μg) patients than non-PVB subjects (402.23 ± 343.8 μg). Other variables were not statistically significant. After adjusting for several important covariates, the analysis indicated that the use of PVB is not associated with a significant change in RFS [1.60 (0.81-3.16), P = 0.172] or OS [1.28 (0.55-3.01)] survival.

DISCUSSION

This retrospective study does not support the hypothesis that the use of regional analgesia is associated with longer survival after surgery for breast cancer.

Circulating and disseminated tumor cells: harbingers or initiators of metastasis?

Tumor cells leave the primary tumor and enter the circulation. Once there, they are called circulating tumor cells (CTCs). A fraction of CTCs are capable of entering distant sites and persisting as disseminated tumor cells (DTCs). An even smaller fraction of DTCs are capable of progressing toward metastases. It is known that the DTC microenvironment plays an important role in sustaining their survival, regulating their growth, and conferring resistance to therapy. But we still have much to learn about the nature of these rare cell populations to predict which will progress and what exactly should cause concern for future relapse. Although recent technological advances in our ability to detect and molecularly and functionally characterize CTCs and DTCs promise to unravel this ambiguity, the timing of dissemination and the precise source of CTCs and DTCs profiled will impact the conclusions that can be made from these endeavors. In this review, we discuss the biology of CTCs and DTCs; the technologies to detect, isolate, and profile these cells; and the exceptions we must apply to our understanding of what role these cells play in the metastatic process. We conclude that a greater effort to understand the unique biology of these cells in context will positively impact our ability to use these cells to predict outcome, monitor treatment efficacy, and reveal therapeutically relevant targets to deplete these populations and ultimately prevent metastasis.

The Role of NSAIDs in Breast Cancer Prevention and Relapse: Current Evidence and Future Perspectives

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) have received considerable interest as potential chemopreventive agents. The aim of this review is to summarize the accumulated knowledge on the effect of NSAIDs on breast cancer incidence and natural history, and the underlying pathophysiology. NSAIDs mainly block inflammation by inhibiting cyclooxygenase enzymes, leading to lower prostaglandin synthesis. The latter has been reported to affect breast cancer risk through hormonal and inflammation-related pathways. Intensity, dose, frequency, duration, and timing of administration may also be significant. There is currently enough evidence to support a role of NSAIDs in breast cancer prevention and relapse, which deserves further large-scale experimental and clinical investigation.

The prognostic impact of COX-2 expression in breast cancer depends on oral contraceptive history, preoperative NSAID use, and tumor size

The association between tumor cyclooxygenase 2 (COX-2) expression and breast cancer prognosis has been inconsistent. The purpose of this study was to evaluate the prognostic significance of COX-2 tumor expression according to adjuvant treatment, and potential effect modifications of non-steroid anti-inflammatory drug (NSAID) use, and other tumor and lifestyle factors. A prospective cohort of 1,116 patients with primary breast cancer in Lund, Sweden, included 2002-2012 was followed until June 2014 (median 5 years). Tumor-specific COX-2 expression was evaluated on tissue microarrays using immunohistochemistry. Associations between COX-2 intensity (negative, weak-moderate, high) and patient and tumor characteristics as well as prognosis were analyzed. Tumor-specific COX-2 expression was available for 911 patients and was significantly associated with higher age at diagnosis and less aggressive tumor characteristics. Higher COX-2 expression was associated with lower risk for breast cancer events during the first five years of follow-up, _adj HR 0.60 (95%CI: 0.37-0.97), per category. The association between COX-2 expression and prognosis was significantly modified by oral contraceptive (OC) use (P_interaction  = 0.048), preoperative NSAID use (P_interaction  = 0.009), and tumor size (P_interaction  = 0.039). COX-2 negativity was associated with increased risk for events during the first five years in ever OC users, _adj HR 1.94 (1.01-3.72) and during the 11-year follow-up in preoperative NSAID users, _adj HR 4.51 (1.18-11.44) as well as in patients with large tumors, _adj HR 2.57 (1.28-5.15). In conclusion, this study, one of the largest evaluating COX-2 expression in breast cancer, indicates that the prognostic impact of COX-2 expression depends on host factors and tumor characteristics.

Breast cancer survival among young women: a review of the role of modifiable lifestyle factors

Almost 7 % of breast cancers are diagnosed among women age 40 years and younger in Western populations. Clinical outcomes among young women are worse. Early age-of-onset increases the risk of contralateral breast cancer, local and distant recurrence, and subsequent mortality. Breast cancers in young women (BCYW) are more likely to present with triple-negative (TNBC), TP53-positive, and HER-2 over-expressing tumors than among older women. However, despite these known differences in breast cancer outcomes and tumor subtypes, there is limited understanding of the basic biology, epidemiology, and optimal therapeutic strategies for BCYW. Several modifiable lifestyle factors associated with reduced risk of developing breast cancer have also been implicated in improved prognosis among breast cancer survivors of all ages. Given the treatment-related toxicities and the extended window for late effects, long-term lifestyle modifications potentially offer significant benefits to BCYW. In this review, we propose a model identifying three main areas of lifestyle factors (energy imbalance, inflammation, and dietary nutrient adequacy) that may influence survival in BCYW. In addition, we provide a summary of mechanisms of action and a synthesis of previous research on each of these topics.

Repurposing Drugs in Oncology (ReDO)-diclofenac as an anti-cancer agent

Diclofenac (DCF) is a well-known and widely used non-steroidal anti-inflammatory drug (NSAID), with a range of actions which are of interest in an oncological context. While there has long been an interest in the use of NSAIDs in chemoprevention, there is now emerging evidence that such drugs may have activity in a treatment setting. DCF, which is a potent inhibitor of COX-2 and prostaglandin E2 synthesis, displays a range of effects on the immune system, the angiogenic cascade, chemo- and radio-sensitivity and tumour metabolism. Both pre-clinical and clinical evidence of these effects, in multiple cancer types, is assessed and summarised and relevant mechanisms of action outlined. Based on this evidence the case is made for further clinical investigation of the anticancer effects of DCF, particularly in combination with other agents - with a range of possible multi-drug and multi-modality combinations outlined in the supplementary materials accompanying the main paper.

Novel Activities of Select NSAID R-Enantiomers against Rac1 and Cdc42 GTPases

Rho family GTPases (including Rac, Rho and Cdc42) collectively control cell proliferation, adhesion and migration and are of interest as functional therapeutic targets in numerous epithelial cancers. Based on high throughput screening of the Prestwick Chemical Library^® and cheminformatics we identified the R-enantiomers of two approved drugs (naproxen and ketorolac) as inhibitors of Rac1 and Cdc42. The corresponding S-enantiomers are considered the active component in racemic drug formulations, acting as non-steroidal anti-inflammatory drugs (NSAIDs) with selective activity against cyclooxygenases. Here, we show that the S-enantiomers of naproxen and ketorolac are inactive against the GTPases. Additionally, more than twenty other NSAIDs lacked inhibitory action against the GTPases, establishing the selectivity of the two identified NSAIDs. R-naproxen was first identified as a lead compound and tested in parallel with its S-enantiomer and the non-chiral 6-methoxy-naphthalene acetic acid (active metabolite of nabumetone, another NSAID) as a structural series. Cheminformatics-based substructure analyses—using the rotationally constrained carboxylate in R-naproxen—led to identification of racemic [R/S] ketorolac as a suitable FDA-approved candidate. Cell based measurement of GTPase activity (in animal and human cell lines) demonstrated that the R-enantiomers specifically inhibit epidermal growth factor stimulated Rac1 and Cdc42 activation. The GTPase inhibitory effects of the R-enantiomers in cells largely mimic those of established Rac1 (NSC23766) and Cdc42 (CID2950007/ML141) specific inhibitors. Docking predicts that rotational constraints position the carboxylate moieties of the R-enantiomers to preferentially coordinate the magnesium ion, thereby destabilizing nucleotide binding to Rac1 and Cdc42. The S-enantiomers can be docked but are less favorably positioned in proximity to the magnesium. R-naproxen and R-ketorolac have potential for rapid translation and efficacy in the treatment of several epithelial cancer types on account of established human toxicity profiles and novel activities against Rho-family GTPases.

A two-clones tumor model: Spontaneous growth and response to treatment

The paper aims at providing a general theoretical frame bridging the macroscopic growth law with the complex heterogeneous structure of real tumors. We apply the "Phenomenological Universality" approach to model the growth of cancer cells accounting for "populations", which are defined not as biologically pre-defined cellular ensemble but as groups of cells behaving homogeneously with respect to their position (e.g. primary or metastatic tumor), growth characteristics, response to treatment, etc. Populations may mutually interact, limit each other their growth or even mutate into another population. To keep the description as simple and manageable as possible only two populations are considered, but the extension to a multiplicity of cell populations is straightforward. Our findings indicate that the eradication of the metastatic population is much more critical in the presence of mutations, either spontaneous or therapy-induced. Furthermore, a treatment that eradicates only the primary tumor, having a low kill rate on the metastases, is ultimately not successful but promotes a "growth spurt" in the latter.

The wisdom of crowds and the repurposing of artesunate as an anticancer drug

Artesunate, a semi-synthetic and water-soluble artemisinin-derivative used as an anti-malarial agent, has attracted the attention of cancer researchers due to a broad range of anti-cancer activity including anti-angiogenic, immunomodulatory and treatment-sensitisation effects. In addition to pre-clinical evidence in a range of cancers, a recently completed randomised blinded trial in colorectal cancer has provided a positive signal for further clinical investigation. Used perioperatively artesunate appears to reduce the rate of disease recurrence - and the Neo-Art trial, a larger Phase II RCT, is seeking to confirm this positive effect. However, artesunate is a generic medication, and as with other trials of repurposed drugs, the Neo-Art trial does not have commercial sponsorship. In an innovative move, the trial is seeking funds directly from members of the public via a crowd-funding strategy that may have resonance beyond this single trial.

Why Does the Weeping Willow Weep? Reconceptualizing Oncogenesis in Breast Cancer

Like other human anatomical systems, the mammary ducts and glands at the time of lactation adhere to a perfect fractal geometry - which is destroyed by breast cancer. Could a loss of fractal geometry of the blood supply to human tissue be an early step in oncogenesis?

The wound inflammatory response exacerbates growth of pre-neoplastic cells and progression to cancer

There is a long-standing association between wound healing and cancer, with cancer often described as a "wound that does not heal". However, little is known about how wounding, such as following surgery, biopsy collection or ulceration, might impact on cancer progression. Here, we use a translucent zebrafish larval model of Ras(G12V)-driven neoplasia to image the interactions between inflammatory cells drawn to a wound, and to adjacent pre-neoplastic cells. We show that neutrophils are rapidly diverted from a wound to pre-neoplastic cells and these interactions lead to increased proliferation of the pre-neoplastic cells. One of the wound-inflammation-induced trophic signals is prostaglandin E2 (PGE2). In an adult model of chronic wounding in zebrafish, we show that repeated wounding with subsequent inflammation leads to a greater incidence of local melanoma formation. Our zebrafish studies led us to investigate the innate immune cell associations in ulcerated melanomas in human patients. We find a strong correlation between neutrophil presence at sites of melanoma ulceration and cell proliferation at these sites, which is associated with poor prognostic outcome.

A Novel Pharmacologic Activity of Ketorolac for Therapeutic Benefit in Ovarian Cancer Patients

PURPOSE

We previously identified the R-enantiomer of ketorolac as an inhibitor of the Rho-family GTPases Rac1 and Cdc42. Rac1 and Cdc42 regulate cancer-relevant functions, including cytoskeleton remodeling necessary for tumor cell adhesion and migration. This study investigated whether administration of racemic (R,S) ketorolac after ovarian cancer surgery leads to peritoneal distribution of R-ketorolac, target GTPase inhibition in cells retrieved from the peritoneal cavity, and measureable impact on patient outcomes.

EXPERIMENTAL DESIGN

Eligible patients had suspected advanced-stage ovarian, fallopian tube or primary peritoneal cancer. Secondary eligibility was met when ovarian cancer was confirmed and optimally debulked, an intraperitoneal port was placed, and there were no contraindications for ketorolac administration. R- and S-ketorolac were measured in serum and peritoneal fluid, and GTPase activity was measured in peritoneal cells. A retrospective study correlated perioperative ketorolac and ovarian cancer-specific survival in ovarian cancer cases.

RESULTS

Elevated expression and activity of Rac1 and Cdc42 was detected in ovarian cancer patient tissues, confirming target relevance. Ketorolac in peritoneal fluids was enriched in the R-enantiomer and peritoneal cell GTPase activity was inhibited after ketorolac administration when R-ketorolac was at peak levels. After adjusting for age, AJCC stage, completion of chemotherapy, and neoadjuvant therapy, women given perioperative ketorolac had a lower hazard of death (HR, 0.30; 95% confidence interval, 0.11-0.88).

CONCLUSIONS

Ketorolac has a novel pharmacologic activity conferred by the R-enantiomer and R-ketorolac achieves sufficient levels in the peritoneal cavity to inhibit Rac1 and Cdc42, potentially contributing to the observed survival benefit in women who received ketorolac.

Current and potential use of MAINTRAC method for cancer diagnosis and prediction of metastasis

Cells shed from solid malignant tumors into the circulation are considered to be the origin of metastases. In spite of a wealth of research on the pathway of metastasis formation, it is still not clear when and how metastases develop, nor is there a consensus on the number and the nature of circulating tumor cells present in individual patients and their relationship to the formation of metastases. We have developed a method to detect a maximum of unselected non-hematological, epithelial cells in the blood, assuming that in cancer patients the majority of these cells are derived from the tumor. Assessment of the number of these cells longitudinally during the course of disease and therapy allows the response to different treatments to be monitored. Due to the viability of the cells, additional analyses such as expression profiles and determination of their sensitivity to drugs can be performed.

Opioids and cancer recurrence

PURPOSE OF REVIEW

With the majority of deaths from cancer because of their metastases, strategies to reduce this from occurring are at the forefront of treatment. It has been hypothesized that morphine may result in an increase in cancer metastases, following many in-vitro and animal studies, but the evidence from human retrospective data is inconclusive. This article will explore the possible mechanisms by which opioids can impact on the natural history of the cancer cell and whether they are likely to be harmful in individuals with cancer.

RECENT FINDINGS

Although there have been trials demonstrating benefits with regional anaesthesia techniques (opioid sparing) in the surgical population, it is not clear whether the source of the benefit arises directly from the avoidance of opioids or an added benefit afforded by regional anaesthesia. Research has shown that in particular cancer cell types, morphine may actually be beneficial and that the μ-opioid receptor (MOR) plays a role in cancer disease. With the crystal structure of the MOR having recently been elucidated, this may offer new opportunities for treatments aimed at reducing cancer metastasis.

SUMMARY

The role opioids play in the development of cancer metastasis and recurrence is far from clear and appears to differ depending on the cancer cell type in question. Prospective randomized controlled trials are currently underway in humans to help clarify the situation further and there results are awaited with anticipation. The negative impact of pain on the immune system is well documented and it appears that appropriate analgesia is paramount in minimizing this. Opioids still constitute a central role in the management of moderate-to-severe cancer pain.

Multimodal hazard rate for relapse in breast cancer: quality of data and calibration of computer simulation

Much has occurred since our 2010 report in Cancers. In the past few years we published several extensive reviews of our research so a brief review is all that will be provided here. We proposed in the earlier reports that most relapses in breast cancer occur within 5 years of surgery and seem to be associated with some unspecified manner of surgery-induced metastatic initiation. These events can be identified in relapse data and are correlated with clinical data. In the last few years an unexpected mechanism has become apparent. Retrospective analysis of relapse events by a Brussels anesthesiology group reported that a perioperative NSAID analgesic seems to reduce early relapses five-fold. We then proposed that primary surgery produces a transient period of systemic inflammation. This has now been identified by inflammatory markers in serum post mastectomy. That could explain the early relapses. It is possible that an inexpensive and non-toxic NSAID can reduce breast cancer relapses significantly. We want to take this opportunity to discuss database quality issues and our relapse hazard data in some detail. We also present a demonstration that the computer simulation can be calibrated with Adjuvant-on-line, an often used clinical tool for prognosis in breast cancer.

Core needle biopsy of breast cancer tumors increases distant metastases in a mouse model

INTRODUCTION: Incisional biopsies, including the diagnostic core needle biopsy (CNB), routinely performed before surgical excision of breast cancer tumors are hypothesized to increase the risk of metastatic disease. In this study, we experimentally determined whether CNB of breast cancer tumors results in increased distant metastases and examine important resultant changes in the primary tumor and tumor microenvironment associated with this outcome. METHOD: To evaluate the effect of CNB on metastasis development, we implanted murine mammary 4T1 tumor cells in BALB/c mice and performed CNB on palpable tumors in half the mice. Subsequently, emulating the human scenario, all mice underwent complete tumor excision and were allowed to recover, with attendant metastasis development. Tumor growth, lung metastasis, circulating tumor cell (CTC) levels, variation in gene expression, composition of the tumor microenvironment, and changes in immunologic markers were compared in biopsied and non-biopsied mice. RESULTS: Mice with biopsied tumors developed significantly more lung metastases compared to non-biopsied mice. Tumors from biopsied mice contained a higher frequency of myeloid-derived suppressor cells (MDSCs) accompanied by reduced CD4 + T cells, CD8 + T cells, and macrophages, suggesting biopsy-mediated development of an increasingly immunosuppressive tumor microenvironment. We also observed a CNB-dependent up-regulation in the expression of SOX4, Ezh2, and other key epithelial-mesenchymal transition (EMT) genes, as well as increased CTC levels among the biopsy group. CONCLUSION: CNB creates an immunosuppressive tumor microenvironment, increases EMT, and facilitates release of CTCs, all of which likely contribute to the observed increase in development of distant metastases.

Inflammatory scores are not interchangeable during the perioperative period of breast cancer surgery

INTRODUCTION

Inflammatory biomarkers and scores are important prognostic factors in breast cancer, and are proposed during the perioperative period. Here, we investigate their correlation and concordance in breast cancer surgical patients.

PATIENTS AND METHODS

With the IRB approval and written informed consent, we included 14 patients (median age: 61 [41 to 82] years) scheduled for conservative surgery (n = 12) or mastectomy (n = 2) for breast cancer. We measured, at baseline, day+1 and day+8, albumin (Alb), C-Reactive Protein (CRP), total white blood cell counts (WBC), lymphocytes (L) and neutrophils (N) counts, and calculated the following inflammatory scores: Neutrophil-to-lymphocyte ratio (NLR), modified Glasgow Prognostic Score (mGPS), Prognostic Index (PI) and Prognostic Nutritional Index (PNI). A linear regression model is used to compare CRP and NLR, and the Kappa statistic to detect discordance (<0) or agreement (>0.4) between the scores.

RESULTS

We measured 170 laboratory values and calculated 182 inflammatory scores. CRP, WBC, N and NLR are significantly different at day+1 compared with baseline (respectively, at baseline, day+1 and day+8 (median[IQR 25-75]): CRP: 0.1[0.1-0.6], 0.85[0.2-1.18], 0.18[0.1-0.4]mg/dL; WBC: 6.36[5.91-7.16], 7.45[6.38-8.16], 7.73[6.25-8.54] × 10(3)/mm(3); N: 3.78[3.21-4.2], 5.05[4.37-5.99] × 10(3)/mm(3); and NLR: 1.95[1.67-2.46], 2.62[2.36-3.73], 2.23[1.46-2.43]) (P < 0.05 for all the comparisons between baseline and day+1). Alb and L tend to decrease (P = 0.06). Discordance is clear between all the inflammatory scores (NLR, mGPS, PI, PNI) (Kappa<0).

CONCLUSION

Inflammatory biomarkers and scores, like CRP, WBCs, N, NLR, PNI, and PI are modified after a breast cancer surgery, but with discordance and no interchangeability.

Comparative benefit from small tumour size and adjuvant chemotherapy: clues for explaining breast cancer mortality decline

Background

Breast cancer mortality steadily declined from the 1990s and this has been attributed to early detection and/or to improvements in therapy. Which of those two has had the greater impact is a subject of contention.

Methods

A database of 386 patients, enrolled in a randomized clinical trial on the effect of adjuvant chemotherapy (CMF), was analysed. The probabilities of recurrence and death were estimated by the Fine and Gray’s model and by the Cox model. Time dependent covariate and interaction effects were investigated by additive models. Absolute risk reductions (ARR) related to adjuvant treatment or to tumour size [diameter ≤ 2 cm (T1) or >2 cm (T2/T3)] were estimated.

Results

CMF-related reduction in recurrence emerges early, reaches a maximum level at 3 years and persists at a constant level thereafter. Tumour-size-related recurrence reduction, after a maximum at 3 years, displays a progressive regular reduction approaching zero. Patients with any tumour size, when given CMF, exhibit mortality reduction that displays an early regular increase and continues to a persistent plateau. In contrast, tumour-size-related mortality reduction reaches a maximum at 5–7 years and then regularly drops to very low values for patients of both trial arms.

Conclusions

Findings reveal that there is a different time-dependent benefit from chemotherapy and from smaller tumour size at diagnosis. The benefit from adjuvant chemotherapy is long-lasting for patients with any tumour size while the early benefit of diagnosing smaller tumours substantially decreases afterwards. Treatment improvements have probably had greater impact on the mortality reduction than mammography screening.

Substrate-selective COX-2 inhibition as a novel strategy for therapeutic endocannabinoid augmentation

Pharmacologic augmentation of endogenous cannabinoid (eCB) signaling is an emerging therapeutic approach for the treatment of a broad range of pathophysiological conditions. Thus far, pharmacological approaches have focused on inhibition of the canonical eCB inactivation pathways - fatty acid amide hydrolase (FAAH) for anandamide and monoacylglycerol lipase (MAGL) for 2-arachidonoylglycerol. We review here the experimental evidence that cyclooxygenase-2 (COX-2)-mediated eCB oxygenation represents a third mechanism for terminating eCB action at cannabinoid receptors. We describe the development, molecular mechanisms, and in vivo validation of 'substrate-selective' COX-2 inhibitors (SSCIs) that prevent eCB inactivation by COX-2 without affecting prostaglandin (PG) generation from arachidonic acid (AA). Lastly, we review recent data on the potential therapeutic applications of SSCIs with a focus on neuropsychiatric disorders.

Reconstruction of the natural history of metastatic cancer and assessment of the effects of surgery: Gompertzian growth of the primary tumor

This work deals with retrospective reconstruction of the individual natural history of solid cancer and assessment of the effects of treatment on metastatic progression. This is achieved through a mathematical model of cancer progression accounting for the growth of the primary tumor, shedding of metastases, their dormancy and growth at secondary sites. To describe dynamics of the primary tumor, we used the Gompertz law, a parsimonious model of tumor growth accounting for its saturation. Parameters of the model were estimated from the age and volume of the primary tumor at surgery and volumes of detectable bone metastases collected from one breast cancer patient and one prostate cancer patient. This allowed us to estimate, for each patient, the ages at cancer onset and inception of all detected metastases, the expected metastasis latency time, parameters of the Gompertzian growth of the primary tumor, and the rates of growth of metastases before and after surgery. We found that for both patients: (1) onset of metastasis occurred when primary tumor was undetectable; (2) inception of all surveyed metastases except one occurred before surgery; and most importantly, (3) resection of the primary tumor led to a dramatic increase in the rate of growth of metastases. The model provides an excellent fit to the observed volumes of bone metastases in both patients. Our results agree well with those obtained previously based on exponential growth of the primary tumor, which serves as model validation. Our findings support the notion of metastatic dormancy and indirectly confirm the existence of stem-like cancer cells in breast and prostate tumors. We also explored the logistic law of primary tumor growth; however, it degenerated into the exponential law for both patients analyzed. The conclusions of this work are supported by a vast body of experimental, clinical and epidemiological knowledge accumulated over the last century.