Risk factors for local recurrence after breast-conserving therapy for invasive carcinomas: a case-control study of histological factors and alterations in oncogene expression

Role of gene signatures combined with pathology in classification of oropharynx head and neck cancer

Treatment personalisation remains an unmet need in oropharynx cancer (OPC). We aimed to determine whether gene expression signatures improved upon clinico-pathological predictors of outcome in OPC. The clinico-pathological predictors, AJCC version 7 (AJCC 7), AJCC 8, and a clinical algorithm, were assessed in 4 public series of OPC (n = 235). Literature review identified 16 mRNA gene expression signatures of radiosensitivity, HPV status, tumour hypoxia, and microsatellite instability. We quality tested signatures using a novel sigQC methodology, and added signatures to clinico-pathological variables as predictors of survival, in univariate and multivariate analyses. AJCC 7 Stage was not predictive of recurrence-free survival (RFS) or overall survival (OS). AJCC 8 significantly predicted RFS and OS. Gene signature quality was highly variable. Among HPV-positive cases, signatures for radiosensitivity, hypoxia, and microsatellite instability revealed significant underlying inter-tumour biological heterogeneity, but did not show prognostic significance when adjusted for clinical covariates. Surprisingly, among HPV-negative cases, a gene signature for HPV status was predictive of survival, even after adjustment for clinical covariates. Across the whole series, several gene signatures representing HPV and microsatellite instability remained significant in multivariate analysis. However, quality control and independent validation remain to be performed to add prognostic information above recently improved clinico-pathological variables.

Molecular Subtypes and Local-Regional Control of Breast Cancer

In the era of personalized medicine, there has been significant progress regarding the molecular analysis of breast cancer subtypes. Research efforts have focused on how classification of subtypes could provide information on prognosis and influence treatment planning. Although much is known about the impact of different molecular subtypes on disease-specific survival, more recent studies have investigated the role of the different molecular subtypes on local-regional recurrence. This is an area of active study, and in recent years there has been significant progress. This article describes outcomes among disease subtypes to aid in optimal surgical decision-making to improve local-regional control.

Identification of miRNAs as biomarkers for acquired endocrine resistance in breast cancer

Therapies targeting estrogen receptor α (ERα) including tamoxifen, a selective estrogen receptor modulator (SERM) and aromatase inhibitors (AI), e.g., letrozole, have proven successful in reducing the death rate for breast cancer patients whose initial tumors express ERα. However, about 40% of patients develop acquired resistance to these endocrine treatments. There is a critical need to develop sensitive circulating biomarkers that accurately identify signaling pathways altered in breast cancer patients resistant to endocrine therapies. Serum miRNAs have the potential to serve as biomarkers of the progression of endocrine-resistant breast cancer due to their cancer-specific expression and stability. Exosomal transfer of miRNAs has been implicated in metastasis and endocrine-resistance. This review focuses on miRNAs in breast tumors and in serum, including exosomes, from breast cancer patients that are associated with resistance to tamoxifen since it is best-studied.

How could breast cancer molecular features contribute to locoregional treatment decision making?

Systemic treatments are tailored to breast cancer (BC) heterogeneity, which is not yet taken into account for radiotherapy (RT) personalization. The primary objective of this review is to summarize existing data suggesting BC subtypes and genetic assays are prognostic and predictive biomarkers useful for RT decision-making and to provide implications for their incorporation into future translational and clinical research. The evidence suggesting that BC subtypes also exhibit distinct "locoregional recurrence (LRR)" patterns is retrospective but consistent and validated in over fifteen studies. The HER-2 positive and triple negative subtypes are the most susceptible to locoregional failure. The high risk of the HER-2 positive subtype can be reversed with trastuzumab administration. Very little is known on the subtypes' intrinsic radiosensitivity properties. Genetic assays have assessed retrospectively signatures' prognostic and predictive value in patients' cohorts (several coming from prospective studies) for LRR risk and radiotherapy (RT) benefit. Further confirmation is needed before their introduction into clinical routine. Evidence on the use of molecular biomarkers for adjuvant RT tailoring is emerging but needs validation and introduction into prospective studies. The plethora of modern RT options (partial breast irradiation, hypofractionation), as well as recent evidence pointing towards more extensive radiotherapy, demand introduction of biological features into clinical trials to improve therapeutic decisions. Open questions, such as tailoring of irradiation after neo-adjuvant chemotherapy in complete responders and the understanding of the interplay between local control, systemic recurrence and survival given modern systemic treatments, need to be addressed under the prism of biology within this heterogeneous disease. Intrinsic radiobiological properties within this heterogeneity need to be highlighted in order to further improve outcomes.

MicroRNA-Related DNA Repair/Cell-Cycle Genes Independently Associated With Relapse After Radiation Therapy for Early Breast Cancer

PURPOSE

Local recurrence and distant failure after adjuvant radiation therapy for breast cancer remain significant clinical problems, incompletely predicted by conventional clinicopathologic markers. We had previously identified microRNA-139-5p and microRNA-1274a as key regulators of breast cancer radiation response in vitro. The purpose of this study was to investigate standard clinicopathologic markers of local recurrence in a contemporary series and to establish whether putative target genes of microRNAs involved in DNA repair and cell cycle control could better predict radiation therapy response in vivo.

METHODS AND MATERIALS

With institutional ethics board approval, local recurrence was measured in a contemporary, prospectively collected series of 458 patients treated with radiation therapy after breast-conserving surgery. Additionally, independent publicly available mRNA/microRNA microarray expression datasets totaling >1000 early-stage breast cancer patients, treated with adjuvant radiation therapy, with >10 years of follow-up, were analyzed. The expression of putative microRNA target biomarkers--TOP2A, POLQ, RAD54L, SKP2, PLK2, and RAG1--were correlated with standard clinicopathologic variables using 2-sided nonparametric tests, and to local/distant relapse and survival using Kaplan-Meier and Cox regression analysis.

RESULTS

We found a low rate of isolated local recurrence (1.95%) in our modern series, and that few clinicopathologic variables (such as lymphovascular invasion) were significantly predictive. In multiple independent datasets (n>1000), however, high expression of RAD54L, TOP2A, POLQ, and SKP2 significantly correlated with local recurrence, survival, or both in univariate and multivariate analyses (P<.001). Low RAG1 expression significantly correlated with local recurrence (multivariate, P=.008). Additionally, RAD54L, SKP2, and PLK2 may be predictive, being prognostic in radiation therapy-treated patients but not in untreated matched control individuals (n=107; P<.05).

CONCLUSIONS

Biomarkers of DNA repair and cell cycle control can identify patients at high risk of treatment failure in those receiving radiation therapy for early breast cancer in independent cohorts. These should be further investigated prospectively, especially TOP2A and SKP2, for which targeted therapies are available.

How to identify patients with increased risk of breast cancer relapse?

A cohort of 362 breast cancer patients had subtype classification accomplished using 4 immunohistochemical markers: luminal A (ER or PR positive, HER2 negative, Ki-67<14%), luminal B (ER or PR positive, HER2 negative, Ki-67≥14%), luminal HER2 (ER or PR positive, HER2 positive), HER2 enriched (ER or PR negative, HER2 positive) or triple negative (ER, PR, and HER2 negative). Multivariable Cox analysis was used to determine the risk of local (LR) or distant (DR) relapse associated with the intrinsic subtypes, adjusting for standard clinicopathologic factors. There have been a total of 124 recurrences. Triple-negative patients were associated with increased risk of LR. Luminal B subtype showed statistical tendency (P=0.053) to LR. For patients undergoing breast conservation surgery, luminal B and HER2-enriched subtypes demonstrated an increased risk to LR, and this was statistically significant on multivariable analysis. After mastectomy, there was no statistical difference between subtypes of LR or DR on multivariable analysis. Luminal A tumors are associated with a low risk of LR or DR. Despite the existence of gene expression profiling, in the current study we demonstrate that analysis of 4 immunohistochemical markers is equally effective and less expensive alternative to identify higher recurrence risk patients.

Over-Expressed Twist Associates with Markers of Epithelial Mesenchymal Transition and Predicts Poor Prognosis in Breast Cancers via ERK and Akt Activation

Overexpression of Twist, a highly conserved basic helix-loop-helix transcription factor, is associated with epithelial-mesenchymal transition (EMT) and predicts poor prognosis in various kinds of cancers, including breast cancer. In order to further clarify Twist's role in breast cancer, we detected Twist expression in breast cancer tissues by immunohistochemistry. Twist expression was observed in 54% (220/408) of breast cancer patients and was positively associated with tumor size, Ki67, VEGF-C and HER2 expression. Conversely, Twist was negatively associated with estrogen receptor (ER), progesterone receptor (PgR) and E-cadherin expression. Patients with Twist expression had a poorer prognosis for 30-month disease free survival (DFS) (82.9%) than patients with negative Twist (92.3%). Overexpression of Twist led to dramatic changes in cellular morphology, proliferation, migratory/invasive capability, and expression of EMT-related biomarkers in breast cancer cells. Moreover, we show that Twist serves as a driver of tumorigenesis, as well as an inducer of EMT, at least in part, through activation of the Akt and extracellular signal-regulated protein kinase (ERK) pathways which are critical for Twist-mediated EMT. Our results demonstrate that Twist expression is an important prognostic factor in breast cancer patients.

Partial breast irradiation: targeting volume or breast molecular subtypes?

The eligibility criteria for partial breast irradiation (APBI) are mainly based on histopathological factors, which not always explain the clinical behaviour of breast cancers. International guidelines represent useful platform to collect data for continued refinement of patient selection, but the clinical applicability to APBI series showed some limitations, particularly among the intermediate and high-risk groups. The heterogeneity of APBI techniques, along with the heterogeneity of breast cancer, generates clinical results, where the predictive value of the histopathological factors can assume different weight. There is a need of further refinement and implementation of risk factors. Currently, the impact of breast cancer subtype on local control is matter of investigation, and treatment decision about radiotherapy is generally made without regard to the breast cancer subtype. However, receptor status information is easily available and some histopathological factors have not a definite role, there is no uniform interpretation. As molecular classification becomes more feasible in the clinical practice, it will provide added value to conventional clinical tumour characteristics in predicting local recurrence in breast cancer and may play an important role as predictor of eventual patient outcomes.

Perioperative measures to optimize margin clearance in breast conserving surgery

Margin status is one of the most important determinants of local recurrence following breast conserving surgery. The fact that up to 60% of patients undergoing breast conserving surgery require re-excision highlights the importance of optimizing margin clearance. In this review we summarize the following perioperative measures that aim to enhance margin clearance: (1) patient risk stratification, specifically risk factors and nomograms, (2) preoperative imaging, (3) intraoperative techniques including wire-guided localization, radioguided surgery, intraoperative ultrasound-guided resection, intraoperative specimen radiography, standardized cavity shaving, and ink-directed focal re-excision; (4) and intraoperative pathology assessment techniques, namely frozen section analysis and imprint cytology. Novel surgical techniques as well as emerging technologies are also reviewed. Effective treatment requires accurate preoperative planning, developing and implementing a consistent definition of margin clearance, and using tools that provide detailed real-time intraoperative information on margin status.

Co-overexpression of GEP100 and AMAP1 proteins correlates with rapid local recurrence after breast conservative therapy

A major problem of current cancer research and therapy is prediction of tumor recurrence after initial treatment, rather than the simple biological characterization of the malignancy and proliferative properties of tumors. Breast conservation therapy (BCT) is a well-approved, standard treatment for patients with early stages of breast cancer, which consists of lumpectomy and whole-breast irradiation. In spite of extensive studies, only 'age' and 'Ki-67 positivity' have been identified to be well correlated with local recurrence after BCT. An Arf6 pathway, activated by GEP100 under receptor tyrosine kinases (RTKs) and employs AMAP1 as its effector, is crucial for invasion and metastasis of some breast cancer cells. This pathway activates β1 integrins and perturbs E-cadherin-based adhesions, hence appears to be integral for epithelial-mesenchymal transdifferentiation (EMT). We here show that expression of the Arf6 pathway components statistically correlates with rapid local recurrence after BCT. We retrospectively analyzed four hundred seventy-nine patients who received BCT in Hokkaido University Hospital, and found 20 patients had local recurrence. We then analyzed pathological samples of patients who experienced local recurrence by use of Kaplan-Meier analysis, Stepwise regression analysis and the t-test, coupled with immunostaining, and found that co-overexpression of GEP100 and AMAP1 correlates with rapidity of the local recurrence. Their margin-status, node-positivity, and estrogen receptor (ER)- or progesterone receptor (PgR)-positivity did not correlated with the rapidity. This study is the first to show that expression of a certain set of proteins correlates with the rapidity of local recurrence. Our results are useful not only for prediction, but highlight the possibility of developing novel strategies to block local recurrence. We also discuss why mRNAs encoding these proteins have not been identified to correlate with local recurrence by previous conventional gene expression profiling analyses.

Lymphatic space invasion is not an independent predictor of outcomes in early stage breast cancer treated by breast-conserving surgery and radiation

To study the prognostic importance of lymphovascular invasion (LVI) in early stage breast cancer after conservative surgery and radiation. From 2/80 to 8/07, 1,478 patients were treated with breast-conserving surgery and radiation with or without systemic therapy. Study eligibility included breast conservation, whole breast postoperative radiation, T1-T2 disease, and known LVI status. Endpoints were 5- and 10-year actuarial outcomes for local control and survival. LVI was present in 427 patients and absent in 1,051 patients. Median follow-up was 68 and 69 months, respectively. Patients with LVI had a younger median age, were more often pre- or perimenopausal, T2, physically palpable, invasive ductal, node positive, grade 3, and treated with chemotherapy compared with patients without LVI. The 5- and 10-year local-regional recurrence was 4.5% and 9.6% with LVI compared with 1.6% and 5.6% without LVI (p = 0.01). The 5- and 10-year overall survival was 83% and 68% for LVI and 91% and 80% for no LVI, respectively (p < 0.0001). Multivariate analysis showed that LVI was not an independent predictor of local-regional control (p = 0.0697) or survival (p = 0.1184). LVI in breast cancer is found in association with other worse prognostic factors for outcome, is associated with a modest increase in local-regional recurrence, but is not an independent predictor of local-regional recurrence or survival on multivariate analysis.

Predictive factors for local recurrence in breast cancer

Risk factors for local recurrence in breast cancer after breast conserving therapy (BCT) differ from those for local recurrence after mastectomy. To better guide optimal treatment of individual patients, it is desirable to identify patients at high risk for local recurrence. Several clinical and histopathologic factors, such as young age and presence of ductal carcinoma in situ, are known to be predictors for local recurrence after BCT. After mastectomy, lymph node status and tumor size are dominant risk factors for local recurrence. The results of recent expression profiling studies have explained differences in prognosis and risk for local recurrence and also explained response to different therapies (adjuvant systemic therapy and radiotherapy). Because of the variation in different subtypes of breast cancer and the difference in amount of tumor burden remaining after surgery, finding robust predictive profiles is complex. In this review, we describe the predictive and prognostic factors for local recurrence after mastectomy and BCT and also describe the role of radiosensitivity in local recurrence.

Age of 40 years or younger is an independent risk factor for locoregional failure in early breast cancer: a single-institutional analysis in saudi arabia

Background. This study was undertaken to evaluate the impact of prognostic factors on the locoregional failure-free survival of early breast cancer patients. Methods. In this single-institutional study, 213 breast cancer patients were retrospectively analysed. Fifty-five of 213 patients were ≤40 years of age at diagnosis. The impact of patient- or treatment-related factors on the locoregional failure-free survival was assessed using the Kaplan-Meier method. The simultaneous impact of factors on the locoregional failure-free survival was assessed using the Cox proportional hazards regression analysis. Results. The median follow-up time of the censored patients was 22 months (mean 28 months, range 3-92 months). On univariate analysis, statistically significant factors for the locoregional failure-free survival were the age (≤40 versus >40 years), T stage (Tis, T0-2 versus T3-4), molecular tumor type (luminal A versus luminal B, Her2neu overexpression, or triple negative), and lymphovascular status (LV0 versus LV1). On multivariate analysis, age and T stage remained statistically significant. Conclusions. Being 40 years or younger has a statistically significant independent adverse impact on the locoregional failure-free survival of patients with early breast cancer.

Prognosis for Survival of Young Women with Breast Cancer by Quantitative p53 Immunohistochemistry

p53 protein detected immunohistochemically has not been accepted as a biomarker for breast cancer patients because of disparate reports of the relationship between the amount of p53 protein detected and patient survival. The purpose of this study was to determine experimental conditions and methods of data analysis for which p53 stain intensity could be prognostic for survival of young breast cancer patients. A tissue microarray of specimens from 93 patients was stained with anti-p53 antibody, and stain intensity measured with a computer-aided image analysis system. A cut-point at one standard deviation below the mean of the distribution of p53 stain intensity separated patients into two groups with significantly different survival. These results were confirmed by Quantitative Nuclear Grade determined by DNA-specific Feulgen staining. P53 provided information beyond ER and PR status. Therefore, under the conditions reported here, p53 protein can be an effective prognostic factor for young breast cancer patients.

ARTEMIN synergizes with TWIST1 to promote metastasis and poor survival outcome in patients with ER negative mammary carcinoma

Introduction

ARTEMIN (ARTN) is an estrogen regulated growth factor, the expression of which promotes resistance to antiestrogen therapies and predicts poorer survival outcome of patients with estrogen receptor (ER) positive mammary carcinoma (ER+MC) treated with tamoxifen. ARTN is also expressed in ER negative mammary carcinoma (ER-MC). Herein, we determined the role of ARTN in ER-MC and defined the mechanism of action producing poor patient prognosis.

Methods

We modulated the expression of ARTN in two ER- (mesenchymal/claudin-low) mammary carcinoma cell lines (BT549 and MDA-MB-231) by forced expression or small interfering RNA (siRNA) mediated depletion. The effects of modulation of ARTN expression were examined by various in vitro measures of oncogenicity, including the expression of TWIST1 messenger RNA (mRNA) and protein. In vitro results were correlated to xenograft studies in immunodeficient mice. Co-expression of ARTN and TWIST1 and their association to poor survival outcome were examined in a cohort of patients with ER-MC. Pathway analysis was performed by pharmacological inhibition of phosphorylation of AKT (pAKT-Ser 473) or modulation of TWIST1 expression.

Results

ARTN expression resulted in ER-MC cells with enhanced mesenchymal characteristics, including increased invasion and a gene expression profile consistent with enhanced mesenchymal phenotype. ARTN stimulated ER-MC cell anchorage independent and 3D matrigel growth, endothelial cell adhesion and transmigration of ER-MC cells through an endothelial cell barrier. Forced expression of ARTN produced a larger, locally invasive tumour mass with tumour emboli that produced distant metastasis. ARTN regulated TWIST1 expression in ER-MC cells and ARTN expression was significantly correlated to TWIST1 expression in a panel of mammary carcinoma cell lines and in a cohort of patients with ER-MC. Low expression of both ARTN and TWIST1 predicted 100% relapse free and overall survival in patients with ER-MC, whereas high expression of both ARTN and TWIST1 was associated with a poor survival outcome. ARTN stimulated an increase in TWIST1 expression via increased AKT activity. siRNA mediated depletion of TWIST1 abrogated ARTN stimulated cellular behaviour associated with metastasis, and forced expression of TWIST1 abrogated the functional effects of ARTN depletion.

Conclusions

ARTN and TWIST1 synergize to produce a worse outcome in ER-MC and combined inhibition of ARTN and phosphatidylinositol 3-kinase/protein kinase B (PI3K/AKT) may therefore provide a novel therapeutic strategy in this subtype of mammary carcinoma.

Impact of established prognostic factors and molecular subtype in very young breast cancer patients: pooled analysis of four EORTC randomized controlled trials

Introduction

Young age at the time of diagnosis of breast cancer is an independent factor of poor prognosis. In many treatment guidelines, the recommendation is to treat young patients with adjuvant chemotherapy regardless of tumor characteristics. However, limited data on prognostic factors are available for young breast cancer patients. The purpose of this study was to determine the prognostic value of established clinical and pathological prognostic factors in young breast cancer patients.

Methods

Data from four European Organisation for Research and Treatment of Cancer (EORTC) clinical trials were pooled, resulting in a dataset consisting of 9,938 early breast cancer patients with a median follow-up of 11 years. For 549 patients aged less than 40 years at the time of diagnosis, including 341 node negative patients who did not receive chemotherapy, paraffin tumor blocks were processed for immunohistochemistry using a tissue microarray. Cox proportional hazard analysis was applied to assess the association of clinical and pathological factors with overall and distant metastasis free survival.

Results

For young patients, tumor size (P = 0.01), nodal status (P = 0.006) and molecular subtype (P = 0.02) were independent prognostic factors for overall survival. In the node negative subgroup, only molecular subtype was a prognostic factor for overall survival (P = 0.02). Young node negative patients bearing luminal A tumors had an overall survival rate of 94% at 10 years' follow-up compared to 72% for patients with basal-type tumors.

Conclusions

Molecular subtype is a strong independent prognostic factor in breast cancer patients younger than 40 years of age. These data support the use of established prognostic factors as a diagnostic tool to assess disease outcome and to plan systemic treatment strategies in young breast cancer patients.

Breast cancer subtypes and the risk of local and regional relapse

PURPOSE

The risk of local and regional relapse associated with each breast cancer molecular subtype was determined in a large cohort of patients with breast cancer. Subtype assignment was accomplished using a validated six-marker immunohistochemical panel applied to tissue microarrays.

PATIENTS AND METHODS

Semiquantitative analysis of estrogen receptor (ER), progesterone receptor (PR), Ki-67, human epidermal growth factor receptor 2 (HER2), epidermal growth factor receptor (EGFR), and cytokeratin (CK) 5/6 was performed on tissue microarrays constructed from 2,985 patients with early invasive breast cancer. Patients were classified into the following categories: luminal A, luminal B, luminal-HER2, HER2 enriched, basal-like, or triple-negative phenotype-nonbasal. Multivariable Cox analysis was used to determine the risk of local or regional relapse associated the intrinsic subtypes, adjusting for standard clinicopathologic factors.

RESULTS

The intrinsic molecular subtype was successfully determined in 2,985 tumors. The median follow-up time was 12 years, and there have been a total of 325 local recurrences and 227 regional lymph node recurrences. Luminal A tumors (ER or PR positive, HER2 negative, Ki-67 < 1%) had the best prognosis and the lowest rate of local or regional relapse. For patients undergoing breast conservation, HER2-enriched and basal subtypes demonstrated an increased risk of regional recurrence, and this was statistically significant on multivariable analysis. After mastectomy, luminal B, luminal-HER2, HER2-enriched, and basal subtypes were all associated with an increased risk of local and regional relapse on multivariable analysis.

CONCLUSION

Luminal A tumors are associated with a low risk of local or regional recurrence. Molecular subtyping of breast tumors using a six-marker immunohistochemical panel can identify patients at increased risk of local and regional recurrence.

Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence (2009)

PURPOSE

To give recommendations on patient selection criteria for the use of accelerated partial-breast irradiation (APBI) based on available clinical evidence complemented by expert opinion.

METHODS AND MATERIALS

Overall, 340 articles were identified by a systematic search of the PubMed database using the keywords "partial-breast irradiation" and "APBI". This search was complemented by searches of reference lists of articles and handsearching of relevant conference abstracts and book chapters. Of these, 3 randomized and 19 prospective non-randomized studies with a minimum median follow-up time of 4 years were identified. The authors reviewed the published clinical evidence on APBI, complemented by relevant clinical and pathological studies of standard breast-conserving therapy and, through a series of personal communications, formulated the recommendations presented in this article.

RESULTS

The GEC-ESTRO Breast Cancer Working Group recommends three categories guiding patient selection for APBI: (1) a low-risk group for whom APBI outside the context of a clinical trial is an acceptable treatment option; including patients ageing at least 50 years with unicentric, unifocal, pT1-2 (<or=30 mm) pN0, non-lobular invasive breast cancer without the presence of an extensive intraductal component (EIC) and lympho-vascular invasion (LVI) and with negative surgical margins of at least 2mm, (2) a high-risk group, for whom APBI is considered contraindicated; including patients ageing <or=40 years; having positive margins, and/or multicentric or large (>30 mm) tumours, and/or EIC positive or LVI positive tumours, and/or 4 or more positive lymph nodes or unknown axillary status (pNx), and (3) an intermediate-risk group, for whom APBI is considered acceptable only in the context of prospective clinical trials.

CONCLUSIONS

These recommendations will provide a clinical guidance regarding the use of APBI outside the context of a clinical trial before large-scale randomized clinical trial outcome data become available. Furthermore they should promote further clinical research focusing on controversial issues in the treatment of early-stage breast carcinoma.

Prognostic value of p53 and bcl-2 expression in patients treated with breast conservative therapy

Prognostic value of p53 and bcl-2 expression on treatment outcome in breast cancer patients has been extensively evaluated, but the results were inconclusive. We evaluated the prognostic significance of these molecular markers in patients treated with breast conserving surgery and radiotherapy. One hundred patients whose immunostaining of p53 and bcl-2 expression was available among 125 patients who underwent radiotherapy after breast conserving surgery and axillary lymph node dissection were enrolled into this study. Eighty-seven patients also received adjuvant chemotherapy and/or hormonal therapy. Conventional clinicopathologic variables and treatment-related factors were also considered. The 5-yr loco-regional relapse-free and distant metastasis-free survival rates were 91.7% and 90.9%, respectively. On univariate analysis, age, T stage and the absence of bcl-2 & estrogen receptor (ER) expression were associated with loco-regional relapse-free survival. When incorporating these variables into Cox proportional hazard model, only bcl-2(-)/ER(-) phenotype was an adverse prognostic factor (P=0.018). As for the distant metastasis-free survival, age, T stage, and p53 expression were significant on univariate analysis. However, p53 expression was the only prognosticator on multivariate analysis (P=0.009). A bcl-2(-)/ER(-) phenotype and p53 expression are useful molecular markers predicting loco-regional relapse-free and distant metastasis-free survival, respectively, in patients treated with breast conserving surgery and radiotherapy.

Tumor aromatase expression as a prognostic factor for local control in young breast cancer patients after breast-conserving treatment

Introduction

We sought to determine whether the levels of expression of 17 candidate genes were associated with locoregional control after breast-conserving treatments of early-stage breast cancers in young, premenopausal women.

Methods

Gene expression was measured by using RT-PCR in the breast tumors of a series of 53 young (younger than 40 years), premenopausal patients. All treatments consisted of primary breast-conserving surgery followed by whole-breast radiotherapy (± regional lymph nodes) with or without systemic treatments (chemotherapy ± hormone therapy). The median follow-up was 10 years.

Results

The 10-year locoregional control rate was 70% (95% CI, 57% to 87%). In univariate analysis, no clinical/pathologic prognostic factors were found to be significantly associated with decreased locoregional control. Expression of three genes was found to be significantly associated with an increased locoregional recurrence rate: low estrogen-receptor β, low aromatase, and high GATA3. Two others were associated with only a trend (P < 0.10): low HER1 and SKP2. In multivariate analysis, only the absence of aromatase was significantly associated with an increased locoregional recurrence rate (P = 0.003; relative risk = 0.49; 95% CI 0.29 to 0.82).

Conclusions

Recent data give credit to the fact that breast cancer in young women is a distinct biologic entity driven by special oncogenic pathways. Our results highlight the role of estrogen-signaling pathways (mainly CYP19/aromatase, GATA3, and ER-β) in the risk of locoregional recurrence of breast cancer in young women. Confirmation in larger prospective studies is needed.

Mutation and accumulation of p53 related to results of adjuvant therapy of postmenopausal breast cancer patients

p53 protein accumulation and gene mutation have been implicated in resistance to cytotoxic treatment. This study was performed to further assess the predictive value of p53 in breast cancer. Postmenopausal patients were randomized to adjuvant chemotherapy with cyclophosphamide, metothrexate, or 5-fluorouracil (CMF) vs. postoperative radiotherapy. The patients were also randomized to adjuvant tamoxifen vs. no endocrine treatment. Immunohistochemistry (IHC) and single-strand conformation polymorphism (SSCP), followed by direct sequencing, was performed. The p53 altered group, regarded as positive for p53 gene mutation and/or p53 protein accumulation, tended to benefit more from CMF than from radiotherapy as compared with others regarding distant recurrences. In the group lacking p53 alteration there was a significantly decreased local recurrence rate in the radiotherapy group as compared with the CMF group (RR = 0.24, 95% CI = 0.083 0.62), whereas no benefit from radiotherapy was found for patients showing p53 alterations. Tamoxifen significantly decreased the rate of distant recurrence for estrogen receptor-positive patients with no apparent difference in relation to p53 alteration. It is suggested that p53 alteration indicates benefit from CMF compared with radiotherapy regarding distant recurrence-free survival and the best local control with radiotherapy is achieved in the absence of p53 alteration. Finally, altered p53 status is probably not a marker of resistance to tamoxifen.

Breast conserving treatment in Denmark, 1989-1998. A nationwide population-based study of the Danish Breast Cancer Co-operative Group

BACKGROUND

Randomised studies have shown that breast conserving surgery followed by radiotherapy is associated with a prognosis similar to mastectomy alone. This formed the basis for recommending breast conserving surgery combined with radiotherapy as a standard treatment for suited breast cancer patients in Denmark.

PATIENTS AND METHODS

To evaluate the results of this treatment, we performed a nationwide population-based follow-up study of patients aged less than 75 years treated in Denmark from 1989 to 1998 based on the database of Danish Breast Cancer Cooperative Group.

RESULTS

At 15 years of follow-up, the Kaplan-Meier estimate of overall survival was 69% among 3 758 patients who received the recommended treatment. Within the first 10 years of follow-up, the cumulative incidences of loco-regional recurrences, distant metastases or other malignant disease, or death as a first event were 9.0, 19.9, and 6.0% respectively, when analysed in a competing risk setting. The risk of loco-regional recurrences was significantly decreased in patients aged 50 years or more and increased with increasing tumour size. There was a pronounced beneficial effect of adjuvant radiotherapy with those not receiving radiotherapy having a hazard ratio of 3.52 (95% CI 2.21-5.61). The effect of resection margins was significant for loco-regional recurrences only in node negative patients.

CONCLUSION

In conclusion, the present study shows that results similar to those from randomised clinical trials can be obtained when breast conserving treatment is applied as a standard treatment in an entire population.

Local recurrence after breast-conserving therapy in relation to gene expression patterns in a large series of patients

PURPOSE

The majority of patients with early-stage breast cancer are treated with breast-conserving therapy (BCT). Several clinical risk factors are associated with local recurrence (LR) after BCT but are unable to explain all instances of LR after BCT. Here, gene expression microarrays are used to identify novel risk factors for LR after BCT.

EXPERIMENTAL DESIGN

Gene expression profiles of 56 primary invasive breast carcinomas from patients who developed a LR after BCT were compared with profiles of 109 tumors from patients who did not develop a LR after BCT. Both unsupervised and supervised methods of classification were used to separate patients into groups corresponding to disease outcome. In addition, for 15 patients, the gene expression profile in the recurrence was compared with that of the primary tumor.

RESULTS

The two main clusters found by hierarchical cluster analysis of all 165 primary invasive breast carcinomas revealed no association with LR. Predefined gene sets (molecular subtypes and "chromosomal instability" signature) are associated with LR (P = 0.0002 and 0.003, respectively). Significant analysis of microarrays revealed an association between LR and cell proliferation, not captured by histologic grading. Class prediction analysis constructed a gene classifier, which was successfully validated, cross-platform, on an independent data set of 161 patients (log-rank P = 0.041). In multivariate analysis, young age was the only independent predictor of LR.

CONCLUSIONS

We have constructed and cross-platform validated a gene expression profile predictive for LR after BCT, which is characterized by genes involved in cell proliferation but not a surrogate for high histologic grade.

Current status of treatment for early-stage invasive breast cancer

Az emlőrák a nők leggyakoribb rákos megbetegedése. Évente több mint egymillió nő betegszik meg emlőrákban. Az emlőrákos morbiditás meredeken emelkedett a fejlett ipari országokban az utóbbi pár évtizedben, de a mortalitási ráta mostanában csökken. Az utóbbi a szervezett lakossági szűréseknek, a korszerű sebészi és sugárterápiás beavatkozásoknak és a hatékonyabb szisztémás kezeléseknek köszönhető. A fejlődés egyik legizgalmasabb területe az új terápiás szerek bevezetése a klinikai gyakorlatba. A célzott terápia (tirozinkinázok gátlása) rohamosan fejlődik. Korai (0./I./II. stádium) emlőrákban a daganatot műtéttel eltávolítják, és ezt követi az adjuváns kezelés. Az adjuváns kezelés célja a lokoregionális és távoli mikroszkopikus daganatdepozitok elpusztítása. A daganatos kiújulás kockázatának megbecsülésére prognosztikai faktorokat használunk. Az optimális individualizált kezelés meghatározását a prediktív faktorok segítik. A dolgozatban a korai emlőrák kezelésének jelenlegi helyzetét tárgyaljuk, beleértve az emlőmegtartó kezelést, a mastectomia utáni sugárkezelést, a hormon- és kemoterápiát, valamint a humán epidermális növekedési faktor receptor-2- (HER-2-) pozitív daganatok trastuzumabkezelését.

[Evidence-based radiotherapy in the treatment of early-stage invasive breast cancer: traditional clinical features and biomarkers]

Adjuvant radiotherapy after modified radical mastectomy and breast-conserving surgery for early-stage invasive breast cancer substantially reduces the risk of locoregional failure and is evidence-based. Using traditional clinical and pathological factors, patients can be classified into subgroups by the risk of locoregional recurrence. In the high-risk groups the absolute benefit of irradiation is larger. However, the patients are over-treated in every subgroup. Substantial proportion of the patients remains free of locoregional recurrence even in the absence of irradiation, and some patients develop locoregional recurrence despite postoperative irradiation. Molecular markers may provide sufficient information to allow accurate individual risk assessment to identify patients who might benefit from irradiation. Despite of hundreds of reports on tumor markers, results are controversial and the number of validated markers for clinical practice is small. Prognostic and predictive factors commonly used in radiotherapy practice are ER, PgR and HER-2. Adjuvant radiotherapy not only reduces locoregional recurrence rates but also improves cancer-specific survival in patients receiving systemic therapy. The highest mortality reduction is observed in mastectomy patients with good prognostic factors (<4 positive nodes, tumor size <2 cm, Grade 1 malignancy, ER- and PgR-positive, HER-2-negative). After mastectomy the chest wall, and after breast conserving surgery the ipsilateral breast are the sites at greatest risk of recurrence. The risk of axillary recurrence is low in patients undergoing axillary dissection. Axillary and supraclavicular recurrences generally forecast a grim prognosis, and they are indicators of distant dissemination. Improvement in survival resulting from the use of irradiation is more related to the prevention of local recurrences. Post-irradiation local recurrence increases the risk of mortality, but with good prognostic factors the 10-year survival is 80-90%. Patients with </=2 cm ipsilateral breast recurrence might receive a second conservative surgery. The radiation dose to the lung and heart can be significantly reduced by individualized CT-based treatment planning. The rate of Grade 3 atrophic dermatitis and fibrosis is 3-4%. The estimated incidence of ipsilateral breast angiosarcoma is less than 0.2%, but the mortality rate is high.

Continuing risk of ipsilateral breast relapse after breast-conserving therapy at long-term follow-up

PURPOSE

Currently, the local treatment of most patients with early invasive breast cancer consists of breast-conserving therapy (BCT). We have previously reported on the risk factors for ipsilateral breast relapse (IBR) in 1,026 patients treated with BCT after a median follow-up of 5.5 years. In the present study, we evaluated the IBR incidence and the risk factors for IBR after prolonged follow-up.

METHODS AND MATERIALS

We updated the disease outcome for all 1,026 patients using the clinical information collected from the medical registration of The Netherlands Cancer Institute and performed step-wise proportional hazard Cox regression analysis to identify the risk factors associated with an increased risk of IBR after BCT at long-term follow-up.

RESULTS

After a median follow-up of 13.3 years, 114 patients had developed an IBR as the first event. The IBR rate was 9.3% and 13.8%, respectively, at 10 and 15 years. Also, the increase in IBR was continuous without reaching a plateau, even after 15 years. Univariate analysis showed that involved surgical resection margins, young age, vascular invasion, and the presence and quantity of an in situ component are risk factors for IBR. Multivariate analysis showed that tumor-positive surgical resection margins (hazard ratio, 2.9; 95% confidence interval, 1.7-5.2, p = 0.0002) or the presence of vascular invasion (hazard ratio, 2.0; 95% confidence interval, 1.2-3.2, p = 0.004) is the major independent risk factor for IBR.

CONCLUSIONS

The data from long-term follow-up showed a constant increase in IBR among patients treated by BCT, even after 15 years, without reaching a plateau. Involved surgical resection margins and vascular invasion were the most important risk factors for IBR.

High-resolution mapping of DNA breakpoints to define true recurrences among ipsilateral breast cancers

BACKGROUND

To distinguish new primary breast cancers from true recurrences, pangenomic analyses of DNA copy number alterations (CNAs) using single-nucleotide polymorphism arrays have proven useful.

METHODS

The pangenomic profiles of 22 pairs of primary breast carcinoma (ductal or lobular) and ipsilateral breast cancers from the same patients were analyzed. Hierarchical clustering was performed using CNAs and DNA breakpoint information. A partial identity score developed using DNA breakpoint information was used to quantify partial identities between two tumors. The nature of ipsilateral breast cancers (true recurrence vs new primary tumor) as defined using the clustering methods and the partial identity score was compared with that based on clinical characteristics. Metastasis-free survival was compared among patients with primary tumors and true recurrences as defined using the partial identity score and by clinical characteristics. All statistical tests were two-sided.

RESULTS

All methods agreed on the nature of ipsilateral breast cancers for 14 pairs of samples. For five pairs, the clinical definition disagreed with both clustering methods. For three pairs, the two clustering methods were discordant and the one using DNA breakpoints agreed with the clinical definition. The partial identity score confirmed the nature of ipsilateral breast cancers as defined by clustering of DNA breakpoints in 21 of 22 pairs. The difference in metastasis-free survival of patients with new primary tumors and those with true recurrences was not statistically significant when tumors were defined based on clinical and histologic characteristics (5-year metastasis-free survival: 76%, 95% confidence interval [CI] = 52% to 100% for new primary tumors and 38%, 95% CI = 17% to 83% for true recurrences; P = .18; new primary tumor vs true recurrence, hazard ratio = 2.8, 95% CI = 0.6 to 13.7), but the difference was statistically significant when tumors were defined using the partial identity score (5-year metastasis-free survival: 100% for new primary tumors and 29%, 95% CI = 11% to 78% for true recurrences; P = .01).

CONCLUSIONS

DNA breakpoint information more often agreed with the clinical determination than CNAs in this population. The partial identity score, which was calculated based on DNA breakpoints, allows statistical discrimination between new primary tumors and true recurrences that could outperform the clinical determination in terms of prognosis.

Age remains the first prognostic factor for loco-regional breast cancer recurrence in young (<40 years) women treated with breast conserving surgery first

PURPOSE

To ascertain the loco-regional recurrence (LRR) rate and its major prognostic factors in patients younger than 40 and to determine the influence of age on the features of breast cancer and its treatment in two age groups: 35 years and [36-39] years.

METHODS AND MATERIALS

Between 1985 and 1995, 209 premenopausal women, younger than 40, were treated for early breast cancers with primary breast conserving surgery followed by radiotherapy+/-chemotherapy. Median age was 37 years with 66 patients (32%) 35 years and 143 older (68%). Median follow-up was 12 years. Tumours' characteristics were: cT1 in 75%, pN0 in 60%.

RESULTS

LRR rate was 38% at 10 years, contralateral breast cancer rate 12%. Age was the only prognostic factor for LRR. The relative risk of LRR increased by 7% for every decreasing year of age. The annual risk of local recurrence peaked between 2 and 3 years after the initial diagnosis and returned to the level of contra-lateral breast cancer at 10 years. The younger population had infiltrating carcinomas that were significantly more commonly ductal, less commonly lobular, and of higher grade - they received chemotherapy more often.

CONCLUSION

Using conventional methods we could find no explanation as to why age remained the most important prognostic factor for breast cancer LRR. Known prognostic factors such as involved surgical margins seemed erased by adequate radiotherapy doses.

Predicting a local recurrence after breast-conserving therapy by gene expression profiling

Introduction

To tailor local treatment in breast cancer patients there is a need for predicting ipsilateral recurrences after breast-conserving therapy. After adequate treatment (excision with free margins and radiotherapy), young age and incompletely excised extensive intraductal component are predictors for local recurrence, but many local recurrences can still not be predicted. Here we have used gene expression profiling by microarray analysis to identify gene expression profiles that can help to predict local recurrence in individual patients.

Methods

By using previously established gene expression profiles with proven value in predicting metastasis-free and overall survival (wound-response signature, 70-gene prognosis profile and hypoxia-induced profile) and training towards an optimal prediction of local recurrences in a training series, we establish a classifier for local recurrence after breast-conserving therapy.

Results

Validation of the different gene lists shows that the wound-response signature is able to separate patients with a high (29%) or low (5%) risk of a local recurrence at 10 years (sensitivity 87.5%, specificity 75%). In multivariable analysis the classifier is an independent predictor for local recurrence.

Conclusion

Our findings indicate that gene expression profiling can identify subgroups of patients at increased risk of developing a local recurrence after breast-conserving therapy.

Gene Expression Profiles of Primary Breast Carcinomas from Patients at High Risk for Local Recurrence after Breast-Conserving Therapy

PURPOSE

Several risk factors for local recurrence of breast cancer after breast-conserving therapy (BCT) have been identified. The identification of additional risk factors would be very useful in guiding optimal therapy and also in improving understanding of the mechanisms underlying local recurrence. We used cDNA microarray analysis to identify gene expression profiles associated with local recurrence.

EXPERIMENTAL DESIGN

Using 18K cDNA microarrays, gene expression profiles were obtained from 50 patients who underwent BCT. Of these 50 patients, 19 developed a local recurrence; the remaining 31 patients were selected as controls as they were free of local recurrence at least 11 years after treatment. For 9 of 19 patients, the local recurrence was also available for gene expression profiling. Unsupervised and supervised methods of classification were used to separate patients in groups corresponding to disease outcome and to study the overall gene expression pattern of primary tumors and their recurrences.

RESULTS

Hierarchical clustering of patients did not show any grouping reflecting local recurrence status. Supervised analysis revealed no significant set of genes that was able to distinguish recurring tumors from nonrecurring tumors. Paired-data analysis of primary tumors and local recurrences showed a remarkable similarity in gene expression profile between primary tumors and their recurrences.

CONCLUSIONS

No significant differences in gene expression between primary breast cancer tumors in patients with or without local recurrence after BCT were identified. Furthermore, analyses of primary tumors and local recurrences show a preservation of the overall gene expression pattern in the local recurrence, even after radiotherapy.

Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in five National Surgical Adjuvant Breast and Bowel Project node-positive adjuvant breast cancer trials

PURPOSE

Locoregional failure after breast-conserving surgery is associated with increased risk of distant disease and death. The magnitude of this risk in patients receiving chemotherapy has not been adequately characterized.

PATIENTS AND METHODS

Our study population included 2,669 women randomly assigned onto five National Surgical Adjuvant Breast and Bowel Project node-positive protocols (B-15, B-16, B-18, B-22, and B-25), who were treated with lumpectomy, whole-breast irradiation, and adjuvant systemic therapy. Cumulative incidences of ipsilateral breast tumor recurrence (IBTR) and other locoregional recurrence (oLRR) were calculated. Kaplan-Meier curves were used to estimate distant-disease-free survival (DDFS) and overall survival (OS) after IBTR or oLRR. Cox models were used to model survival using clinical and pathologic factors jointly with IBTR or oLRR as time-varying predictors.

RESULTS

Four hundred twenty-four patients (15.9%) experienced locoregional failure; 259 (9.7%) experienced IBTR, and 165 (6.2%) experienced oLRR. The 10-year cumulative incidence of IBTR and oLRR was 8.7% and 6.0%, respectively. Most locoregional failures occurred within 5 years (62.2% for IBTR and 80.6% for oLRR). Age, tumor size, and estrogen receptor status were significantly associated with IBTR. Nodal status and estrogen and progesterone receptor status were significantly associated with oLRR. The 5-year DDFS rates after IBTR and oLRR were 51.4% and 18.8%, respectively. The 5-year OS rates after IBTR and oLRR were 59.9% and 24.1%, respectively. Hazard ratios for mortality associated with IBTR and oLRR were 2.58 (95% CI, 2.11 to 3.15) and 5.85 (95% CI, 4.80 to 7.13), respectively.

CONCLUSION

Node-positive breast cancer patients who developed IBTR or oLRR had significantly poorer prognoses than patients who did not experience these events.

Influence of the time between surgery and radiotherapy on local recurrence in patients with lymph node-positive, early-stage, invasive breast carcinoma undergoing breast-conserving surgery: results of the French Adjuvant Study Group

BACKGROUND

Radiotherapy (RT) after breast-conserving surgery (BCS) has produced significant reductions in ipsilateral breast carcinoma (BC) recurrence. It was shown previously that a delay in the initiation of RT resulted in a higher local recurrence (LR) rate. In the current retrospective analysis, the authors investigated whether the RT-adjuvant therapy sequence modified local-disease-free survival (L-DFS) after BCS in patients with early-stage, lymph node-positive BC.

METHODS

Among 7 French Adjuvant Study Group trials, 1831 patients were assessable, including 475 patients who received RT directly after BCS (95 patients received no adjuvant therapy, and 380 patients received hormone therapy), 567 patients who received RT after the third chemotherapy (CT) cycle (250 patients received 1-3 courses, and 317 patients received 4-6 courses), and 789 patients received RT after the sixth CT cycle. In the 1356 patients who received CT, the regimens consisted of fluorouracil 500 mg/m(2); epirubicin 50 mg/m(2), 75 mg/m(2), or 100 mg/m(2); and cyclophosphamide 500 mg/m(2) in 83.5% of patients.

RESULTS

After a median follow-up of 102 months, 214 patients (11.7%) developed LR. The 9-year L-DFS rates were 92.0%, 81.5%, and 87.4%, respectively (P < 0.0001). It was worse in patients who received 1-3 CT cycles (P = 0.02). Patients who received hormone therapy were less likely to develop LR (P = 0.02). In the multivariate analysis, the timing of RT was not associated with a higher rate of LR, whereas tumor size > 2 cm and no hormone therapy were prognostic factors.

CONCLUSIONS

In the study population, there was no increase in the risk of LR when RT was delayed to deliver adjuvant CT. Prognostic factors were tumor size, and hormone therapy. The number of CT courses could modified this risk.

The use of Bcl-2 and PTHLH immunohistochemistry in the diagnosis of peripheral chondrosarcoma in a clinicopathological setting

Distinguishing osteochondroma from low-grade secondary peripheral chondrosarcoma can be difficult. In osteochondroma, growth-signalling pathways are thought to be downregulated through exostosin (EXT) inactivation. A previous pilot study focusing on expression of putative EXT downstream effectors indicated that progression of osteochondroma towards grade I chondrosarcoma was characterised by upregulation of Bcl-2 and parathyroid hormone-like hormone (PTHLH). We investigated their use as diagnostic markers in a large nationwide series of 71 osteochondromas and 34 chondrosarcomas. Bcl-2 immunohistochemistry proved to be a valuable diagnostic tool: scoring negative in 95% (specificity) of the osteochondromas and positive in 57% (sensitivity) of the chondrosarcomas, reaching a positive predictive value of 84% and negative predictive value of 82%. Positivity was not related to age, hereditary status, gender or thickness of the cartilage cap. Presence of internal controls and verification using mRNA in situ hybridisation strengthened the reliability of the immunohistochemical staining. PTHLH showed more variable staining, being positive in osteochondromas from females or adolescent males, suggesting age- and gender-dependent expression. Thus, in cases where the distinction between osteochondroma and chondrosarcoma is difficult, Bcl-2 is a valuable diagnostic marker for malignancy, regardless of tumour size, patient gender or age, and this can be extended with PTHLH for non-adolescent male patients.

Bases génétiques de la radiosensibilité des cancers du sein

Local-regional radiation therapy is one of the major therapeutic means in the management of breast cancer. Three questions however arise from the important advances achieved in this domain in the past years. The first question concerns the possibilities to identify and overcome the radioresistance of a subset of tumours. The second question is how to recognize women likely to benefit from adjuvant radiation therapy, and therefore to diminish treatment indications in other groups. Finally, the third question is how to identify subjects at high risk for long term injury following breast irradiation, in order to adapt techniques and indications in such populations. The major advances of breast cancer molecular genetics in the past years should provide clinicians with tools to answer these important questions. In this paper, we review the molecular germline (BRCA1, BRCA2, ATM, ...) and somatic (p53, tyrosine kinase receptors, as well as actors of cell cycle, signal transduction, apoptosis, DNA repair ...) main bases of breast cancer radiosensitivity. Recent methods of exploration of the genetic background of both the host and the tumours (gene and protein expression profiles) are also reviewed as major tools of breast cancer management in the next few years.

Effect of breast-conserving therapy versus radical mastectomy on prognosis for young women with breast carcinoma

BACKGROUND

Among middle-aged and older women with early breast carcinoma, breast-conserving therapy (BCT) has been shown to have an effect on survival that is similar to that of modified radical mastectomy (RM). Nonetheless, it remains to be established whether BCT also is the optimal treatment option for early breast carcinoma in young women, because these women generally have more aggressive disease and a higher frequency of local recurrence compared with older women.

METHODS

We investigated a cohort of 9285 premenopausal women with primary breast carcinoma who were age < 50 years at diagnosis. These women were identified from a population-based Danish breast carcinoma database containing detailed information on patient and tumor characteristics, predetermined treatment regimens, and survival.

RESULTS

In total, 7165 patients (77.2%) were treated with RM, and 2120 patients (22.8%) were treated with BCT. We calculated the relative risk of death within the first 10 years after diagnosis according to surgical treatment and age, both before and after adjustment for known prognostic factors. No increased risk of death was observed among women who received BCT compared with women who underwent RM, regardless of age at diagnosis (< 35 years, 35-39 years, 40-44 years, or 45-49 years), despite the increased risk of local recurrence among young women. Restricting the analysis to women with small tumors (size < 2 cm) yielded similar results.

CONCLUSIONS

Despite having a higher rate of local recurrence, young women with breast carcinoma who receive BCT are similar to young women treated with RM in terms of survival.

Conservative surgery in breast cancer. Significance of resection margins

We approached the issue of surgical margins in the conservative treatment of breast cancer by examining the literature germane to four precise questions: At what distance from the macroscopic margin of the tumour should the resection margin be? To what extent do histologically clear resection margins indicate complete local control of the disease? To what extent do histologically involved margins indicate persistence of disease? and Does the local recurrence rate correlate with the status of the resection margin? We propose categorizing margin involvement into five groups (absent, focal, minimal, moderate and extensive involvement) according to strict histological criteria, and assigning increasingly aggressive subsequent treatments according to the extent of any margin involvement.

Size of invasive breast cancer and risk of local recurrence after breast-conservation therapy

Risk of local recurrence is one important factor that determines a woman's suitability for breast-conservation therapy. With the evolution of oncoplastic surgery, tumours of a size that traditionally require mastectomy may be treated by breast conservation and partial breast reconstruction. This article reviews the evidence relating to tumour size as a risk factor for local recurrence to assess whether this change in practice is appropriate. A literature review through Medline and Pubmed was performed. All pathological studies analysing tumour size as a predictor of multifocality and all randomised trials and large case series of breast conservation including tumours larger than 2 cm were reviewed and critically interpreted. Pathological studies report consistent evidence that tumour size is not predictive of multifocality. Randomised trials and clinical series of breast conservation report conflicting evidence relating to tumour size as a risk factor for local recurrence, although most studies report no association. Evidence relating to cancers over 3 cm is limited. There is little evidence to justify the use of tumour size alone as an exclusion criterion for breast-conservation therapy. A registration study of patients with cancers larger than 3 cm treated by breast conservation with or without partial breast reconstruction is proposed.

Molecular markers in clinical radiation oncology

Radiation therapy plays a critical role in the management of a majority of patients diagnosed with cancer. Identification of factors that help predict which patients are at risk for relapse within the irradiated field remains an active area of investigation. Although conventional clinical and pathologic factors have been helpful in identifying risk and guiding clinical decision-making for both local and systemic management, there is clearly a need to identify additional prognostic markers, which can aid in refining our treatment strategies and improving outcomes. A substantial amount of research efforts have been devoted to identifying molecular markers for prognostic and therapeutic strategies. The recent emergence of a powerful armamentarium of molecular tools has resulted in rapid expansion of our fund of knowledge and understanding of the molecular biology underlying tumor behavior and response. While a majority of these efforts have been focused on risk factors for metastatic disease and survival, there is a rapidly growing body of literature focused on molecular factors associated with radiation resistance and locoregional failure. In this review, we summarize recent advances and the available literature evaluating molecular markers as they relate to radiation sensitivity of solid tumors. Literature regarding the potential application of expression of genes related to apoptosis, angiogenesis, cell cycle, DNA repair and growth factors will be reviewed. Some of the basic biology and laboratory evidence demonstrating how the marker relates to radiation response and available correlative clinical studies employing these markers as prognostic tools are presented. The majority of molecular markers that have potential clinical significance with respect to radiation sensitivity and local control will be highlighted.

New trends in breast conservation therapy

Breast conservation therapy for early-stage invasive breast cancer provides survival equivalent to mastectomy. Careful patient selection and surgical technique are necessary to minimize local recurrence. Extensive studies of breast conservation therapy over the past 15 years have identified risk factors for local recurrence, and have proven that certain cases previously thought to be ineligible for lumpectomy (such as occult breast cancer, locally advanced breast cancer, macromastia, and cancer in pregnant patients), can be safely managed with modified BCT approaches. Recent trends in breast cancer management, such as expanded applications of induction chemotherapy, use of magnetic resonance imaging and ultra sound, and touch-prep cytology for intraoperative margin evaluation, can improve success rates for BCT. New developments with brachytherapy may also improve BCT availability by shortening duration of treatment. Innovations with minimally invasive tumor ablation techniques are investigational at present, but may obviate the need for surgical resections in selected patients in the future. Local recurrences that develop after breast conservation therapy should be managed aggressively, as long-term survival can frequently be achieved.

Mastectomy by inverted drip incision and immediate reconstruction: data from 510 cases

BACKGROUND

Immediate reconstruction of the breast can be performed in selected cases after mastectomy for breast cancer or after prophylactic mastectomy in patients with a high risk of developing breast cancer. Despite the frequency with which these procedures are performed, data from large series of subpectoral implantation of silicone prostheses in combination with a skin-saving approach are lacking.

METHODS

In this retrospective study, data on complications and late surgical interventions in 356 patients who underwent 510 mastectomies with an inverted drip incision and immediate reconstruction (MIDIIR) were analyzed to determine potential prognostic factors of early complications.

RESULTS

In 82% of the MIDIIRs, the postoperative course was uneventful. In 18%, the complications were infection (32 cases), necrosis of the skin flap (29 cases), bleeding (31 cases), and protrusion of the prosthesis (20 cases), resulting in surgery in 9, 12, 15, and 20 cases, respectively. At the end of the follow-up period, 30 (6%) prostheses were definitively removed. Age, size of the prostheses, radiotherapy, previous lumpectomy, and indication for mastectomy were not significant factors for the prognosis of early complications.

CONCLUSIONS

With the right technique and indications, MIDIIR is a very safe procedure and should be one of the surgical treatments that can be offered in the overall management of patients with, or at high risk for, breast cancer.

Molecular and genetic markers in the local-regional management of breast cancer

The clinical application of molecular markers in the diagnosis, staging, and management of breast cancer continues to expand. Although the use of molecular markers in local-regional disease does not approach the level of their application in the systemic management of breast cancer, a growing body of rature supports the potential for molecular and genetic factors in clinical decision making regarding the local-regional management of breast cancer. As with conventional clinical and histopathologic factors, data regarding molecular and genetic factors as they relate to local-regional relapse may be conflicting and are subject to the usual limitations of predominantly retrospective studies. There are, however, some consistent data suggesting associations between local-regional control of disease and several molecular markers, including hormone receptor status, HER2/neu, p53, proliferative markers, and others. Interpretation of these data and how to use this information in clinical practice remains challenging. The available rature regarding the use of genetic and molecular markers in the local-regional management of breast cancer is summarized in this review.

Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer trial 10902

PURPOSE

To evaluate whether preoperative neoadjuvant chemotherapy in patients with primary operable breast cancer results in better overall survival (OS) and relapse-free survival rates and whether preoperative chemotherapy permits more breast-conserving surgery procedures than postoperative chemotherapy.

PATIENTS AND METHODS

Six hundred ninety-eight breast cancer patients (T1c, T2, T3, T4b, N0 to 1, and M0) were enrolled onto a randomized phase III trial that compared four cycles of fluorouracil, epirubicin, and cyclophosphamide administered preoperatively versus the same regimen administered postoperatively (the first cycle administered within 36 hours after surgery). Patients were followed up for OS, progression-free survival (PFS), and locoregional recurrence (LRR).

RESULTS

At a median follow-up of 56 months, there was no significant difference in terms of OS (hazards ratio, 1.16; P =.38), PFS (hazards ratio, 1.15; P =.27), and time to LRR (hazards ratio, 1.13; P =.61). Fifty-seven patients (23%) were downstaged by the preoperative chemotherapy, whereas 14 patients (18%) underwent mastectomy and not the planned breast-conserving therapy.

CONCLUSION

The use of preoperative chemotherapy yields similar results in terms of PFS, OS, and locoregional control compared with conventional postoperative chemotherapy. In addition, preoperative chemotherapy enables more patients to be treated with breast-conserving surgery. Because preoperative chemotherapy does not improve disease outcome compared with postoperative chemotherapy, future trials should involve quality-of-life studies to investigate whether patients will benefit from this treatment modality.

Up-regulation of PTHrP and Bcl-2 expression characterizes the progression of osteochondroma towards peripheral chondrosarcoma and is a late event in central chondrosarcoma

Chondrosarcomas are malignant cartilage-forming tumors arising centrally in bone (central chondrosarcoma) or within the cartilaginous cap of osteochondroma (peripheral chondrosarcoma). For hereditary multiple osteochondromas, two responsible genes, EXT1 and EXT2, have been cloned. Their recently elucidated role in heparan sulfate biosynthesis and Hedgehog diffusion leads to the hypothesis that EXT inactivation affects fibroblast growth factor (FGF) and Indian Hedgehog (IHh)/parathyroid hormone-related peptide (PTHrP) signaling, two important pathways in chondrocyte proliferation and differentiation. The expression of PTHrP, PTHrP-receptor, Bcl-2, FGF2, FGFR1, FGFR3, and p21 is investigated by immunohistochemistry in osteochondromas (n = 24) and peripheral (n = 29) and central (n = 20) chondrosarcomas. IHh/PTHrP and FGF signaling molecules are mostly absent in osteochondromas. Although no somatic EXT mutations were found in sporadic osteochondromas, the putative EXT downstream targets are affected similarly in sporadic and hereditary tumors. In chondrosarcomas, re-expression of FGF2, FGFR1, PTHrP, Bcl-2, and p21 is found. Expression levels increase with increasing histological grade. Up-regulation of PTHrP and Bcl-2 characterizes malignant transformation of osteochondroma because PTHrP and Bcl-2 expression is significantly higher in borderline and grade I peripheral chondrosarcomas compared with osteochondromas. In contrast, up-regulation of PTHrP and Bcl-2 seems to be a late event in central cartilaginous tumorigenesis because expression is mainly restricted to high-grade central tumors.