Predictive and prognostic markers for invasive breast cancer

Computer-assisted quantification of tumor-associated collagen signatures to improve the prognosis prediction of breast cancer

BACKGROUND

Collagen fibers play an important role in tumor initiation, progression, and invasion. Our previous research has already shown that large-scale tumor-associated collagen signatures (TACS) are powerful prognostic biomarkers independent of clinicopathological factors in invasive breast cancer. However, they are observed on a macroscale and are more suitable for identifying high-risk patients. It is necessary to investigate the effect of the corresponding microscopic features of TACS so as to more accurately and comprehensively predict the prognosis of breast cancer patients.

METHODS

In this retrospective and multicenter study, we included 942 invasive breast cancer patients in both a training cohort (n = 355) and an internal validation cohort (n = 334) from one clinical center and in an external validation cohort (n = 253) from a different clinical center. TACS corresponding microscopic features (TCMFs) were firstly extracted from multiphoton images for each patient, and then least absolute shrinkage and selection operator (LASSO) regression was applied to select the most robust features to build a TCMF-score. Finally, the Cox proportional hazard regression analysis was used to evaluate the association of TCMF-score with disease-free survival (DFS).

RESULTS

TCMF-score is significantly associated with DFS in univariate Cox proportional hazard regression analysis. After adjusting for clinical variables by multivariate Cox regression analysis, the TCMF-score remains an independent prognostic indicator. Remarkably, the TCMF model performs better than the clinical (CLI) model in the three cohorts and is particularly outstanding in the ER-positive and lower-risk subgroups. By contrast, the TACS model is more suitable for the ER-negative and higher-risk subgroups. When the TACS and TCMF are combined, they could complement each other and perform well in all patients. As expected, the full model (CLI+TCMF+TACS) achieves the best performance (AUC 0.905, [0.873-0.938]; 0.896, [0.860-0.931]; 0.882, [0.840-0.925] in the three cohorts).

CONCLUSION

These results demonstrate that the TCMF-score is an independent prognostic factor for breast cancer, and the increased prognostic performance (TCMF+TACS-score) may help us develop more appropriate treatment protocols.

Identification of a Transcription Factor Signature That Can Predict Breast Cancer Survival

BACKGROUND

The expression pattern of transcription factors (TFs) can be used to develop potential prognostic biomarkers for cancer. In this study, we aimed to identify and validate a TF signature for predicting disease-free survival (DFS) of breast cancer (BRCA) patients.

METHODS

Lasso and the Cox regression analyses were applied to construct a TF signature based on a gene expression dataset from TCGA. The prognosis value of the TF signature was investigated in the TCGA database, and its reliability was further validated in 3 independent datasets from Gene Expression Omnibus (GEO). The prognosis performance of the TF signature was compared with 4 previously published gene signatures. To investigate the association between the TF signature and hallmarks of cancer, Gene Set Enrichment Analysis (GSEA) was carried out. The correlations of the TF signature and the levels of immune infiltration were also investigated.

RESULTS

An 11-TF prognostic signature was constructed with good survival prediction performance for BRCA patients. By using the risk score model based on the 11-TF signature, BRCA patients were stratified into low- and high-risk groups and showed good and poor disease-free survival (DFS), respectively. The risk score was an independent prediction indicator when adjusting for other clinicopathological factors. Furthermore, the 11-TF signature had a better survival prediction performance compared to 4 previously published gene signatures. Moreover, the risk score was a cancer hallmark. Finally, a high-risk score was associated with higher infiltration of M0 and M2 macrophages and was associated with a lower infiltration of resting memory CD4+ T cells and CD8+ T cells.

CONCLUSION

The findings in this study identified and validated a novel prognostic TF signature, which is an independent biomarker for the prediction of DFS in BRCA patients.

Prevalence of Histological Characteristics of Breast Cancer in Rwanda in Relation to Age and Tumor Stages

Breast cancer is a complex disease, and it is the most common cause of morbidity and mortality among women worldwide. In Sub-Saharan Africa, the clinical characteristics and tumor profiles of breast cancer are still unknown. In the present study we aimed to determine breast tumor profiles of the Rwandan patients in relation to age and tumor stages. We compare our findings to related results from other sub-Saharan Africa studies. Data on age at diagnosis, tumor stage, and hormonal profiles of 138 patients diagnosed between January 2015 and December 2018 were retrospectively retrieved from electronic medical records at three referral hospitals in Rwanda. We compared our results to related findings reported in other Sub-Saharan African countries. All statistical analyses were done using SPSS Inc., Chicago, IL, USA, version 20 and R software languages. The mean age at diagnosis was 49.7 years (SD = 13) and ranged from 17 to 86 years. The majority of patients (57.2%) were diagnosed before 50 years of age compared with 42.8% aged > 50 years. Tumor stage III was the commonest accounting for 62% followed by stage II with 24.8%. The distribution of breast tumor subtypes was ER-, PR-, HER2-: 37.7%; ER+, PR+, HER2-: 31.2%; ER-, PR-, HER2+: 14.5%; ER+, PR+, HER2+: 5.1%; and other subtypes represented 11.6%. There was no statistically significant difference in age and tumor stages between the molecular subtypes. Our findings revealed the predominance of hormonal negative tumors among Rwandan patients with breast cancer. Triple negative was found to be the most common breast tumor subtype regardless of age and tumor stage. Larger prospective studies could examine genetics and environmental factors that may play a role in the differences of tumor characteristics in Sub-Saharan populations.

A nomogram for individual prediction of vascular invasion in primary breast cancer

OBJECTIVES

To explore the feasibility of preoperative prediction of vascular invasion (VI) in breast cancer patients using nomogram based on multiparametric MRI and pathological reports.

METHODS

We retrospectively collected 200 patients with confirmed breast cancer between January 2016 and January 2018. All patients underwent MRI examinations before the surgery. VI was identified by postoperative pathology. The 200 patients were randomly divided into training (n = 100) and validation datasets (n = 100) at a ratio of 1:1. Least absolute shrinkage and selection operator (LASSO) regression was used to select predictors most associated with VI of breast cancer. A nomogram was constructed to calculate the area under the curve (AUC) of receiver operating characteristics, sensitivity, specificity, accuracy, positive prediction value (PPV) and negative prediction value (NPV). We bootstrapped the data for 2000 times without setting the random seed to obtain corrected results.

RESULTS

VI was observed in 79 patients (39.5%). LASSO selected 10 predictors associated with VI. In the training dataset, the AUC for nomogram was 0.94 (95% confidence interval [CI]: 0.89-0.99, the sensitivity was 78.9% (95%CI: 72.4%-89.1%), the specificity was 95.3% (95%CI: 89.1%-100.0%), the accuracy was 86.0% (95%CI: 82.0%-92.0%), the PPV was 95.7% (95%CI: 90.0%-100.0%), and the NPV was 77.4% (95%CI: 67.8%-87.0%). In the validation dataset, the AUC for nomogram was 0.89 (95%CI: 0.83-0.95), the sensitivity was 70.3% (95%CI: 60.7%-79.2%), the specificity was 88.9% (95%CI: 80.0%-97.1%), the accuracy was 77.0% (95%CI: 70.0%-83.0%), the PPV was 91.8% (95%CI: 85.3%-98.0%), and the NPV was 62.7% (95%CI: 51.7%-74.0%). The nomogram calibration curve shows good agreement between the predicted probability and the actual probability.

CONCLUSION

The proposed nomogram could be used to predict VI in breast cancer patients, which was helpful for clinical decision-making.

Comprehensive analysis of novel three-long noncoding RNA signatures as a diagnostic and prognostic biomarkers of human triple-negative breast cancer

Currently, traditional predictors of prognosis (tumor size, nodal status, progesterone receptor [PR], estrogen receptor [ER], or human epidermal growth factor receptor-2 [HER2]) are insufficient for precise survival prediction for triple-negative breast cancer (TNBC). Long noncoding RNAs (lncRNAs) have been observed to exert critical functions in cancer, including in TNBC. Nevertheless, systematically tracking expression-based lncRNA biomarkers based on the sequence data for the prediction of prognosis in TNBC has not yet been investigated. To ascertain whether biomarkers exist that can distinguish TNBC from adjacent normal tissue or nTNBC, we implemented a comprehensive analysis of lncRNA expression profiles and clinical data of 1097 BC samples from The Cancer Genome Atlas database. A total of 1510 differentially expressed lncRNAs in normal and TNBC samples were extracted. Similarly, 672 differentially expressed lncRNAs between nTNBC and TNBC samples were detected. The receiver operating characteristic curve analysis indicated that three upregulated lncRNAs (AC091043.1, AP000924.1, and FOXCUT) may be of strong diagnostic value for predicting the existence of TNBC in the training and validation sets (area under the curve (AUC > 0.85). Kaplan-Meier analysis demonstrated that the other three lncRNAs (AC010343.3, AL354793.1, and FGF10-AS1) were associated with the prognosis of TNBC patients (P < 0.05). We used the three overall survival (OS)-related lncRNAs to establish a three-lncRNA signature. Multivariate Cox regression analysis suggested that the three-lncRNA signature was a prognostic factor independent of other clinical variables ( P < 0.01) for predicting OS in TNBC patients that could be utilized to classify patients into high- or low-risk subgroups. Our results might provide efficient signatures for clinical diagnosis and prognostic evaluation of TNBC.

Immunohistochemical features of multifocal and multicentric lobular breast carcinoma

PURPOSE

Patient age, tumor size, axillary lymph node status, expression of estrogen, progesterone and HER2 receptors, as well as the histological grade, are widely accepted prognostic and predictive parameters in breast carcinoma. In invasive lobular carcinoma (ILC), the prognostic factors, such as nodal status and tumor size are believed to be the most valuable ones. The aim of this was set to determine the possible linkage between MFity/MCity of ILC and immunohistochemical predictive (ER, PR, HER2) and prognostic parameters (BRCA1, p53, E-cadherin, Ki-67).

MATERIAL/METHODS

Out of 2486 cases diagnosed with BC from south-eastern Serbia, the presence ILC was noted in 334 cases. Immunohistochemical characterization of predictive and prognostic parameters in ILC was done.

RESULTS

The occurrence of multifocal (MFC) and multicentric carcinoma (MCC) was observed in 18.9% of ILC. Bilateral (BL) BCs were found to be statistically significantly more frequent in younger women, compared to those with MFC, MCC or nonMFC/MCC/BL. No significant correlation was found between MFC/MCC and the presence of axillary lymph node metastases, and expression of immunohistochemical predictive and prognostic parameters. Based on literature data and the findings from the current work, MFity/MCtiy might represent negative morphologic prognostic parameters in ILC.

CONCLUSIONS

In 334 cases analyzed, no statistically significant correlations were observed between MF/MC and the expression of immunohistochemical predictive and prognostic parameters.

Mammary Epithelial Cells Treated Concurrently with TGF-α and TGF-β Exhibit Enhanced Proliferation and Death

Transforming growth factor-α (TGF-α) stimulates while TGF-β inhibits mammary epithelial cell growth, suggesting that when cells are treated concurrently with the growth factors their combined effects would result in no net growth. However, combined treatments stimulate proliferation and cellular transformation in several cell lines. The objective of this paper was to describe the effect of long-term (6 days) concurrent TGF-α and TGF-β treatment on normal mammary epithelial cell growth pattern, morphology, and gene expression. Growth curve analysis showed that TGF-α enhanced while TGF-β suppressed growth rate until Day 4, when cells entered lag phase. However, cells treated concurrently with both growth factors exhibited a dichotomous pattern of growth marked by growth and death phases (with no intermittent lag phase). These changes in growth patterns were due to a marked induction of cell death from Day 2 (16.5%) to Day 4 (89.5%), resulting in the transition from growth to death phases, even though the combined treated cultures had significantly more ( P < 0.05) cells in S phase on Day 4. TGF-β stimulated epithelial to mesenchyme transdifferentiation (EMT) in the presence of TGF-α, as characterized by increased expression of fibronectin and changes in TGF-β receptor binding. Expression patterns of genes that regulate the cell cycle showed significant interaction between treatment and days, with TGF-β overriding TGF-α–stimulated effects on gene expression. Overall, the combined treatments were marked by enhanced rates of cellular proliferation, death, and trans-differentiation, behaviors reminiscent of breast tumors, and thus this system may serve as a good model to study breast tumorigenesis.

Predictive immunohistochemical biomarkers in the context of neoadjuvant therapy for breast cancer

The adoption of personalized medicine has led to the search for prognostic and predictive markers that can be applied to individual patients to give optimal information for their clinical management. We have used samples from randomized clinical trials of hormonal and chemotherapy to identify relevant markers of sensitivity and resistance using a neoadjuvant approach by linking expression of a panel of proteins involved in growth factor receptor signaling, angiogenesis, estrogen receptor signaling, and hypoxia to individual patient response. We evaluated samples from randomized clinical trials of epirubicin with or without tamoxifen, and letrozole with or without metronomic cyclophosphamide, to study chemotherapy, hormonal therapy, and antiangiogenic effects. We present a proof of principle of this approach in identifying several key pathways that are associated with clinical and pathological response. Thus, we have shown that the hypoxia-inducible factor (HIF) pathway, mitogen activated protein kinase, and phosphorylated estrogen receptor-α can identify patients who are likely to respond to hormonal therapy and that HIF signaling is also a marker of resistance for anthracycline-based chemotherapy. To redress the role of HIF, we then evaluated samples from a randomized control trial of an anthracycline chemotherapy with and without erythropoietin. These studies demonstrate that the approach of using primary systemic therapy in breast can identify markers of response and potentially targets for rationale design of new therapies.

Morphologic complexity of epithelial architecture for predicting invasive breast cancer survival

Background

Precise criteria for optimal patient selection for adjuvant chemotherapy remain controversial and include subjective components such as tumour morphometry (pathological grade). There is a need to replace subjective criteria with objective measurements to improve risk assessment and therapeutic decisions. We assessed the prognostic value of fractal dimension (an objective measure of morphologic complexity) for invasive ductal carcinoma of the breast.

Methods

We applied fractal analysis to pan-cytokeratin stained tissue microarray (TMA) cores derived from 379 patients. Patients were categorized according to low (<1.56, N = 141), intermediate (1.56-1.75, N = 148), and high (>1.75, N = 90) fractal dimension. Cox proportional-hazards regression was used to assess the relationship between disease-specific and overall survival and fractal dimension, tumour size, grade, nodal status, estrogen receptor status, and HER-2/neu status.

Results

Patients with higher fractal score had significantly lower disease-specific 10-year survival (25.0%, 56.4%, and 69.4% for high, intermediate, and low fractal dimension, respectively, p < 0.001). Overall 10-year survival showed a similar association. Fractal dimension, nodal status, and grade were the only significant (P < 0.05) independent predictors for both disease-specific and overall survival. Among all of the prognosticators, the fractal dimension hazard ratio for disease-specific survival, 2.6 (95% confidence interval (CI) = 1.4,4.8; P = 0.002), was second only to the slightly higher hazard ratio of 3.1 (95% CI = 1.9,5.1; P < 0.001) for nodal status. As for overall survival, fractal dimension had the highest hazard ratio, 2.7 (95% CI = 1.6,4.7); P < 0.001). Split-sample cross-validation analysis suggests these results are generalizable.

Conclusion

Except for nodal status, morphologic complexity of breast epithelium as measured quantitatively by fractal dimension was more strongly and significantly associated with disease-specific and overall survival than standard prognosticators.

CpG hypomethylation of MDR1 gene in tumor and serum of invasive ductal breast carcinoma patients

OBJECTIVES

Multidrug resistance 1 (MDR1) gene encodes P-glycoprotein (P-gp), a transmembrane calcium-dependent efflux pump, implicated in drug resistance. In this prospective study, methylation status of MDR1 promoter and its correlation with clinicopathological parameters were evaluated in tumor and serum of breast cancer patients.

DESIGN AND METHODS

Methylation-specific PCR was carried out to investigate the promoter methylation status of MDR1 in tumor and serum of 100 patients with invasive ductal carcinomas of breast (IDCs). The effect of promoter methylation on protein expression was evaluated by immunohistochemistry.

RESULTS

MDR1 was hypomethylated in 47% tumors and 44% paired sera of IDC patients and correlated significantly with increased tumor size and advanced tumor stage. Promoter hypomethylation of MDR1 in serum DNA showed 98% specificity and 50% sensitivity.

CONCLUSIONS

Hypomethylation of MDR1 promoter in IDCs accounted for P-gp overexpression and aggressive biologic behavior in a subset of patients. Detection of these epigenetic changes in circulating DNA may not only enhance insight into the biological behavior of the primary tumor of an individual but may also provide valuable information regarding prognosis that can be readily monitored throughout the disease course.

CD24 expression has a prognostic impact in breast carcinoma

We investigated the prognostic significance of BAG-1 and CD24 in invasive breast carcinomas. Seventy cases of invasive breast carcinoma were studied immunocytochemically for the expression of BAG-1 and CD24. The results were correlated with several prognostic parameters, including 5-year survival. Univariate analysis showed a significant correlation of BAG-1 and CD24 overall positive staining with several adverse prognostic parameters, such as increased stage (p<0.0001), tumor grade 3 (p=0.016 and p=0.02, respectively), positive lymph nodes (p<0.0001), and increased tumor size (p<0.0001). Similar results were found for BAG-1 nuclear staining, as well as for positive cytoplasmic CD24 expression. Both of our markers studied had a significant, negative effect on survival. Multivariate analysis further revealed an independent prognostic impact for CD24 overall staining. The results of our study showed that overall cytoplasmic and especially nuclear BAG-1 expression, as well as overall and cytoplasmic CD24 expression, correlates with adverse prognostic parameters. An independent prognostic value for overall CD24 staining was also demonstrated.

Hypoxia-inducible factor-1alpha expression predicts a poor response to primary chemoendocrine therapy and disease-free survival in primary human breast cancer

PURPOSE

To investigate the relationship of hypoxia-inducible factor-1alpha (HIF-1alpha) tumor expression in predicting the response to epirubicin and disease-free survival (DFS) in patients with breast cancer enrolled in a single institution trial of primary anthracycline and tamoxifen therapy.

EXPERIMENTAL DESIGN

The expression of HIF-1alpha was assessed by immunohistochemistry in 187 patients with T(2-4) N(0-1) breast cancer enrolled in a randomized trial comparing four cycles of single agent epirubicin versus epirubicin + tamoxifen as primary systemic treatment. All patients postoperatively received four cycles of the four weekly i.v. CMF regimen (cyclophosphamide, methotrexate, and 5-fluorouracil). Patients with estrogen receptor (ER)-positive primary tumors also underwent 5 years of treatment with adjuvant tamoxifen. Carbonic anhydrase IX (CAIX) was also scored as a marker of HIF activity.

RESULTS

Overall response to therapy progressively decreased with increasing tumor HIF-1alpha (P < 0.05), and HIF-1alpha was an independent predictor of response (P < 0.048). HIF-1alpha expression was also associated with a significantly shorter DFS (P < 0.02) in all patients and in ER-positive but not in ER-negative patients. Furthermore, CAIX positivity conferred a significantly shorter DFS (P = 0.02) compared with CAIX-negative tumors in patients with HIF-1alpha-negative tumors.

CONCLUSIONS

HIF-1alpha expression in patients with breast cancer is a marker of poor therapy response and outcome, especially in ER-positive patients. The combination of two hypoxia markers has greater utility than assessing just one, and patients with hypoxia markers in their tumors may be suitable for administration of drugs that reduce HIF-1alpha expression and increase oxygen delivery to the tumor bed before starting neoadjuvant therapies.

TrkC: a new predictive marker in breast cancer?

Available data involve neurotrophins and their receptors in carcinomas. Quantitative evaluation of these molecules in these tumors might be useful as prognostic marker and eventual treatments. Our study on 40 mammary tumors tries to correlate expression of these molecules and prognosis. Immunohistochemistry for NGF, BDNF, NT3, TrkA, TrkB, TrkC, and p75 was used. Patient's age, histopathology, Bloom-Richardson grading, estrogen and progesterone receptors, Ki-67 index, HER-2, p53 were evaluated. Statistics found inverse relationship between grading and TrkC expression. We found significantly higher TrkC expression in Grade I than in Grade III tumors. Rise in TrkC expression could indicate good prognosis.

Biologic and clinical characteristics of breast cancer with single hormone receptor positive phenotype

PURPOSE

Response to endocrine therapy in breast cancer correlates with estrogen receptor (ER) and progesterone receptor (PgR) status. It is usually easier to decide treatment strategies in cases of double-positive/-negative phenotypes than in single-positive tumors.

PATIENTS AND METHODS

We have examined a large and well-characterized series of primary invasive breast carcinoma (1,944 cases) with long-term clinical follow-up and hormone therapy data. Patients were stratified according to ER and PgR expression and the study was focused on the single-positive groups (ER-/PgR+ and ER+/PgR-), to assess their main features and evaluate any prognostic and predictive difference between them and compare them with the double-positive/-negative tumors.

RESULTS

ER+/PgR-tumors were found more frequently in elderly, postmenopausal women. The majority were grade 2 ductal/no specific type carcinomas. There was no difference between the two groups with regard to lymph node stage. Survival analyses showed no difference between the two groups in terms of disease-free interval and overall survival. However, when compared with the double-negative phenotype, ER+/PgR-showed an association with better outcome but no such survival advantage was detected in case of ER-/PgR+ tumors. In the group of patients with ER+ tumors who received adjuvant hormonal therapy, absence of PgR (ER+/PgR-) was an independent predictor of development of recurrence and shorter survival and, hence, poorer response to hormonal therapy.

CONCLUSION

ER+/PgR-and ER-/PgR+ tumors are biologically and clinically distinct groups of breast cancer that may require different treatment strategies with ER-/PgR+ exhibiting more aggressive behavioral characteristics.

Prognostic markers in triple-negative breast cancer

BACKGROUND

Triple-negative breast cancer (estrogen receptor-negative, progesterone receptor-negative, and HER2-negative) is a high risk breast cancer that lacks the benefit of specific therapy that targets these proteins.

METHODS

In this study, the authors examined a large and well characterized series of invasive breast carcinoma (n = 1944) with a long-term clinical follow-up (median, 56 months) by using tissue microarray. The series were also stained with concurrent immunohistochemical prognostic panels (estrogen receptor, progesterone receptor, HER-2, androgen receptor, epidermal growth factor receptor (EGFR), P-cadherin, E-cadherin, and basal (CK5/6, CK14), and p53), to characterize this specific subgroup of breast cancer and to identify prognostic markers that can identify tumors with more aggressive behavior.

RESULTS

Of informative cases, 16.3% were of the triple-negative phenotype. The majority of these tumors were grade 3, ductal/no-specific-type carcinomas. There were positive associations with larger size, pushing margins, poorer Nottingham Prognostic Index, development of recurrence and distant metastasis, and poorer outcome. In addition, associations were found with loss of expression of androgen receptor and E-cadherin, and positive expression of basal cytokeratins (basal phenotype), P-cadherin, p53, and EGFR. In all tumors, tumor size, lymph node stage, and androgen receptor were the most useful prognostic markers. In the lymph node-positive subgroup, both size and androgen receptor retained their prognostic significance. However, in the lymph node-negative tumors, basal phenotype was the sole prognostic marker identified in this subgroup. Other parameters including age, histological grade, tumor size, vascular invasion or other biomarkers included in the current study were not significant.

CONCLUSIONS

The authors concluded that assessment of androgen receptor and basal phenotype, in addition to the established pathologic variables, mainly lymph node status and tumor size, can be used to select high-risk and low-risk patients at the time of primary surgery and can provide valuable information on treatment options in these triple-negative tumors.

Basal phenotype identifies a poor prognostic subgroup of breast cancer of clinical importance

BACKGROUND

Breast cancer is recognised to be a heterogeneous disease with a range of morphological appearances and behaviours. The recently recognised basal phenotype (BP) is associated with poor survival, but the clinical implications of this class of breast cancers remain to be adequately defined.

METHODS

We have examined a well-characterised series of 1872 invasive breast carcinomas with a long term follow-up to assess the clinical significance of BP.

RESULTS

A pragmatic definition of the BP as immunophenotypic evidence of basal cytokeratins CK5/6 and/or CK14 expression was used. These tumours were associated with shorter overall survival and disease-free interval in our series as a whole and in both the lymph node (LN) negative and LN positive subgroups. When stratified by histological grade, BP was of highly significant prognostic value in grade 3 but not in grades 1 or 2 tumours. Similarly, it was associated with poor survival in the moderate group of the Nottingham prognostic Index but not in the other groups. In a subgroup comprising LN negative grade 3 tumours, BP was the most powerful prognostic marker followed only by tumour size, while the other variables were non-significant. Patients with BP were more likely to respond to chemotherapy than those with non-basal tumours.

CONCLUSIONS

Our results provide robust evidence that BP is an important class of breast cancers with a particularly aggressive behaviour in patients with LN negative grade 3 disease. We recommend routine identification of BP in breast cancer and the development of effective adjuvant treatment strategies. These are important observations as these tumours typically lack hormone receptor and HER-2 overexpression limiting the range of relevant adjuvant therapies.

Multivariate analysis of oestrogen receptor alpha, pS2, metallothionein and CD24 expression in invasive breast cancers

Determination of oestrogen receptor alpha (ER) represents at present the most important predictive factor in breast cancers. Data of ours and of other authors suggest that promising predictive/prognostic factors may also include pS2, metallothionein (MT) and CD24. Present study aimed at determining prognostic and predictive value of immunohistochemical determination of ER, pS2, MT, and CD24 expression in sections originating from 104 patients with breast cancer. An univariate and multivariate analysis was performed. Both univariate and multivariate analyses demonstrated that cytoplasmic-membranous expression of CD24 (CD24c-m) represents a strong unfavourable prognostic factor in the entire group and in most of the subgroups of patients. In several subgroups of the patients also a prognostic value was demonstrated of elevated expression of pS2 and of membranous expression of CD24. Our studies demonstrated that all patients with good prognostic factors (higher ER and pS2 expressions, lower MT expression, CD24c-m negativity) survived total period of observation (103 months). The study documented that cytoplasmic-membranous expression of CD24 represented an extremely strong unfavourable prognostic factor in breast cancer. Examination of the entire panel of the studied proteins permitted to select a group of patients of an exceptionally good prognosis.

Cytoplasmic overexpression of ALCAM is prognostic of disease progression in breast cancer

BACKGROUND

Activated leucocyte cell adhesion molecule (ALCAM, CD166) is a cell surface member of the immunoglobulin superfamily. ALCAM expression has prognostic relevance in prostate and colon cancer.

OBJECTIVE

To evaluate ALCAM protein expression in breast cancer by immunohistochemistry and to correlate expression levels with clinicopathological data.

METHODS

162 primary breast carcinomas with a mean clinical follow up time of 53 months were immunostained using a monoclonal ALCAM antibody. The staining was evaluated as an immunoreactive score (IRS) and grouped into low v high for both membranous and cytoplasmic staining.

RESULTS

Intraductal and invasive carcinomas showed a higher ALCAM expression (median IRS 4 and 6 respectively) than normal breast tissue (IRS 2). In univariate survival analyses a significant association of high cytoplasmic ALCAM expression with shortened patient disease-free survival (mean (SD) five year non-progression rate, 69.4 (4.6)% v 49.4 (11.1)%, p = 0.0142) was found. In multivariate analyses of disease-free survival times, high cytoplasmic ALCAM expression (relative risk (RR) = 2.086, p = 0.026) and nodal status (RR = 2.246, p = 0.035) were significantly associated with earlier disease progression, whereas tumour grading (RR = 1.6, p = 0.052) was of borderline significance.

CONCLUSIONS

The data suggest that strong cytoplasmic ALCAM expression in primary breast cancer, as detected by immunohistochemistry, might be a new marker for a more aggressive breast cancer biology.

DNA replication licensing and cell cycle kinetics of normal and neoplastic breast

Mcm2–7 (MCM) proteins are part of the origin licensing machinery that regulates initiation of DNA replication. Geminin is a licensing repressor and prevents reinitiation of DNA replication during S–G2–M phase by blocking reloading of Mcm2–7 at replication origins. Here, we have analysed these replication licensing factors (RLFs) to determine whether the pathway becomes deregulated during mammary carcinogenesis, and have assessed their potential value as prognostic markers. Protein expression profiles were generated for Ki67, Mcm2, geminin, HER-2, ER and PR in a series of reduction mammoplasty (n=18) and breast cancer specimens (n=120), and compared to clinicopathological parameters. A large proportion of epithelial cells of the terminal duct lobular unit reside in a primed ‘replication licensed’ but not proliferating state. This state is characterised by Mcm2 expression and absence of Ki67 and the S/G2/M marker geminin. In breast cancers, increasing tumour grade is associated with increased Ki67, Mcm2 and geminin expression. The Mcm2/Ki67 ratio decreases through the grades, indicating a shift from a predominantly licensed state to an actively proliferating state. This shift is associated with an increase in the geminin/Ki67 ratio, signifying a shortening of G1 phase in breast cancer cells. Ki67, Mcm2 and the Mcm2/Ki67 ratio are statistically significantly associated with the Nottingham Prognostic Index (NPI), but geminin and the geminin/Ki67 ratio are not. Ki67, Mcm2 and Mcm2/Ki67 are highly correlated with one another, with Mcm2 being the single most important predictor of NPI score (P<0.001). However, only 12% of variation in NPI is explained by Mcm2, as the labelling index for this marker is approaching 100% for many of the high-grade tumours. The origin licensing phenotypes of normal breast and breast cancers therefore relate to their cellular differentiation status, and high-level MCM expression in more poorly differentiated tumours severely constrains their use as prognostic markers in breast cancer.

CD24 and human carcinoma: tumor biological aspects

CD24 is a mucin-like adhesion molecule that has recently raised attention and lent substantial improvements for our understanding of tumor biology. Functionally, CD24 enhances the metastatic potential of malignant-cells, because it has been identified as a ligand of P-selectin, an adhesion receptor on activated endothelial cells and platelets. Moreover, it has been described as a diagnostic molecular marker of malignant tumor and for patient prognosis. This article reviews the experimental and clinical data on CD24 expression and carcinomas from the point of view of tumor biology. Based on the research, CD24 expression will be analyzed as a potentially significant parameter for a wide variety of human cancer diagnoses. Understanding the functions and implications CD24 might aid the clinician in the selection of an appropriate therapy for individual patients: for example, the intravenous administration of C1324-specific antibodies to treat cancers.

Relationship between the expression of cyclooxygenase 2 and MDR1/P-glycoprotein in invasive breast cancers and their prognostic significance

INTRODUCTION

Recent reports suggest that expression of the cyclooxygenase 2 (COX-2) enzyme may up-regulate expression of MDR1/P-glycoprotein (MDR1/P-gp), an exponent of resistance to cytostatic drugs. The present study aimed at examining the relationship between the expression of COX-2 and of MDR1/P-gp in a group of breast cancer cases.

METHODS

Immunohistochemical reactions were performed using monoclonal antibodies against COX-2 and MDR1/P-gp on samples originating from 104 cases of primary invasive breast cancer.

RESULTS

COX-2-positive cases were shown to demonstrate higher expression of MDR1/P-gp (P < 0.0001). The studies also demonstrate that COX-2 expression was typical for cases of a higher grade (P = 0.01), a shorter overall survival time (P < 0.0001) and a shorter progression-free time (P < 0.0001). In the case of MDR1/P-gp, its higher expression characterised cases of a higher grade (P < 0001), with lymph node involvement (P < 0001), and shorter overall survival (P < 0.0001) and progression-free time (P < 0.0001).

CONCLUSION

Our studies confirmed the unfavourable prognostic significance of COX-2 and MDR1/P-gp. We also document a relationship between COX-2 and MDR1/P-gp, which suggests that COX-2 inhibitors should be investigated in trials as a treatment supplementary to chemotherapy of breast cancers.

Altered expression of metastasis-associated and regulatory molecules in effusions from breast cancer patients: a novel model for tumor progression

PURPOSE

The aim of this study was to characterize phenotypic alterations along the progression of breast carcinoma from primary tumor to pleural effusion through analysis of the expression of proteases, laminin receptors (LRs), and transcription factors involved in invasion and metastasis.

EXPERIMENTAL DESIGN

The material studied consisted of 60 malignant pleural effusions from breast cancer patients and 68 corresponding solid tumors (37 primary and 31 metastatic tumors). Expression of matrix metalloproteinases [MMPs (MMP-1, MMP-2, MMP-9, and MMP-14)], the MMP inhibitor tissue inhibitor of metalloproteinase-2, the MMP inducer EMMPRIN, the 67-kDa LR, the alpha6 integrin subunit, and the transcription factors AP-2, Ets-1, and PEA3 was studied using immunohistochemistry, mRNA in situ hybridization, reverse transcription-polymerase chain reaction, zymography, and flow cytometry. Hormone receptor (estrogen receptor and progesterone receptor) status and c-erbB-2 status were also studied.

RESULTS

Significantly reduced estrogen receptor (P < 0.001) and progesterone receptor (P = 0.001) expression was seen in effusions compared with primary tumors, with opposite findings for c-erbB-2 (P = 0.003). Tumor cell MMP-2 protein expression in effusions was higher than that in primary tumors (P < 0.001) and lymph node metastases (P = 0.01). In situ hybridization demonstrated higher MMP-2 (P = 0.007), PEA3 (P = 0.038), and EMMPRIN (P = 0.026) mRNA expression in effusions. The time to progression from primary tumor to effusion was significantly shorter for patients whose primary tumors expressed MMP-1 (P = 0.016) and who expressed the 67-kDa LR protein in primary tumor (P = 0.007) and effusion (P = 0.015).

CONCLUSIONS

Our data provide documented evidence of molecular events that occur during the progression of breast carcinoma from primary tumor to effusion. The coordinated up-regulation of MMP-2 and Ets transcription factors in carcinoma cells in effusions is in full agreement with our previous reports linking these factors to poor prognosis in ovarian cancer. The rapid progression to effusion in cases showing MMP-1 and 67-kDa LR expression in primary tumor cells links aggressive clinical behavior with expression of metastasis-associated molecules in this setting.

Echogenicity of breast cancer: is it of prognostic value?

Echogenicity of colorectal metastases to the liver has been shown to correlate with prognosis. While there have been many studies looking at the echogenicity of breast cancer, there has been no study relating the issue of echogenicity to prognosis of breast cancer. In this study, we found that hyperechoic and mixed echogenicity breast cancers are rare compared to hypoechoic breast cancers. There was, however, no difference in the groups with respect to histological size, grade, axillary metastases, hormone receptor status and lymphovascular invasion.

Carbonic anhydrase-9 expression levels and prognosis in human breast cancer: association with treatment outcome

Here, we set out to assess CA9 expression levels by real-time quantitative RT-PCR in breast cancer tissue samples obtained from 253 patients, and correlated those with relapse-free (RFS) survival. The median follow-up time was 75 months (range 2-168 months). CA9 expression was mainly found in high-grade, steroid receptor negative cancer tissues. CA9 levels were not significantly associated with RFS (P=0.926, hazard ratio (HR)=0.99, 95% CI=0.80-1.22) in the total cohort of 253 patients. In multivariate analysis with other clinicopathological factors, CA9 (P=0.018, HR=0.77, 95% CI=0.62-0.96), the interaction of adjuvant chemotherapy with CA9 (P=0.009, HR=1.31, 95% CI=1.07-1.61) and the interaction of adjuvant endocrine therapy with CA9 (P<0.001, HR=1.41, 95% CI=1.20-1.66) all contributed significantly to the final model. These results indicate that patients with low CA9 levels benefit more from adjuvant treatment than do patients with high levels. Thus, the determination of CA9 levels could aid in the selection of patients who will not benefit from adjuvant therapy, and whose prognosis will more likely improve with other treatment modalities.

Differentiation, proliferation and retinoid receptor status of papillary carcinoma of the thyroid

Messenger RNA expression of retinoic acid receptors (RARalpha, RARbeta and RARgamma) and retinoid X receptors (RXRalpha, RXRbeta and RXRgamma) was examined using reverse transcription-polymerase chain reaction in 42 papillary thyroid carcinomas (PTCs). A loss of mRNA expression was observed in 18 cases of the 42 PTCs, including three cases for RARalpha, 14 cases for RARbeta, six cases for RXRalpha and five cases for RXRbeta. The expressions of RARgamma and RXRgamma were found in all 42 PTCs. Based on Ki 67/MIB1 labeling index (LI), the 42 PTCs were classified into Group A (20 cases; LI = 0-2%), Group B (17 cases; LI = 2-5%) and Group C (5 cases; LI > 5%). The PTCs of groups B and C showed solid, trabecular or scirrhous arrangements, infiltrative growth, loss of cellular polarity and cohesiveness more frequently, but capsulated growth pattern less frequently, when compared with PTCs of Group A. They also showed more frequent extrathyroidal extension than Group A. However, no significant differences were identified in sex, age, nodal status and tumor size. Loss of expression for one or more retinoid receptors frequently occurred in groups B and C. These results suggest that the loss of retinoid receptors might occur during the loss of differentiation and tumor progression of PTC.