Abstract P5-13-02: Chemoprevention utilization in patients with a history of atypical hyperplasia, atypical lobular hyperplasia, or lobular carcinoma in-situ: A retrospective chart review of patients diagnosed at an urban hospital with a large minority patient population

Background: The Breast Cancer Prevention Trial (BCPT) and the Study of Tamoxifen and Raloxifene (STAR) trial showed that chemoprevention can reduce the risk of invasive breast cancer by nearly 50%. Despite these results, studies have shown that while an estimated 2 million women in the United States are eligible for chemoprevention, actual acceptance of these medications is low. Improving chemoprevention utilization rates hinges on better understanding current rates of utilization and factors affecting patient acceptance. Reported rates and barriers to chemoprevention use may not accurately reflect true utilization patterns in lower socioeconomic, minority patient populations. The aim of this IRB approved retrospective study was to characterize the rate and factors associated with chemoprevention use in patients with a diagnosis of atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma in-situ (LCIS) at an urban hospital with a high minority population.

Methods – A retrospective chart review was performed for all diagnoses of ADH, ALH, and LCIS made at the University of Maryland Medical Center between the years 2005-2015. Concurrent DCIS or invasive cancer were excluded. Demographic and clinical information including age, race, education, GAIL score, BMI, and use of chemoprevention was recorded. Univariable and multivariable logistic regression were performed to identify factors associated with chemoprevention discussion and use.

Results – 301 diagnoses of ADH/ALH/or LCIS were obtained and 127 women were eligible for analysis. The median age was 53 years old with 47% of patients being premenopausal. The majority were African-American (65%) and 51% had a high school degree or less. The median 5 year risk for developing breast cancer based on the GAIL model was 2.4%. The chemoprevention utilization rate for our patient population was 28% (n=34). Race, menopausal status, and breast density were not associated with chemoprevention discussion or use. We found that patients were more likely to have a chemoprevention discussion with their provider if they were older (p=0.03) or if they were referred to medical oncology (p<0.001, Fisher's exact test).

Conclusions - Our study evaluated chemoprevention use in an understudied predominantly African-American patient population. We found a higher rate of chemoprevention utilization (28%) compared to previously reported rates. Age and medical oncology referral had a significant impact on provider-patient chemoprevention discussion. Though limited due to small sample size, our study nonetheless provided thought provoking results. Older patients may be at higher risk for developing breast cancer, however, it is important to consider that younger patients with risk factors may have a more favorable endocrine therapy benefit-risk ratio. In addition, our results highlight the importance of encouraging all physicians who are involved in women's' breast health to have a chemoprevention discussion with eligible patients, or for these physicians to refer patients to a medical oncologist for further discussion.

Citation Format: DeRidder A, Mainor C, Goloubeva O, Ioffe O, Bellavance E, Tkaczuk K, Rosenblatt P. Chemoprevention utilization in patients with a history of atypical hyperplasia, atypical lobular hyperplasia, or lobular carcinoma in-situ: A retrospective chart review of patients diagnosed at an urban hospital with a large minority patient population [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 P5-13-02.

Abstract P1-03-06: Improvement in risk predictive value of Nottingham prognostic index by determining GP88 tumor tissue expression for estrogen receptor positive breast cancer patients

Background: The Nottingham Prognostic Index (NPI), which includes nodal status, tumor size and histological grade was established to provide predictive value information on post-surgery survival for primary breast cancer patients. Attempts to improve NPI's performance have included addition of other biomarker expression and morphological features such as vascular invasion. In the present study, we investigated whether expression of the autocrine growth and survival factor GP88 (progranulin), known to be overexpressed in breast cancer, whereas it is negative in normal mammary tissue, would improve NPI's predictive value.

Methods: We examined the tumor tissue GP88 expression by immunohistochemistry (IHC) in formalin fixed paraffin embedded tissue sections from 508 cases of estrogen receptor positive (ER+) invasive ductal carcinoma (IDC) with known clinical outcomes (disease-free and overall survivals) and with known NPI. GP88 IHC tumor tissue expression was determined using an anti-GP88 antibody (clone 6B3) developed in our laboratory. GP88 expression was scored (0, 1+, 2+, 3+) by two board certified pathologists and classified into two IHC score groups of GP88 < 3+ (0, 1+, 2+) and GP88 = 3+. The correlation between GP88 scoring, NPI and disease-free (DFS) and overall survival (OS) outcomes was then examined by Kaplan Meier analysis, Cox proportional Hazard (CPH) ratio and Pearson's C2 test.

Results: Kaplan-Meier survival graphs categorized by NPI scores (< 3.4, 3.4-5.4, and >5.4) and by GP88 expression (< 3+ and 3+) showed that for each NPI subgroup, patients with GP88 IHC score of 3+ had a worse disease-free survival (DFS) and overall survival (OS) than patients within the same NPI subgroup with tumors that had GP88 IHC score < 3+. When adjusted for NPI, high GP88 score was highly significantly associated with recurrence with a hazard ratio of 3.30 (95% CI 2.12 to 5.14).

Conclusions: The data suggest that measuring GP88 tumor tissue expression by IHC at time of diagnosis for breast cancer patients with primary ER+ IDC could provide recurrence prediction and survival information complementary to that provided by the determination of NPI alone and thus may be useful for risk management of patients diagnosed with breast cancer.

Citation Format: Serrero G, Hawkins DM, Bejarano PA, Ioffe O, Tkaczuk KR, Elliott RE, Head JF, Phillips J, Godwin AK, Weaver J, Hicks D, Yue B. Improvement in risk predictive value of Nottingham prognostic index by determining GP88 tumor tissue expression for estrogen receptor positive breast cancer patients [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 P1-03-06.

P2-12-32: Association between Progranulin (GP88) Expression and Recurrence Risk for Breast Cancer Patients with Estrogen Receptor Positive Invasive Ductal Carcinoma

Purpose: GP88 (progranulin) is a critical player of breast tumorigenesis for estrogen receptor positive (ER+) breast cancer. Pathological studies showed that GP88 was expressed in invasive ductal carcinoma (IDC), but not in normal mammary tissue, benign lesions or lobular carcinoma. The present study examines GP88 prognostic significance in association with recurrence risk for patients with ER+ IDC.

Patients and Methods: Two retrospective multi-site clinical studies examined GP88 expression by immunohistochemistry (IHC) analysis in paraffin-embedded tumor tissues in correlation with patients’ survival outcomes. The training study established a GP88 cut-off value associated with decreased disease-free (DFS) and overall (OS) survivals. The validation study verified the GP88 cut-off value and compared GP88 prognostic information with other prognostic factors in multivariate analysis.

Results: GP88 expression is associated with a statistically significant increase in recurrence risk for ER+ IDC patients. The training study established that GP88 3+ score by IHC analysis was associated with decreased DFS (p=0.0004) and OS (p=0.0036). The independent validation study verified that GP88 3+ score for the high risk group and demonstrated that GP88 3+ score was associated with a 5.9-fold higher hazard of disease recurrence and a 2.5-fold higher mortality hazard compared to patients with tumor GP88<3+. GP88 remained an independent risk predictor after considering age, nodal status, tumor size, tumor grade, progesterone receptor expression, treatment and disease stage.

Conclusion: Our training and validation studies demonstrate that the survival factor GP88 is a prognostic biomarker, predictive of recurrence risk and increased mortality for ER+ IDC patients, independent from other prognostic factors. These results provide support for measuring GP88 tissue expression for newly diagnosed early stage breast cancer patients.

This work was supported by grants R43CA124179, and U01CA113916 from the National Cancer Institute, grants 07-2007-064 and 02-2010-010 from the Avon Foundation for Women.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-32.

Abstract P4-11-18: CT Simulation Alone Appears To Be Appropriate for Pre-Operative Partial Breast Radiation

Introduction: Pre-operative radiotherapy is being evaluated at several centers as a method to potentially increase patient eligibility for partialbreast radiotherapy. Theoretically pre-operative radiotherapy will decrease the volume of normal tissue irradiated which could decrease the morbidity. This study was performed to determine whether CT based imaging could be used for radiotherapy planning.

Material and Methods: Between December 2008 and February 2010, 204 breast cancer patients were seen in the breast evaluation and treatment program clinic at the University of Maryland Marlene and Stewart Greenebaum Cancer Center. Patients with a new diagnosis of breast cancer and no prior treatment were included in the study if they underwent MRI of the breast and a CT, including the breast, within 30 days of each other, and images were available for review. Measurements of maximum tumor dimension obtained from CT and MRI were compared. These measurements were also compared to the maximum pathologic tumor dimension, when pathology was available. Measurements were compared using correlative paired t-tests. Associations between these measurements and T stage, tumor diameter, nodal involvement, receptor status and histologic subtype were explored. Specifically, the risk of CT underestimating the size of the tumor in the pre-operative setting was also evaluated, with a 3 mm underestimation of size chosen as significant. Results: CT and MRI images were available for 40 patients. Twelve patients who underwent imaging after receiving induction chemotherapy were excluded, leaving 28 patients for analysis. In 25 patients, CT images were obtained as part of a staging PET/CT. Pathology was available in 19 patients; nine patients received neo-adjuvant chemotherapy after imaging was obtained. The average maximum tumor dimension was 10% smaller on CT than MRI (4.25 cm (range 1.1 — 9.1 cm) versus 4.72 cm (range 1.3 — 9.0 cm)), but this difference was not statistically significant. Tumor measurements obtained by CT and MRI were only statistically different in the presence of lobular carcinoma (p=0.049). The CT underestimated the MRI measurement by greater than 3 mm in 9 out of 28 (32.14%) patients, six of whom had extensive calcifications on mammogram. When the maximum tumor dimension obtained from CT was compared to pathological size, CT underestimated the pathologic tumor size by greater than 3 mm in only 4 out of 19 (21.1%) patients. All 4 patients had pathologic T3 tumors and were node positive. For comparison, the MRI similarly underestimated the tumor size in 3 of these 4 cases. Limiting our analysis to tumors less than 3 cm in diameter, only 1 out of 7 patients had a pathologic tumor size that was 3 mm greater than the maximum tumor dimension obtained from CT imaging.

Conclusions: Measurements of maximum tumor dimension on CT are on average 10% smaller than measurements obtained from MRI, although not statistically different. The risk of underestimating pathologic maximum tumor dimension was similar for CT and MRI. The risk appeared to be less for infiltrating ductal carcinoma and tumors < 3 cm. CT based treatment planning for pre-operative partial breast radiotherapy seems appropriate although additional data is needed to confirm these findings.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-18.

Drug Response Indicator Test (DRIT) as a predictive test for treatment outcomes in advanced breast cancer patients (ABC)

1119

Background: There are limited options for selecting an optimal treatment regimen for ABC patients (pts). DRIT is a platform technology that provides a profile of a patient's tumor's sensitivity or resistance to commonly used chemotherapeutic, hormonal, or biological agents as a basis for individualized anticancer treatment approach. DRIT may allow physicians to choose more effective drug treatments before initiation of therapy and improve the efficacy and toxicity profile of cancer therapies. Methods: DRIT analysis is based on fluorescent dye-labeled monoclonal antibody staining followed by computer-assisted microscopy to quantitatively measure expression levels in tumor sections. The interpretation of DRI expression levels results in classification of tumors as sensitive or resistant to treatment with a mechanistically related drug. This study utilized the following drug/DRI combinations: hormonal therapy/estrogen receptor; capecitabine/thymidylate synthase; docetaxel, paclitaxel, abraxane/β-tubulin isoform III; trastuzumab/HER-2; gemcitabine/ribonucleotide reductase. DRIT was performed on the tumor tissue of consented study participants with ABC who were then deemed to be sensitive or resistant to a given agent/agents. We then analyzed retrospectively clinical treatment outcomes (clinically sensitive to therapy defined as-stable disease+partial response+complete response or resistant to therapy-no response to therapy) for 91 treatment interventions in 71 pts with the DRIT tissue data. Results: We found that the DRIT sensitivity was 0.99, with specificity of 0.59, positive predictive value of 0.88, negative predictive value of 0.93 and overall predictive value of 88% for treatment outcomes for this cohort of ABC pts. Conclusions: This study suggests that DRIT can provide more accurate prediction of treatment outcomes for ABC pts than the standard of care approach and therefore has a potential to avoid unnecessary ineffective drug treatment exposure. Prospective study in ABC pts is currently conducted at the UMGCC.

[Table: see text]

A predictive test for therapeutic treatment outcomes of advanced gastrointestinal cancer patients (AGC)

e15079

Background: There are currently limited options for selecting an optimal treatment regimen for AGC patients. The Drug Response Indicator Test (DRIT) is a platform technology that provides a detailed profile of a patient's tumor response to commonly used chemotherapeutic drugs, as a basis for individualized treatment. Establishment of DRIT will allow physicians to choose effective drug treatments to improve the efficacy of cancer therapies on an individual basis. Methods: DRIT analysis is based on fluorescent dye-labeled monoclonal antibody staining followed by computer-assisted microscopy to measure expression levels in tumor sections. The interpretation of the Drug Response Indicator (DRI) expression levels result in classification of tumors as sensitive or resistant to treatment with a mechanistically related drug. Clinical outcomes are then analyzed with respect to the DRI data. This study utilized the following drug/DRI combinations: capecitabine, 5-flurouracil/thymidylate synthase; docetaxel, paclitaxel, abraxane/β-tubulin isoform III; gemcitabine/ribonucleotide reductase; platinum salts/ERCC-1; Irinotecan/Topoisomerase I. Results: DRIT retrospective studies were performed on a cohort of 33 consented patients (pts) receiving 55 treatments for AGC at UMGCC. This cohort included pts treated for rectal/colon, gastric, esophageal & pancreatic cancers. DRIT sensitivity was 0.96, positive predictive value 0.84, negative predictive value 0.67 and overall predictive accuracy 83 %. DRI expression level cut-off points indicating sensitivity or resistance to a specific treatment were derived from previous retrospective breast cancer studies using similar drug complements (abstract 6075 San Antonio Breast Conference 2008). Conclusions: This study indicates that DRIT can provide accurate prediction of treatment outcomes for individual AGC patients. DRI expression level cut-off points indicating sensitivity or resistance to a specific treatment may be applied to both breast cancer & AGC. DRIT will allow for tailoring of chemotherapy based on the specific biomarker expression within each patient's tumor tissue.

[Table: see text]

A retrospective study of drug response indicator test (DRIT) as a predictive test for therapeutic treatment outcomes of advanced breast cancer patients (ABC)

Abstract #6075

We conducted a retrospective study of DRIT, an investigational diagnostic test to predict chemotherapy and endocrine therapy treatment outcomes in ABC. DRIT is a quantitative measurement of Drug Response Indicator (DRI) expression levels in formalin fixed, paraffin embedded tumor tissue. DRI chosen for each drug is related to the perceived mechanism of action of the drug. The quantitative measurement of DRI expression in the tumor tissue is based on the fluorescent dye-labeled monoclonal antibody (mAb) staining, followed by acquisition of digital images using computer-assisted microscopy, calibrated to an external standard. DRI expression measurement results in classification of the tumor as sensitive or resistant to a particular drug based on our in vitro studies of drug sensitivity/resistance in cell lines. If a tumor is classified as sensitive to a drug/s by DRIT, this predicts that the patient (Pt) will respond to treatment, while if a tumor is classified as resistant this predicts that the Pt will not respond to the drug/s therapy. Clinically the treatment outcome is classified into a responsive group (non-progressive disease,CR, PR, SD) & a non-responsive group (progressive disease, PD). The drugs & DRI tested are: capcitabine/thymidylate synthase; Taxanes /β-tubulin isoform III, trastuzamab/HER-2, Endocrine therapy/estrogen receptor, gemcitabine/ribonucleotide reductase. 51 ABC received mono or doublet therapy as first 3 lines of therapy-(80 treatments). The percent accuracy (number of accurate predictions/number of treatment interventions) for monotherapy is 87% (61/70), 100% (10/10) for doublet therapy and 89% (71/80) for all treatments. The accuracy of prediction for responsive patients is 86% (60/69) and 100% (11/11) for non responsive patients. DRIT diagnostic performance for 80 treatment outcome predictions for endocrine therapy and mono and doublet chemotherapy is as follows: sensitivity 1.00, specificity 0.55, positive predictive value 0.87, negative predictive value 1.00, and overall accuracy 0.88. For the standard of care outcomes, the favorable response rate for the 80 treatments is 75% (60/80), the potential favorable response rate with DRIT input is 86% (60/69) with 11 ineffective treatments identified by DRIT accurately 100% (11/11). Thus, DRIT input can identify effective (86%) & ineffective (100%) treatments in this cohort of ABC patients. DRIT is under developement as a diagnostic test to predict treatment outcomes prior to the selection of a particular drug for anticancer therapy, so that the most effective drug can be prescribed for an individual cancer patient. This retrospective study in ABC patients shows that DRIT has a potential to be a useful test to predict treatment outcomes.
 Supported in part by Maryland Industry Partnership Program – MIPS.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6075.

Tissue expression of the growth factor GP88 is a predictor of recurrence in patients with estrogen receptor positive breast tumors

Abstract #1088

Background
 Our laboratory is working on the characterization of novel breast cancer targets that have therapeutic an/or diagnostic applications. We have previously identified the growth factor GP88 as a significant player of breast tumorigenesis. GP88 is expressed in human breast cancer cells in a positive correlation with tumorigenesis. In estrogen receptor positive breast cancer cells, GP88 mediates estrogen proliferation effect and its increase is associated with resistance to anti-estrogen therapy. Inhibition of GP88 expression in human breast adenocarcinoma lead to inhibition of tumor incidence and tumor growth in nude mice. Pathological studies showed that ductal carcinoma expressed GP88 whereas benign lesions and normal mammary tissue were negative. Based on this evidence, the present study was carried out to investigate whether high GP88 expression in estrogen receptor positive invasive ductal carcinoma is associated with increased recurrence and decreased overall survival.
 Methods
 Under an IRB approved study, 239 archival formalin-fixed, paraffin-embedded estrogen receptor positive invasive ductal carcinoma with a minimum of 4 years follow-up were obtained from three United States tumor banks The clinical data included patients demographics such as age and race, tumor characteristics including tumor size, tumor grade, nodal status, disease stage and receptor status, time and type of first recurrence, time and status of last follow-up. GP88 expression was determined by immunohistochemistry using Oncostain 88TM IHC kit on five-micrometer sections. GP88 expression was scored as: <10% of cells staining – negative, >10% of cells staining – positive with positive staining graded from weak/focal (1+) to moderate/focal or diffuse (2+) to strong/diffuse (3+). The statistical analysis of GP88 expression in all cases was carried out. The Oncostain 88TM test performance was evaluated for its ability to predict disease-free (DFS) and/or overall survivals (OS) using Kaplan Meier curves and the Cox proportional hazards models for quantification of risk.
 Results
 The data show that ER+ cases with high GP88 expression (3+) had a hazard ratio for OS of 2.29 (95% CI, 1.38-3.78; p< 0.0013) and a HR for DFS of 2.88 (95% CI 1.59-5.24; p<0.0005). GP88 3+ remained highly significant for OS and DFS even when the data were adjusted for covariates such as nodal status, disease stage, tumor grade, tumor size, supporting the findings that GP88 brings independent information on the recurrence risk and overall survival of ER+ invasive ductal carcinoma.
 Conclusion
 This study demonstrates for the first time that high GP88 expression (3+) is a predictor of higher recurrence and increased mortality in ER+ IDC. These data provide a novel biomarker tissue assay (Oncostain 88TM) with prognostic significance in breast cancer.
 This study was supported by grant 1R43 CA 124179-01A1 from the National Institutes of Health.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1088.

Clinical significance of pleural lavage cytology in non-small cell lung cancer: A meta-analysis

18031

Background: The clinical significance of pleural lavage cytology (PLC) in non-small-cell lung cancer (NSCLC) remains controversial. This study was performed to estimate the associations of positive PLC with the main clinicopathological characteristics, and its prognostic value. Methods: PLC studies were identified on Medline, supplemented by manual search of bibliographies and proceedings. Authors were contacted for updated information. The quality of the studies was evaluated, and the data were extracted. Pooled odds ratios (ORs) and pooled hazard ratios (HRs) with confidence intervals [95% CIs] were calculated to evaluate the association of positive PLC with clinico-pathological characteristics and survival respectively. Results: Nineteen articles assessing PLC in NSCLC were selected for this study after exclusion of repeated publications or reports with little clinical detail. Positive PLC was diagnosed in 10.2% (516) of a total of 5073 patients. Positive PLC was strongly associated with lymphatic permeation (OR 4.96 [3.29, 7.54]), pleural invasion (OR 4.38 [2.16, 8.89], and vascular involvement (OR 2.94 [1.99, 4.35]). It was also found to be associated with advanced T stage, N stage, and TNM stage. Positive PLC was more frequent in adenocarcinoma than in squamous cell carcinoma (OR 2.32, [1.51, 3.52]). It was relatively more common in moderately- and poorly-differentiated tumors than in well-differentiated tumors (OR 1.89 [0.86, 4.16]). No association was found between positive PLC and fine needle aspiration cytology (OR 1.04 [0.58, 1.81]). Positive PLC was associated with high overall recurrence (OR 2.51 [1.79, 3.53]), as well as high local recurrence (OR 3.85 [1.57, 9.44]) and distant recurrence (2.58 [1.76, 3.76]). In analysis of survival, the overall HR for mortality was 2.43 [1.87, 3.16], suggesting significantly poorer survival for patients with positive PLC. Conclusions: Positive PLC in NSCLC is strongly associated with several existing poor prognosticators including pleural invasion, lymphatic spread, and vascular involvement. It may indicate locally advanced disease with high risk of recurrence and poor survival. We recommend that the PLC test be included in future clinical trials of adjuvant therapy for patients with NSCLC.

No significant financial relationships to disclose.

Cutaneous histopathology of Rocky Mountain spotted fever

The dermatologic diagnosis of Rocky Mountain spotted fever (RMSF) is often presumptive; the clinical presentation includes skin rash and febrile illness with or without a clear history of tick bite. The characteristic cutaneous manifestations include a generalized skin eruption with purpuric, blanching or non-blanching macules and papules usually involving the extremities. Although skin biopsies are often performed to confirm the diagnosis, the spectrum of cutaneous histopathology in RMSF has not been well described. We studied a series of 26 cases of RMSF, of which 10 were surgical specimens and 16 were autopsies. The microscopic changes were correlated with the duration of illness. The main histopathologic feature was lymphohistiocytic capillaritis and venulitis with extravasation of erythrocytes, edema, predominantly perivascular and some interstitial infiltrate. Leukocytoclastic vasculitis (LCV) with neutrophilic infiltrate and nuclear dust was seen in 11 of 15 (73%) specimens from involved skin. These lesions with LCV also showed notable epidermal change including basal layer vacuolar degeneration with mild dermoepidermal interface lymphocytic exocytosis. Six lesions with LCV displayed focal fibrin thrombi and capillary wall necrosis. Apoptotic keratinocytes were noted in 3 lesions with LCV. Subepidermal blister was observed in the skin lesion of an autopsied patient with LCV changes. Another lesion of a fatal case with LCV also contained features of acute neutrophilic eccrine hidradenitis. Focal small nerve twig inflammation was noted in a third autopsy case with LCV. Plasma cells were seen in 6 of 34 specimens (18%); and eosinophils were observed in 3 (9%). The subcutaneous fat contained a mild perivascular inflammation and one case revealed focal lobular neutrophilic inflammation. Immunohistologic (IH) staining using polyclonal rabbit anti-Rickettsia rickettsii demonstrated positive staining of the organisms in the affected endothelial cells in all 12 cases tested. The cutaneous histopathology of RMSF is caused by endothelial damage by the rickettsial organisms which elicit an initial lymphohistiocytic small vessel vasculitis with progression to LCV. The vasculitis in RMSF is, therefore, considered to be a form of septic vasculitis.