Patterns of metastatic breast carcinoma: influence of tumour histological grade

Long-Term Non-progression in Metastatic Breast Cancer Beyond 5 Years: Case Series and Review

Purpose of review

Metastatic breast cancer (MBC) was traditionally viewed as homogeneously progressive and incurable among all comers, but there is new evidence that MBC harbors a range of tumor molecular/immune subtypes and degrees of aggressiveness. Thus, MBC is not rapidly fatal in all affected patients.

Recent findings

A small subset of patients will attain long-term disease control, or undetectable disease, and will enjoy a prolonged survival with little disability from their disease or treatment. Though the term is controversial, some patients with long-term non-detectable disease may effectively be considered “cured”. To best advise treatment options in these patients, it is imperative to identify patients most likely to benefit from aggressive treatment.

Summary

In this review, we delineate the clinical, pathologic, and disease characteristics associated with long-term non-progression in MBC. We include a single institution case series of long-term non-progressive MBC patients and their characteristics as an example of the frequency of this sub-population of MBC. Future prospective trials are warranted to examine the utility of clinical characteristics as predictors of long-term survival in MBC.

Distribution of Neck Metastases and Survival in Patients with Breast Carcinoma

PURPOSE

Neck metastases in breast carcinoma are relatively rare and patients show poor survival rates. A controversy exists over whether neck metastases can be treated as distant or loco-regional metastases. The literature concerning the distribution of metastases in the neck is lacking, as well as data about whether metastases in the higher neck regions cause poorer survival than those in the supraclavicular fossa.

METHODS

Ultrasound investigation with fine-needle biopsy was performed on 41 breast cancer and confirmed neck metastases patients in a 6-year period. We analysed the distribution of neck metastases and patient survival rates using Kaplan-Meier survival curves and Cox regression.

RESULTS

The median survival time from the diagnosis of primary disease to that of neck metastases was 21 months. The presence of metastases in sites other than the neck significantly worsened survival, but multiple metastatic sites did not make it significantly worse. The number of nodes and presence of conglomerates did not considerably affect survival.

CONCLUSION

Neck metastases in breast carcinoma can be found not only in the supraclavicular fossa, but elsewhere in the neck as well. Survival of patients with metastases in higher neck regions was shorter, but not very much so. Survival of patients with metastases limited just to the neck was substantially better, therefore early detection and aggressive treatment that could include neck dissection should be considered.

Breast cancer metastasis to gynaecological organs: a clinico-pathological and molecular profiling study

Breast cancer metastasis to gynaecological organs is an understudied pattern of tumour spread. We explored clinico-pathological and molecular features of these metastases to better understand whether this pattern of dissemination is organotropic or a consequence of wider metastatic dissemination. Primary and metastatic tumours from 54 breast cancer patients with gynaecological metastases were analysed using immunohistochemistry, DNA copy-number profiling, and targeted sequencing of 386 cancer-related genes. The median age of primary tumour diagnosis amongst patients with gynaecological metastases was significantly younger compared to a general breast cancer population (46.5 versus 60 years; p < 0.0001). Median age at metastatic diagnosis was 54.4, time to progression was 4.8 years (range 0-20 years), and survival following a diagnosis of metastasis was 1.95 years (range 0-18 years). Patients had an average of five involved sites (most frequently ovary, fallopian tube, omentum/peritoneum), with fewer instances of spread to the lungs, liver, or brain. Invasive lobular histology and luminal A-like phenotype were over-represented in this group (42.8 and 87.5%, respectively) and most patients had involved axillary lymph nodes (p < 0.001). Primary tumours frequently co-expressed oestrogen receptor cofactors (GATA3, FOXA1) and harboured amplifications at 8p12, 8q24, and 11q13. In terms of phenotype conversion, oestrogen receptor status was generally maintained in metastases, FOXA1 increased, and expression of progesterone receptor, androgen receptor, and GATA3 decreased. ESR1 and novel AR mutations were identified. Metastasis to gynaecological organs is a complication frequently affecting young women with invasive lobular carcinoma and luminal A-like breast cancer, and hence may be driven by sustained hormonal signalling. Molecular analyses reveal a spectrum of factors that could contribute to de novo or acquired resistance to therapy and disease progression.

A Nomogram for Distinction and Potential Prediction of Liver Metastasis in Breast Cancer Patients

Liver metastasis from breast cancer has poor prognosis. We aimed at developing a reliable tool for making a distinction and prediction for liver metastasis in breast cancer patients, thus helping clinical diagnosis and treatment. In this study, totally 6238 patients from SEER database with known distant metastasis status and clinicopathologic variables were enrolled and divided randomly into training and validating groups. Logistic regression was used to screen variables and a nomogram was constructed. After multivariate logistic regression, sex, histology type, N stage, grade, age, ER, PR, HER2 status as significant variables for constructing the nomogram. The nomogram for distinguishing and predicting liver metastasis in breast cancer passed the calibration and validation steps and the areas under the receiver operating characteristic curve of the training set and the validation set were 0.6602 and 0.6511 respectively. Our nomogram is a reliable and robust tool for the distinction and prediction of liver metastasis in breast cancer patients, thus helping better choose medical examinations and optimize therapeutic regimen under the cooperation among medical oncologists and surgeons.

Encapsulation of Au/Fe3O4 nanoparticles into a polymer nanoarchitecture with combined near infrared-triggered chemo-photothermal therapy based on intracellular secondary protein understanding

The combination of the functions of near infrared-triggered molecule release and chemo-photothermal therapy improved the therapeutic effect, but clarification of the cancer damage pathway in terms of protein molecule levels has yet to be well studied. In this study, we developed a polymer encapsulation synthesis of Au/Fe₃O₄@polymer nanoparticles as a Swiss army knife to integrate near infrared absorption, magnetism, and doxorubicin (DOX) loading ability into a single package. By exposing to near infrared absorption, the Au/Fe₃O₄@polymer nanoparticles possessed photothermal therapy, exhibiting anti-tumor growth suppression of HT-29 tumor-bearing nude mice with less body weight loss. To deeply understand the interactions between the drug-loaded nanocarriers and the protein structures of the treated cells, delivering therapeutic DOX agent combined with photothermal therapy with Au/Fe₃O₄@polymer nanostructures to cancer cells was investigated. Synchrotron-based FTIR imaging and confocal imaging showed direct observation of the efficient photo-chemotherapy impacting MCF7, MCF7/ADR, and HT-29 cells after the near infrared radiation-triggered DOX release. Our demonstration outlines how the cell destruction in the molecular mechanism was initiated by chemo-photothermal combination therapy after the translocation of DOX from the cytosol to the nuclei, leading to altered intracellular secondary proteins. For preclinical application of potential diagnosis to cancer cells, Au/Fe₃O₄@polymer nanoparticles performed integrated computed tomography/magnetic resonance imaging contrast enhancement and near infrared-triggered chemo-photothermal therapy.

Relation between primary tumor FDG avidity and site of first distant metastasis in patients with breast cancer

Identification of tumor imaging features associated with metastatic pattern may allow better understanding of cancer dissemination. Here, we investigated how primary tumor F-fluorodeoxyglucose (FDG) avidity influences the first site of breast cancer metastasis.Subjects were 264 patients with advanced breast cancer who underwent positron emission tomography/computed tomography at diagnosis and had metastasis at presentation (n = 193) or metastatic relapse after surgery (n = 71). Primary tumor FDG avidity (maximum SUV [SUVmax] ≥10.1) was compared with histology and first metastatic sites.The most common site of first metastasis was the bone, occurring in 62.7% of patients with metastasis at presentation and 38.0% of those with metastatic relapse. First metastasis to lung occurred in 30.1% and 35.2%, and to liver in 25.4% and 15.2% of respective groups. In patients with metastasis at presentation, primary tumors were FDG avid in 98/193 cases, and this was associated with more frequent first metastasis to lung (37.8% vs 22.1%; P = 0.018). In patients with metastasis relapse, primary tumors were FDG avid in 31/71 cases, and this was associated with more frequent first metastasis to lung (48.4% vs 25.0%; P = 0.041) and liver (29.0% vs 5.0%; P = 0.008). In patients with metastasis relapse, primary tumors that were FDG avid but hormone receptor negative had more first metastasis to lung (57.9% vs 26.9%; P = 0.016).FDG-avid primary breast tumors have favored first spread to the lung and liver, which suggests that tumor cells with heightened glycolytic activity better colonize these organs.

Causas de muerte por cáncer de mama en Colombia

<p>Objetivo Revisar las causas directas de muerte por cáncer de mama en Colombia según datos de los certificados de defunción en el año 2008.Material y Métodos Se revisaron las causas directas de muerte en pacientes cuyo código de causa básica de defunción fue el de tumor maligno de la mama según el   registro de defunciones del Departamento Nacional de Estadística de Colombia (DANE) en el año 2008. Se evalúa su distribución por código de diagnóstico de la causa directa de muerte, grupos de edad, nivel educativo, estado civil, seguridad social y sitio de defunción.Resultados Las principales causas directas de muerte en mujeres fueron insuficiencia o falla respiratoria, paro cardiorespiratorio, falla orgánica múltiple o multisistémica, cáncer de seno y cáncer de mama metastásico. La mayoría de las muertes tuvieron el código C509 y se presentaron en mayores de 50 años. En hombres la causa más frecuente fue la falla respiratoria. Conclusiones Las principales denominaciones anotadas en los registros de defunción como causa directa de muerte por cáncer de mama fueron insuficiencia, paro respiratorio y paro cardiorespiratorio. Sin embargo, se evidencia que esto surge por problemas en el registro al no ceñirse a la Clasificación internacional de enfermedades (CIE-10). Se requiere mejorar la calidad de los registros de defunción para aprovechar la información que aporta este documento.</p>

Evaluating the utility of trefoil factor 1 as a mammary-specific immunostain compared and in conjunction with GATA-3 and mammaglobin in the distinction between carcinoma of breast and lung

OBJECTIVES

The distinction between metastatic breast carcinomas (BCs) and primary lung carcinomas (PLCs) can be difficult. This study tested the utility of trefoil factor 1 (TFF1) for this purpose and compared it with mammaglobin and GATA protein binding 3 (GATA-3).

METHODS

Tissue microarrays containing 365 BCs and 338 PLCs were stained with TFF1, mammaglobin, and GATA-3, and an H-score was calculated. Sensitivity, specificity, and accuracy were calculated, and logistical regression analysis was performed.

RESULTS

Accuracy of correctly classifying the tumor type was 81.9%, 71.3%, and 64.0% for GATA-3, mammaglobin, and TFF1, respectively. Odds ratios for selecting BCs were 25.69, 93.15, and 4.17, respectively, with P values less than .001. With a single exception, the best immunopanel included GATA-3 and mammaglobin in all comparisons.

CONCLUSIONS

TFF1 demonstrated breast specificity but was inferior to mammaglobin and GATA-3. Therefore, its routine clinical use may not be justified. TFF1 showed little benefit when added to an immunopanel.

Crosstalk between cancer cells and blood endothelial and lymphatic endothelial cells in tumour and organ microenvironment

Tumour and organ microenvironments are crucial for cancer progression and metastasis. Crosstalk between multiple non-malignant cell types in the microenvironments and cancer cells promotes tumour growth and metastasis. Blood and lymphatic endothelial cells (BEC and LEC) are two of the components in the microenvironments. Tumour blood vessels (BV), comprising BEC, serve as conduits for blood supply into the tumour, and are important for tumour growth as well as haematogenous tumour dissemination. Lymphatic vessels (LV), comprising LEC, which are relatively leaky compared with BV, are essential for lymphogenous tumour dissemination. In addition to describing the conventional roles of the BV and LV, we also discuss newly emerging roles of these endothelial cells: their crosstalk with cancer cells via molecules secreted by the BEC and LEC (also called angiocrine and lymphangiocrine factors). This review suggests that BEC and LEC in various microenvironments can be orchestrators of tumour progression and proposes new mechanism-based strategies to discover new therapies to supplement conventional anti-angiogenic and anti-lymphangiogenic therapies.

Differences in fluorescence profiles from breast cancer tissues due to changes in relative tryptophan content via energy transfer: tryptophan content correlates with histologic grade and tumor size but not with lymph node metastases

The correlation between histologic grade, an increasingly important measure of prognosis for patients with breast cancer, and tryptophan levels from tissues of 15 breast carcinoma patients was investigated. Changes in the relative content of key native organic biomolecule tryptophan were seen from the fluorescence spectra of cancerous and paired normal tissues with excitation wavelengths of 280 and 300 nm. Due to a large spectral overlap and matching excitation–emission spectra, fluorescence resonance energy transfer from tryptophan-donor to reduced nicotinamide adenine dinucleotides-acceptor was noted. We used the ratios of fluorescence intensities at their spectral emission peaks, or spectral fingerprint peaks, at 340, 440, and 460 nm. Higher ratios correlated strongly with high histologic grade, while lower-grade tumors had low ratios. Large tumor size also correlated with high ratios, while the number of lymph node metastases, a major factor in staging, was not correlated with tryptophan levels. High histologic grade correlates strongly with increased content of tryptophan in breast cancer tissues and suggests that measurement of tryptophan content may be useful as a part of the evaluation of these patients.

Comparison of breast and abdominal adipose tissue mesenchymal stromal/stem cells in support of proliferation of breast cancer cells

In this study, we compared MSCs from breast and abdominal tissue in terms of their expression of genes deemed important in the support of breast cancer growth and their effect on gene profile of macrophages after coculture. In addition, we investigated the role of MSCs, alone or in combination with macrophages, on proliferation of breast cancer cell lines. Our results show that MSCs derived from breast and abdominal adipose tissues have a comparable gene expression profile, have similar effect on gene expression of macrophages, and are comparable in supporting breast cancer cell line proliferation.

Histone demethylase JMJD2C is a coactivator for hypoxia-inducible factor 1 that is required for breast cancer progression

Hypoxia-inducible factor 1 (HIF-1) activates transcription of genes encoding proteins that play key roles in breast cancer biology. We hypothesized that interaction of HIF-1 with epigenetic regulators may increase HIF-1 transcriptional activity, and thereby promote breast cancer progression. We report that the histone demethylase jumonji domain containing protein 2C (JMJD2C) selectively interacts with HIF-1α, but not HIF-2α, and that HIF-1α mediates recruitment of JMJD2C to the hypoxia response elements of HIF-1 target genes. JMJD2C decreases trimethylation of histone H3 at lysine 9, and enhances HIF-1 binding to hypoxia response elements, thereby activating transcription of BNIP3, LDHA, PDK1, and SLC2A1, which encode proteins that are required for metabolic reprogramming, as well as LOXL2 and L1CAM, which encode proteins that are required for lung metastasis. JMJD2C expression is significantly associated with expression of GLUT1, LDHA, PDK1, LOX, LOXL2, and L1CAM mRNA in human breast cancer biopsies. JMJD2C knockdown inhibits breast tumor growth and spontaneous metastasis to the lungs of mice following mammary fat pad injection. Taken together, these findings establish an important epigenetic mechanism that stimulates HIF-1-mediated transactivation of genes encoding proteins involved in metabolic reprogramming and lung metastasis in breast cancer.

[Patient follow-up after treatment for breast cancer]

Patient follow-up after treatment for a breast cancer is based on the local recurrence risk. Annual mammography remains the main point of this follow-up and tumor markers detection has still no interest. Absence of benefit of an intensive clinical, biological and radiological surveillance has been proved for a long time but expert recommendations still are a subject of discussion although they knew no evolution for more than 10 years. Evolution of those follow-up modalities will depend on the future indications of MRI and PET. About distant recurrence, a better knowledge of the risk is now possible thanks to the tumor biological profile study. Nevertheless, intensification of follow-up for some kind of high-risk tumors will have interest only if we can propose a therapeutic alternative in metastatic situation.

Brk protects breast cancer cells from autophagic cell death induced by loss of anchorage

Brk, a tyrosine kinase expressed in a majority of breast tumors, but not normal mammary tissue, promotes breast carcinoma cell proliferation. Normal epithelial cells are dependent on cell-cell or cell-matrix interactions for survival and undergo apoptosis after disruption of these interactions. Tumor cells are less sensitive to the induction of apoptosis and are predicted to have the potential to disseminate. We investigated whether Brk has further roles in breast tumor progression by relating its expression to tumor grade and demonstrating its role in the regulation of carcinoma cell survival under non-adherent conditions. Brk expression was determined by reverse transcription PCR on RNA extracted from surgical samples of human breast cancers. Breast carcinoma cell survival in suspension culture was examined when Brk protein levels were suppressed by RNA interference. Additionally, the effect of experimentally overexpressing Brk in otherwise Brk-negative breast carcinoma cells was assessed. Brk mRNA expression was notably higher in grade 3 breast tumors, as compared with lower tumor grades. In suspension culture, Brk suppression increased the rate of cell death, as compared with controls, and this cell death program exhibited characteristics of autophagy but not of apoptosis. Conversely, experimental expression of Brk in Brk-negative cells increased cell survival whereas kinase-inactive Brk did not. Therefore, Brk enhances breast carcinoma cell survival in suspension, suggesting a role for Brk in supporting breast cancer cell dissemination.

Stereotactic body radiotherapy is effective salvage therapy for patients with prior radiation of spinal metastases

PURPOSE

To provide actuarial outcomes and dosimetric data for spinal/paraspinal metastases, with and without prior radiation, treated with stereotactic body radiotherapy (SBRT).

METHODS AND MATERIALS

A total of 39 consecutive patients (60 metastases) were treated with SBRT between April 2003 and August 2006 and retrospectively reviewed. In all, 23 of 60 tumors had no previous radiation (unirradiated) and 37/60 tumors had previous irradiation (reirradiated). Of 37 reirradiated tumors, 31 were treated for "salvage" given image-based tumor progression. Local failure was defined as progression by imaging and/or clinically.

RESULTS

At last follow-up, 19 patients were deceased. Median patient survival time measured was 21 months (95% CI = 8-27 months), and the 2-year survival probability was 45%. The median total dose prescribed was 24 Gy in three fractions prescribed to the 67% and 60% isodose for the unirradiated and reirradiated cohorts, respectively. The median tumor follow-up for the unirradiated and reirradiated group was 9 months (range, 1-26) and 7 months (range, 1-48) respectively. Eight of 60 tumors have progressed, and the 1- and 2-year progression-free probability (PFP) was 85% and 69%, respectively. For the salvage group the 1 year PFP was 96%. There was no significant difference in overall survival or PFP between the salvage reirradiated vs. all other tumors treated (p = 0.08 and p = 0.31, respectively). In six of eight failures the minimum distance from the tumor to the thecal sac was <or=1 mm. Of 60 tumors treated, 39 have >or=6 months follow-up and no radiation-induced myelopathy or radiculopathy has occurred.

CONCLUSION

Spine SBRT has shown preliminary efficacy and safety in patients with image-based progression of previously irradiated metastases.

Liver resection for breast cancer metastasis: does it improve survival?

PURPOSE

To assess the outcome and prognostic factors of liver surgery for breast cancer metastasis.

METHODS

We retrospectively examined 16 patients who underwent partial liver resection for breast cancer liver metastasis (BCLM). All patients had been treated with chemotherapy or hormonotherapy, or both, before referral for surgery. We confirmed by preoperative radiological examinations that metastasis was confined to the liver. The survival curve was estimated using the Kaplan-Meier method. Univariate and multivariate analysis were conducted to evaluate the role of the known factors of breast cancer survival.

RESULTS

The median age of the patients was 54 years (range 38-68) and the median disease-free interval between the diagnoses of breast cancer and liver metastasis was 54 months (range 7-120). Nine major and 7 minor hepatectomies were performed. There was no postoperative death. The overall 1-, 3-, and 5-year survival rates were 94%, 61%, and 33%, respectively. The median survival rate was 42 months. Univariate analysis revealed that hormone receptor status, number of metastases, a major hepatectomy, and a younger age were associated with a poorer prognosis. The survival rate was not influenced by the disease-free interval, grade or stage of breast cancer, or intraoperative blood transfusions. The number of liver metastases was identified as a significant independent factor of survival according to the Cox proportional hazard model (P = 0.04).

CONCLUSIONS

Liver resection, when done in combination with adjuvant therapy, can improve the prognosis of selected patients with BCLM.

Histopathologic factors significantly associated with initial organ-specific metastasis by invasive ductal carcinoma of the breast: a prospective study

The purpose of this study was to identify histologic factors significantly associated with initial organ-specific metastasis by 1044 invasive ductal carcinomas (IDCs) of the breast with and without adjuvant therapy, separately, according to nodal status and pathologic TNM stage status. The following histologic factors were prospectively analyzed by multivariate analyses for distant organ metastasis and bone metastasis in patients with IDC who did not receive adjuvant therapy, and for distant organ metastasis, bone metastasis, liver metastasis, and lung metastasis in patients with IDC who received adjuvant therapy: (1) invasive tumor size, (2) histologic grade, (3) tumor necrosis, (4) fibrotic focus (FF), (5) lymphatic invasion, (6) blood vessel invasion, (7) adipose tissue invasion, (8) skin invasion, (9) muscle invasion, (10) age, (11) estrogen (ER)/progesterone (PR) status, and (12) nodal status. The results showed that FF diameter greater than 8 mm and FF fibrosis grade 1 were the factors that most accurately predicted distant organ metastasis and bone metastasis in patients with IDC who did not receive adjuvant therapy. In patients with IDC who received adjuvant therapy, FF diameter greater than 8 mm was the factor that most accurately predicted bone metastasis, and the presence of tumor necrosis and ER-/PR- were very important predictive factors for metastasis to the lung. Ten or more nodal metastases (N3) were the factor that most accurately predicted liver metastasis. Based on these findings, FF characteristics can be concluded to be the most important histologic factors for predicting metastasis to the bone, the presence of tumor necrosis and ER-/PR- for predicting metastasis to the lung, and N3 for predicting metastasis to the liver.

Cyberknife radiosurgery for breast cancer spine metastases: a matched-pair analysis

BACKGROUND

There are few options for breast cancer patients with spinal metastases recurrent within a previous radiation treatment field. CyberKnife radiosurgery has been used in our institution to treat such patients. To evaluate their outcomes, as there are no comparable radiation treatment options, the outcomes were compared between 18 patients with spinal metastases from breast cancer treated with CyberKnife stereotactic radiosurgery, 17 of which had prior radiotherapy to the involved spinal region and were progressing, and 18 matched patients who received conventional external beam radiotherapy (CRT) up-front for spinal metastases.

METHODS

Radiosurgery was delivered in 3 to 5 fractions to doses ranging from 2100 to 2800 cGy. Women were matched to patients in a CRT group with respect to time from original diagnosis to diagnosis of metastases, estrogen receptor / progesterone receptor (ER/PR) status, presence or absence of visceral metastases, prior radiotherapy, and prior chemotherapy. Survival and complications were compared between treatment groups. Surviving patients were followed out to 24 months.

RESULTS

The CyberKnife and CRT groups were comparable along all matching dimensions and in performance status before treatment. Outcomes of treatment were similar for patients in both groups; ambulation, performance status, and pain worsened similarly across groups posttreatment. Survival and the number of complications appeared to favor the CyberKnife group, but the differences did not reach statistical significance.

CONCLUSIONS

The statistical comparability of the CyberKnife and CRT groups reflects the small sample size and stringent requirements for significance of the matched-pair analysis. Nevertheless, comparability in these difficult cases shows that salvage CyberKnife treatment is as efficacious as initial CRT without added toxicity.

Opinion: emerging mechanisms of tumour lymphangiogenesis and lymphatic metastasis

Malignant tumours can spread to lymph nodes through lymphatic vessels. Recent studies show that tumours produce a range of growth factors that directly or indirectly stimulate lymphatic vessel growth (lymphangiogenesis) and lymphatic metastasis. These findings indicate that tumour lymphangiogenesis, similar to haemangiogenesis, is a complex process that is regulated by multiple growth factors. Understanding the underlying mechanisms by which tumours induce lymphangiogenesis might provide important information for the therapeutic intervention of metastatic spread.