Analysis of RhoC expression and lymphovascular emboli in inflammatory vs non-inflammatory breast cancers in Egyptian patients

Biological features of inflammatory breast cancer in North Africa: burden and research priorities

We aimed to review all published literature reporting biological data about inflammatory breast cancer (IBC) in populations from North Africa. Methods: We reviewed all studies that evaluated biological features of IBC in six North African countries between 1990 and 2017. Among 118 screened studies, 13 were included, none about Mauritania/Libya. Results: Across the studies, hormonal receptors were positive in 46–69% of cases, reaching 83% in Algeria. HER2 was overexpressed in 25–39% of cases. Recombinant human C protein expression was the highest in Egyptian patients (87%) compared with other North African populations. Using mRNA expression recombinant human C protein was expressed in 83% of Tunisian patients. WISP3 gene expression showed positive immunohistochemistry staining in 17% and mRNA expression in 26.8% of IBC. Conclusion: Biological aspects of IBC across North Africa show important similarities and differences.

Inflammatory breast cancer in north Africa: comparison of clinical and molecular epidemiologic characteristics of patients from Egypt, Tunisia, and Morocco

Understanding molecular characteristics that distinguish inflammatory breast cancer (IBC) from non-IBC is crucial for elucidating breast cancer etiology and management. We included 3 sets of patients from Egypt (48 IBC and 64 non-IBC), Tunisia (24 IBC and 40 non-IBC), and Morocco (42 IBC and 41 non-IBC). Egyptian IBC patients had the highest combined erythema, edema, peau d'orange, and metastasis among the 3 IBC groups. Egyptian IBC tumors had the highest RhoC expression than Tunisians and Moroccan IBCs (87% vs. 50%, vs. 38.1, for the 3 countries, respectively). Tumor emboli were more frequent in Egyptian IBC than non-IBC (Mean ± SD: 14.1 ± 14.0 vs. 7.0 ± 12.9, respectively) (P < 0.001) and Tunisians (Mean ± SD: 3.4 ± 2.5 vs. 1.9 ± 2.0, respectively) (P < 0.01). There was no difference of emboli in Moroccan tumors (1.7 ± 1.2 vs. 1.8 ± 1.2 for IBC and non-IBC, respectively (P=0.66). This study illustrates that RhoC overexpression and tumor emboli are more frequent in IBC relative to non-IBC from Egypt and Tunisia. Tumors of Moroccans were significantly different from Egyptian and Tunisian tumors for RhoC expression and emboli. Future studies should focus on relating epidemiologic factors and clinical pictures to molecular features of IBC in these and other populations.

Inflammatory breast cancer (IBC): clues for targeted therapies

Inflammatory breast cancer (IBC) is the most aggressive type of advanced breast cancer characterized by rapid proliferation, early metastatic development and poor prognosis. Since there are few preclinical models of IBC, there is a general lack of understanding of the complexity of the disease. Recently, we have developed a new model of IBC derived from the pleural effusion of a woman with metastatic secondary IBC. FC-IBC02 cells are triple negative and form clusters (mammospheres) in suspension that are strongly positive for E-cadherin, β-catenin and TSPAN24, all adhesion molecules that play an important role in cell migration and invasion. FC-IBC02 cells expressed stem cell markers and some, but not all of the characteristics of cells undergoing epithelial mesenchymal transition (EMT). Breast tumor FC-IBC02 xenografts developed quickly in SCID mice with the presence of tumor emboli and the development of lymph node and lung metastases. Remarkably, FC-IBC02 cells were able to produce brain metastasis in mice on intracardiac or intraperitoneal injections. Genomic studies of FC-IBC02 and other IBC cell lines showed that IBC cells had important amplification of 8q24 where MYC, ATAD2 and the focal adhesion kinase FAK1 are located. MYC and ATAD2 showed between 2.5 and 7 copies in IBC cells. FAK1, which plays important roles in anoikis resistance and tumor metastasis, showed 6–4 copies in IBC cells. Also, CD44 was amplified in triple-negative IBC cells (10–3 copies). Additionally, FC-IBC02 showed amplification of ALK and NOTCH3. These results indicate that MYC, ATAD2, CD44, NOTCH3, ALK and/or FAK1 may be used as potential targeted therapies against IBC.

Anti-tumor effects of Ganoderma lucidum (reishi) in inflammatory breast cancer in in vivo and in vitro models

The medicinal mushroom Ganoderma lucidum (Reishi) was tested as a potential therapeutic for Inflammatory Breast Cancer (IBC) using in vivo and in vitro IBC models. IBC is a lethal and aggressive form of breast cancer that manifests itself without a typical tumor mass. Studies show that IBC tissue biopsies overexpress E-cadherin and the eukaryotic initiation factor 4GI (eIF4GI), two proteins that are partially responsible for the unique pathological properties of this disease. IBC is treated with a multimodal approach that includes non-targeted systemic chemotherapy, surgery, and radiation. Because of its non-toxic and selective anti-cancer activity, medicinal mushroom extracts have received attention for their use in cancer therapy. Our previous studies demonstrate these selective anti-cancer effects of Reishi, where IBC cell viability and invasion, as well as the expression of key IBC molecules, including eIF4G is compromised. Thus, herein we define the mechanistic effects of Reishi focusing on the phosphoinositide-3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR) pathway, a regulator of cell survival and growth. The present study demonstrates that Reishi treated IBC SUM-149 cells have reduced expression of mTOR downstream effectors at early treatment times, as we observe reduced eIF4G levels coupled with increased levels of eIF4E bound to 4E-BP, with consequential protein synthesis reduction. Severe combined immunodeficient mice injected with IBC cells treated with Reishi for 13 weeks show reduced tumor growth and weight by ∼50%, and Reishi treated tumors showed reduced expression of E-cadherin, mTOR, eIF4G, and p70S6K, and activity of extracellular regulated kinase (ERK1/2). Our results provide evidence that Reishi suppresses protein synthesis and tumor growth by affecting survival and proliferative signaling pathways that act on translation, suggesting that Reishi is a potential natural therapeutic for breast and other cancers.

Human cytomegalovirus infection enhances NF-κB/p65 signaling in inflammatory breast cancer patients

Human Cytomegalovirus (HCMV) is an endemic herpes virus that re-emerges in cancer patients enhancing oncogenic potential. Recent studies have shown that HCMV infection is associated with certain types of cancer morbidity such as glioblastoma. Although HCMV has been detected in breast cancer tissues, its role, if any, in the etiology of specific forms of breast cancer has not been investigated. In the present study we investigated the presence of HCMV infection in inflammatory breast cancer (IBC), a rapidly progressing form of breast cancer characterized by specific molecular signature. We screened for anti-CMV IgG antibodies in peripheral blood of 49 non-IBC invasive ductal carcinoma (IDC) and 28 IBC patients. In addition, we screened for HCMV-DNA in postsurgical cancer and non-cancer breast tissues of non-IBC and IBC patients. We also tested whether HCMV infection can modulate the expression and activation of transcriptional factor NF-κB/p65, a hallmark of IBC. Our results reveal that IBC patients are characterized by a statistically significant increase in HCMV IgG antibody titers compared to non-IBC patients. HCMV-DNA was significantly detected in cancer tissues than in the adjacent non-carcinoma tissues of IBC and IDC, and IBC cancer tissues were significantly more infected with HCMV-DNA compared to IDC. Further, HCMV sequence analysis detected different HCMV strains in IBC patients tissues, but not in the IDC specimens. Moreover, HCMV-infected IBC cancer tissues were found to be enhanced in NF-κB/p65 signaling compared to non-IBC patients. The present results demonstrated a correlation between HCMV infection and IBC. Etiology and causality of HCMV infection with IBC now needs to be rigorously examined.

Assessment of diagnosis of inflammatory breast cancer cases at two cancer centers in Egypt and Tunisia

The diagnosis of inflammatory breast cancer (IBC) is largely clinical and therefore inherently somewhat subjective. The objective of this study was to evaluate the diagnosis of IBC at two centers in North Africa where a higher proportion of breast cancer is diagnosed as IBC than in the United States (U.S.). Physicians prospectively enrolled suspected IBC cases at the National Cancer Institute (NCI) - Cairo, Egypt, and the Institut Salah Azaiz (ISA), Tunisia, recorded extent and duration of signs/symptoms of IBC on standardized forms, and took digital photographs of the breast. After second-level review at study hospitals, photographs and clinical information for confirmed IBC cases were reviewed by two U.S. oncologists. We calculated percent agreement between study hospital and U.S. oncologist diagnoses. Among cases confirmed by at least one U.S. oncologist, we calculated median extent and duration of signs and Spearman correlations. At least one U.S. oncologist confirmed the IBC diagnosis for 69% (39/50) of cases with photographs at the NCI-Cairo and 88% (21/24) of cases at the ISA. All confirmed cases had at least one sign of IBC (erythema, edema, peau d'orange) that covered at least one-third of the breast. The median duration of signs ranged from 1 to 3 months; extent and duration of signs were not statistically significantly correlated. From the above-mentioned outcomes, it can be concluded that the diagnosis of a substantial proportion of IBC cases is unambiguous, but a subset is difficult to distinguish from other types of locally advanced breast cancer. Among confirmed cases, the extent of signs was not related to delay in diagnosis.

Considerations in setting up and conducting epidemiologic studies of cancer in middle- and low-income countries: the experience of a case-control study of inflammatory breast cancer in North Africa in the past 10 years

This article illustrates some issues we faced during our experience in conducting an epidemiologic case-control study of inflammatory breast cancer in North Africa. We expect that some of the questions we had to ask in order to address these issues might be helpful to others in setting up epidemiologic studies in developing regions. We describe our experience from different angles including the use of multiple sites to achieve adequate sample size, standardizing diagnosis of disease, identifying cancer cases at the time of diagnosis, control selection procedures, logistics of study implementation, questionnaire development and interviewing, biologic specimens, and procedures for protection of human subjects. We have developed a brief checklist to summarize important issues for conducting future epidemiologic studies in these or similar low- or middle-income countries.

Inflammatory and non-inflammatory breast cancer survival by socioeconomic position in the Surveillance, Epidemiology, and End Results database, 1990-2008

Although it has been previously reported that patients with inflammatory breast cancer (IBC) experience worse survival than patients with other breast cancer (BC) types, the socioeconomic and ethnic factors leading to this survival difference are not fully understood. The association between county-level percent of persons below the poverty level and BC-specific (BCS) survival for cases diagnosed from 1990 to 2008 in the Surveillance, Epidemiology, and End Results (SEER) database linked to census derived county attributes was examined. A sub-analysis of cases from 2000 to 2008 also examined BCS survival by an index combining percent below poverty and less than high school graduates as well as metropolitan versus non-metropolitan county of residence. The Kaplan-Meier estimator was used to construct survival curves by stage, inflammatory status, and county-level socioeconomic position (SEP). Stage and inflammatory status stratified proportional hazards models, adjusted for age, race/ethnicity, tumor and treatment characteristics were used to determine the hazard of BCS death by county-level SEP. Kaplan-Meier survival curves indicated IBC has worse survival than stage matched non-IBC, (stage III IBC median survival = 4.75 years vs. non-IBC = 13.4 years, p < 0.0001). Residing in a lower SEP, non-metro county significantly worsens BCS survival for non-IBC in multivariate proportional hazards models. African American cases appear to have worse survival than non-Hispanic Whites regardless of inflammatory status, stage, county-level SEP, tumor, or treatment characteristics. This is the first study to examine IBC survival by SEP in a nation-wide population-based tumor registry. As this analysis found generally poorer survival for IBC, regardless of SEP or race/ethnicity, it is important that interventions that help educate women on IBC symptoms target women in various SEP and race/ethnicity groups.

Molecular and epidemiological characteristics of inflammatory breast cancer in Algerian patients

Inflammatory breast cancer (IBC) shows a high incidence in Tunisia and Egypt but epidemiological and molecular characteristics have not been described in Algeria. We compared 117 IBC and 59 non-IBC locally advanced breast cancers (LABC), for estrogen and progesterone receptors, HER2, and EGFR protein expression by immunohistochemistry, and HER2 gene amplification by chromogenic in situ hybridization. Demographic, clinico-pathological, and molecular variables were compared with chi-square and Fisher's exact tests to test for significance (P < 0.05, two-tailed). Overall survival (OS) and disease-free survival (DFS) were plotted using Kaplan-Meier curves and compared using the log-rank test. Tumor emboli were detected in 77% of IBC. Palpable masses were found in all LABC but only in 32% of IBC (P < 0.001). Recurrences were higher in LABC than in IBC (48 vs. 35%; P = 0.14) but OS was worse in IBC (68 vs. 71%; P = 0.06). There were no significant differences between IBC and LABC by demographics or by clinico-pathological parameters. The majority of IBC and LABC tumors were luminal A (62 and 64%), followed by basal (~18%, each), triple negative (~18%, each), and HER2+ (~10%, each) subtypes. In multivariate analyses, grade was associated with worse OS (P = 0.04), and DFS (P < 0.001) in IBC; chemo- and radio-therapy were associated with improved OS and DFS, respectively (P < 0.05 for each) in LABC. In conclusion, IBC in Algeria shows similar characteristics to IBC described for Egypt and Tunisia with subtle molecular differences. Current therapeutic treatments were not very effective in this population and new approaches are much needed.

Patterns of seeking medical care among Egyptian breast cancer patients: relationship to late-stage presentation

Breast cancer is the most common cancer among Egyptian women, accounting for 37.6% of female tumors, and is often diagnosed at later stages. The objective of this study was to investigate breast cancer patient navigation through the health care system in the Nile Delta. Interviews were conducted with 163 newly diagnosed breast cancer patients at the Tanta Cancer Center (TCC), the major cancer center of the region. Patients described their medical care pathway from the initial symptom experienced until their arrival at TCC. Patients whose initial contact was with a general surgeon (OR: 7.6, 95% CI: 2.1, 27.6), primary care provider (OR: 12.2, 95% CI: 2.9, 51.0), or gynecologist (OR: 8.6, 95% CI: 1.4, 53.4) were significantly more likely to experience a delay in reaching the TCC as compared to those visiting a surgical oncologist. Overcoming health care system and patient navigation barriers in developing countries may reduce the time for breast cancer patients to reach a cancer center for early management.

Association of inflammatory and noninflammatory breast cancer with socioeconomic characteristics in the Surveillance, Epidemiology, and End Results database, 2000-2007

BACKGROUND

Inflammatory breast cancer (IBC) is a rare and highly aggressive form of primary breast cancer. Little is known about the risk factors for IBC, specifically the association with socioeconomic position (SEP).

METHODS

The association between breast cancer type (IBC vs. non-IBC) with county-level SEP in the Surveillance, Epidemiology, and End Results database for cases diagnosed from 2000 to 2007 was examined. County-level SEP characteristics included metropolitan versus non-metropolitan residence, percentage below the poverty level, percentage less than high-school graduate, and an index combining the poverty and high-school variables. IBC and non-IBC age-adjusted incidence rates were calculated, stratified on SEP and race/ethnicity. The odds of IBC versus non-IBC given a particular SEP characteristic, adjusting for age and race/ethnicity, was examined through fitting of hierarchical logistic regression models (HLM).

RESULTS

Incidence rates for IBC generally increased as SEP decreased, whereas the opposite was found for non-IBC. HLM results showed that low SEP is associated with higher odds of IBC: highest (≥ 20%) versus lowest (<10%) persons below the poverty level [OR (95% confidence interval, CI) = 1.25 (1.09-1.43)]; highest (>28.76%) versus lowest (≤ 15.99%) persons less than high-school graduate [OR (95% CI) = 1.25 (1.10-1.42)]; and low SEP as measured by poverty-high school index versus high SEP [OR (95% CI)= 1.26 (1.11-1.44)].

CONCLUSION

Overall breast cancer has been found to be positively associated with SEP, whereas in this analysis, IBC was associated with decreasing SEP.

IMPACT

Studies focused on understanding the disparity in IBC incidence, as well as interventions to eliminate these differences are needed.

Ganoderma lucidum (Reishi) inhibits cancer cell growth and expression of key molecules in inflammatory breast cancer

Inflammatory breast cancer (IBC) is the most lethal and least understood form of advanced breast cancer. Its lethality originates from its nature of invading the lymphatic system and absence of a palpable tumor mass. Different from other metastatic breast cancer cells, IBC cells invade by forming tumor spheroids that retain E-cadherin-based cell-cell adhesions. Herein we describe the potential of the medicinal mushroom Ganoderma lucidum (Reishi) as an attractive candidate for anti-IBC therapy. Reishi contains biological compounds that are cytotoxic against cancer cells. We report the effects of Reishi on viability, apoptosis, invasion, and its mechanism of action in IBC cells (SUM-149). Results show that Reishi selectively inhibits cancer cell viability although it does not affect the viability of noncancerous mammary epithelial cells. Apoptosis induction is consistent with decreased cell viability. Reishi inhibits cell invasion and disrupts the cell spheroids that are characteristic of the IBC invasive pathology. Reishi decreases the expression of genes involved in cancer cell survival and proliferation (BCL-2, TERT, PDGFB), and invasion and metastasis (MMP-9), whereas it increases the expression of IL8. Reishi reduces BCL-2, BCL-XL, E-cadherin, eIF4G, p120-catenin, and c-Myc protein expression and gelatinase activity. These findings suggest that Reishi is an effective anti-IBC therapeutic.

Targeting RhoC by Way of Ribozyme Trangene in Human Breast Cancer Cells and its Impact on Cancer Invasion

Background

Cell motility and migration are known to be regulated by the Rho family of GTPases through their effects on the actin cytoskeleton. In breast cancer studies, RhoC has been identified as a highly specific marker in detecting tumors that developed metastases. This study aims to investigate the impact of targeting RhoC in human breast cancer cells by utilising ribozyme transgene technology and to assess its effect on cancer cell invasion.

Methods

Retroviral hammerhead ribozyme transgenes, regulated by doxycycline, were designed to specifically target human RhoC mRNA. The breast cancer cell line MDA-MB-231 was transfected with either a retroviral RhoC transgene or a control retroviral transgene. Stably transfected cells were tested for their invasiveness and migratory properties in vitro.

Results

In vitro testing of the invasiveness of wild type, plasmid control and the RhoC knockdown cells showed that MDA-MB-231^DRHOC cells had significantly reduced invasiveness compared with MDA-MB-231^WT (p < 0.038 RHOC2 knockdown cells; p < 0.006 RHOC3 knockdown cells) and MDA-MB-231^pRevTRE control plasmid cells (p < 0.07 RHOC2 knockdown cells; p < 0.002 RHOC3 knockdown cells). An even greater reduction in invasiveness of the MDA-MB-231^DRHOC cells compared with the MDA-MB-231^WT cells was seen in response to hepatocyte growth factor (HGF/SF) (p < 0.009 RHOC1 knockdown; p = 0.004 RHOC2 knockdown; p = 0.00007 RHOC3 knockdown). The addition of doxycycline significantly improved the effectiveness of the ribozyme transgenes (p < 0.04 for all three Rho ribozymes), but did not improve the effectiveness of these knockdown cells when treated with HGF/SF (p > 0.1 for all three ribozymes).

Conclusions

This data would indicate that targeting RhoC may be an effective way to reduce the invasive potential of human breast cancer cells.

Clinical and epidemiologic profile of breast cancer in Tanzania

PURPOSE

breast cancer is a highly heterogeneous disease globally. Public health prevention measures require an understanding of the burden of breast cancer and its risk factors. The purpose of this study was to describe the clinical, pathologic, and epidemiologic characteristics of breast cancer patients in Tanzania.

METHODS

data was abstracted from the medical records of all breast cancer patients attending Ocean Road Cancer Institute (ORCI) over a 2-year period from July 2007 to June 2009. Tumor tissue paraffin blocks were collected for all patients with available tissues for the determination of estrogen receptor (ER) and progesterone receptor (PR). Data for all patients was analyzed descriptively and by using unconditional logistic regression, by comparing early stage (ES), defined as stages I and II and late stage (LS), defined as stages III and IV patients to obtain odds ratios (ORs), 95% confidence intervals (CIs), and P-values.

RESULTS

among the 488 patients, stage was determined for 356~patients, 90.7% of whom presented in LS. Of the 57 tumor tissues, 49.1% were ER-/PR-. Patients with ulceration (OR = 4.97; 95% CI= 1.07, 23.04; p=0.04) and peau d'orange (OR= 6.78; 95{\%} CI $=$ 1.48, 31.17; p=0.01) were more likely to present in LS rather than ES. Male breast cancer accounted for 2.9% of all breast cancers and inflammatory breast cancer (IBC) comprised 4.3-5.5% of cases based on registered t4d diagnosis or the criteria of IBC signs, if t4d was not reported in the medical records.

CONCLUSION

most breast cancer patients in Tanzania are diagnosed at advanced disease stages with about half of the tumors being ER-/PR-. These data strongly support that reducing barriers to care, down-staging of disease at diagnosis, implementation of clinical guidelines for management of advanced cases, and palliative care are the four most essential factors that need to be addressed to reduce morbidity and mortality from breast cancer in Tanzania. Further research is needed to quantify the magnitude and molecular features of two relatively rare forms of breast cancer that may account for a greater proportion of the burden of breast cancer in Tanzania compared to the USA and Western Europe: male breast cancer and IBC.