Tissue microarray-based study of patients with lymph node-negative breast cancer shows that HER2/neu overexpression is an important predictive marker of poor prognosis

ERBB2 Amplification as a Predictive and Prognostic Biomarker in Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinomas (UTUCs) occur in about 5-10% of all urothelial carcinomas and are frequently discovered in high-stage disease. We aimed to evaluate human epidermal growth factor receptor 2 (ERBB2) protein expression immunohistochemically and ERBB2 amplification in UTUCs by fluorescence in situ hybridization, applying a tissue microarray technique. ERBB2 overexpression and ERBB2 amplification were defined according to the recommendations of the American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) for breast cancer and gastric carcinoma (GC), revealing scores of 2+ and 3+ in 10.2% and 41.8% of UTUCs, respectively. The performance parameters showed obviously higher sensitivity of ERBB2 immunoscoring according to the ASCO/CAP criteria for GC. ERBB2 amplification was detected in 10.5% of UTUCs. ERBB2 overexpression was more likely to be found in high-grade tumors and was associated with tumor progression. Univariable Cox regression analysis revealed a significantly lower progression-free survival (PFS) in cases with ERBB2 immunoscores of 2+ or 3+ according to the ASCO/CAP guidelines for GC. UTUCs with ERBB2 amplification showed a significantly shorter PFS in the multivariable Cox regression analysis. Irrespective of their ERBB2 status, patients with UTUC treated with platin showed a significantly lower PFS than UTUC patients who had not received any platin-based therapy. In addition, UTUC patients with a normal ERBB2 gene status who had not received platin-based therapy showed significantly longer overall survival. The results suggest that ERBB2 is a biomarker for progression in UTUCs and may define a distinct subgroup of UTUCs. As previously shown, ERBB2 amplification is infrequent. However, the small number of patients diagnosed with ERBB2-amplified UTUC might benefit from ERBB2-targeted cancer therapy. In clinical-pathological routine diagnostics, the determination of ERBB2 amplification is an established method in some defined entities and also successful in small samples. Still, the simultaneous use of ERBB2 immunohistochemistry and ERBB2 in situ hybridization would be important in order to record the low rate of amplified UTUC cases as completely as possible.

Prognostic implications of HER2 heterogeneity in gastric cancer

The prognostic implications of human epidermal growth receptor 2 (HER2) heterogeneity in gastric cancer (GC) are not well established. Therefore, the aim of the present study was to determine to the effect of HER2 status on the prognosis of GC patients. We retrieved data on 248 pathologically-confirmed, consecutive patients with primary adenocarcinoma of the stomach or gastro-esophageal junction who underwent surgical resection at Kurume University Medical Center between July 2000 and December 2012. HER2 status was classified as HER2 positive or negative and HER2 heterogeneity or homogeneity. The endpoint was overall survival (OS), which was compared using the generalized Wilcoxon test. HER2 status was positive in 36 patients (14.5%) and negative in 212 patients (85.5%). Among the 36 HER2 positive patients, 25 patients (69.4%) had HER2 heterogeneity and the remaining 11 patients (30.6%) had HER2 homogeneity. Among the 141 patients with stage III or IV disease, the prognosis of the HER2 homogeneity group was significantly worse than that of the HER2 heterogeneity group (p = 0.019; median OS 193 and 831 days, respectively). The prognosis was not significantly different between the HER2 positive group and the HER2 negative group (p = 0.84; median OS 552 and 556 days, respectively). The present study was conducted with small samples, however, the results of the study suggest that HER2 homogeneity but not HER2 positivity may represent a prognostic indicator in GC.

Correlation between hormone receptor status and age, and its prognostic implications in breast cancer patients in Bahrain

Objectives:

To assess the correlation between hormone receptor status (HRS) and age, and its significance as a predictor of outcome in patients with breast cancer (BC).

Methods:

This retrospective review was conducted on 109 patients diagnosed with BC at Salmaniya Medical Complex, Manama, Bahrain from 2010-2013. Patients were divided into 2 age groups; under and over 40 years, and were analyzed for tumor histology, lymph node status, stage, and HRS.

Results:

Younger patients with BC were more likely to be of higher stage, grade, and of larger size. Older women were more likely to be estrogen receptor (ER) positive (72.6% versus 55.3%), and progesterone receptor (PR) positive (71% versus 53.2%) (p=0.03). The human epidermal growth factor receptor (HER)-2 over-expression was seen more in younger women (51% versus 40%) (p=0.2). Younger patients had higher lymph node metastases (88.6% versus 56.1%) (p=0.0004), and higher distant metastases (26.7% versus 6.8%) (p=0.005). The HER-2 over-expression strongly correlated with lymph node status. A total of 63.4% of lymph node positive patients had HER-2 over-expression compared with only 13.3% of lymph node negative patients (p<0.00001).

Conclusion:

Breast cancer is more aggressive and advanced in younger women, a fact that can be significantly attributed to under expression of ER and PR, and over expression of HER-2, which also correlates well with lymph node status, as a measure of aggressiveness. Further studies should evaluate the genetic profile of BC in such population to improve their outcomes.

Prognostic role of HER2 expression in bladder cancer: a systematic review and meta-analysis

OBJECTIVE

The prognostic role of human epidermal growth factor receptor 2 (HER2) in bladder cancer (BCa) remains controversial. Thus, we conducted a meta-analysis to assess the prognostic significance of HER2 for patients with BCa.

MATERIALS AND METHODS

Systematically computerised searching in PubMed, Scopus database, Embase and Cochrane Library Database was conducted. Published studies comparing the prognosis in patients with BCa stratified by HER2 status were included, and relationships between HER2 positivity and gender, stage, grade, lymph node metastasis and survival were analysed.

RESULTS

Nine studies with 2,242 eligible patients were identified. HER2 expression was significantly correlated with poor disease-specific survival [pooled hazard ratio (HR) 2.00; 95% confidence interval (CI) 1.22-3.29; P=0.006] and disease-free survival (pooled HR 1.68; 95% CI 1.33-2.14; P<0.0001) of patients with BCa. The positive rates of HER2 ranged from 27.8 to 85.2% with a pooled positive rate of 41.2% (1,006/2,442). HER2 expression was significantly associated with tumour grade [high grade vs. low grade: odds ratio (OR) 4.08; 95% CI 1.29-12.93] and lymph node metastasis (positive vs. negative: OR 1.71; 95% CI 1.07-2.75).

CONCLUSIONS

This meta-analysis indicated that HER2 expression is associated with poor prognosis. Thus, HER2 could serve as a useful biomarker for clinical prediction.

Relationship between chemotherapy and prognosis in different subtypes of node-negative breast cancer

Knowledge is limited about the relationship between chemotherapy and prognosis among the subtypes of axillary node-negative breast cancer (ANNBC). In this study, a population including 2,236 primary and operable ANNBC patients, with a median age of 53, were included. All breast tumors were classified into five immunohistochemically defined subtypes-luminal A, luminal B, luminal human epidermal growth factor receptor 2 (HER2), HER2 overexpression, and triple negative. With a median follow-up of 73.6 months, the rate of relapse was lowest in luminal A (6.5 %) and highest in HER2 overexpression subtype (16.4 %). Multivariate analysis indicated that the risks of relapse and death were enhanced in HER2 overexpression and triple-negative (TN) subtypes, and these two subtypes were independent predictors of relapse and death. Luminal A patients with risk factors could benefit from chemotherapy in terms of relapse-free survival (RFS). The relapse rate of TN patients after chemotherapy with taxanes was lower compared with that after chemotherapy without taxanes. In conclusion, women with ANNBC were at higher risks of relapse and death if suffering from HER2 overexpression or TN diseases. Chemotherapy could reduce the recurrence rate of luminal A patients with risk factors. TN patients may benefit from adjuvant chemotherapy containing taxanes.

Activation of the unfolded protein response bypasses trastuzumab-mediated inhibition of the PI-3K pathway

HER2-positive breast cancer initially responds to trastuzumab treatment, but over time, resistance develops and rapid cancer progression occurs, for which various explanations have been proposed. Here we tested the hypothesis that induction of the unfolded protein response (UPR) could override HER2 inhibition by trastuzumab, leading to the re-activation of growth signaling and the activation of the downstream target Lipocalin 2 (LCN2). Trastuzumab significantly inhibited the basal expression of LCN2 in HER2 (+) SKBr3 human breast cancer cells. The induction of the UPR completely abrogated trastuzumab-mediated LCN2 downregulation, and, in fact caused an increase in transcription and secretion of LCN2 over baseline. Reduction of the UPR using 4-phenyl butyric acid (PBA) a chemical chaperone that ameliorates ER stress, restored trastuzumab-mediated inhibition. Inhibition of the PI3K/AKT signaling pathway in trastuzumab-treated/UPR-induced SKBr3 cells partially reduced the upregulation of LCN2. These results suggest that the UPR is a possible way to override the effect of trastuzumab in HER2(+) cancer cells.

Neurotrophin-3 modulates breast cancer cells and the microenvironment to promote the growth of breast cancer brain metastasis

Metastasis, which remains incompletely characterized at the molecular and biochemical levels, is a highly specific process. Despite the ability of disseminated cancer cells to intravasate into distant tissues, it has been long recognized that only a limited subset of target organs develop clinically overt metastases. Therefore, subsequent adaptation of disseminated cancer cells to foreign tissue microenvironment determines the metastatic latency and tissue tropism of these cells. As a result, studying interactions between the disseminated cancer cells and the adjacent stromal cells will provide a better understanding of what constitutes a favorable or unfavorable microenvironment for disseminated cancer cells in a tissue-specific manner. Previously, we reported a protein signature of brain metastasis showing increased ability of brain metastatic breast cancer cells to counteract oxidative stress. In this study, we showed that another protein from the brain metastatic protein signature, neurotrophin-3 (NT-3), has a dual function of regulating the metastatic growth of metastatic breast cancer cells and reducing the activation of immune response in the brain. More importantly, increased NT-3 secretion in metastatic breast cancer cells results in a reversion of mesenchymal-like (EMT) state to epithelial-like (MET) state and vice versa. Ectopic expression of NT-3 in EMT-like breast cancer cells reduces their migratory ability and increases the expression of HER2 (human epidermal growth factor receptor 2) and E-cadherin at the cell-cell junction. In addition, both endogenous and ectopic expression of NT-3 reduced the number of fully activated cytotoxic microglia. In summary, NT-3 appears to promote growth of metastatic breast cancer cells in the brain by facilitating the re-epithelialization of metastatic breast cancer cells and downmodulating the cytotoxic response of microglia. Most importantly, our results provide new insights into the latency and development of central nervous system macrometastases in patients with HER2-positive breast tumors and provide mechanistic rationale to target HER2 signaling for HER2-positive breast cancer brain metastasis.

Cancer in Pacific people in New Zealand

PURPOSE

To describe cancer incidence rates among Pacific people living in New Zealand from 1981 to 2004.

METHODS

Linked census-cancer registration data were used to calculate age-standardized cancer incidence rates for Pacific people. Both trends over time within Pacific people and differences in rates between Pacific and European/Other people in New Zealand were assessed.

RESULTS

Pacific rates were higher for cancers of the cervix, endometrium, gallbladder, lip, mouth and pharynx, liver, lung, ovary, pancreas, stomach, and thyroid, and lower for colorectal, bladder, and testicular cancers and melanoma. Differences were large, ranging from a 90 % lower rate of melanoma to over seven times higher rate of liver cancer compared to European/Other. Breast and prostate cancers were the commonest malignancies for Pacific women and men, respectively. Important changes for Pacific women over time include a 64 % decrease in cervical cancer incidence (ptrend = 0.02) and a 245 % increase for lung cancer (ptrend = 0.02), while men had a 366 % increase in prostate cancer (ptrend = 0.02).

CONCLUSIONS

Pacific people in New Zealand have a disproportionate cancer burden related to infectious diseases such as HPV and Hepatitis B. However, with escalating evidence for causal associations between diabetes, obesity, and physical inactivity with various cancers, the challenge will be to prevent these cancers from rising in Pacific people who have the highest rates of these conditions in New Zealand. Disparities for tobacco-related cancers support tobacco consumption as another important cause of cancer incidence disparity. Continued efforts are needed to reduce infectious disease and improve screening program uptake among Pacific people.

Analysis of matrix metalloproteinase-1 gene polymorphisms and expression in benign and malignant breast tumors

A guanine insertion polymorphism in matrix metalloproteinase-1 promoter (MMP-1 2G) is linked to early onset and aggressiveness in cancer. We determined the role of MMP-1 2G on MMP-1 expression and breast cancer severity in patients with breast diseases. We observed no significant difference in genotype distribution among different disease groups. However, MMP-1 expression was significantly higher in atypical ductal hyperplasia than in benign breast disease and in invasive breast cancer compared to in situ breast cancer. MMP-1 2G insertion polymorphism in the invasive group also correlated significantly with the expression of MMP-1 and breast cancer prognostic markers HER2 and P53.

The role of neoadjuvant (HER)2-targeted therapies in (HER)2-overexpressing breast cancers

Women receiving neoadjuvant systemic therapy for primary operable or inoperable breast cancer can potentially benefit in a number of ways, but the main advantage, which has been consistently demonstrated, is improved tumour resectability. Given the improvement in outcomes with the adjuvant use of trastuzumab in patients with early-stage breast cancer positive for the human epidermal growth factor receptor 2 (her2), questions have been raised about the use of trastuzumab in the neoadjuvant setting. The present paper reviews the currently available data and outlines suggestions from a panel of Canadian oncologists about the use of trastuzumab and other her2-targeted agents in the neoadjuvant setting.

The panel focussed on

the use of trastuzumab and other her2-targeted agents as neoadjuvant therapy in primary operable, locally advanced, and inflammatory breast cancer; and

possible choices of chemotherapeutic regimens with trastuzumab.

The suggestions described here will continue to evolve as data from current and future trials with trastuzumab and other her2-targeted agents emerge.

Implications of genomic instability in the diagnosis and treatment of breast cancer

Tumorigenesis is a multistep process resulting from DNA mutations observed at the DNA sequence and chromosome level as well as epigenetic changes, which affect expression of oncogenes and tumor suppressor genes. Breast cancer is a very heterogeneous disease that manifests in various histological and clinical types. Defects in the biological action of the genome driven by various alterations, such as point mutations and chromosomal rearrangements, lead to the collapse of genome integrity, uncontrolled cell proliferation and failure in apoptotic cell death. Detailed profiling of breast cancer-associated genomic alterations is indispensable for the design of individualized anticancer therapy, by suggesting diagnostic and prognostic criteria as well as the outcome of applied treatment. Among various directions of cancer research, identification of genomic alterations in breast cancer and their translation into clinical applications is at the forefront.

Prognostic significance of triple negative breast cancer at tumor size 1 cm and smaller

AIMS

The purpose of this study was to clarify the prognostic significance of triple-negative breast cancer (TNBC) with a tumor size ≤ 1 cm.

MATERIALS AND METHODS

Patients with primary operable breast cancer with a tumor size ≤ 1 cm were enrolled at Changhua Christian Hospital and National Cheng-Kung University Hospital. Tumors negative for ER, PR, and HER-2 were classified as TNBCs and compared with tumors with any receptor positivity (non-TNBC) for disease-free survival (DFS) and cancer-specific survival (CSS).

RESULTS

From 1995 to 2006, a total of 377 patients with tumor size ≤ 1 cm were enrolled. Compared with non-TNBC patients, TNBC patients with a tumor size ≤ 1 cm as a whole or in a lymph node-positive subgroup were not associated with a poorer 5-year DFS and CSS. In lymph node-negative patients (pT1a-bN0M0), TNBC was associated with a poorer 5-year CSS but not DFS. Compared with the hormone receptor-positive, HER-2-negative subgroup, TNBC was associated with poorer DFS and CSS. In the multivariate Cox regression hazard analysis, lymph node invasion was the most important cause of disease recurrence and cancer-specific death.

CONCLUSION

TNBC is very likely an independent risk factor in small (≤1 cm) node-negative invasive breast cancer. With tumors 1 cm and smaller, lymph node invasion was the single most important prognostic factor.

The quantitative detection of total HER2 load by quantum dots and the identification of a new subtype of breast cancer with different 5-year prognosis

Accurate classification is fundamental for breast cancer (BC) personalized care. Current BC classification based on the either traditional morphological staging or molecular signatures seems inefficient to reveal the"true"behaviors of invasive BC evolution. An appropriate approach combining the macro- and micro-pathologic information might be more useful academically as well as clinically. Here we explore a holistic approach by integrating a key molecular prognostic indicator of BC, HER2, with quantitative determination using quantum dots (QDs)--based nanotechnology and spectral analysis, and a key macropathologic indicator, tumor size, resulting a new indicator, total HER2 load. This indicator might better reveal BC heterogeneity and new subtypes of BC with different 5-year disease-free survival compared with current methods, which could be helpful in formulating a more personalized targeted therapy for BC. Furthermore, this mode integrating macro- and micro-pathological indicators might help gain new insights into invasive BC biological behaviors.

HER2/neu protein expression and fine needle breast aspiration from Argentinean patients with non-palpable breast lesions

The objective of this pilot project was to investigate whether the breast fine needle aspiration (FNA) technique is a useful tool for determining the increased risk of breast cancer in patients with non-palpable breast lesions. FNA is a minimally invasive technique that isolates mammary epithelial cells from breast cells in the suspicious region. In this study, two FNA samples were collected from 12 patients. The level of HER2/neu expression at the mRNA level (in serum) was measured in each patient. As gene amplification is characteristic of cancer cells and may assist in diagnosis and prognostic assessment, it is crucial that gene amplification of HER2/neu in patients with non-palpable breast lesions is compared to breast biopsy results. In serum, the level of HER2/neu was determined by ELISA assay. Gene amplification was determined by PCR and confirmed by IHC employing monoclonal ERRB2 in the FNA sample. The results indicate that FNA has a good correlation with breast biopsy. FNA combined with mammographic imaging is a strong tool for determining favorable treatment options for patients.

A risk stratification by hormonal receptors (ER, PgR) and HER-2 status in small (< or = 1 cm) invasive breast cancer: who might be possible candidates for adjuvant treatment?

As the use of screening mammography expands, the proportion of invasive breast cancer > or = 1 cm is increasing. The aims of this study were: (1) to identify risk factors for systemic metastases in patients with > or = 1 cm invasive breast cancer and (2) to investigate the patient groups at the greatest risk for metastases with such small tumors. Data were collected retrospectively from the breast cancer registry of our institution for patients with invasive breast cancer from October 1994 to December 2004. Of 4,036 patients who received curative breast cancer surgery, we identified 427 patients who had T1a or T1b breast cancer excluding 39 patients who received neoadjuvant chemotherapy. Ipsilateral axillary lymph node involvement was found in 13% (57/427) of patients at the time of surgery. A multivariate analysis was conducted in 370 (T1aN0, T1bN0) patients without lymph node involvement. In a Cox-regression model, HER-2 positive and triple negative (TN) groups were identified as independent risk factors to predict distant relapse-free survival (DRFS) [Hazard ratio (HR) 8.8, P = 0.003 for HER-2 positive group; HR 5.1, P = 0.026 for TN group] in T1bN0 tumors. Statistical significance was not maintained when the analysis was limited to T1aN0 tumors. Even though T1aN0 and T1bN0 tumors have a relatively low risk of systemic failure, antiHER-2-directed therapy for HER-2 group and new innovative adjuvant systemic treatment for TNBC patients with T1bN0 tumors should be considered. Prospective adjuvant trials are warranted in these subgroups of patients.

Should adjuvant trastuzumab be offered in very early-stage (pT1a/bN0M0) HER2-neu-positive breast cancer? A current debate

There are many controversies regarding the treatment of very early-stage (pT1a/bN0M0) breast cancer (BC), generally considered to have a very good prognosis. The debate is the benefit of an adjuvant treatment of HER2-neu (namely HER-2)-positive subcentimetric carcinoma with trastuzumab. Current guidelines do not suggest, with the highest level of evidence, whether trastuzumab should be administered after adjuvant chemotherapy in the treatment of high-risk pT1a/bN0M0 breast cancer. The major phase III trials that confirmed the benefit of adjuvant immunotherapy did not include small (<1 cm diameter) node-negative breast cancer. Several retrospective case series of HER-2-positive pT1a/bN0M0 carcinoma seem to demonstrate that they have a higher risk of relapse compared to the HER-2-negative counterpart. HER-2 also seems to confer an independent risk of recurrence and/or death in a multivariate analysis within large node-negative breast cancer populations. In particular, the best way to select higher-risk tumours that may achieve the best results from a trastuzumab-based therapy appears to be the in situ hybridization, which should follow the new recommended algorithm of the ASCO/CAP guidelines in case of doubtful results. According to the evidence that the survival of HER-2-positive BC can be improved with the introduction of trastuzumab respect to the HER-2-negative counterpart, there is today less uncertainty about the curative role of anti-HER-2 therapy in very early disease.

The role of HER2-targeted therapies in women with HER2-overexpressing metastatic breast cancer

The role of targeted therapies in the treatment of women with breast cancer has been rapidly evolving. Trastuzumab, a monoclonal antibody against the human epidermal growth factor receptor 2 (HER2), was the first HER2-targeted therapy that clearly demonstrated a significant clinical benefit for women with HER2-overexpressing metastatic breast cancer (mbc). However, in recent years it has become increasingly apparent that, when trastuzumab is used in the first-line setting in combination with chemotherapy, most women eventually develop progressive disease. Determining the treatment options available to women who have progressed while on trastuzumab therapy has been hampered by a paucity of high-quality published data. In addition, with the standard use of trastuzumab in the adjuvant setting (for eligible HER2-positive patients), the role of anti-HER2 agents for patients who experience a breast cancer relapse has become a clinically relevant question. This manuscript reviews current available data and outlines suggestions from a panel of Canadian oncologists about the use of trastuzumab and other HER2-targeted agents in two key mbc indications:Treatment for women with HER2-positive mbc progressing on trastuzumab (that is, treatment beyond progression)Treatment for women with HER2-positive mbc recurring following adjuvant trastuzumab (that is, re-treatment)The suggestions set out here will continue to evolve as data and future trials with trastuzumab and other HER2-targeted agents emerge.