Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer (MBC) was published in 2021. A special, hybrid guidelines meeting was convened by ESMO and the Korean Society of Medical Oncology (KSMO) in collaboration with nine other Asian national oncology societies in May 2022 in order to adapt the ESMO 2021 guidelines to take into account the differences associated with the treatment of MBC in Asia. These guidelines represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with MBC representing the oncological societies of China (CSCO), India (ISMPO), Indonesia (ISHMO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO). The voting was based on the best available scientific evidence and was independent of drug access or practice restrictions in the different Asian countries. The latter were discussed when appropriate. The aim of these guidelines is to provide guidance for the harmonisation of the management of patients with MBC across the different regions of Asia, drawing from data provided by global and Asian trials whilst at the same time integrating the differences in genetics, demographics and scientific evidence, together with restricted access to certain therapeutic strategies.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with early breast cancer: a KSMO-ESMO initiative endorsed by CSCO, ISMPO, JSMO, MOS, SSO and TOS

In view of the planned new edition of the most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of primary breast cancer published in 2015, it was decided at the ESMO Asia Meeting in November 2018, by both the ESMO and the Korean Society of Medical Oncology (KSMO), to convene a special face-to-face guidelines meeting in 2019 in Seoul. The aim was to adapt the latest ESMO 2019 guidelines to take into account the ethnic and geographical differences associated with the treatment of early breast cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with early breast cancer representing the oncology societies of Korea (KSMO), China (CSCO), India (ISMPO) Japan (JSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices, and the drug availability and reimbursement situations, in the individual participating Asian countries.

Abstract P4-06-21: MEK inhibitor cobimetinib induces immunogenic cell death and immune-modulatory effects in triple negative breast cancer

Background

Triple-negative breast cancer (TNBC) has been associated with a robust tumor immune infiltrate. Tumor-infiltrating lymphocytes (TILs) in TNBC have been demonstrated a prognostic value. The mitogen-activated protein kinase (MAPK) signaling pathway have been shown to regulate the immune response with the production of immunomodulatory cytokines, such as TNFα, interleukin (IL)-1, IL-10, and IL-12. Clinical studies have shown that the high expression level of Extracellular signal–related kinase (ERK), a member of the MAPK pathway, correlates with shorter survival in TNBC patients. Accordingly, ERK is a potential target for anti-tumor and cancer immunotherapy. In this study, we aimed to investigate a MEK inhibitor cobimetinib and elucidate whether the MEK/ERK pathway is implicated in immunogenic cell death (ICD) and/or other immunomodulatory effects.

Methods

Mouse TNBC cell line 4T1 was treated with cobimetinib. The cell viability and cell apoptosis were determined by MTT assay and flow cytometric analysis. Cobimeinib-induced damage-associated molecular patterns (DAMPs), such as such as cell-surface translocation of calreticulin (CRT), extracellular release of ATP, and increase in high-mobility group box protein B1 (HMGB1) release from dying tumor cells, were examined by immunoblotting and flow cytometric analysis. Further, the molecular mechanisms involving cobimetinib-induced cell death were examined by Immunoblotting. Last but not least, establishment of 4T1 animal model in immunocompetent and immunodeficient mice was conducted to investigate the efficacy of cobimetinib in restoration of immunosurveillance and cancer metastasis in vivo.

Results

The results showed that cobimetinib impaired cell proliferation and induced cell apoptosis in a dose-dependent manner in 4T1 cells. Importantly, cobimetinib treated 4T1 cells elicited ICD, by increasing HMGB1 and ATP release, and by promoting membrane exposure of CRT. The molecular mechanisms involved in cobimetinib-induced DAMPs were partially through the downregulation of p-ERK expression. Moreover, cobimetinib induced processing of procaspase-3 and -8 in 4T1 cells, thereby resulting in caspase activation. In addition, 4T1 tumor bearing immunocompetent mice treated with cobimetinib showed reduced size of primary tumors, fewer lung metastases and increased survival. In addition, we noticed that the tumor-suppressive effects of cobimetinib were much stronger in immunocompetent mice than in immunodeficient mice, evident by distinct mice survival in drug-treated mice. Flow cytometric analysis of murine splenocytes also revealed that cobimetinib treatment increased total number of CD8+ T cells, dendritic cell maturation, and suppressed the number of Myeloid-derived suppressor cells (MDSCs) in immunocompetent mice.

Conclusions

Our findings suggested that the MEK/ERK inhibitor cobimetinib induces ICD in vitro and exerts additional immune-modulatory effects in immunocompetent TNBC mice model. Our study highlights the possibility for the use of cobimetinib as an ICD inducer and immunomodulator for therapeutic intervention in TNBC.

Keywords

Cobimetinib, immunogenic cell death, MAPK, ERK phosphorylation, immune regulation

Citation Format: Liu C-Y, Lau K-Y, Chen J-L, Chu P-Y, Huang C-T, Wang W-L, Lien P-J, Tseng L-M. MEK inhibitor cobimetinib induces immunogenic cell death and immune-modulatory effects in triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-21.

Abstract P5-21-13: Olaparib monotherapy versus chemotherapy for patients with HER2-negative metastatic breast cancer and a germline BRCA mutation: Asian subgroup analysis from the phase III OlympiAD trial

Background

In the Phase III OlympiAD trial (NCT02000622, D0819C00003), olaparib (Lynparza™) showed a significant progression-free survival (PFS) improvement compared with chemotherapy treatment of physician's choice (TPC) in patients (pts) with metastatic breast cancer (mBC) and a germline BRCA mutation (gBRCAm) (Robson et al. NEJM 2017). Here, we present data from a subgroup analysis of Asian pts. It is not yet known whether Asian pts, in comparison with the global patient population, may experience instances of differential toxicity with olaparib therapy.

Methods

OlympiAD, an open-label, multicenter, Phase III trial, randomized (2:1) pts with HER2-negative mBC and a gBRCAm to olaparib tablets (300 mg twice daily) or single-agent TPC (21-day cycles of capecitabine, eribulin or vinorelbine). Pts must have received ≤2 lines of chemotherapy for mBC and prior anthracycline and taxane in the adjuvant, neo-adjuvant or metastatic setting. Primary endpoint was PFS by blinded independent central review (BICR). Region (Asia, Europe, North America, South America) was a pre-defined subgroup for PFS.

Results

The Asian subgroup analysis included pts randomized at centers in China, Japan, Korea and Taiwan. Of 87 Asian pts randomized (median age 46 years), 86 received study treatment (n=59, olaparib; n=27, TPC). In the olaparib group, 29/59 (49%) had estrogen receptor positive (ER+) and/or progesterone receptor positive (PR+) tumors, and 30/59 (51%) had triple negative breast cancer (TNBC). In the TPC group, 13/28 (46%) had ER+/PR+ tumors and 15/28 (54%) had TNBC. The primary endpoint, PFS by BICR, favored olaparib with a hazard ratio (HR) of 0.53 (95% confidence interval [CI] 0.29–0.97; median 5.7 vs 4.2 months; 77% maturity), and was supported by investigator-assessed PFS (HR 0.29, 95% CI 0.16–0.55). In the overall OlympiAD study population (N=302), the PFS by BICR favored olaparib with a HR of 0.58 (95% CI 0.43–0.80; P=0.0009). Within the Asian subgroup, objective response rate (ORR) (RECIST) was 64% for olaparib versus 38% for the TPC group. Time to second progression, PFS2, was longer for pts receiving olaparib versus TPC (HR 0.43, 95% CI 0.22–0.84; 57% maturity). Grade ≥3 adverse events (AEs) occurred in 46% and 59% of pts receiving olaparib and TPC, respectively. The most common grade ≥3 AE was anemia (olaparib, 20%; TPC, 15%). In both treatment groups, 7% of pts discontinued study treatment due to AEs (n=4, olaparib; n=2, TPC). The tolerability profile of olaparib between the subgroup of Asian pts and the overall OlympiAD population will be examined in our data presentation.

Conclusion

Olaparib demonstrated an efficacy benefit compared with TPC in pts with HER2-negative mBC and a gBRCAm in this subgroup analysis of Asian pts from the Phase III OlympiAD trial. Discontinuation rates due to toxicity were low, highlighting that olaparib was generally well-tolerated. The efficacy of olaparib within the subgroup of Asian pts was consistent with that shown for the full OlympiAD dataset; consistent hazard ratios were shown in favor of olaparib using the primary endpoint of PFS by BICR, and for the key secondary endpoints of PFS by investigator assessment, PFS2, and ORR.

Citation Format: Im S-A, Xu B, Li W, Robson M, Ouyang Q, Yeh D-C, Iwata H, Park Y-H, Sohn JH, Tseng L-M, Goessl C, Wu W, Runswick S, Masuda N. Olaparib monotherapy versus chemotherapy for patients with HER2-negative metastatic breast cancer and a germline BRCA mutation: Asian subgroup analysis from the phase III OlympiAD trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-13.

Abstract P3-05-19: Regorafenib induces immunogenic cell death via p-stat3 inhibition in triple negative breast cancer cells

Background

Metastatic triple-negative breast cancer (TNBC), despite being chemo-sensitive, remains poor prognostic. Rising data have suggested some anti-cancer agents exert immunostimulatory activities through inducing immunogenic cell death (ICD). ICD can be detected by presence of damage-associated molecular patterns (DAMPs) such as cell surface exposure of calreticulin (CRT), secretion of ATP, and increase in high-mobility group box protein B1 (HMGB1) release from dying tumor cells. Signal transducer and activator of transcription 3 (STAT3) activity is activated in TNBC and regorafenib has been shown to suppress p-STAT3 signal. We tested whether regorafenib induces ICD in TNBC.

Methods

Mice TNBC cell line 4T1 cells were treated with regorafenib and cell survival was examined by MTT assay and flow cytometric analysis. DAMPs were examined by western blot analysis, immunofluorescence microscopy and luminescent assay. The correlation between regorafenib-mediated ICD and STAT3 inhibition were validated in ectopic STAT3 transfected 4T1 cells. Moreover, we investigated the combination strategies of regorafenib with immune checkpoint blockade in syngeneic 4T1 tumor bearing mice (TNBC animal model) with treatment of regorafenib or mPD1 treatment alone/ combination of mPD1 and regorafenib.

Results

The results demonstrated that regorafenib reduced cell survival and induced cell apoptosis in a dose-dependent pattern in 4T1 cell line. Regorafenib induced ICD, as evidenced by it triggered the release of HMGB1 and ATP, as well as the exposure of CRT on the cell surface. Moreover, regorafenib-induced ICD was attenuated by ectopic expression of STAT3 (thus increased phosphorylation of STAT3) in STAT3-overexpressed 4T1 cells. Last but not the least, we observed 4T1 tumor bearing mice with treatment of regorafenib alone, or anti-PD1 monoclonal antibody (mAb) alone, or in combination of regorafenib and anti–PD1 mAb resulted in reduced size of primary tumors, increased survival and fewer lung metastases. Flow cytometric analysis revealed regorafenib treatment increased activated CD8+ T cells, increased antigen-presenting dendritic cells, and suppressed regulatory T cells (Tregs) in mice spleen.

Conclusions

Regorafenib induced ICD in 4T1 cells via the inhibition of p-STAT3. Regorafenib also promoted CD8+ T cells activation and antigen presenting ability of dendritic cells, and suppressed Tregs. Our study demonstrated regorafenib as an ICD-inducer and immunomodulator and its potential combination with immune checkpoint blockade in TNBC.

Citation Format: Liu C-Y, Lau K-Y, Huang T-T, Chen J-L, Chu P-Y, Huang C-T, Wang W-L, Tseng L-M. Regorafenib induces immunogenic cell death via p-stat3 inhibition in triple negative breast cancer cells [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-19.

Abstract P5-08-29: Trends in age shifting and decreasing mortality of female breast cancer in Taiwan with emerging molecular subset of unmet medical need: A 30-year cohort observation from Taipei Veterans General Hospital

Background: Over the past thirty years, Taiwan has become a modern Asian country with an increasing incidence of breast cancer. We hypothesized that the epidemiological and demographic features of breast cancer patients in Taiwan have changed by using cohort study based on data collected from past three decades. However, despite improvement in prognosis of most breast cancer subtypes, we found that one subtype of luminal B type her-2 negative did not show significant improvement in overall survival and disease free survival from our cohort comparison.

Methods:Patients with primary breast cancer diagnosed between 1979 and 2010 were identified from the cancer registry database at Taipei Veterans General Hospital, Taiwan. Three periods of time were divided (1979 to 1988, 1989 to 1998, and 1999 to 2010) and compared to determine the epidemiological changes in female breast cancer in Taiwan.

Results:From 1979 to 2010, data from a total of 8417 breast cancer patients were collected. The ratio of breast cancer patients aged ≤ 35 years decreased from 13.3% in 1979 to 1988, to 10.6% in 1989 to 1998, and to 5.2% during 1999 to 2010.In the period of 1979 to 1988, 55.7% of patients were aged ≤ 50 years, and in the period of 1999-2010, only 45.7% of breast cancer patients were aged ≤ 50 yrs.From 1979-1988, ductal carcinoma in situ (DCIS) was rarely diagnosed (0.2%), and the ratio of patients who initially presented with DCIS increased to 2.9% in 1989 to 1998, and to 11.8% in 1999 to 2010. Patients diagnosed with stage I breast cancer also increased from 16.7% in 1979-1988 to 28.4% in 1999-2010.Patients diagnosed and treated in 1999-2010 (5-year overall survival: 81.7%) had a much better outcome than patients treated in 1979-1988 (5-year overall survival: 66.3%). Cohort comparison of survival outcome for breast cancer subtypes in luminal A type, luminal B type Her-2 positive, luminal B type Her-2 negative, Her-2 type, and triple negative type disclosed no improvement in both 5-year survival and 5-year disease free survival outcomes in the subtype of luminal B type Her-2 negative.

Conclusions: The epidemiological features of female breast cancer in Taiwan have changed over the past thirty years. A molecular subtype of luminal B type Her-2 negative was characterized as an emerging group with unmet medical need.

Citation Format: Lin Y-S, Tseng L-M, Liu C-Y. Trends in age shifting and decreasing mortality of female breast cancer in Taiwan with emerging molecular subset of unmet medical need: A 30-year cohort observation from Taipei Veterans General Hospital [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-29.

Abstract P3-07-12: Targeting SET to disrupt oncogenic CIP2A feedforward loop shows therapeutic potential in triple negative breast cancer cells

Triple-negative breast cancer (TNBC) remains a difficult-to-treat cancer with a need for new therapeutic target. The serine/threonine protein phosphatase 2A (PP2A) functions as a tumor suppressor and enhancing PP2A activity by PP2A-activating agents is a promising anti-cancer approach. There are intrinsic inhibitors of PP2A including SET and cancerous inhibitor of protein phosphatase 2A (CIP2A), both of which interact and inhibit PP2A, playing oncogenic roles. Here we studied the tumor promoting effects of SET and CIP2A and discovered a potent linkage between SET and CIP2A-feedforward pathway in TNBC. We further demonstrated the anticancer activity of a novel SET/PP2A protein-protein interaction inhibitor, TD-19. Analyzing TCGA and clinical TNBC cohort, SET and CIP2A overexpressions correlated with worse survival in TNBC patients. Tumors from TNBC patients with higher SET expressions were significantly associated with higher Ki-67 and p-Akt expressions.

Table 1 High SET H score (>180) N=21Low SET H score (<=180) N=70P valueAge [median (range)]54 (36-69)56 (30-88)0.185Primary tumor (T)  0.99916 (28.6)21 (30.0) 213 (61.9)43 (61.4) 3-42 (9.5)6 (8.6) Nodal status (N)  0.12208 (38.1)45 (64.3) 17 (33.3)12 (17.1) 2-36 (28.6)13 (18.6) Stage  0.49812 (9.5)14 (20.0) 213 (61.9)41 (58.6) 36 (28.6)15 (21.4) Grade  0.78311 (4.8)4 (5.7) 28 (38.1)21 (30.0) 312 (57.1)45 (64.3) Tumor necrosis13 (61.9)40 (57.1)0.698Lymphovascular invasion6 (30.0)15 (21.4)0.549CIP2A [median (range)]120 (40-220)100 (30-300)0.253p-Akt [median (range)]200 (65-300)160 (20-300)0.011Ki-67 [median (range)]30 (0-87.5)22.5 (0-85)0.004

Consistent with clinical results, TNBC cells with ectopic overexpression of SET and CIP2A showed significantly increased cell proliferation, migration and invasion, and colony-formation. Moreover, TD-19 demonstrated anti-tumor effects through inhibiting SET-PP2A interaction and CIP2A/PP2A/pAkt-mediated pathway in vitro and in a TNBC xenograft mouse model. Mechanistically, TD19 downregulated CIP2A mRNA via affecting Elk-1 amount in nucleus thereby decreased the binding of Elk-1 to the CIP2A-promotor. Furthermore, given that ERK-dependent phosphorylation of Elk-1 is essential for Elk-1 shuttling from cytoplasm to nucleus and PP2A controls ERK activation (phosphorylation), we hypothesized a CIP2A-feedforward loop consisting of pERK/pElk-1/CIP2A/PP2A may contribute to the oncogenesis in TNBC. Indeed, with TD19 treatment, SET/PP2A interaction was inhibited, PP2A activity was increased, and expressions of the CIP2A-feedforward loop members were suppressed. This loop was validated by knockdown of PP2A and ectopic expression of Elk-1. In addition, ectopic expression of SET increased pAkt, pERK, pElk-1 and CIP2A expressions, suggesting a positive linkage between SET and CIP2A feedforward signaling. Importantly, combining TD-19 with cisplatin demonstrated enhanced anti-proliferative and apoptotic effects in association with CIP2A downregulation in vitro. In summary, we discover a novel oncogenic CIP2A-feedforward loop in TNBC and targeting SET to disrupt oncogenic CIP2A feedforward loop shows therapeutic potential in TNBC.

Citation Format: Huang T-T, Liu C-Y, Chen Y-T, Chu P-Y, Huang C-T, Wang W-L, Wu C-Y, Shiau C-W, Chen K-F, Tseng L-M. Targeting SET to disrupt oncogenic CIP2A feedforward loop shows therapeutic potential in triple negative breast cancer cells [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-07-12.

Abstract OT1-04-03: Randomized phase II study of induction bevacizumab, etoposide and cisplatin followed by whole brain radiotherapy (WBRT) versus WBRT alone in breast cancer with untreated brain metastases (A-PLUS)

Background For breast cancer (BC) patients with brain metastases (BM) who are not suitable for surgery/radiosurgery, whole brain radiotherapy (WBRT) remained the only standard treatment. Recently, we have demonstrated that bevacizumab preconditioning followed by etoposide and cisplatin (BEEP) is a highly effective treatment for BM of BC progressing from WBRT (Clin Cancer Res. 2015;21(8):1851). The CNS objective response rate is 77.1% according to volumetric criteria, and 60% according to RECIST 1.1. It has been demonstrated that enlarged brain tumor size is a predictor of WBRT failure. We hypothesized that, for BC with BM, induction BEEP treatment could decrease the size of brain metastases and thereby enhance effectiveness of WBRT. Methods This is a Phase II, randomized, open-labelled study (NCT02185352). Key inclusion criteria: BC with measurable brain metastatic tumor who had not received WBRT and not suitable for surgery or radiosurgery; KPS ≥30%. Key exclusion criteria: patients who had leptomeningeal metastases; history of disease progression during prior cisplatin treatment. In the experimental arm, patients will be treated by induction BEEP for three cycles followed by WBRT. In the control arm, patients will receive upfront WBRT for brain metastases. The BEEP regimen consist of bevacizumab (15 mg/kg) on Day 1 and, with a 1 day window period, followed by etoposide (70 mg/m2/day, Day 2 to Day 4) and cisplatin (70 mg/m2, Day 2), in a 21-day cycle. Stratification is based on the Graded Prognostic Assessment (GPA) score. Primary endpoint: brain-specific progression free survival (PFS) according to RECIST 1.1; key secondary endpoint: the 2-month brain-specific objective response rate (BS-ORR) of BEEP alone and WBRT alone. Other secondary endpoints include overall survival, extra-CNS tumor PFS, safety, time-to-improvement of neurological function,brain-specific PFS according to volumetric criteria, and BS-ORR. Approximately 126 patients will be 2:1 randomized. Multi-center recruitment is ongoing. To our knowledge this is the first randomized trial investigating a targeted therapy plus chemotherapy as induction regimen followed by WBRT as first line treatment for BC with BM.

Citation Format: Lu Y-S, Tseng L-M, Yu J-C, Rau K-M, Chao T-Y, Chen S-C, Chiu C-F, Chang Y-C, Chen TW-W, Lin C-H, Chang D-Y, Chao T-C, Huang S-M, Huang C-S, Cheng A-L. Randomized phase II study of induction bevacizumab, etoposide and cisplatin followed by whole brain radiotherapy (WBRT) versus WBRT alone in breast cancer with untreated brain metastases (A-PLUS) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-04-03.

Abstract P1-09-04: Proliferation and p21 refine risk of relapse in residual disease after HER2-directed therapies

Background: Patients (pts) with residual disease (RD) after neoadjuvant therapy are at higher risk of relapse. We investigated whether biomarkers assessed at surgery in patients pts with RD in the NeoSphere study were informative for risk of distant event free survival (DEFS)

Methods: In NeoSphere 417 HER2+ pts were randomized to neoadjuvant TD, TPD, TP or PD (T=trastuzumab, P=pertuzumab, D=docetaxel), and received FAC/FEC and trastuzumab after surgery. 296 pts had RD. Affymetrix derived gene expression profiles (GEPs) were available at surgery for 201 pts (67.9%). 176 pts (60.1%) had paired samples before and after treatment with available GEPs. We investigated the prognostic value of proliferation evaluated by Mitosis Kinase Score (MKS) (Bianchini G Cancer Res 2010), and performed a gene discovery for association between gene expression at surgery and DEFS.

Results: MKS as continuous marker was associated with significantly higher risk of relapse when assessed at surgery (HR 1.80 [1.23-2.65]; p=0.002), but not before treatment (HR 1.50 [0.80-2.78]; p=0.20). In paired samples, there was an average decrease (p=9.2E-11) of MKS after treatment, which was prominent in ER+ and chemotherapy-containing arms. In ER- and TP arm there were cases of increase and of decrease of MKS. In ER+ the 5 years DEFS was 94.3% in the Low/Int MKS tertiles group (pooled) vs 70.5% in the High MKS tertile group (HR 5.41 [1.87-15.6]; p=0.002). In ER-, the 5 years DEFS was 85.0% in the Low/Int vs 64.1% in the High group (HR 2.89 [1.08-7.76]; p=0.035). Notably, MKS at surgery after the two monoclonal alone was also prognostic.

In the gene discovery approach only the expression of CDKN1A (p21)at surgery was associated with DEFS after correction for false discovery rate (FDR=0.01). Pre-treatment p21 was not associated with DEFS. Paired comparison showed significant upregulation of p21 in all patients, treatment arms and ER groups. The Int/High p21 tertiles group (pooled) had lower risk of recurrence than the low tertile in ER+ (HR 4.31 [1.60-11.6]; p=0.004) and in ER- (HR 5.81 [1.87-18.1]; p=0.002) groups. p21 in TP arm was also prognostic. MKS and p21 expression provided independent prognostic information and remained significant after correction for clinico-pathological variables (nodes and T stage) and tumor-infiltrating lymphocytes. Combining the two markers, there was a group at very low risk (Low/Int MKS and Int/High p21) and one at high risk (High MKS and Low p21). The other tertiles combinations had intermediate risk. In ER+, the 5 yrs DEFS was 94.9% in the low risk group and 52.9% in the high risk (p=1.9E-05). In ER-, the 5 yrs DEFS was 96.5% in the low and 45.5% in the high risk group (p=0.001).The markers' combination was also prognostic in the two monoclonal only arm.

Conclusions: Proliferation (MKS) and p21 expression are modulated by trastuzumab and/or pertuzumab regimens. Tumors with high MKS and low p21 in RD after neoadjuvant therapy defined a group at very high risk of relapse. Tumors with low/int proliferation and int/high p21 had low risk of recurrence similar to that of patients achieving pCR. Whether the pharmacodynamic modulation of p21 could be used as surrogate marker of long term benefit in patients with RD deserves additional investigation.

Citation Format: Bianchini G, Pienkowski T, Im Y-H, Bianchi GV, Tseng L-M, Liu M-C, Lluch A, de la Haba-Rodríguez J, Semiglazov V, Oh D-Y, Poirier B, Pedrini JL, Valagussa P, Gianni L. Proliferation and p21 refine risk of relapse in residual disease after HER2-directed therapies [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-04.

Abstract P4-13-27: A phase Ib dose de-escalation study of combined tamoxifen and goserelin acetate with alpelisib (BYL719) or buparlisib (BKM120) in premenopausal patients with HR+/HER2– locally advanced or metastatic breast cancer

Background: Growing evidence suggests that concomitant inhibition of the phosphatidylinositol 3-kinase (PI3K)/AKT/mammalian target of rapamycin pathway could enhance and extend the clinical benefit of endocrine therapies in hormone receptor-positive (HR+) metastatic breast cancer (mBC). In this Phase Ib study (NCT02058381), alpelisib (a p110α-selective inhibitor) or buparlisib (a pan-PI3K inhibitor) was combined with tamoxifen and goserelin acetate in premenopausal women with mBC, a more prevalent patient population in Asian vs Western countries.

Methods: Premenopausal women with HR+/human epidermal growth factor receptor 2-negative (HER2–) locally advanced or mBC and no prior endocrine therapy for metastatic disease were recruited in Taiwan, Republic of Korea, and Thailand. Patients (pts) received tamoxifen (20 mg once daily [QD]) and goserelin (3.6 mg Q28D) with either alpelisib (350 mg QD; Group 1) or buparlisib (100 mg QD; Group 2) on a continuous dosing schedule in 28-day cycles. The primary objective was to define the recommended Phase II dose (RP2D) for each combination, based on dose-limiting toxicities (DLTs) observed during Cycle 1, using a dose de-escalation design. Secondary objectives included pharmacokinetics, safety and tolerability (per Common Terminology Criteria for Adverse Events v4.03), efficacy (per Response Evaluation Criteria In Solid Tumors v1.1), and impact on quality of life.

Results: As of February 2, 2015, 12 pts, all Asian, have been treated in the first cohort. In Group 1, 6 pts with a median age of 43 were treated with alpelisib (350 mg starting dose), and no DLTs were observed in Cycle 1. In Group 2, 6 pts with a median age of 47 were treated with buparlisib (100 mg starting dose), and 1 DLT of Grade (G) 3 alanine aminotransferase/aspartate aminotransferase elevation was observed. In Group 1, significant toxicities included hypokalemia (G3: 1 pt), rash (G3: 1 pt; G1/2: 2 pts), anemia (G3: 1 pt), leukopenia (G3: 1 pt), and infections (G3: 1 pt; G1/2: 1 pt); no G4 toxicities were reported. In Group 2, significant toxicities included liver toxicity (G4: 1 pt; G3: 1 pt; G1/2: 2 pts), psychiatric disorders (G4: 1 pt; G3: 1 pt; G1/2: 1 pt), rash (G3: 1 pt; G1/2: 2 pts), hypertension (G3: 1 pt; G1/2: 1 pt), and hyperglycemia (G3: 1 pt). No pts in Group 1, and 5/6 pts in Group 2, have discontinued treatment due to adverse events (AEs). Median treatment duration was 110 days in Group 1 and 71 days in Group 2.

Conclusions: The combination of alpelisib (350 mg) with tamoxifen and goserelin resulted in a manageable toxicity profile. Meanwhile, the same combination with full-dose buparlisib (100 mg) was less well tolerated; despite the appearance of only one DLT during Cycle 1, the majority of pts subsequently stopped treatment due to AEs. An expansion phase is ongoing, and results will be integrated with safety, tolerability, and efficacy results for the first 15 pts enrolled in each group. PIK3CA status at baseline will also be assessed.

Citation Format: Lu Y-S, Ro J, Tseng L-M, Chao T-Y, Chitapanarux I, Valenti R, Canatar A, Salomon H, Park YH. A phase Ib dose de-escalation study of combined tamoxifen and goserelin acetate with alpelisib (BYL719) or buparlisib (BKM120) in premenopausal patients with HR+/HER2– locally advanced or metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-27.

Abstract OT1-4-04: A phase II randomized, open-label, neoadjuvant study of LCL161, an oral antagonist of inhibitor of apoptosis proteins, in combination with paclitaxel in patients with triple-negative breast cancer

Background: Inhibitor of apoptosis proteins (IAPs) negatively regulate cell death through a variety of mechanisms. LCL161 is an oral small-molecule antagonist of IAPs that has demonstrated single-agent activity and synergy with paclitaxel in breast cancer tumor models. In preclinical studies, a gene expression signature has been shown to enrich for response to LCL161. The recommended dose of LCL161 1800 mg once weekly has demonstrated preliminary antitumor activity with paclitaxel in an ongoing Phase Ib study in patients with breast cancer.

Trial design: This is a Phase II, randomized, open-label study of neoadjuvant paclitaxel with or without LCL161 in women with operable, newly diagnosed triple-negative breast cancer (NCT01617668). Key inclusion criteria include women with histologically confirmed diagnosis of triple-negative breast cancer; clinical stages T2, N0–N2, M0; candidates for mastectomy or breast-conserving surgery; ECOG performance status ≤1; known status of the LCL161-predictive gene expression signature (positive and negative gene signature is a stratification factor); and adequate bone marrow and organ function. Key exclusion criteria are: bilateral or inflammatory breast cancer; locally recurrent breast cancer; patients currently receiving systemic therapy for any other malignancy, or having received systemic therapy for a malignancy in the preceding 3 months; impaired gastrointestinal function that may affect the absorption of LCL161; or uncontrolled cardiac disease.

Patients are randomized 1:1 to receive paclitaxel IV (80 mg/m2 weekly) with or without oral LCL161 (1800 mg once weekly) for 12 weeks (corresponding to 4 treatment cycles). Each treatment arm is stratified 1:1 based on gene expression signature status (positive or negative).

Endpoints: The primary endpoint is pathologic complete response (pCR), defined as the absence of invasive disease in the breast after 12 weeks of therapy, analyzed separately in the gene expression signature positive and negative groups. The key secondary endpoint is the pCR rate following treatment with LCL161 and paclitaxel in gene expression signature-positive or -negative tumors. Other secondary endpoints include: pCR rate in breast after 12 weeks of therapy in the full study population, and in patients with gene expression signature-positive and -negative tumors treated with paclitaxel alone; pCR rate in breast, regional nodes and axilla; biomarker evaluation including caspase 3 activation in tumor; safety; and pharmacokinetics of LCL161.

Statistical methods: pCR analysis will be performed according to treatment group and gene expression signature status. An absolute increase of at least 7.5% in pCR rate of the experimental arm over the control arm will be considered as evidence of clinically relevant efficacy.

Target accrual: Approximately 200 patients will be randomized into this study. Recruitment is ongoing across America, Europe, and Asia.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-4-04.

Distant metastasis in triple-negative breast cancer

Triple-negative breast cancer (TNBC) relapses more frequently than hormone receptor-positive subtypes and is often associated with poor outcomes. This retrospective study reviewed the pattern of distant metastasis with regard to survival in patients with TNBC. A total of 205 TNBC patients were analyzed. TNBC patients with lung metastases had the longest median post-metastatic OS (with 95% confidence interval) of 16.6 (10.3-22.9) months, followed by the bone, 16.3 (11.7-20.8) months, the liver, 8.9 (3.5-14.4) months, the pleura, 7.5 (2.8-12.3) months, and the brain, 4.3 (0.6-8.0) months. Kaplan-Meier plots indicated that TNBC patients with metastatic spread to brain, liver, and pleural had poorer post-metastatic OS rate than patients with lung metastases (p = 0.001, 0.004, and 0.029, respectively). Moreover, brain and liver metastases correlated significantly with poorer post-metastatic OS as compared to bone metastasis (p = 0.004 and 0.011, respectively). Route of first metastasis correlated significantly with survival of TNBC patients with brain metastases being the poorest survival indicator, followed by metastases to liver, pleura, bone, and lung.

Abstract P3-12-10: Age, breast cancer subtype approximation and the risk of the development of brain metastasis in breast cancer patients

Purpose: Biological subtypes and age were well-known risk factors associated with the development of brain metastasis in breast cancer patients. However the impact of each biological subtype in different age group was less discussed.

Patient and methods: Patients with invasive ductal carcinoma of breast diagnosed from January 2000 to December 2009 were divided by age of diagnosis into three groups: age below 35, age from 36–59 and age above 60. Four biological subtypes of breast cancer subtype were approximated as luminal A, luminal B, HER2 enriched and triple negative breast cancer by intergrading status of estrogen receptor, progesterone receptor and HER2 and grade.

Result: With a median follow-up time of 54.2 months, there were 164 patients (7.3%) among the 2248 enrolled patients developed brain metastasis. Patients with HER2 enriched [hazard ratio (HR) 2.53; 95% confidence interval (CI): 1.57–4.07, p < 0.0001)], triple negative breast cancer (HR 4.42; 95% CI: 2.86–6.85, p < 0.0001) and diagnosed age younger than 35 years-old (HR 2.09; 95% CI: 1.15–3.81, p = 0.016) were strongly associated with higher incidence of brain metastasis. Table 1 showed the important characteritics according to different age group.

Abstract P6-11-05: Novel sorafenib-derivatives induce apoptosis in breast cancer cells through STAT3 inhibition

Background: STAT3 has emerged as a novel potential anti-cancer target and its signaling is constitutively activated in various cancers including breast cancer. Our previous study has shown that STAT3 is a major kinase-independent target of sorafenib in HCC. (J Hepatol. 2011). Moreover, recent evidence has shown that p-STAT3 can be down-regulated by phosphatases, such as SHP-1 tyrosine phosphatase. We have designed and synthesized a series of sorafenib analogues devoid of sorafenib's kinase inhibition activity, some of which showed stronger p-STAT3 inhibition and apoptosis-inducing effects than sorafenib in HCC cells (Eur J Med Chem. 2011). Here, we tested the efficacy of novel sorafenib derivatives, SC-1 and SC-43, in breast cancer cells and examined the drug mechanism.

Methods: Six Breast cancer cell lines were used for in vitro studies. Cell viability was examined by MTT-assay. Apoptosis was examined by both flow cytometry and Western blot. Signal transduction pathways in cells were assessed by Western Blot. SHP-1 activity was measured by a phosphatase activity assay kit. In vivo efficacy of Sorafenib, and sorafenib derivatives were tested in xenografted nude mice.

Results: Sorafenib, SC-1 and SC-43 induced apoptosis in association with down-regulation of P-STAT3 and its downstream proteins Cyclin D1 and survivin in a dose-dependent manner in breast cancer cell lines (HCC-1937, MDA MB-468, MDA MB-231, MDA MB-453, SKBR-3, MCF-7) and the apoptotic effects induced by SC-1 and SC-43 were more potent than Sorafenib. Over-expression of STAT3 in MDA MB-468 cells protected cells from apoptosis induced by sorafenib, SC-1 and SC-43. Moreover, SC-1 and SC-43 up-regulated higher SHP-1 activity than sorafenib by in vitro phosphatase assays. Knockdown of SHP-1 by siRNA reduced apoptosis induced by SC-1 and SC-43. Importantly, SC-1 and SC-43 showed in vivo efficacy in MDA-468 xenografted tumor.

Conclusions: Our data indicated that inhibiton of p-STAT3 by up-regulating SHP-1 activity mediated apoptotic effects of sorafenib, SC-1 and SC-43 in breast cancer cells.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-11-05.

Abstract OT1-1-17: LUX-Breast 2: Phase II, open-label study of oral afatinib in HER2-overexpressing metastatic breast cancer (MBC) patients (pts) who progressed on prior trastuzumab and/or lapatinib*

Background: Management of HER2-overexpressing MBC has improved over the past decade. However, pts still develop resistance to currently available HER2-targeted therapies and novel effective treatments are increasingly required as dual targeted combinations are given in early treatment lines already. Current therapies focus on targeting HER2 and do not inhibit all relevant ErbB Family dimers. Afatinib is an oral, irreversible ErbB Family Blocker that inhibits signaling through activated EGFR (ErbB1), HER2 (ErbB2) and ErbB4 receptors and transphosphorylation of ErbB3. Preclinical studies have demonstrated efficacy in trastuzumab-sensitive, and trastuzumab-resistant human BC xenograft models dependent on ErbB signaling. Efficacy of afatinib in a trastuzumab-resistant SUM190 xenograft model has been shown to be increased by addition of intravenous (i.v.) vinorelbine. Afatinib monotherapy has shown promising clinical benefit in 46% of HER2-overexpressing MBC pts who progressed on prior trastuzumab, with 10% of pts achieving a partial response.1

Methods: This open-label Phase II trial (NCT01271725) investigates efficacy and safety of afatinib alone (40 mg/day) followed by afatinib ‘beyond progression’ in combination with chemotherapy in 120 pts with HER2-overexpressing MBC, who progressed on prior neoadjuvant and/or adjuvant trastuzumab and/or lapatinib. Pts who progress on afatinib monotherapy receive afatinib + either weekly paclitaxel 80 mg/m2 or vinorelbine i.v. 25 mg/m2. Eligible pts have confirmed HER2-overexpressing BC, Stage IV disease measurable by RECIST 1.1, progressed on trastuzumab and/or lapatinib therapy in either neoadjuvant and/or adjuvant setting, are eligible for retreatment with paclitaxel (i.e. should not have been pretreated with paclitaxel within the past 12 months), or are eligible for treatment with vinorelbine (i.e. should not have been pretreated with vinorelbine). Exclusion criteria include inadequate cardiac, renal, hepatic and hematological function, pre-existing gastrointestinal dysfunction, rapidly progressing visceral MBC, interstitial lung disease, and active brain metastases. The primary endpoint is objective response (OR) and secondary endpoints include best overall response, duration of OR, progression-free survival (PFS) and safety. PFS and safety will be assessed separately for afatinib mono- and combination therapy. An early stopping rule was deployed to minimize the number of pts treated should afatinib be ineffective; once 20 evaluable pts (according to RECIST 1.1) completed at least two courses of afatinib (or progressed during the first course), a meeting was held to evaluate the objective tumor response rate and to decide whether to proceed with the trial or stop due to futility. If at least one unconfirmed OR had been witnessed from all available information at the time, then the trial was to continue to full accrual. This early stopping rule for futility has been passed and the trial will continue to full accrual. Pt enrollment began in May 2011 in ∼40 sites and five countries.

1. Lin NU, et al. Breast Cancer Res Treat 2012. DOI: 10.1007/s10549-012-2003-y.

*Updated abstract from ASCO 2012.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT1-1-17.

Abstract PD07-02: βIII Tubulin Expression by Immunohistochemistry (IHC) and mRNA in a Randomized Phase 2 Neoadjuvant Breast Cancer (BC) Study of Ixabepilone (ixa) Compared to Paclitaxel (pac)

Background: Overexpression of βIII tubulin has been shown to correlate with poor prognosis and reduced response to taxanes. Ixa exhibits activity in βIII overexpressing tumor models and BC patients (pts) with high βIII mRNA levels. We report the prevalence of βIII by a validated IHC assay and the correlation of βIII protein and mRNA expression in BC tissue samples. Methods: In this neoadjuvant BC study CA163-100, 295 patients were randomized 1:1 to ixa (40 mg/m2 IV x 4 cycles) or pac (80 mg/m2 IV wkly x 12) after all pts received 4 cycles of doxorubicin (60 mg/m2) plus cyclophosphamide (600 mg/m2). Pre-chemotherapy formalin-fixed paraffin-embedded pt tissue sections were assessed for intensity and percentage of tumor cell staining of βIII by IHC. RNA was extracted from additional pre-chemotherapy core needle biopsy specimens and profiled for gene expression using Affymetrix HG-U133Av2 gene chips. Tumors were classified as basal-like, Her2-enriched, luminal-like A and B and normal-like using a 50-gene subtype predictor. In addition, Her2 and hormone receptor status was used for tumor subtyping. Results: βIII staining data were obtained for 261 pts, of which 247 were randomized to either ixa or pac arms of study CA163-100. The prevalence of βIII positivity was 39.1% (102/261) using the prespecified cut-off of ≥50% (2+, 3+) positive cells. The distribution of IHC scores was bimodal. 64% of specimens classified as βIII negative had no observable staining, while 77% of βIII positive specimens had a majority of tumor cells staining at the highest intensity (3+). IHC and gene expression profiling data were available for 235 pts and a correlation between βIII tubulin protein and mRNA expression was observed. The relative βIII mRNA expression levels were significantly higher in pts classified as βIII positive vs. βIII negative by IHC (P<0.0001) and 80% of tumors classified as βIII tubulin positive by IHC, had high relative TUBB3 mRNA levels, using a median cut-off. An association between βIII IHC status and breast cancer subtypes was also seen with 69% (62/90) of βIII positive specimens also classified as basal-like and conversely, 55% (62/113) of basal-likes classified as βIII positive. Nearly half (48%) the specimens in this cohort were basal-like, a classification that was quite concordant with triple negative status and as such, triple negative tumors were also enriched for βIII positivity. Conclusion: βIII is reliably measured by a validated IHC assay, providing a bimodal distribution of scores in this BC study. Correlative analyses of βIII status by BC subtype suggest that βIII positivity is significantly associated with aggressive basal-like/TN breast cancers. The clinical utility of βIII as a potential tool to select patients who may benefit from ixa in this study will be presented separately.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD07-02.

Abstract PD07-01: Phase 2 Study of Ixabepilone Versus Paclitaxel as Neoadjuvant Therapy for Early Stage Breast Cancer with Comparative Biomarker Analysis

Background: Anthracyclines (A) and taxanes (T) are standard neoadjuvant treatments for breast cancer (BC), achieving pathologic complete response (pCR) rates of 20-30% in unselected patient (pt) populations. Ixabepilone (ixa) is approved for treatment of metastatic BC: plus capecitabine (Cap) in pts progressing after A and T or as monotherapy after progression on A, T and Cap. Prior data suggest that overexpression of βIII tubulin is associated with resistance to paclitaxel (P) while activity of ixa was unaffected. We present the first randomized comparison of neoadjuvant ixa and P in early stage BC. Primary objectives were to estimate pathologic complete response rate (pCR) in the overall population and in biomarker-defined populations. Methods Pts with early stage BC were biopsied for immunohistochemical (IHC) and mRNA biomarker analyses prior to chemotherapy. Following 4 cycles of doxorubicin/cyclophosphamide (AC), pts were randomized to either every 3 week ixa (40mg/m2:4 cycles) or weekly P (80mg/m2:12 doses). Post-therapy surgery and pathological reports were used to assess pCR. Baseline βIII expression was assessed via a standardized IHC assay (Dako, CA) and predefined single gene mRNA markers (including TUBB3, CAPG, TACC3) were assessed via Affymetrix gene expression profilling. The pCR rate and cutoff for biomarker positivity were estimated using a cross-validation method. Secondary endpoints in the study included clinical objective response rate and safety. Results Pts (N=384) were enrolled in 15 countries: 313 pts were treated with AC. 295 pts were randomized; 289 were treated with either ixa or P. Of these, 247 (123, ixa; 124, P) had βIII IHC data and 231 (114, ixa; 117, P) had both pathologic and βIII IHC data. Baseline characteristics were balanced between arms, including triple negative pts (TN, 49%). The pCR rate in all randomized pts was 24.3% (90% CI: 18.6-30.8) with ixa and 25.2% (90% CI: 19.4-31.7) with P. pCR rates were similar regardless of sub-group.

Table 1. pCR rates

No significant interaction was observed between βIII expression and treatment arms (logistic regression analysis). Secondary efficacy measures were consistent with the pCR results. No clinically meaningful differences in efficacy endpoints were noted between ixa and P with mRNA markers (TUBB3, CAPG and TACC3; analyses are ongoing with others). The safety profiles of ixa and P were similar, including incidence of peripheral neuropathy (Grade 3/4: ixa 4.1% vs P 3.5%). An exception was greater neutropenia with ixa (Grade 3/4; 41.3% versus 8.4% with P) although there was no difference in the rate of febrile neutropenia (0.7%). Summary Overall, the results indicated that ixa had similar efficacy to P when measured by pCR in the neoadjuvant BC setting. No clinically meaningful differences were noted in the efficacy profile of ixa compared to P across the subsets analyzed. Ixa or P following AC was well tolerated with similar safety profiles.

Modulation of HER2 expression by ferulic acid on human breast cancer MCF7 cells

BACKGROUND

The molecular mechanisms underlying the mitogenic effect of ferulic acid (FA), an active compound derived from Angelica sinensis, have never been elucidated. It was the aim of this study to investigate the proliferative effect of FA on human breast cancer cell lines and to elucidate its modulation mechanism on HER2 expression in MCF7 line.

MATERIALS AND METHODS

By using MCF7 (oestrogen receptor-positive; ER+, HER2-low), BT474 (ER+, HER2-high), MDAMB231 (ER-, HER2-low) and SKBR3 (ER-, HER2-high) human breast cancer cell lines as in vitro models, the mitogenic effects of FA were assessed by trypan blue dye exclusion assay and DNA flow cytometry. Ferulic acid-modulated cell signalling and HER2 gene expression were evaluated in MCF7 line by Western blot and real-time RT-PCR analysis.

RESULTS

Ferulic acid ER-dependently stimulated cell proliferation on MCF7 cells in a concentration-dependent manner. The HER2 oncogene (one of the prognostic factors of breast cancer) and ESR1 gene (oestrogen receptor-alpha; ERalpha) transcription were markedly up-regulated by FA treatment. Besides, HER2 signalling and its downstream molecules such as AKT and ERK1/2 were involved in FA-modulated ERalpha and cyclin D1 synthesis. Addition of anti-HER2 antibody, trastuzumab, abrogated FA-enhanced proliferative effect on MCF7 cells, indicated a positive feedback control for the action of HER2 in this setting. The fact that the ER antagonist blocked most of the FA-up-regulated HER2 expression, and that trastuzumab down-regulated ERalpha gene expression, suggested a cross-talk between ERalpha and HER2 signalling on MCF7 cells.

CONCLUSION

The authors' conclude that FA causes human breast cancer cell proliferation by up-regulation of HER2 and ERalpha expression.

Polymorphism of estrogen metabolism genes and cataract

Cataract is the leading cause of visual impairment in older adults in the world. Age-related lens opacities are common and are frequent causes of loss of vision. The incidence of cataract increases significantly with increasing age in women only. The onset coincides with estrogen deficiency that occurs after menopause. Hormone replacement therapy has proven beneficial to selected postmenopausal women. Estrogen effects on biological system are modulated via the estrogen receptors (ER) and/or estrogen metabolites. Although ER have been detected in ocular tissue, whether ER polymorphism is related to cataract is not known at present. The polymorphisms of estrogen metabolizing enzymes are also related to the serum concentration and activity of estrogen. Polymorphism such as cytochrome P450c17 (A2/A2), cytochrome P450c1A (vt/vt) will result in increased formation of catechol estrogen, while people with catechol-O-methyltransferase (COMT) polymorphism COMT (L/L) will have decreased metabolism of catechol estrogen and decreased level of methoxyestradiol. COMT was also involved in tamoxifen metabolism which may further decrease the activity of COMT in breast cancer patients treated with tamoxifen. It is known that a 4-7% increase in cataract was found in tamoxifen-treated breast cancer patients than non-user. The 7.0% COMT (L/L) genotype in general population corresponded well with the 4-7% of cataract formation in tamoxifen-treated breast cancer patients. Our hypothesis is that breast cancer patients with COMT (L/L) genotype may be at increased risk of cataract formation after tamoxifen treatment.

Clinicopathologic and prognostic differences between patients with hepatitis B- and C-related resectable hepatocellular carcinoma

BACKGROUND AND PURPOSE

Hepatitis B and C viral infections are important factors in the development of hepatocellular carcinoma (HCC). This study examined the clinicopathologic and prognostic differences in patients with hepatitis B- and C-related resectable HCC.

METHODS

A total of 270 HCC patients who underwent hepatic resection were enrolled. Among these patients, 211 were positive for hepatitis B surface antigen (HBsAg) and 59 were positive for anti-hepatitis C virus antibody (anti-HCV). The clinical manifestations, pathologic features, and treatment outcomes were compared between the HBsAg-positive and anti-HCV-positive groups.

RESULTS

Compared to anti-HCV-positive patients, HBsAg-positive patients were significantly younger, had a higher familial incidence of HCC, larger tumor size, and a higher incidence of multiple tumors. HCC patients who were anti-HCV positive had worse liver function and a higher incidence of history of blood transfusion. DNA flow cytometric analysis revealed significantly more proliferative activity in the non-tumor part of the liver in HBsAg-positive HCC patients. The 1-, 3-, and 5-year overall survival rates of HBsAg-positive patients were 79%, 57%, and 48%, respectively, and for anti-HCV-positive patients were 91%, 75%, and 62%, respectively. HBsAg-positive patients had a significantly lower overall survival rate than anti-HCV-positive patients (p = 0.018).

CONCLUSIONS

HBsAg-positive patients with resectable HCC had a less favorable survival rate after tumor resection than anti-HCV-positive HCC patients. This survival difference might have been related to the relatively advanced stage of disease and the higher proliferative activity of the non-tumor part of the liver in HBsAg-positive HCC patients.

Tie-1 tyrosine kinase is an independent prognostic indicator for invasive breast cancer

Receptor tyrosine kinases are known to be involved in the growth, progression and metastasis of solid tumors. We investigated the relationship between tie-1 expression and progression of invasive ductal breast carcinoma with immunohistochemical analysis. Tie-1 protein was detected in the microvessel endothelial cells and cytoplasm of tumor cells. The tumor size and stage were significantly associated with the expression of tie-1, which portends a worse 5-year disease-free status (39.3% v 59.2%, p = 0.07) and overall survival rate (67.3% v 93%, p = 0.02) than those without tie-1 expression. Multivariate analysis demonstrated that larger tumor size, presence of lymph node metastasis and tie-1 expression were independent prognostic parameters, both in 5-year disease-free survival and overall survival. Patients with lymph node metastases and tie-1 expression had the worst 5-year disease-free survival (0%) and overall survival (42.4%) compared to those without tie-1 expression (50.2%, 85%). In lymph node negative patients, those without tie-1 expression had better 5-year disease-free survival and overall survival (72.9%, 100%) compared to those with tie-1 expression (65.5%, 87.7%). We conclude that tie-1 expression is an independent prognostic factor for invasive ductal breast carcinoma, adversely affecting survival of breast cancer patients with positive nodes to a significant extent.

Sonographic features of breast abscesses with emphasis on "hypoechoic rim" sign

BACKGROUND

There are only limited reports on the ultrasound (US) features of breast abscess. The purpose of this paper is to review the US features of breast abscess with emphasis on "hypoechoic rim" sign which is more commonly seen in chronic abscess.

METHODS

In a period of 10 years, 20,998 patients were referred for breast US examinations. Medical records identified 204 patients in whom breast abscess was diagnosed. All patients were examined using high-resolution real-time US scanners. The initial ultrasound reports and hard copy images were all carefully reviewed. The grading of the echogenicity of the abscess was classified from grade 0 to grade 5. The contours of the lesions were described as smooth, macrolobulated, microlobulated, irregular, zigzag, spiculate or indistinct. The wall thickness was measured to document the presence of "hypoechoic rim" which denoted a wall thickness greater than 2 mm. The associated findings and other acoustic phenomena related to the lesion were recorded.

RESULTS

One hundred and thirty-six patients (136/204) having specific aspiration and/or biopsy/histopathological results were included in the study. All of the 136 patients showed abnormal US findings (100%). Most lesions showed grade 1 or grade 2 echogenicity (117, 86%). The contour of the abscess was usually smooth (42, 31%), macrolobulated (42, 31%), or irregular (22, 16%). A hypoechoic rim was noticed in 18 lesions (13%). Focal skin thickening was chiefly noticed in 91% of superficial abscesses (39/43) and 17% of intramammary abscesses (14/84). Diffuse skin thickening was exclusively evident in the breasts coexisting with mastitis. Hypoechoic interstitial streaks were not a common finding (7%), occurring in acute abscesses. The other findings included surrounding hypoechoic amorphous tissue (26%), posterior wall enhancement (71%), distal enhancement (60%) and lateral shadows (57%).

CONCLUSIONS

US plays an important role in confirmation of the clinical diagnosis of breast abscess and aids significantly in the management of inflammatory breast diseases. Presence of the hypoechoic rim surrounding a fluid space or a central area of low-level echoes (i.e., grade 1 to grade 3) is indicative of a chronic abscess.

The surgical treatment and prognostic factors of well-differentiated thyroid cancers in Chinese patients: a 20-year experience

BACKGROUND

Well-differentiated thyroid cancers (WDTC) are usually slow-growing neoplasm with an indolent clinical course. Assessment of treatment modalities for them requires a long-term follow-up in a large population, and is still of much debate. A systematic analysis of the history, prognosis and therapy for this disease in Taiwan is lacking.

METHODS

A retrospective analysis of clinical and pathological records was conducted on 488 patients (149 male and 339 female, male: females = 1:2.28) treated for WDTC in the Veterans General Hospital-Taipei from 1971 to 1991 with subsequently follow-up until December 1994 (Mean follow-up: 8.5 years). Factors influencing recurrence, survival and different treatment were analyzed.

RESULTS

Papillary thyroid cancer increased obviously as compared to our experience from 1959-1976. Changing tumor behaviors, including increasing female/male ratio, higher percentage of papillary cancer, decreasing primary tumor size and lower distant metastatic rate at the time of initial diagnosis, were noted. Factors influencing survival, as determined by univariate analysis, included age, gender, distant metastasis, extrathyroidal invasion, tumor size, nodal involvement, histological type, extent of surgical therapy and use of postoperative radioactive iodine. Those patients aged more than 45 at initial diagnosis, with primary tumors larger than 4 cm, with extrathyroidal invasion, and with distant metastasis at initial diagnosis were classified as being at high risk. The others were at low risk. Total or near total thyroidectomy (TTx), depending on the judgement of each surgeon, had much higher complication rate than lobectomy with/without isthmusectomy, but offered no benefit effect on disease-free survival or overall survival rates. Postoperative radioactive iodine ablation treatment and thyroxine replacement in suppressive dose after TTX improved survival among high risk patients. Lobectomy with/without isthmusectomy in low risk patients, followed by thyroxine suppression therapy, was adequate to improve the postoperative outcome and with low complication rate. Lymph node resection in patients with clinically palpable nodes improved longterm prognosis.

CONCLUSIONS

Changing tumor behavior of WDTC leading to favorable prognosis has been noticed since 1971. Total or near total thyroidectomy is worthwhile in high risk patients with WDTC but does not appear necessary in low-risk patients. Lymph node dissection for metastatic lymph node could improve the survival rate.