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Engin A. Obesity-Associated Breast Cancer: Analysis of Risk Factors and Current Clinical Evaluation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1460:767-819. [PMID: 39287872 DOI: 10.1007/978-3-031-63657-8_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Several studies show that a significantly stronger association is obvious between increased body mass index (BMI) and higher breast cancer incidence. Additionally, obese and postmenopausal women are at higher risk of all-cause and breast cancer-specific mortality compared with non-obese women with breast cancer. In this context, increased levels of estrogens, excessive aromatization activity of the adipose tissue, overexpression of pro-inflammatory cytokines, insulin resistance, adipocyte-derived adipokines, hypercholesterolemia, and excessive oxidative stress contribute to the development of breast cancer in obese women. Genetic evaluation is an integral part of diagnosis and treatment for patients with breast cancer. Despite trimodality therapy, the four-year cumulative incidence of regional recurrence is significantly higher. Axillary lymph nodes as well as primary lesions have diagnostic, prognostic, and therapeutic significance for the management of breast cancer. In clinical setting, because of the obese population primary lesions and enlarged lymph nodes could be less palpable, the diagnosis may be challenging due to misinterpretation of physical findings. Thereby, a nomogram has been created as the "Breast Imaging Reporting and Data System" (BI-RADS) to increase agreement and decision-making consistency between mammography and ultrasonography (USG) experts. Additionally, the "breast density classification system," "artificial intelligence risk scores," ligand-targeted receptor probes," "digital breast tomosynthesis," "diffusion-weighted imaging," "18F-fluoro-2-deoxy-D-glucose positron emission tomography," and "dynamic contrast-enhanced magnetic resonance imaging (MRI)" are important techniques for the earlier detection of breast cancers and to reduce false-positive results. A high concordance between estrogen receptor (ER) and progesterone receptor (PR) status evaluated in preoperative percutaneous core needle biopsy and surgical specimens is demonstrated. Breast cancer surgery has become increasingly conservative; however, mastectomy may be combined with any axillary procedures, such as sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection whenever is required. As a rule, SLNB-guided axillary dissection in breast cancer patients who have clinically axillary lymph node-positive to node-negative conversion following neoadjuvant chemotherapy is recommended, because lymphedema is the most debilitating complication after any axillary surgery. There is no clear consensus on the optimal treatment of occult breast cancer, which is much discussed today. Similarly, the current trend in metastatic breast cancer is that the main palliative treatment option is systemic therapy.
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Affiliation(s)
- Atilla Engin
- Faculty of Medicine, Department of General Surgery, Gazi University, Besevler, Ankara, Turkey.
- Mustafa Kemal Mah. 2137. Sok. 8/14, 06520, Cankaya, Ankara, Turkey.
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Gao T, Shao F. Risk factors and prognostic factors for inflammatory breast cancer with bone metastasis: A population-based study. J Orthop Surg (Hong Kong) 2021; 29:23094990211000144. [PMID: 34060362 DOI: 10.1177/23094990211000144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Inflammatory breast cancer (IBC) is a rare type of breast cancer with poor prognosis. IBC patients with bone metastasis (BM) often suffer from many complications. This study was performed to identify risk factors with strong capability of predicting high BM risk for IBC patients and find prognostic factors for those patients. METHODS The Surveillance, Epidemiology and End Results (SEER) database was used to collect the clinicopathological and survival information of IBC patients. 966 IBC patients diagnosed between 2010 and 2015 were included to study the risk factors for developing BM by using Multivariable logistic regression. A total of 194 and 176 patients were included to analyze independent prognostic factors for overall survival (OS) and cancer specific survival (CSS) of IBC patients with BM respectively. RESULTS Of the 966 IBC patients, 194 (20.1%) patients were with BM. The risk factors for developing BM in IBC patients included unmarried marital status, double breast tumor, N1 stage, N3 stage, and liver metastases had higher risk of BM, while those of uninsured status and triple negative breast cancer (TNBC) were less likely to have BM. Analysis of prognostic factors for OS and CSS of IBC patients with BM showed that TNBC subtype and liver metastases were independently significantly associated with poorer OS and CSS of BM patients, while chemotherapy could serve as an independent prognostic factor for better OS and CSS of BM patients. CONCLUSION Marital status, double breast tumor, N1 stage, N3 stage, and liver metastases should be considered for prediction of BM in IBC patients. TNBC subtype and liver metastases may indicate poor survival and chemotherapy can indicate improved survival for IBC patients with BM.
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Affiliation(s)
- Tianyuan Gao
- Department of Pathology, Second Affiliated Hospital of Wannan Medical College, Anhui Wuhu, China
| | - Fang Shao
- Department of Breast Surgery, 162737Changzhou No. 4 People's Hospital, Soochow University, Changzhou, China
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Santiago-Sánchez GS, Noriega-Rivera R, Hernández-O’Farrill E, Valiyeva F, Quiñones-Diaz B, Villodre ES, Debeb BG, Rosado-Albacarys A, Vivas-Mejía PE. Targeting Lipocalin-2 in Inflammatory Breast Cancer Cells with Small Interference RNA and Small Molecule Inhibitors. Int J Mol Sci 2021; 22:8581. [PMID: 34445288 PMCID: PMC8395282 DOI: 10.3390/ijms22168581] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 12/13/2022] Open
Abstract
Inflammatory Breast Cancer (IBC) is an aggressive form of invasive breast cancer, highly metastatic, representing 2-4% of all breast cancer cases in the United States. Despite its rare nature, IBC is responsible for 7-10% of all breast cancer deaths, with a 5-year survival rate of 40%. Thus, targeted and effective therapies against IBC are needed. Here, we proposed Lipocalin-2 (LCN2)-a secreted glycoprotein aberrantly abundant in different cancers-as a plausible target for IBC. In immunoblotting, we observed higher LCN2 protein levels in IBC cells than non-IBC cells, where the LCN2 levels were almost undetectable. We assessed the biological effects of targeting LCN2 in IBC cells with small interference RNAs (siRNAs) and small molecule inhibitors. siRNA-mediated LCN2 silencing in IBC cells significantly reduced cell proliferation, viability, migration, and invasion. Furthermore, LCN2 silencing promoted apoptosis and arrested the cell cycle progression in the G0/G1 to S phase transition. We used in silico analysis with a library of 25,000 compounds to identify potential LCN2 inhibitors, and four out of sixteen selected compounds significantly decreased cell proliferation, cell viability, and the AKT phosphorylation levels in SUM149 cells. Moreover, ectopically expressing LCN2 MCF7 cells, treated with two potential LCN2 inhibitors (ZINC00784494 and ZINC00640089) showed a significant decrease in cell proliferation. Our findings suggest LCN2 as a promising target for IBC treatment using siRNA and small molecule inhibitors.
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Affiliation(s)
- Ginette S. Santiago-Sánchez
- Department of Biochemistry, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico; (G.S.S.-S.); (R.N.-R.); (B.Q.-D.)
- Comprehensive Cancer Center, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico;
| | - Ricardo Noriega-Rivera
- Department of Biochemistry, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico; (G.S.S.-S.); (R.N.-R.); (B.Q.-D.)
- Comprehensive Cancer Center, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico;
| | - Eliud Hernández-O’Farrill
- Department of Pharmaceutical Sciences, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico;
| | - Fatma Valiyeva
- Comprehensive Cancer Center, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico;
| | - Blanca Quiñones-Diaz
- Department of Biochemistry, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico; (G.S.S.-S.); (R.N.-R.); (B.Q.-D.)
- Comprehensive Cancer Center, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico;
| | - Emilly S. Villodre
- Department of Breast Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.S.V.); (B.G.D.)
| | - Bisrat G. Debeb
- Department of Breast Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.S.V.); (B.G.D.)
| | - Andrea Rosado-Albacarys
- Department of General Sciences, Rio Piedras Campus, University of Puerto Rico, San Juan 00936, Puerto Rico;
| | - Pablo E. Vivas-Mejía
- Department of Biochemistry, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico; (G.S.S.-S.); (R.N.-R.); (B.Q.-D.)
- Comprehensive Cancer Center, Medical Sciences Campus, University of Puerto Rico, San Juan 00936, Puerto Rico;
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Multi-center investigation of the clinical and pathological characteristics of inflammatory breast cancer based on Chinese Society of Breast Surgery (CSBrs-007). Chin Med J (Engl) 2020; 133:2552-2557. [PMID: 32925286 PMCID: PMC7722570 DOI: 10.1097/cm9.0000000000001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Inflammatory breast cancer (IBC) is an aggressive type of cancer with poor prognosis and outcomes. This study aimed to investigate clinicopathological features, molecular characteristics, and treatments among Chinese patients diagnosed with IBC. Methods We collected data of 95 patients with IBC who were treated by members of the Chinese Society of Breast Surgery, from January 2017 to December 2018. The data, including demographic characteristics, pathological findings, surgical methods, systemic treatment plans, and follow-up, were obtained using a uniform electronic questionnaire. The clinicopathological features of different molecular types in patients without distant metastases were compared using the Kruskal-Wallis (H) test followed by post hoc analyses. Results Lymph node metastasis was noted in 75.8% of all patients, while distant metastasis was noted in 21.4%. Pathological findings indicated invasive ductal and lobular carcinomas in 86.8% and 5.3% of cases, respectively. Hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2−) (41.5%) and HR−/HER2+ (20.1%) were the most common biologic subtypes, followed by HR+/HER2+ (19.1%) and HR−/HER2− (19.1%). Stage III IBC was treated via pre-operative neoadjuvant chemotherapy in 87.7% of the cases, predominantly using anthracycline and taxanes. A total of 91.9% of patients underwent surgical treatment. Among them, 77.0% of the patients underwent modified radical mastectomy, 8.1% of whom also underwent immediate breast reconstruction. The Kruskal-Wallis test revealed that the efficacy of chemotherapy significantly differed among those with HR+/HER2− and HR−/HER2− tumors (adjusted P = 0.008), and Ki-67 expression significantly differed in HR−/HER2+ and HR+/HER2+ molecular subtypes (adjusted P = 0.008). Conclusion Our study provides novel insight into clinicopathological characteristics and treatment status among patients with IBC in China, and might provide a direction and basis for further studies. Trial registration chictr.org.cn, No. ChiCTR1900027179; http://www.chictr.org.cn/showprojen.aspx?proj=45030
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Kupstas AR, Hoskin TL, Day CN, Boughey JC, Habermann EB, Hieken TJ. Biological subtype, treatment response and outcomes in inflammatory breast cancer using data from the National Cancer Database. Br J Surg 2020; 107:1033-1041. [PMID: 32057107 DOI: 10.1002/bjs.11469] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/08/2019] [Accepted: 11/16/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Although inflammatory breast cancer (IBC) is postulated to be a distinct biological entity, practice guidelines and previous data suggest that treatment and outcomes are influenced by standard approximated biological subtype. The aim of this study was validation in a large recent National Cancer Database (NCDB) patient cohort. METHODS Patients with non-metastatic IBC treated in 2010-2015 with neoadjuvant systemic therapy and surgery were identified from the NCDB. Approximated biological subtypes were categorized as oestrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-), ER-/HER2- and HER2+. Total pathological complete response (pCR) was defined as ypT0/ypTis, ypN0. χ2 tests were used to compare pCR rates, and Kaplan-Meier curves and Cox proportional hazards regression to analyse overall survival. RESULTS Among 4068 patients with IBC (median age 56 years), the approximated biological subtype was ER+/HER2- in 1575 (38·7 per cent), HER2+ in 1323 (32·5 per cent) and ER-/HER2- in 1170 (28·8 per cent). A total of 3351 patients (84·0 per cent) were cN+ at presentation, with no differences across subtypes. Total pCR rates varied significantly by subtype: ER+/HER2- (6·2 per cent), HER2+ (38·8 per cent), ER-/HER2- (19·1 per cent) (P < 0·001), as did breast pCR rates (10·4, 44·5 and 25·2 per cent respectively) and nodal pCR rates (16·9, 56·9 and 33·1 per cent). The 5-year overall survival rate varied significantly across subtypes (ER+/HER2- 64·9 per cent, HER2+ 74·0 per cent, ER-/HER2- 44·0 per cent; P < 0·001) and by pCR within subtypes (all P < 0·001). In multivariable analysis, ER-/HER2- subtype (hazard ratio 2·89 versus HER2+ as reference; P < 0·001) and absence of total pCR (hazard ratio 3·23; P < 0·001) predicted worse survival. CONCLUSION Both treatment response and survival in patients with IBC varied with approximated biological subtype, as among other invasive breast cancers. These data support continued tailoring of systemic treatment to approximated biological subtype and highlight the recent improved outcomes in patients with HER2+ disease.
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Affiliation(s)
- A R Kupstas
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - T L Hoskin
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - C N Day
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - J C Boughey
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - E B Habermann
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - T J Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Wang Z, Chen M, Pan J, Wang X, Chen XS, Shen KW. Pattern of distant metastases in inflammatory breast cancer - A large-cohort retrospective study. J Cancer 2020; 11:292-300. [PMID: 31897225 PMCID: PMC6930435 DOI: 10.7150/jca.34572] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 09/26/2019] [Indexed: 12/20/2022] Open
Abstract
Inflammatory breast cancer (IBC) is a fatal form of breast cancer. IBC patients present with unfavorable prognosis mainly attributable to high risk of distant metastasis. Thus, in this cohort study, we aimed to explore metastatic profiles of different molecular subtypes of IBC and elucidate the clinical and prognostic characteristics among different metastatic sites. Patients diagnosed as IBC between 2010 and 2016 were identified from the Surveillance, Epidemiology and End Results (SEER) database. Chi-square tests were performed to compare metastatic distribution among different molecular subtypes. We further used odds ratio calculation to analyze the combined metastatic patterns. Kaplan-Meier methods and multivariate Cox regression models were applied to analyze survival data among different metastatic organs. In total, we enrolled 635 IBC patients between 2010 and 2014 as the training cohort and 242 IBC patients between 2015 and 2016 as the validation cohort, All the included patients were recorded with known metastatic status, follow-up data and molecular subtype. In the present study, we elaborated the following three points: (1) Elucidating the distribution of single-organ metastases in IBC. Bone and brain were the most and least common metastatic lesions for all subtypes of IBC, separately. (2) Clarifying the combined metastatic patterns and tendency of co-metastases. Bi-organ metastasis occurred most frequently among all combined metastases. Several combinations, such as liver and bone, lung and brain, were preferential for bi-organ metastasis. (3) Analyzing prognostic values of single-organ and bi-organ metastases. All single-organ distal metastases were independent risk factors indicating an unfavorable prognosis. In conclusion, our results would provide more information for clinical decision and future studies.
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Affiliation(s)
- Zheng Wang
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Mo Chen
- Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Junjie Pan
- Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Xuan Wang
- Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Xiao-Song Chen
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Kun-Wei Shen
- Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Wu SG, Zhang WW, Wang J, Dong Y, Sun JY, Chen YX, He ZY. Inflammatory breast cancer outcomes by breast cancer subtype: a population-based study. Future Oncol 2018; 15:507-516. [PMID: 30378451 DOI: 10.2217/fon-2018-0677] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To assess the outcomes of breast cancer subtype in inflammatory breast cancer (IBC). METHODS We retrospectively assessed IBC patients from the SEER program. RESULTS We identified 626 patients, including 230 (36.7%),100 (17.6%), 113 (18.1%), and 173 (27.6%) patients with HoR+/HER2-, HoR+/HER2+, HoR-/HER2+, and HoR-/HER2- subtype disease, respectively. Multivariate analysis demonstrated that, using HoR+/HER2- subtype as reference, patients with HoR+/HER2+ subtype had better breast cancer-specific survival (BCSS) and overall survival (OS), and patients with HoR-/HER2- subtype had worse BCSS and OS, while BCSS and OS were comparable for HoR-/HER2+ subtype. Similar trends were observed in patients who received surgery, radiotherapy, chemotherapy or trimodality therapy. CONCLUSION Breast cancer subtype is clinically useful for predicting survival outcome in IBC. The HoR+/HER2- subtype shows poorer survival outcome than HoR+/HER2+ subtype.
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Affiliation(s)
- San-Gang Wu
- Department of Radiation Oncology, Xiamen Cancer Hospital, the First Affiliated Hospital of Xiamen University, Xiamen 361003, PR China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, PR China
| | - Jun Wang
- Department of Radiation Oncology, Xiamen Cancer Hospital, the First Affiliated Hospital of Xiamen University, Xiamen 361003, PR China
| | - Yong Dong
- Department of Oncology, the 3rd People's Hospital of Dongguan City, Dongguan 523326, PR China
| | - Jia-Yuan Sun
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, PR China
| | - Yong-Xiong Chen
- Eye Institute of Xiamen University, Fujian Provincial Key Laboratory of Ophthalmology & Visual Science, Medical College, Xiamen University, Xiamen 361005, PR China
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, PR China
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Influence of Biologic Subtype of Inflammatory Breast Cancer on Response to Neoadjuvant Therapy and Cancer Outcomes. Clin Breast Cancer 2018; 18:e501-e506. [DOI: 10.1016/j.clbc.2017.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/01/2017] [Accepted: 10/02/2017] [Indexed: 01/02/2023]
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Patel SA, Ng M, Nardello SM, Ruth K, Bleicher RJ. Immediate breast reconstruction for women having inflammatory breast cancer in the United States. Cancer Med 2018; 7:2887-2902. [PMID: 29761885 PMCID: PMC6051180 DOI: 10.1002/cam4.1546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 02/10/2018] [Accepted: 03/15/2018] [Indexed: 01/07/2023] Open
Abstract
Inflammatory breast cancer (IBC) is an aggressive malignancy having a poor prognosis. Traditionally, reconstruction is not offered due to concerns about treatment delay, margin positivity, recurrence, and poor long-term survival. There is a paucity of literature, however, evaluating whether immediate breast reconstruction (IBR) is associated with greater mortality in patients with IBC. A population-based study was conducted via the SEER-Medicare-linked database (1991-2009). Female patients greater than 65 years were reviewed who had mastectomy and reconstruction claims for nonmetastatic IBC. Competing risk and Cox regression were used to assess whether IBR was associated with higher breast cancer-specific mortality (BCSM) or overall mortality (OM). Among 552 936 patients, 1472 (median age 74 years) were diagnosed with IBC and had a mastectomy. Forty-four patients (3%) underwent IBR. Younger age, a lower Charlson comorbidity score, and a greater median income were predictors of IBR use. Tumor grade, hormone receptor status, and lymph node status were independent predictors of adjusted OM and BCSM. There was no difference by IBR status in BCSM or covariate-adjusted BCSM (sHR 1.04; CI 0.71-1.54; P = .83 and sHR 1.13; CI 0.84-1.93; P = .58, respectively). Cumulative incidence of OM was lower among IR patients (P = .013), and IR did not influence the cumulative incidence of BCSM (P = .91). IBR was not associated with increased overall and BCSM mortality. Although further study of IBR in the IBC setting may be of value, these data suggest that IBC should not be considered an absolute contraindication to IBR.
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Affiliation(s)
- Sameer A. Patel
- Department of Surgical OncologyFox Chase Cancer CenterPhiladelphiaPAUSA
| | - Marilyn Ng
- Division Plastic, Reconstructive and Hand SurgeryDepartment of SurgeryNorthwell Health‐Staten Island University HospitalStaten IslandNYUSA
| | | | - Karen Ruth
- Department of BiostatisticsFox Chase Cancer CenterPhiladelphiaPAUSA
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Huang L, Chen S, Yang WT, Shao Z. Risk factors of locoregional relapse in locally advanced breast cancer treated with neoadjuvant chemotherapy following mastectomy and radiotherapy. Oncotarget 2018; 8:39703-39710. [PMID: 28055977 PMCID: PMC5503645 DOI: 10.18632/oncotarget.14407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/13/2016] [Indexed: 12/15/2022] Open
Abstract
We seek to investigate the prognostic factors that could possibly increase the locoregional recurrence of breast cancer patients who do not achieve pathological complete response after neoadjuvant chemotherapy, and to build a prognostic nomogram to predict patients' outcome. The retrospective analysis included 510 patients who had received neoadjuvant chemotherapy followed by surgery and radiotherapy. 62 locoregional events occurred after a median 61 months of follow-up. The five-year cumulative incidence of local recurrence and regional recurrence were 8.63% and 4.31%, respectively. Multivariate analysis revealed that positivity for ≥ 4 lymph nodes and Ki-67 index ≥ 14% were independent factors. According to our prognostic model, the 5-year locoregional free survival rates in the low, intermediate, and high-risk groups were 95.5%, 89.1%, and 67.1%, respectively (p < 0.001). Annual recurrence curves indicated that the relapse peak after mastectomy emerged in the first 1 year. Positivity for ≥ 4 lymph nodes and Ki-67 index ≥ 14% were independent factors for locoregional recurrence. This prognostic model has considerable clinical value in predicting locoregional recurrence, which could help clinicians to design appropriate locoregional treatment specifically and to perform surveillance individually.
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Affiliation(s)
- Liang Huang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center/Cancer Institute, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Sheng Chen
- Department of Breast Surgery, Fudan University Shanghai Cancer Center/Cancer Institute, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wentao T Yang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Pathology, Fudan University Shanghai Cancer Center/Cancer Institute, Shanghai, China
| | - Zhiming Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center/Cancer Institute, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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11
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A standard mastectomy should not be the only recommended breast surgical treatment for non-metastatic inflammatory breast cancer: A large population-based study in the Surveillance, Epidemiology, and End Results database 18. Breast 2017. [PMID: 28649032 DOI: 10.1016/j.breast.2017.06.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Standard mastectomy has long been the recommended breast surgical treatment for non-metastatic inflammatory breast cancer (IBC). The objective of this population-based study was to evaluate the significance of various breast surgical treatments for this highly aggressive subtype. METHODS The Surveillance, Epidemiology, and End Results program registry was searched to identify women with non-metastatic IBC receiving standard treatment including breast surgery, radiation therapy and chemotherapy diagnosed between 1998 and 2013. Comparisons of the proportions of various breast surgery procedures over the years were performed using Pearson's chi-square test. Breast cancer-specific survival (BCSS) and overall survival (OS) were estimated using the Kaplan-Meier product limit method and compared across groups using the log-rank statistic. Cox models were then fitted to compare the association between various breast surgical procedures and BCSS or OS after adjusting for patient and tumor characteristics. RESULTS A total of 3374 cases were identified. Over the years, the proportion of contralateral prophylactic mastectomy (CPM), breast reconstruction and both were increasing. The proportion of implant-based reconstruction was also increasing with no difference in survival compared with other types of reconstruction. There was no statistically significant difference in BCSS or OS among various breast surgery treatments, such as breast conserving surgery, CPM, breast reconstruction and standard unilateral mastectomy. CONCLUSIONS Breast surgery is of great significance to the clinical outcome of IBC. Standard mastectomy should not be the only recommended breast surgical treatment.
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12
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Simpson AB, McCray D, Wengler C, Crowe JP, Djohan R, Tendulkar R, O'Rourke C, Grobmyer SR, Valente SA. Immediate Reconstruction in Inflammatory Breast Cancer: Challenging Current Care. Ann Surg Oncol 2016; 23:642-648. [PMID: 27638670 DOI: 10.1245/s10434-016-5554-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND Inflammatory breast cancer (IBC) is an aggressive disease that is treated with trimodality therapy consisting of neoadjuvant chemotherapy, surgery, and post-mastectomy radiation therapy (PMRT). Traditionally, modified radical mastectomy without reconstruction has been the operation of choice for patients with IBC due to fears of high rates of margin positivity, risk of local recurrence, and the need for PMRT. METHODS A retrospective review was performed to evaluate women with IBC at our institution from 2006 to 2014 who completed trimodality therapy. Patients were identified as undergoing reconstruction or no reconstruction (NR), with reconstruction being further classified as immediate (IR) if reconstruction occurred at the initial surgery, or delayed (DR) if initial reconstruction occurred after PMRT. RESULTS Sixty women with IBC were identified using inclusion criteria. The median follow-up was 2.3 years (range 1.4-4.6). Patients with IR had a statistically significant increased risk (p = 0.006) in postoperative complication rates compared with DR (0 %) and NR (2.6 %). Two patients had positive skin margins on final pathology (one IR, one NR), with both eventually having recurrence. Time to PMRT was delayed 10 days in patients with IR compared with those without IR. No statistically significant difference in recurrence rates was observed (p = 0.86) when comparing patients with IR and those with NR, and no difference in survival was observed between patients who had reconstruction and those without (p = 0.91). CONCLUSION Performing IR with mastectomy for IBC is associated with increased complications, but is not associated with decreased survival or increased recurrence in selected patients. IR in selected IBC patients can facilitate successful breast reconstruction.
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Affiliation(s)
- Ashley B Simpson
- Department of General Surgery, Division of Breast Services, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Devina McCray
- Department of General Surgery, Division of Breast Services, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Craig Wengler
- Department of General Surgery, Division of Breast Services, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joseph P Crowe
- Department of General Surgery, Division of Breast Services, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Risal Djohan
- Department of Plastic of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rahul Tendulkar
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Colin O'Rourke
- Quantitative Health Services, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen R Grobmyer
- Department of General Surgery, Division of Breast Services, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephanie A Valente
- Department of General Surgery, Division of Breast Services, Cleveland Clinic Foundation, Cleveland, OH, USA
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13
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Maluta S, Kolff MW. Role of Hyperthermia in Breast Cancer Locoregional Recurrence: A Review. Breast Care (Basel) 2015; 10:408-12. [PMID: 26989361 DOI: 10.1159/000440792] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
In patients with locoregional recurrences of breast cancer not suitable for resection, subsequent local control is difficult to maintain in previously irradiated areas when reirradiation alone or reirradiation with chemotherapy is used. Due to the limited number of treatment options there is a high risk of subsequent failure and uncontrollable local disease. In this group of patients, local hyperthermia combined with radiotherapy increases the clinical response and local control, adding limited acute and late toxicity, as has been shown in randomized trials. Hyperthermia is an artificial elevation of tissue temperature (range 40-44°C for 30-60 min). If hyperthermia is applied shortly before or after radiation, the effect of radiation is enhanced by influencing intratumoral hypoxia and by inhibiting sublethal damage repair in the tumor. Moreover, hyperthermia combined with radiation reduces the total dose of radiation needed compared to radiation alone, of which a higher dose is needed to obtain the same effect. Few data are available on the combination of radiotherapy and hyperthermia with chemotherapy, although the results of trimodality treatment consisting of reirradiation and hyperthermia together with liposomal doxorubicin are promising. Therefore, this literature review was performed to provide more comprehensive data on the mechanism and use of hyperthermia in locoregional recurrence of breast cancer.
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Affiliation(s)
- Sergio Maluta
- Department of Hyperthermia, Serena Medical Center, Padova, Italy
| | - Merel Willemijn Kolff
- Department of Radiotherapy and Hyperthermia, Academic Medical Center, Amsterdam, The Netherlands
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14
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Zhang C, Wang S, Israel HP, Yan SX, Horowitz DP, Crockford S, Gidea-Addeo D, Clifford Chao KS, Kalinsky K, Connolly EP. Higher locoregional recurrence rate for triple-negative breast cancer following neoadjuvant chemotherapy, surgery and radiotherapy. SPRINGERPLUS 2015; 4:386. [PMID: 26240784 PMCID: PMC4519490 DOI: 10.1186/s40064-015-1116-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 06/25/2015] [Indexed: 12/31/2022]
Abstract
Background Breast cancer subtype, determined by expression of estrogen/progesterone receptor (ER/PR) and human epidermal growth factor receptor (HER)-2, is predictive for prognosis. The importance of subtype to locoregional recurrence (LRR) following neoadjuvant chemotherapy (NAC) is unknown, particularly after adjuvant radiotherapy (RT). Methods We retrospectively identified 160-breast cancer patients registered at Columbia University Medical Center from 1999 to 2012 treated with NAC, surgery and adjuvant RT. Results Patients were grouped by receptor status: hormone receptor positive (HR+) [(ER or PR+)/HER2−; n = 75], HER2+ (n = 46), or triple-negative (TNBC) [ER (−) PR (−) HER2 (−); n = 36]. The median follow-up was 28 months. 92.0% received an anthracycline-taxane based NAC and 80.4% of HER2+ patients received trastuzumab. All underwent surgical resection followed by RT. 15.6% had a pathologic complete response (pCR): 26% of HER2+, 5% of HR+, and 25% of TN. The actuarial rate of DM was 13.8% for the entire cohort, with equivalent rates by subtypes in non-pCR patients. The overall rate of LRR was 8%. However, the LRR rate was significantly higher for TNBC patients (22.2%) than HER2+ (5.6%) (p = 0.025) or HR+ (3.0%) (p = 0.037) in non-pCR group. In the pCR group, two patients had recurrence; one LRR and one a DM, both had TNBC. All LRR occurred in or near the radiation field. Conclusions TNBC patients with < pCR to NAC have a significantly higher LRR rate as compared to other subtypes even with surgery and adjuvant RT. Our data support a need to further intensify local therapy in TNBC patients.
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Affiliation(s)
- Chi Zhang
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
| | - Shuang Wang
- Department of Biostatistics, Columbia University School of Medicine, New York, NY USA
| | | | - Sherry X Yan
- Columbia University School of Medicine, New York, NY USA
| | - David P Horowitz
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
| | - Seth Crockford
- Columbia University School of Medicine, New York, NY USA
| | - Daniela Gidea-Addeo
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
| | - K S Clifford Chao
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
| | - Kevin Kalinsky
- Department of Medical Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
| | - Eileen P Connolly
- Department of Radiation Oncology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
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15
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Bernier J. Post-mastectomy radiotherapy after neodjuvant chemotherapy in breast cancer patients: A review. Crit Rev Oncol Hematol 2015; 93:180-9. [DOI: 10.1016/j.critrevonc.2014.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 10/20/2014] [Accepted: 10/21/2014] [Indexed: 11/28/2022] Open
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16
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Allensworth JL, Evans MK, Bertucci F, Aldrich AJ, Festa RA, Finetti P, Ueno NT, Safi R, McDonnell DP, Thiele DJ, Van Laere S, Devi GR. Disulfiram (DSF) acts as a copper ionophore to induce copper-dependent oxidative stress and mediate anti-tumor efficacy in inflammatory breast cancer. Mol Oncol 2015; 9:1155-68. [PMID: 25769405 DOI: 10.1016/j.molonc.2015.02.007] [Citation(s) in RCA: 167] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 12/20/2022] Open
Abstract
Cancer cells often have increased levels of reactive oxygen species (ROS); however, acquisition of redox adaptive mechanisms allows for evasion of ROS-mediated death. Inflammatory breast cancer (IBC) is a distinct, advanced BC subtype characterized by high rates of residual disease and recurrence despite advances in multimodality treatment. Using a cellular model of IBC, we identified an oxidative stress response (OSR) signature in surviving IBC cells after administration of an acute dose of an ROS inducer. Metagene analysis of patient samples revealed significantly higher OSR scores in IBC tumor samples compared to normal or non-IBC tissues, which may contribute to the poor response of IBC tumors to common treatment strategies, which often rely heavily on ROS induction. To combat this adaptation, we utilized a potent redox modulator, the FDA-approved small molecule Disulfiram (DSF), alone and in combination with copper. DSF forms a complex with copper (DSF-Cu) increasing intracellular copper concentration both in vitro and in vivo, bypassing the need for membrane transporters. DSF-Cu antagonized NFκB signaling, aldehyde dehydrogenase activity and antioxidant levels, inducing oxidative stress-mediated apoptosis in multiple IBC cellular models. In vivo, DSF-Cu significantly inhibited tumor growth without significant toxicity, causing apoptosis only in tumor cells. These results indicate that IBC tumors are highly redox adapted, which may render them resistant to ROS-inducing therapies. DSF, through redox modulation, may be a useful approach to enhance chemo- and/or radio-sensitivity for advanced BC subtypes where therapeutic resistance is an impediment to durable responses to current standard of care.
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Affiliation(s)
- Jennifer L Allensworth
- Department of Surgery, Duke University Medical Center, Durham, NC, USA; Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Myron K Evans
- Department of Surgery, Duke University Medical Center, Durham, NC, USA; Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - François Bertucci
- Department of Medical Oncology and Molecular Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Amy J Aldrich
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard A Festa
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
| | - Pascal Finetti
- Department of Medical Oncology and Molecular Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Naoto T Ueno
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, USA
| | - Rachid Safi
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Donald P McDonnell
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA; Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
| | - Dennis J Thiele
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
| | - Steven Van Laere
- Translational Cancer Research Unit, Oncology Center, General Hospital Sint-Augustinus, Antwerp, Wilrijk, Belgium
| | - Gayathri R Devi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA; Department of Pathology, Duke University Medical Center, Durham, NC, USA.
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17
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Hanf V, Schütz F, Liedtke C, Thill M. AGO Recommendations for the Diagnosis and Treatment of Patients with Advanced and Metastatic Breast Cancer: Update 2014. ACTA ACUST UNITED AC 2014; 9:202-9. [PMID: 25177262 DOI: 10.1159/000363551] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Volker Hanf
- Frauenklinik, Klinikum Fürth, Frankfurt/M., Germany
| | - Florian Schütz
- Universitätsfrauenklinik Heidelberg, Frankfurt/M., Germany
| | - Cornelia Liedtke
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Schleswig-Holstein/Campus Lübeck, Frankfurt/M., Germany
| | - Marc Thill
- Klinik für Gynäkologie und Geburtshilfe, Agaplesion Markus Krankenhaus, Frankfurt/M., Germany
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18
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Puglisi F, Fontanella C, Numico G, Sini V, Evangelista L, Monetti F, Gori S, Del Mastro L. Follow-up of patients with early breast cancer: Is it time to rewrite the story? Crit Rev Oncol Hematol 2014; 91:130-41. [DOI: 10.1016/j.critrevonc.2014.03.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 02/24/2014] [Accepted: 03/11/2014] [Indexed: 12/11/2022] Open
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19
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Debeb BG, Gong Y, Atkinson RL, Sneige N, Huo L, Gonzalez-Angulo AM, Hung MC, Valero V, Ueno NT, Woodward WA. EZH2 expression correlates with locoregional recurrence after radiation in inflammatory breast cancer. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2014; 33:58. [PMID: 25051981 PMCID: PMC4431485 DOI: 10.1186/s13046-014-0058-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/27/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhancer of zeste homolog 2 (EZH2), a member of the polycomb group proteins, has been shown to promote cancer progression and breast cancer stem cell (CSC) expansion. Breast CSCs are associated with resistance to radiation in inflammatory breast cancer (IBC), a rare but aggressive variant of breast cancer. In this retrospective study, we examined the clinical role of EZH2 in locoregional recurrence (LRR) of IBC patients treated with radiation. PATIENTS AND METHODS 62 IBC patients who received radiation (7 pre-operative, 55 post-operative) and had adequate follow up to assess LRR were the subject of this study. Positive EZH2 status was defined as nuclear immunohistochemical staining in at least 10% of invasive cancer cells. Association of EZH2 expression with clinicopathologic features were evaluated using the Chi-square statistic and actuarial LRR free survival (LRFS) was determined using the Kaplan-Meier method. RESULTS The median follow-up for this cohort was 33.7 months, and the 5-year overall LRFS rate was 69%. Of the 62 patients, 16 (25.8%) had LRR, and 15 out of 16 LRR occurred in EZH2 expressing cases. Univariate analysis indicated that patients who had EZH2-positive IBC had a significantly lower 5-year locoregional free survival (LRFS) rate than patients who had EZH2-negative IBC (93.3% vs. 59.1%; P = 0.01). Positive EZH2 expression was associated significantly with negative ER status (97.1% in ER- vs 48.1% in ER+; P < 0.0001) and triple-negative receptor status (P = 0.0001) and all triple-negative tumors were EZH2-positive. In multivariate analysis, only triple negative status remained an independent predictor of worse LRFS (hazard ratio 5.64, 95% CI 2.19 - 14.49, P < 0.0001). CONCLUSIONS EZH2 correlates with locoregional recurrence in IBC patients who received radiation treatment. EZH2 expression status may be used in addition to receptor status to identify a subset of patients with IBC who recur locally in spite of radiation and may benefit from enrollment in clinical trials testing radiosensitizers.
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Affiliation(s)
- Bisrat G Debeb
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - Yun Gong
- Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - Rachel L Atkinson
- Department of Clinical Cancer Prevention, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - Nour Sneige
- Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA.
| | - Lei Huo
- Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - Ana Maria Gonzalez-Angulo
- Department of Breast Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA.
| | - Mien-Chie Hung
- Department of Molecular and Cellular Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. .,Center for Molecular Medicine and Graduate Institute of Cancer Biology, China Medical University, Taichung, Taiwan.
| | - Vicente Valero
- Department of Breast Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - Naoto T Ueno
- Department of Breast Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - Wendy A Woodward
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. .,Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1202, 77030, Houston, TX, USA.
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