Update on Management of Ductal Carcinoma in Situ

Ductal carcinoma in situ (DCIS) represents 18% to 25% of all diagnosed breast cancers, and is a noninvasive, nonobligate precursor lesion to invasive cancer. The diagnosis of DCIS represents a wide range of disease, including lesions with both low and high risk of progression to invasive cancer and recurrence. Over the past decade, research on the topic of DCIS has focused on the possibility of tailoring treatment for patients according to their risk for progression and recurrence, which is based on clinicopathologic, biomolecular and genetic factors. These efforts are ongoing, with recently completed and continuing clinical trials spanning the continuum of cancer care. We conducted a review to identify recent advances on the topic of diagnosis, risk stratification and management of DCIS. While novel imaging techniques have increased the rate of DCIS diagnosis, questions persist regarding the optimal management of lesions that would not be identified with conventional methods. Additionally, among trials investigating the potential for omission of surgery and use of active surveillance, 2 trials have completed accrual and 2 clinical trials are continuing to enroll patients. Identification of novel genetic patterns is expanding our potential for risk stratification and aiding our ability to de-escalate radiation and systemic therapies for DCIS. These advances provide hope for tailoring of DCIS treatment in the near future.

Abstract P6-10-06: A preoperative window-of-opportunity study of imlunestrant in estrogen receptor-positive, HER2-negative early breast cancer: Results from the EMBER-2 study

Background: Imlunestrant is a novel, orally bioavailable selective estrogen receptor degrader (SERD) with pure antagonistic properties that result in sustained inhibition of estrogen receptor (ER)-dependent gene transcription and cell growth. In a phase 1 study, imlunestrant monotherapy showed favourable safety, pharmacokinetics (PK) and preliminary efficacy in heavily pre-treated ER-positive (ER+) advanced breast cancer patients (Jhaveri ASCO 2022). Here, we present pharmacodynamic (PD) data from the preoperative window of opportunity (WOO) study (EMBER-2, NCT04647487), evaluating the biological activity of imlunestrant monotherapy in ER+, HER2-negative (HER2-) early breast cancer (EBC).

Methods: Post-menopausal women with stage I–III operable ER+ (>50%) or Allred score >5, HER2- untreated EBC ≥1 cm in diameter were randomized 1:1 to imlunestrant 400 mg once daily (QD) or imlunestrant 800 mg QD for 15 days (treatment window of -2 to +7 days) up to the surgery date. Pre- and on-treatment tumor samples were compared for changes in PD biomarkers. Primary study objective was change in ER expression (measured by IHC and quantified by H-score). Secondary objectives were change in progesterone receptor (PR) expression (measured by IHC and quantified by H-score) and Ki-67 (measured by IHC and expressed by percentage positive scoring) along with evaluation of safety and tolerability.

Results: From Apr 28, 2021, to Mar 11, 2022, 58 patients were enrolled of which 54 were biomarker-evaluable for ER expression (400 mg: n = 28; 800 mg: n = 26). Patient demographics and tumor characteristics for all enrolled patients were similar across cohorts, with a median age of 64 years (50-83), 72% invasive ductal carcinoma (IDC), 28% invasive lobular carcinoma (ILC), 59% stage I, 36% stage II and 5% stage III disease. 91% of the patients had a compliance rate higher than 80%. Among biomarker evaluable patients, relative reduction in PD biomarkers after a median of 15 days (range 13 to 23 days) of treatment are presented in Table 1. There was no significant difference in PD biomarker modulation noted between the two imlunestrant doses (400 mg vs 800 mg) or based on tumor histology (IDC, ILC). Imlunestrant was well tolerated. There were no discontinuations due to adverse events (AEs). Treatment-related AEs (TRAEs) were mainly grade 1, most commonly: fatigue (10%), diarrhea (9%), hot flushes (7%), and nausea (5%). There were no TRAEs of diarrhea and nausea observed at the 400 mg dose. No grade 3 or higher TRAEs were reported.

Conclusion: Imlunestrant demonstrated evidence of target engagement along with consistent biological activity across all evaluated dose levels and was well tolerated in an EBC population, further supporting continued adjuvant development in the ongoing EMBER-4 study. Additional biomarker analyses for the EMBER-2 study are also planned.

Table 1. Relative reduction in PD biomarkers from Baseline to Day 15

Citation Format: Patrick Neven, Nicole Stahl, Maria Vidal, Miguel Martín, Nadia Harbeck, Peter A. Kaufman, Francois-Clement Bidard, Peter A. Fasching, Philippe Aftimos, Erika Hamilton, Stacey Carter, Peter Schmid, Duncan Wheatley, Manali Bhave, Kelly K. Hunt, Swati A. Kulkarni, Roohi Ismail-Khan, Claudia Karacsonyi, Shawn T. Estrem, Umut Ozbek, Bastien Nguyen, Eva Ciruelos. A preoperative window-of-opportunity study of imlunestrant in estrogen receptor-positive, HER2-negative early breast cancer: Results from the EMBER-2 study. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-10-06.

Abstract PD10-05: PD10-05 Neoadjuvant tamoxifen therapy reactivates tumor suppressor protein p53 in luminal breast cancer patients: Results from a window-of-opportunity clinical trial

Therapeutic effect of tamoxifen (Tam) against ER+ breast cancer (BC) is known to be mediated by its binding to estrogen receptor-alpha (ERά/ESR1) and inhibiting estrogen signaling leading to altered gene expression. Besides this canonical mode of function, our pre-clinical studies had revealed a novel mechanism wherein ESR1 directly binds wild type p53 (wt TP53) resulting in repression of its tumor suppressor functions, and Tam blocks this inactivation of TP53. Although patients with Luminal Tumors expressing wt TP53 are known to be more responsive to tamoxifen therapy, the underlying mechanism in tumors has remained unknown. To test the hypothesis that abrogation of the ESR1-mediated functional inactivation of TP53 is one of the major mechanisms that underlie the early effects of Tam therapy, we conducted a window of opportunity clinical trial in newly diagnosed luminal breast cancer patients undergoing surgical therapy. Methods: 59 women with ER+ invasive BC were randomized to 20mg Tam daily for 28 days prior to surgery or standard of care (SOC). TP53 status was confirmed by massively parallel sequencing. ER+ wt TP53 tumors were included in the study. IHC was performed on FFPE tissue from tumors to compare expression of ESR1 and TP53 along with their selected downstream targets. ESR1–TP53 interaction in situ was determined by Proximity Ligation Assay (PLA).17β-estradiol and Tam metabolites were measured in the plasma, tumor, and surrounding normal tissue using LC-MS/MS. Global transcriptome analysis in tumors was conducted by RNA-seq. Proteome expression in resected tumors was analyzed by reverse phase protein array (RPPA) with 216 proteins. Findings: Importantly, IHC on tumor tissues showed that the levels of ESR1 and TP53 were not altered in response to Tam therapy, whereas ESR1–TP53 interaction was considerably disrupted by Tam (in situ PLA data). Differential gene expression (DGE) analysis using DESeq2 R package followed by GSEA pathway analysis showed that 307 genes were differentially expressed (p< 0.05) (log FC>1.5) in tumors from Tam-treated versus untreated patients in response to Tam therapy. Pathways representing TP53 signaling, stem cells, and low-grade luminal breast cancer were upregulated in the Tam treated group while those representing adipogenesis, invasive breast cancer, estradiol response, ras signaling, and E2F targets were downregulated. “Master Regulators” identified by iRegulon included several p53 targets. Integration of RNA-seq and RPPA data revealed that DEGs fall into three categories: (i) regulated by TP53, (ii) regulated by ESR1, and (iii) regulated by both TP53 and ESR1. Together, the data demonstrated that in addition to its conventional effects mediated by its binding to ESR1 and inhibiting estrogen signaling leading to altered gene expression, Tam disrupted the ESR1–TP53 interaction leading to functional reactivation of TP53 and reprogramming of gene expression. Conclusions: Our data 1) support ESR1–TP53 crosstalk in tumors as a novel mechanism underlying endocrine therapy response of luminal BC patients, and 2) highlight the importance of factoring TP53 into therapeutic strategies for ER+ BC patients, and 3) have implications in stratifying ER+ BC patients to those who will or will not be responsive to Tam therapy.

Citation Format: Gokul M. Das, Swati A. Kulkarni, Chetan Oturkar, Spencer Rosario, Stephen B. Edge, Jianmin Wang, Wendy M. Swetzig, Alan D. Hutson, Benny Kaipparettu, Adrienne Groman, Araba Adjei, Andrew K. Goey, Carl D. Morrison, Shicha Kumar. PD10-05 Neoadjuvant tamoxifen therapy reactivates tumor suppressor protein p53 in luminal breast cancer patients: Results from a window-of-opportunity clinical trial [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD10-05.

Ergonomics Workshop Improves Musculoskeletal Symptoms in General Surgery Residents

INTRODUCTION

Poor operative ergonomics can lead to muscle fatigue and injury. However, formal ergonomics education is uncommon in surgical residencies. Our study examines the prevalence of musculoskeletal (MSK) symptoms, baseline ergonomics knowledge, and the impact of an ergonomics workshop in general surgery residents.

METHODS

An anonymous voluntary presurvey and postsurvey was distributed to all general surgery residents at a single academic residency, assessing resident characteristics, MSK symptoms, and ergonomic knowledge before and after an ergonomics workshop. The workshop consisted of a lecture and a personalized posture coaching session with a physiatrist.

RESULTS

The presurvey received 33/35 (94%) responses. Of respondents, 100% reported some degree of MSK pain. Prevalence of muscle stiffness and fatigue decreased with increasing height. Females reported higher frequencies of MSK pain (P = 0.01) and more muscle fatigue than males (100% versus 73%, P = 0.03). All residents reported little to no ergonomics knowledge with 68% reporting that ergonomics was rarely discussed in the operating room. The postsurvey received 26/35 (74%) responses. Of respondents, 100% reported the workshop was an effective method of ergonomics education. MSK symptom severity improved in 82% of residents. Reports that ergonomics was rarely discussed in the operating room significantly decreased to 22.8% of residents (P < 0.01).

CONCLUSIONS

Surgical resident ergonomics knowledge is poor and MSK symptoms are common. Resident characteristics are associated with different MSK symptoms. Didactic teaching and personalized posture coaching improve ergonomics knowledge and reduce MSK symptom severity. Surgical residencies should consider implementing similar interventions to improve resident wellbeing.

Using ecological momentary assessment to understand associations between daily physical activity and symptoms in breast cancer patients undergoing chemotherapy

PURPOSE

Understanding real-time relationships between physical activity (PA) and symptoms during chemotherapy (CT) could have important implications for intervention. This study used ecological momentary assessment to examine the relationship between objective PA and symptoms during CT.

METHODS

Breast cancers patients (n = 67; M_age = 48.6 (SD = 10.3)) participated in data collection at three time points during CT: beginning, middle, and end. At each time point, participants answered four prompts assessing symptoms and wore an accelerometer for 10 days (3 days pre-CT, day of CT, and 6 days post-CT). Multilevel linear regression models examined the between- and within-person associations between moderate to vigorous (MVPA) and light-intensity physical activity (LPA) and same and next-day symptom ratings controlling for covariates.

RESULTS

On days when individuals engaged in more LPA or MVPA, separately, they reported improved affect, anxiety, fatigue, physical functioning (walking and activities of daily living), pain, and cognition that day (p < 0.001 for all). Findings were consistent for next-day symptom ratings with the exception that only previous day LPA was related to next-day fatigue and neither LPA nor MVPA were related to next-day cognition (p < 0.001 for all). No between-person effects were found.

CONCLUSIONS

Within person higher than usual PA on a given day, regardless of intensity, is associated with improved symptoms ratings on the current and next day.

IMPLICATIONS FOR CANCER SURVIVORS

Encouraging breast cancer patients undergoing CT to engage in daily PA could help manage CT-associated symptoms.

A lysosome-targeted DNA nanodevice selectively targets macrophages to attenuate tumours

Activating CD8+ T cells by antigen cross-presentation is remarkably effective at eliminating tumours. Although this function is traditionally attributed to dendritic cells, tumour-associated macrophages (TAMs) can also cross-present antigens. TAMs are the most abundant tumour-infiltrating leukocyte. Yet, TAMs have not been leveraged to activate CD8+ T cells because mechanisms that modulate their ability to cross-present antigens are incompletely understood. Here we show that TAMs harbour hyperactive cysteine protease activity in their lysosomes, which impedes antigen cross-presentation, thereby preventing CD8+ T cell activation. We developed a DNA nanodevice (E64-DNA) that targets the lysosomes of TAMs in mice. E64-DNA inhibits the population of cysteine proteases that is present specifically inside the lysosomes of TAMs, improves their ability to cross-present antigens and attenuates tumour growth via CD8+ T cells. When combined with cyclophosphamide, E64-DNA showed sustained tumour regression in a triple-negative-breast-cancer model. Our studies demonstrate that DNA nanodevices can be targeted with organelle-level precision to reprogram macrophages and achieve immunomodulation in vivo.

A Single-Center Study of Adherence to Breast Cancer Screening Mammography Guidelines by Transgender and Non-Binary Patients

BACKGROUND

Adherence to screening guidelines among transgender and non-binary (TGNB) populations is not well studied. This study examines breast cancer screening patterns among TGNB patients at an urban academic medical center.

METHODS

Demographic information, risk factors, and screening mammography were collected. Mammography rates were calculated in populations of interest according to national guidelines, and mammogram person-years were also calculated. Univariate and multivariate logistic regression was performed.

RESULTS

Overall, 253 patients were analyzed: 193 transgender women and non-binary people designated male at birth (TGNB DMAB) and 60 transgender men and non-binary people designated female at birth (TGNB DFAB). The median (interquartile range) age was 53.2 years (42.3-62.6). Most patients had no family history of breast cancer (n = 163, 64.4%) and were on hormone therapy (n = 191, 75.5%). Most patients where White (n = 164, 64.8%), employed (n = 113, 44.7%), and had public insurance (n = 128, 50.6%). TGNB DFAB breast screening rates were low, ranging from 2.0 to 50.0%, as were TGNB DMAB screening rates, ranging from 7.1 to 47.6%. The screening rates among the TGNB DFAB and TGNB DMAB groups did not significantly differ from one another. Among TGNB DFAB patients, univariate analyses showed no significant predictors for mammography. Among TGNB DMAB patients, not being on hormone therapy resulted in fewer odds of undergoing mammography. There were no significant findings on multivariate analyses.

CONCLUSION

Mammography rates in the TGNB population are lower than institutional and national rates for cisgender patients, which are 77.3% and 66.7-78.4%, respectively. Stage of transition, organs present, hormone therapy, and risk factors should be considered to guide screening.

High-Resolution Full-3D Specimen Imaging for Lumpectomy Margin Assessment in Breast Cancer

BACKGROUND

Two-dimensional (2D) specimen radiography (SR) and tomosynthesis (DBT) for breast cancer yield data that lack high-depth resolution. A volumetric specimen imager (VSI) was developed to provide full-3D and thin-slice cross-sectional visualization at a 360° view angle. The purpose of this prospective trial was to compare VSI, 2D SR, and DBT interpretation of lumpectomy margin status with the final pathologic margin status of breast lumpectomy specimens.

METHODS

The study enrolled 200 cases from two institutions. After standard imaging and interpretation was performed, the main lumpectomy specimen was imaged with the VSI device. Image interpretation was performed by three radiologists after surgery based on VSI, 2D SR, and DBT. A receiver operating characteristic (ROC) curve was created for each method. The area under the curve (AUC) was computed to characterize the performance of the imaging method interpreted by each user.

RESULTS

From 200 lesions, 1200 margins were interpreted. The AUC values of VSI for the three radiologists were respectively 0.91, 0.90, and 0.94, showing relative improvement over the AUCs of 2D SR by 54%, 13%, and 40% and DBT by 32% and 11%, respectively. The VSI has sensitivity ranging from 91 to 94%, specificity ranging from 81 to 85%, a positive predictive value ranging from 25 to 30%, and a negative predicative value of 99%.

CONCLUSIONS

The ROC curves of the VSI were higher than those of the other specimen imaging methods. Full-3D specimen imaging can improve the correlation between the main lumpectomy specimen margin status and surgical pathology. The findings from this study suggest that using the VSI device for intraoperative margin assessment could further reduce the re-excision rates for women with malignant disease.

Evaluation of the Novel 4R Oncology Care Planning Model in Breast Cancer: Impact on Patient Self-Management and Care Delivery in Safety-Net and Non-Safety-Net Centers

PURPOSE

Optimal cancer care requires patient self-management and coordinated timing and sequence of interdependent care. These are challenging, especially in safety-net settings treating underserved populations. We evaluated the 4R Oncology model (4R) of patient-facing care planning for impact on self-management and delivery of interdependent care at safety-net and non-safety-net institutions.

METHODS

Ten institutions (five safety-net and five non-safety-net) evaluated the 4R intervention from 2017 to 2020 with patients with stage 0-III breast cancer. Data on self-management and care delivery were collected via surveys and compared between the intervention cohort and the historical cohort (diagnosed before 4R launch). 4R usefulness was assessed within the intervention cohort.

RESULTS

Survey response rate was 63% (422/670) in intervention and 47% (466/992) in historical cohort. 4R usefulness was reported by 79.9% of patients receiving 4R and was higher for patients in safety-net than in non-safety-net centers (87.6%, 74.2%, P = .001). The intervention cohort measured significantly higher than historical cohort in five of seven self-management metrics, including clarity of care timing and sequence (71.3%, 55%, P < .001) and ability to manage care (78.9%, 72.1%, P = .02). Referrals to interdependent care were significantly higher in the intervention than in the historical cohort along all six metrics, including primary care consult (33.9%, 27.7%, P = .045) and flu vaccination (38.6%, 27.9%, P = .001). Referral completions were significantly higher in four of six metrics. For safety-net patients, improvements in most self-management and care delivery metrics were similar or higher than for non-safety-net patients, even after controlling for all other variables.

CONCLUSION

4R Oncology was useful to patients and significantly improved self-management and delivery of interdependent care, but gaps remain. Model enhancements and further evaluations are needed for broad adoption. Patients in safety-net settings benefited from 4R at similar or higher rates than non-safety-net patients, indicating that 4R may reduce care disparities.

Daily Physical Activity and Symptom Reporting in Breast Cancer Patients Undergoing Chemotherapy: An Intensive Longitudinal Examination

BACKGROUND

Increased activity is beneficial during chemotherapy, but treatment-related symptoms may be a barrier. This study examines the relationship between daily fluctuations in symptoms and activity during chemotherapy.

METHODS

Women undergoing chemotherapy for breast cancer [n = 67; M _age = 48.6 (SD = 10.3)] wore an accelerometer 24 hours/day and received four text prompts/day to rate symptoms for 10 consecutive days at the beginning, middle, and end of chemotherapy. Mixed-effects models were used to examine the between and within-person relationships between symptom ratings on a given day and moderate to vigorous physical activity (MVPA) and light physical activity (LPA) on that day and the following day controlling for relevant covariates and using the Bonferroni correction for multiple comparisons.

RESULTS

For MVPA and LPA, within-person associations were statistically significant for same day affect, fatigue, pain, walking, activities of daily living (ADL) physical function, and cognitive function. Previous day anxiety was associated with next day LPA. Every one point worse symptom rating than an individual's overall average was associated with: (i) between 1.49 (pain) and 4.94 (fatigue) minutes less MVPA and between 4.48 (pain) and 24.72 (ADL physical function) minutes less LPA that day, and (ii) 11.28 minutes less LPA the next day. No between-person effects were significant for MVPA or LPA.

CONCLUSIONS

Daily within-person variations in symptoms were associated with MVPA and LPA during chemotherapy for breast cancer.

IMPACT

Future work should explore relationships between symptoms and activity further and identify whether tailoring to symptoms enhances efficacy of physical activity promotion interventions during chemotherapy.

Is Breast Magnetic Resonance Imaging an Accurate Predictor of Nodal Status After Neoadjuvant Chemotherapy?

BACKGROUND

With increasing use of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC), preoperative imaging assessment of axillary lymph nodes (ALNs) has become more important in operative planning and patient counseling. We aimed to assess if MRI is an accurate predictor of the ALN status after NAC.

METHODS

We used our institutional proprietary prospective database to review all patients with newly diagnosed breast cancer between August 2015 and March 2017 who received NAC, underwent post-NAC MRI, and axillary surgery. Imaging findings, axillary surgery, and histopathology results were analyzed.

RESULTS

Of 114 patients receiving NAC, 50 underwent post-NAC MRI before surgery. The mean age was 46 y; 36% were triple-negative, 26% were triple-positive, 26% were ER-positive and HER2/neu-negative, and 12% were ER-negative and Her2/neu-positive. Post-NAC MRI ALN status was normal in 35 patients, of which 30 underwent SLNB and five went directly to axillary lymph node dissection (ALND). 26 of these 35 were negative for metastasis on final pathology resulting in a negative-predictive value of 74.3%. In 15 patients with an abnormal post-NAC MRI ALN status, eight went directly to ALND and seven underwent SLNB. Eight of these 15 were positive for metastasis on final pathology resulting in a positive predictive value of 53.3%.

CONCLUSIONS

Assessment of axillary imaging findings on post-NAC MRI predicts the absence of nodal disease with higher accuracy than its presence but not with adequate accuracy as surrogate for surgical pathologic evaluation of ALNs. This information is valuable in both patient counseling and axillary surgical management after NAC.

Abstract OT3-09-02: A large-scale multicenter phase II study evaluating the protective effect of a tissue selective estrogen complex (TSEC) in women with newly diagnosed ductal carcinoma in situ (DCIS)

Background: TSECs were developed to treat menopausal symptoms after progesterone containing hormone replacement therapy was found to significantly increase the risk of invasive breast cancer (IBC). The first of this class of agents combines conjugated estrogens (CE), a collection of steroidal estrogens that collectively have both estrogen receptor (ERα) agonistic and antagonistic activity, and bazedoxifene (BZA), a third generation selective estrogen receptor modulator that does not stimulate the mammary gland or endometrium. The FDA approved CE/BZA for treatment of menopausal symptoms and osteoporosis after five randomized placebo controlled trials demonstrated the safety, efficacy and tolerability of CE/BZA in healthy postmenopausal women. Since then, a substantial body of evidence has emerged suggesting that CE/BZA may have additional therapeutic benefits in women. It is widely accepted that progression to IBC occurs through both epithelial and stromal mechanisms. Recent in vitro and in vivo data provide support that CE/BZA prevents progression to IBC through its effects on both epithelium and stroma. In epithelial cells, CE/BZA antagonizes estrogen-induced proliferation and expression of markers of ERα activity and also degrades ERα protein. In the stroma, CE/BZA increases expression of the scavenger receptor CD36 and consequently, reduces expression of extracellular matrix proteins (ECM) and pro-inflammatory cytokines that have been shown to contribute to the development of pro-tumorigenic microenvironment. Based on these preliminary data, we hypothesized that CE/BZA will have an anti-tumorigenic effect in the breast. Our ultimate objective is to provide postmenopausal women diagnosed with DCIS a novel and safe therapeutic option to prevent progression to IBC. Specific Aims: Aim 1: To assess epithelial contributions by determining if a short intervention of CE/BZA will have antagonistic activity in breast epithelium of postmenopausal women with ER + DCIS. Aim 2: To assess stromal contributions by determining if a short intervention of CE/BZA will alter expression of stromal markers of progression in breast tissue of postmenopausal women with ER + DCIS. Aim 3: To determine if a short intervention of CE/BZA is well tolerated and safe in postmenopausal women with ER + DCIS. Trial Design: We are currently conducting a multicenter randomized placebo controlled window of opportunity trial with CE/BZA in post-menopausal women with DCIS, a non-obligate precursor to IBC. The duration of intervention is 28 ± 7 days prior to surgical resection to enable comparison of CE/BZA on the breast using the diagnostic core biopsy and surgical sample. To date 33/166 women have enrolled in the trial. Eligibility Criteria: Post-menopausal women between 18-79 years of age diagnosed with ER (+) DCIS (&gt;1cm on imaging) undergoing surgery are eligible. Women must not be on current hormonal therapy, have a current or past diagnosis of IBC, other ER sensitive tumors or have recurrent DCIS. Statistics: Results will be compared between diagnostic biopsy and surgical resection specimens and contrasted between the CE/BZA intervention group and placebo group using Fisher’s exact test for categorical variables and independent sample t-tests, or rank sum tests for continuous data. For RNAseq data, transcripts that have &gt;1.5-fold expression change (at 20% FDR) between control and experimental samples will be used for downstream analysis, such as to plot heat maps, pathway and gene ontology analysis. Summary: At the conclusion of this study, we will have the first direct evidence of the potential benefits of CE/BZA therapy on DCIS lesions in the human breast, along with an initial assessment of symptoms and pharmacogenomics that will inform the design of future studies.

Citation Format: Swati A. Kulkarni, Geoffrey Greene, Thea Tlsty, Luis Blanco, Judy Garber, Al George, Fred Rademaker, Seema A Khan, Nora Hansen, Kevin Bethke, Rebecca Aft, Julia Tchou. A large-scale multicenter phase II study evaluating the protective effect of a tissue selective estrogen complex (TSEC) in women with newly diagnosed ductal carcinoma in situ (DCIS) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-09-02.

Radiology as the Point of Cancer Patient and Care Team Engagement: Applying the 4R Model at a Patient's Breast Cancer Care Initiation

Radiologists aspire to improve patient experience and engagement, as part of the Triple Aim of health reform. Patient engagement requires active partnerships among health providers and patients, and rigorous teamwork provides a mechanism for this. Patient and care team engagement are crucial at the time of cancer diagnosis and care initiation but are complicated by the necessity to orchestrate many interdependent consultations and care events in a short time. Radiology often serves as the patient entry point into the cancer care system, especially for breast cancer. It is uniquely positioned to play the value-adding role of facilitating patient and team engagement during cancer care initiation. The 4R approach (Right Information and Right Care to the Right Patient at the Right Time), previously proposed for optimizing teamwork and care delivery during cancer treatment, could be applied at the time of diagnosis. The 4R approach considers care for every patient with cancer as a project, using project management to plan and manage care interdependencies, assign clear responsibilities, and designate a quarterback function. The authors propose that radiology assume the quarterback function during breast cancer care initiation, developing the care initiation sequence, as a project care plan for newly diagnosed patients, and engaging patients and their care teams in timely, coordinated activities. After initial consultations and treatment plan development, the quarterback function is transitioned to surgery or medical oncology. This model provides radiologists with opportunities to offer value-added services and solidifies radiology's relevance in the evolving health care environment. To implement 4R at cancer care initiation, it will be necessary to change the radiology practice model to incorporate patient interaction and teamwork, develop 4R content and local adaption approaches, and enrich radiology training with relevant clinical knowledge, patient interaction competence, and teamwork skill set.

Abstract CT012: Novel effect of tamoxifen therapy: disruption of ER-p53 interaction leading to altered gene expression profile in human breast tumors

Introduction: We have reported that ERα binds to wild type (wt) p53 and inactivates its tumor suppressor activity. This interaction is augmented by estradiol and disrupted by tamoxifen (TAM). Moreover, retrospective clinical studies have shown that ER+ breast cancer (BC) expressing wt p53 is more responsive to TAM therapy compared to those expressing mutant p53. We conducted a window of opportunity trial in women with ER+ BC expressing wt p53 to test our hypothesis that TAM relieves the functional suppression of p53 by ERα.

Methods: Women with ER+ invasive BC were randomized to 20mg TAM daily for 4 weeks prior to surgery or standard of care (SOC.) Wt p53 status in tumors was confirmed by massively parallel sequencing. Only ER+ wt p53 tumors were analyzed. ERα-p53 interaction was determined by Proximity Ligation Assay (PLA). Global transcriptome analysis in surgically resected tumors was conducted by RNA-seq. The multiplexed libraries were sequenced on HiSeq 2500 using 100 cycle paired end sequencing and an average 50 million paired end reads were generated for each sample. Immunohistochemistry was performed on FFPE tissue from diagnostic biopsies and surgically resected tumors to compare expression of ERα and p53 selected downstream targets.17β-estradiol and TAM metabolites were measured in the plasma, tumor and surrounding normal tissue using LC-MS/MS. Steady-state levels of TAM were confirmed. Polymorphisms affecting TAM metabolism enzymes were determined by genotyping.

Findings: 53 women completed the study and 36 had adequate tissue for analysis (16 TAM and 20 SOC). PLA demonstrated that ERα-p53 interaction was disrupted in 75% of TAM treated patients. Differential gene expression (DEG) analysis using DESEq2 R package followed by GSEA pathway analysis showed that 300 genes were upregulated and 272 genes were downregulated (p&lt;0.05) in response to TAM therapy. DEG included those involved in the regulation of cell cycle, apoptosis, immune response, energy metabolism, growth factors and receptors, and membrane transporters. Importantly, several p53-target genes responded strongly to TAM therapy (repression targets of p53 were downregulated and activation targets were upregulated) while pro-proliferative ERα targets were downregulated. Detailed results and analysis will be provided at the presentation.

Conclusions: In human BC, we have shown that in addition to its conventional effects, TAM disrupts the ERα-p53 interaction leading to functional reactivation of p53. Our data 1) supports the role of ERα-p53 crosstalk in endocrine resistance of ER+ tumors, 2) provides insight into the mechanism underlying favorable response of wt p53 to TAM therapy, and 3) has implications toward stratifying ER+ BC patients to those who will or will not be responsive to TAM therapy.

Citation Format: Swati A. Kulkarni, Chetan C. Oturkar, Stephen B. Edge, Jianmin Wang, John H. Walton, Wendy M. Swetzig, Araba Adjei, Robert Bies, Alan D. Hutson, Adrienne Groman, Morrison D. Carl, Jerry Fetterly, Schika Kumar, Gokul M. Das. Novel effect of tamoxifen therapy: disruption of ER-p53 interaction leading to altered gene expression profile in human breast tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT012. doi:10.1158/1538-7445.AM2017-CT012

The Breast-Thyroid Cancer Link: A Systematic Review and Meta-analysis

Rates of thyroid cancer in women with a history of breast cancer are higher than expected. Similarly, rates of breast cancer in those with a history of thyroid cancer are increased. Explanations for these associations include detection bias, shared hormonal risk factors, treatment effect, and genetic susceptibility. With increasing numbers of breast and thyroid cancer survivors, clinicians should be particularly cognizant of this association. Here, we perform a systematic review and meta-analysis of the literature utilizing PubMed and Scopus search engines to identify all publications studying the incidence of breast cancer as a secondary malignancy following a diagnosis of thyroid cancer or thyroid cancer following a diagnosis of breast cancer. This demonstrated an increased risk of thyroid cancer as a secondary malignancy following breast cancer [OR = 1.55; 95% confidence interval (CI), 1.44-1.67] and an increased risk of breast cancer as a secondary malignancy following thyroid cancer (OR = 1.18; 95% CI, 1.09-1.26). There is a clear increase in the odds of developing either thyroid or breast cancer as a secondary malignancy after diagnosis with the other. Here, we review this association and current hypothesis as to the cause of this correlation.

Society of Surgical Oncology Breast Disease Working Group Statement on Prophylactic (Risk-Reducing) Mastectomy

Over the past several years, there has been an increasing rate of bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM) surgeries. Since publication of the 2007 SSO position statement on the use of risk-reducing mastectomy, there have been significant advances in the understanding of breast cancer biology and treatment. The purpose of this manuscript is to review the current literature as a resource to facilitate a shared and informed decision-making process regarding the use of risk-reducing mastectomy.

Improving confidence in (Q)SAR predictions under Canada's Chemicals Management Plan - a chemical space approach

One of the key challenges of Canada's Chemicals Management Plan (CMP) is assessing chemicals with limited/no empirical hazard data for their risk to human health. In some instances, these chemicals have not been tested broadly for their toxicological potency; as such, limited information exists on their potential to induce human health effects following exposure. Although (quantitative) structure activity relationship ((Q)SAR) models are able to generate predictions to address data gaps for certain toxicological endpoints, the confidence in predictions also needs to be addressed. One way to address this issue is to apply a chemical space approach. This approach uses international toxicological databases, for example, those available in the Organisation for Economic Co-operation and Development (OECD) QSAR Toolbox. The approach,assesses a model's ability to predict the potential hazards of chemicals that have limited hazard data that require assessment under the CMP when compared to a larger, data-rich chemical space that is structurally similar to chemicals of interest. This evaluation of a model's predictive ability makes (Q)SAR analysis more transparent and increases confidence in the application of these predictions in a risk-assessment context. Using this approach, predictions for such chemicals obtained from four (Q)SAR models were successfully classified into high, medium and low confidence levels to better inform their use in decision-making.

Examining the Relationship between Pre-Malignant Breast Lesions, Carcinogenesis and Tumor Evolution in the Mammary Epithelium Using an Agent-Based Model

INTRODUCTION

Breast cancer, the product of numerous rare mutational events that occur over an extended time period, presents numerous challenges to investigators interested in studying the transformation from normal breast epithelium to malignancy using traditional laboratory methods, particularly with respect to characterizing transitional and pre-malignant states. Dynamic computational modeling can provide insight into these pathophysiological dynamics, and as such we use a previously validated agent-based computational model of the mammary epithelium (the DEABM) to investigate the probabilistic mechanisms by which normal populations of ductal cells could transform into states replicating features of both pre-malignant breast lesions and a diverse set of breast cancer subtypes.

METHODS

The DEABM consists of simulated cellular populations governed by algorithms based on accepted and previously published cellular mechanisms. Cells respond to hormones, undergo mitosis, apoptosis and cellular differentiation. Heritable mutations to 12 genes prominently implicated in breast cancer are acquired via a probabilistic mechanism. 3000 simulations of the 40-year period of menstrual cycling were run in wild-type (WT) and BRCA1-mutated groups. Simulations were analyzed by development of hyperplastic states, incidence of malignancy, hormone receptor and HER-2 status, frequency of mutation to particular genes, and whether mutations were early events in carcinogenesis.

RESULTS

Cancer incidence in WT (2.6%) and BRCA1-mutated (45.9%) populations closely matched published epidemiologic rates. Hormone receptor expression profiles in both WT and BRCA groups also closely matched epidemiologic data. Hyperplastic populations carried more mutations than normal populations and mutations were similar to early mutations found in ER+ tumors (telomerase, E-cadherin, TGFB, RUNX3, p < .01). ER- tumors carried significantly more mutations and carried more early mutations in BRCA1, c-MYC and genes associated with epithelial-mesenchymal transition.

CONCLUSIONS

The DEABM generates diverse tumors that express tumor markers consistent with epidemiologic data. The DEABM also generates non-invasive, hyperplastic populations, analogous to atypia or ductal carcinoma in situ (DCIS), via mutations to genes known to be present in hyperplastic lesions and as early mutations in breast cancers. The results demonstrate that agent-based models are well-suited to studying tumor evolution through stages of carcinogenesis and have the potential to be used to develop prevention and treatment strategies.

Abstract P4-08-03: Demonstration of the evolutionary dynamics of the progression from breast hyperplasia to cancer using the duct epithelial agent based model (DEABM)

Introduction: Abnormal proliferation in the breast is clinically seen ranging from hyperplasia to atypia to in situ carcinomas (DCIS) to invasive cancers. Whether these states comprise points along an evolutionary continuum is a subject of debate, but has significant implications for prevention, prognosis, and treatment. Due to the length of time involved, tumor evolution is difficult to study in vivo and in vitro models. We hypothesize a continuum from hyperplasia to cancer can be demonstrated by examining patterns of accumulated mutations in tumors. We employ a previously developed computational model of ductal epithelial dynamics, the DEABM (1), to simulate and track accumulated mutations during the progression from a normal epithelial population through hyperplastic states to the development of invasive tumors

Methods: Simulation experiments were performed using an expanded DEABM, which incorporates the functions of luminal and myoepithelial cells, their progenitors and fibroblasts. DNA damage can potentially disrupt 12 functional pathways regulated by oncogenes and tumor suppressors implicated in breast cancer (BRCA1, P53, E-cadherin, RUNX3, Myc, ER, TGF-b, MMP-3, EGFR, HER-2 and Telomerase). The expanded DEABM allows for sequential tracking of genetic lesions in each cell. 3,000 simulations in both wild-type (WT) and BRCA1-mutated states were run over 40 years of simulated menses. Cell populations were characterized as normal, hyperplastic or malignant based on quantitative cell expansion from baseline, as well as by mutational profiles, sequential order of mutations and ER status.

Results: Tumor profiles approximated epidemiologic rates of cancer incidence and ER/HER2 status. 2.6 % of WT developed malignancy vs. 45.9% of BRCA1. WT tumors were 54% ER+/HER2-, 17% ER+/HER2+, 6% ER-/HER2+ and 22% ER-/HER2-. BRCA1 tumors were 29% ER+/HER2-, 7% ER+/HER2+, 13% ER-/HER2+ and 50% ER-/HER2-. Hyperplastic populations carried more mutations than non-hyperplastic populations (p&gt;.01) and were more likely to carry mutations in telomerase, E-cadherin and genes related to ER expression (TGFB, RUNX3, p&lt;.01), similar to the early mutations found in ER+ tumors (RUNX3, TGFB, telomerase p&lt;.01). Early P53 mutations were common in all tumors (p&lt;.01). ER- tumors were more likely to carry early mutations in BRCA1, MYC and genes associated with epithelial-mesenchymal transition (MMP-3, p&lt;.01). ER- tumors carried significantly more mutations than ER+ (p&lt;.01), corresponding to data on increased genomic instability in ER- and BRCA1-associated tumors.

Conclusion: The DEABM generates diverse tumors that express tumor markers consistent with epidemiologic data. The DEABM also generates non-invasive, hyperplastic populations, analogous to atypia and/or DCIS, via mutations to genes known to be present in hyperplastic lesions and early mutations in breast cancers. The results demonstrate that agent-based models are well-suited to studying tumor evolution through stages of carcinogenesis and have the potential to be used to develop prevention and treatment strategies.

Ref: Chapa J, et al. "Examining the Pathogenesis of Breast Cancer Using a Novel Agent-Based Model of Mammary Ductal Epithelium Dynamics." PloS one 8.5 (2013).

Citation Format: Joaquin Chapa, Gary An, Swati A Kulkarni. Demonstration of the evolutionary dynamics of the progression from breast hyperplasia to cancer using the duct epithelial agent based model (DEABM) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-08-03.

Abstract P2-12-06: Sources of information and influence on decisions regarding contralateral prophylactic mastectomy: A prospective study

Background: The number of women with a newly diagnosed ipsilateral breast cancer requesting contralateral prophylactic mastectomy (CPM) has increased significantly in recent years. Little is known about the sources of information women utilize as part of their decision making process regarding the choice of CPM.

Methods: A 55-item survey validated with breast cancer survivors was administered to 136 women with newly diagnosed breast cancer before they underwent surgical therapy at two institutions. Women were asked about the influence of medical personnel, individuals outside of medicine, websites and social media on their decision to keep or remove their healthy breast.

Results: The median age was 58 years (range 30-85); 69.2% were White, 26.7% were African American and 4.2% were Asian; Thirty-eight (28.6%) of patients had a first-degree relative with breast cancer. Seventy-five (58.6%) had a lumpectomy, 41 (32%) had a unilateral mastectomy and 12 (9.4%) had a CPM. About 80% of women felt the information they were given about breast cancer treatment was consistent. Fifty-five patients (41.7%) sought out extra information beyond what the doctor gave them. Sources of information that had strong or some influence were websites and books recommended by their doctor (44%), websites, followed books not recommended by their doctor (30.4%), and magazines (15.4%). Only 6.7% said that social media had some or strong influence on their decision making; 61.7% stated that they completely or mostly relied on their doctor’s advice to make treatment decisions and ranked their doctor’s spoken advice (74.3%) as the most important source of information in making their decision to keep or remove their healthy breast. However, Eighty-two women (62.6%) stated that information provided by staff did not include any information about removing the healthy breast. Forty-one (36%) stated that no one discussed contralateral breast cancer risk and 67 women (59%) stated that no one talked with them about the possibility that cancer could turn up somewhere else even if both breasts were removed. Of medical personnel, women stated that their surgeon (81%) had the most influence on their decision, followed by their oncologist (59.1%) and reconstructive surgeon (29.8%). When asked who influenced their decision outside of medicine, 58.7% of women stated that other breast cancer survivors influenced them. Reconstructive surgeons and the spouse/partner had more influence on those &lt;50 years old compared to &gt;50 years old (p=0.03). Oncologists (p=0.004), nurses and trained counselors (p=0.06-0.08), had more of an influence for African Americans compared to Whites.

Conclusions: Many women with newly diagnosed breast cancer do not receive information about CPM, contralateral breast cancer risk or how CPM affects recurrence from their physician. However, women still highly value their doctor’s advice and information provided by their doctor but one third of women state that websites identified on their own strongly influence their decision making for CPM. These findings highlight an opportunity for physicians to educate women about the utility of CPM as part of their surgical treatment.

Citation Format: Swati A Kulkarni, Martha Van Haitsma, Kristen Wroblewski, Sarah Rabbit, Kathy Yao. Sources of information and influence on decisions regarding contralateral prophylactic mastectomy: A prospective study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-12-06.

Commentary on the Canadian National Breast Screening study

In the setting of the 25-year follow-up of the Canadian National Breast Screening Study, the Society of Surgical Oncology continues to endorse mammographic screening for women beginning at 40 years of age, while acknowledging that mammography has both risks and benefits. Further investigation is warranted to develop better screening methods and to determine optimal screening schedules for women based on their risk of future breast cancer and their imaging characteristics.

Abstract P5-10-02: Investigating the response and adaptation of estrogen receptor (ER)+ tumors in response to decreased estrogen availability using an agent-based model of the mammary epithelium

Introduction: Breast tumors consist of heterogenous cell populations with dominant features that can change over time. The development of resistance to previously effective therapies is an example of tumor evolution in response to selective pressure, where the differential composition of cells within a tumor may predispose to identifiable patterns of tumor growth and progression. We employ a previously developed computational model of ductal epithelial dynamics (the Duct Epithelial Agent Based Model or DEABM), able to reproduce known rates of tumorigenesis in both wild-type and BRCA1 populations, to investigate the putative population dynamics of ER+ tumors in response to decreased estrogen availability (DEA).

Methods: The DEABM is composed of computational agents representing individual cells (luminal and myoepithelial cells, their progenitor cells and fibroblasts) behaving based on rules established from published cellular and molecular mechanisms. Cells implement DNA damage/repair, cell division in response to estrogen/local growth factors, and apoptosis. Unrepaired DNA damage impacts genomic integrity, including eight representative oncogenes and tumor suppressors affecting critical pathways previously implicated in breast cancer (BRCA1, P53, E-cadherin, RUNX3, Myc, TGF-beta, MMP-3 and Telomerase). ER+ tumors were generated in 40 year simulations of wild-type and BRCA1 populations and subjected to DEA (90% reduction in estrogen effect targeted to ER+ cells, which could generally represent endocrine therapy for breast cancer.) Cell populations were characterized by mutation profiles, ER status, and response to estrogen suppression. Simulations were continued until development of DEA resistance, identified by reversal of growth suppression, and the mutations present at that point were analyzed for change.

Results: 3500 DEABM simulations over 40 years generated 69 wild-type ER+ tumors and 119 BRCA ER+ tumors. Of these 25% of wild-type ER+ tumors were sensitive to DEA vs. 35% of BRCA1 tumors, consistent with previously reported response rates. The percentage of ER+ cells was higher in initially sensitive tumors than in initially resistant tumors (84% vs. 66%, p = .001). Tumors initially resistant to DEA were more likely to carry mutations in the genes p53, E-cadherin and Myc (p = .001). Sensitive tumors acquired a significant increase in mutations during the interval between responsiveness to DEA and development of resistance (p = .001). Lastly, sensitive BRCA1 carriers were more likely to convert from ER+ to ER- status (p = .001).

Discussion: The DEABM generated simulated breast tumors with intra-tumoral heterogeneity that demonstrate varied responsiveness to DEA, similar to what is observed clinically. These results suggest there may be definable patterns of tumor evolution in response to DEA that could potentially guide the development or sequencing of therapeutic regimens. Computational models such as the DEABM can aid in visualizing molecular data in a dynamic form and allow researchers to carry out “thought experiments” concerning tumor behavior and intervention effect.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-10-02.

Utilization of radiotherapy for malignant phyllodes tumors: analysis of the National Cancer Data Base, 1998-2009

BACKGROUND

Malignant phyllodes tumors of the breast have traditionally been treated with surgical excision. Recently, the use of adjuvant radiotherapy has been advocated to reduce the risk of local recurrence; however, this recommendation is controversial in the absence of consistent outcome data. We hypothesize that there has been a trend toward increased utilization of adjuvant radiotherapy for malignant phyllodes tumors despite its uncertain effect on outcomes.

METHODS

Using the National Cancer Data Base, predictors of radiotherapy utilization were examined for women with malignant phyllodes from 1998 to 2009. Kaplan-Meier and Cox regression models were generated to determine the effect of radiotherapy on local recurrence (LR), disease-free survival (DFS), and overall survival (OS).

RESULTS

Of the 3,120 patients with malignant phyllodes, 57 % underwent breast conservation surgery and 42 % underwent mastectomy. Overall, 14.3 % of women received adjuvant radiotherapy. Utilization of radiotherapy doubled over the study period (9.5 % in 1998-1999 vs. 19.5 % in 2008-2009, p < 0.001). Women were significantly more likely to receive radiotherapy if they were diagnosed later in the study, were age 50-59 years old, had tumors >10 cm, or had lymph nodes removed. For the 1,774 patients with available recurrence data, overall recurrence was 14.1 %, and LR was 5.9 %. In adjusted models, adjuvant radiotherapy reduced LR (aHR 0.43, 95 % CI 0.19-0.95) but did not impact DFS or OS after 53 months' median follow-up.

CONCLUSIONS

Utilization of adjuvant radiotherapy for malignant phyllodes doubled from 1998 to 2009. Radiotherapy significantly reduced LR but had no effect on DFS or OS.

Dietary intakes of total and specific lignans are associated with clinical breast tumor characteristics

Dietary lignans may affect breast cancer by modifying tumor characteristics likely to affect prognosis. We investigated usual dietary intakes of total and specific lignans with tumor characteristics in 683 women with breast cancer and 611 healthy women without breast cancer enrolled in the Data Bank and BioRepository at Roswell Park Cancer Institute (RPCI). Clinicopathologic data were abstracted from the RPCI breast cancer database. Dietary lignan intakes were calculated from FFQ. OR and 95% CI were estimated with logistic regression adjusting for potential confounders and stratified by menopausal status. Women in the highest compared to the lowest tertile of total lignan intakes had a 40-50% lower odds of breast cancer regardless of menopausal status and substantially reduced odds of an invasive tumor, especially among premenopausal women [OR 0.48 (95% CI 0.26-0.86)]. Lignan intakes were inversely associated with odds of grade 3 tumors among premenopausal women. Lignan intakes were inversely associated with risk of estrogen receptor (ER) negative (ER(-)) breast cancer among premenopausal women [OR 0.16 (95% CI 0.03-0.44)] and particularly triple negative tumors [ER(-), progesterone receptor negative, HER2 negative; OR 0.16 (95% CI 0.04-0.62)]. There were significant differences in the contribution to these effects by specific lignans, especially matairesinol and lariciresinol. In summary, in this case-control study of dietary lignan intakes and breast cancer, we found that higher lignan intakes were associated with lower risks of breast cancer with more favorable prognostic characteristics. Future investigations are warranted to explore the strong associations observed with ER(-) cancer in premenopausal women.

The expression of TRMT2A, a novel cell cycle regulated protein, identifies a subset of breast cancer patients with HER2 over-expression that are at an increased risk of recurrence

Background

Over-expression of HER2 in a subset of breast cancers (HER2+) is associated with high histological grade and aggressive clinical course. Despite these distinctive features, the differences in response of HER2+ patients to both adjuvant cytotoxic chemotherapy and targeted therapy (e.g. trastuzumab) suggests that unrecognized biologic and clinical diversity is confounding treatment strategies. Furthermore, the small but established risk of cardiac morbidity with trastuzumab therapy compels efforts towards the identification of biomarkers that might help stratify patients.

Methods

A single institution tissue array cohort assembled at the Clearview Cancer Institute of Huntsville (CCIH) was screened by immunohistochemistry staining using a large number of novel and commercially available antibodies to identify those with a univariate association with clinical outcome in HER2+ patients. Staining with antibody directed at TRMT2A was found to be strongly associated with outcome in HER2+ patients. This association with outcome was tested in two independent validation cohorts; an existing staining dataset derived from tissue assembled at the Cleveland Clinic Foundation (CCF), and in a new retrospective study performed by staining archived paraffin blocks available at the Roswell Park Cancer Institute (RPCI).

Results

TRMT2A staining showed a strong correlation with likelihood of recurrence at five years in 67 HER2+ patients from the CCIH discovery cohort (HR 7.0; 95% CI 2.4 to 20.1, p < 0.0004). This association with outcome was confirmed using 75 HER2+ patients from the CCF cohort (HR 3.6; 95% CI 1.3 to 10.2, p < 0.02) and 64 patients from the RPCI cohort (HR 3.4; 95% CI 1.3-8.9, p < 0.02). In bivariable analysis the association with outcome was independent of grade, tumor size, nodal status and the administration of conventional adjuvant chemotherapy in the CCIH and RPCI cohorts.

Conclusions

Studies from three independent single institution cohorts support TRMT2A protein expression as a biomarker of increased risk of recurrence in HER2+ breast cancer patients. These results suggest that TRMT2A expression should be further studied in the clinical trial setting to explore its predictive power for response to adjuvant cytotoxic chemotherapy in combination with HER2 targeted therapy.

TLE3 as a candidate biomarker of response to taxane therapy

Introduction

The addition of taxanes (Ts) to chemotherapeutic regimens has not demonstrated a consistent benefit in early-stage breast cancer. To date, no clinically relevant biomarkers that predict T response have been identified.

Methods

A dataset of immunohistochemistry stains in 411 patients was mined to identify potential markers of response. TLE3 emerged as a candidate marker for T response. To test the association with T sensitivity, an independent 'triple-negative' (TN) validation cohort was stained with anti-TLE3 antibody.

Results

TLE3 staining was associated with improved 5-year disease-free interval (DFI) in the overall cohort (n = 441, P < 0.004), in patients treated with cyclophosphamide (C), methotrexate, and 5-fluorouracil (n = 72, P < 0.02), and in those treated with regimens containing doxorubicin (A) and a T (n = 65, P < 0.04). However, no association was shown with outcome in untreated patients (n = 203, P = 0.49) or those treated with a regimen containing A only (n = 66, P = 0.97). In the TN cohort, TLE3 staining was significantly associated with improved 5-year DFI in all patients (n = 81, P < 0.015), in patients treated with AC + T (n = 45, P < 0.02), but not in patients treated with AC (n = 17, P = 0.81). TLE3 was independent of tumor size, nodal status, and grade by bivariable analysis in both cohorts.

Conclusions

TLE3 staining is associated with improved DFI in T-treated patients in two independent cohorts. Since the validation study was performed in a TN cohort, TLE3 is not serving as a surrogate for estrogen receptor or HER2 expression. TLE3 should be studied in large clinical trial cohorts to establish its role in T chemotherapy selection.

Multiple primary tumors in men with breast cancer diagnoses: a SEER database review

BACKGROUND

Male breast cancer (MBC) comprises 1% of all breast cancers and less than 1% of cancer cases in men. After a diagnosis of MBC, men are at risk of developing a second primary cancer, particularly a second primary breast cancer. The objective of this study is to analyze the characteristics of the population of men diagnosed with a second malignancy, specifically a second MBC.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, 4,873 male patients diagnosed with invasive or in situ breast cancer from 1973 to 2004 were identified and data from patients who developed a second MBC were reviewed. Additional non-breast primary cancer diagnoses were also recorded.

RESULTS

A review of 4,966 records corresponding to 4,873 patients revealed 4,462 invasive and 504 in situ breast cancer events. Of the 4,873 patients, 93 (1.9%) were identified with a second MBC. Among the 4,873 patients with MBC, 1,001 (21%) have other non-breast primary cancer diagnoses recorded in the SEER registry.

CONCLUSIONS

Although MBC is uncommon, these patients are at risk of a contralateral breast cancer and second primary non-breast cancers. Our findings support that men with breast cancer would benefit from continued long-term surveillance for breast cancer and appropriate screening for non-breast cancers.

Integrated approach to assess the domain of applicability of some commercial (Q)SAR models

An integrated framework of data analysis has been proposed to systematically address the determination of the domain of applicability (DA) of some commercial Quantitative Structure Activity Relationship ((Q)SAR) models based on the structure of test chemicals. This framework forms one of the important steps in dealing with the growing concerns on reliability of model-based predictions on toxicity of chemicals specifically in the regulatory context. The present study uses some of the well-known mutagenicity and carcinogenicity models that are available within the Casetox (MultiCASE Inc.) and TOPKAT (Accelrys Software Inc.) programs. The approach enumerated in this paper employs chemoinformatics tools that facilitate comparisons of key structural features as well as application of cluster analysis techniques. The approach has been illustrated using a set of eleven chemical structures selected from the Canadian Domestic Substances List (DSL) that are not present in the model training sets, and the efficacy of the approach has also been assessed using seven chemicals with known toxicities. The methodologies presented here could help address the issue of DA of complex (Q)SAR models and at the same time, serve as useful tools for regulators to make a preliminary assessment of (Q)SAR based systems thereby helping the process of hazard-based regulatory assessments of chemicals.

Influence of structural and functional modifications of selected genotoxic carcinogens on metabolism and mutagenicity - a review

Alterations in molecular structure are responsible for the differential biological response(s) of a chemical inside a biosystem. Structural and functional parameters that govern a chemical's metabolic course and determine its ultimate outcome in terms of mutagenic/carcinogenic potential are extensively reviewed here. A large number of environmentally-significant organic chemicals are addressed under one or more broadly classified groups each representing one or more characteristic structural feature. Numerous examples are cited to illustrate the influence of key structural and functional parameters on the metabolism and DNA adduction properties of different chemicals. It is hoped that, in the event of limited experimental data on a chemical's bioactivity, such knowledge of the likely roles played by key molecular features should provide preliminary information regarding its bioactivation, detoxification and/or mutagenic potential and aid the process of screening and prioritising chemicals for further testing.

In silico techniques for the study and prediction of xenobiotic metabolism: a review

Knowledge about metabolism is very important to understand the health risks posed by chemicals. The biochemical process of metabolism causes activation, inactivation, toxification, detoxification as well as changes in the physicochemical properties of a chemical. The long time consumption and high costs associated with animal tests and the challenges faced by traditional quantitative structure-activity relationship (QSAR) models in dealing with situations wherein parent chemical structures are less relevant to the ultimate effects have led to the development of in silico techniques for the prediction of xenobiotic metabolism. The strengths and limitations of some of the most commonly used in silico expert systems, and their application in studying metabolism of xenobiotic chemicals, have been reviewed. The in silico metabolism simulators possessed several distinguishing features imparted in part by the nature of knowledge rules (algorithms) encoded within them and in part by the integration of QSAR libraries and computational engines.

Triangular approach for the diagnosis of monoclonal gammopathy in malignancies

Monoclonal Gammopathy (MG) in multiple myeloma (MM) is an established association but its occurrence in nonmyelomatous malignancies and other inflammatory conditions is still a subject of research. We carried out this study to detect monoclonal gammopathy in myelomatous and nonmyelomatous malignancies by adopting the triangular approach of correlating radiologic findings, bone marrow studies and electrophoretic findings. 200 cases of malignancies (25 cases of multiple myeloma and 175 cases of nonmyelomatous malignancies) were studied. Serum and urine electrophoresis was carried out in every case and positive cases were subjected for typing by immunoelectrophoresis (IEP). The incidence of monoclonal gammopathy in nonmyelomatous malignancies was 2.29% (4/175 cases), in epithelial malignancies was 0.8% (1/125 cases) and 6% (3/50 cases) in haematological malignancies. Though the study sample was small, these interesting findings warrant more exhaustive research in this field.

Quantitative structure-activity relationships based on functional and structural characteristics of organic compounds

In the present quantitative structure-activity relationship (QSAR) modeling, organic compounds, including priority pollutants, have been considered and classified based on their functional and structural characteristics. Five physico-chemical characteristics have been used to develop a QSAR model for Pimephales promelas, by means of multiple regression analysis. Collinearity diagnostics was carried out using two different approaches based on condition index and K correlation index. The outlier analysis was carried out using the variable subsets obtained through both the approaches. An attempt has been made to justify the deletion of outliers in each group referring to their physico-chemical characteristics. The expressions obtained by using both approaches provide almost the same prediction accuracy, however, the latter approach resulted in expressions with reduced number of molecular descriptors. The QSARs obtained through this exercise would certainly assist in designing environment-friendly molecules with lower toxicity.

Immunocytochemical localization of bioregulatory peptides in marmoset testes

Immunocytochemical localization of neuropeptides (beta-endorphin, substance P, arginine vasopressin, oxytocin), pituitary hormones (adrenocorticotropin, prolactin, growth hormone, follicle stimulating hormone (FSH), gonadal inhibin, gastrin, and human chorionic gonadotrophin (hCG)) was carried out in marmoset testis during development. Both intensity of immunostaining and distribution of these peptides in testicular compartments viz. seminiferous tubules and Leydig cells changed dramatically during development. In vitro biosynthesis of inhibin and FSH was increased by hCG, whereas prolactin (5 micrograms) and prostatic inhibin peptide suppressed the synthesis of these hormones.

Disseminated nocardiosis

A middle aged female suffering from idiopathic thrombocytopenic purpura (ITP), on treatment with steroids, developed bronchopneumonia and pyopneumothorax due to opportunistic infection by Nocardia asteroides. Aspirates obtained from the lungs, liver, spleen, kidneys and bone marrow were positive for Nocardia asteroides, confirming disseminated infection in an immunocompromised host. The patient succumbed to the infection.

FSH in testes of marmosets during development: immunocytochemical localization and de novo biosynthesis

Immunocytochemical localization of FSH was carried out in various cell types of marmoset testes during development using antisera generated against intact as well as beta-subunit of human FSH. Significant differences in the intensity as well as distribution of FSH in various cell types were observed in neonatal, pubertal, and adult marmosets. Intensity of staining in Leydig cells was maximum at day 1 and in adults (1-3 years), whereas it was minimum at 3 months. In seminiferous tubules (Sertoli cells), FSH was present in trace amount until puberty and subsequently increased at maturity. Further studies demonstrate de novo biosynthesis of FSH-like moiety in vitro by testicular tissue, which was age dependent.

Cellular distribution of inhibin in marmoset testes during development

Using polyclonal antibodies against a 13 KD human testicular inhibin, immunocytochemical localization studies were carried out in marmoset monkey testes. The pattern as well as the intensity of immunocytochemical staining for inhibin vary substantially during development. In early development (day 1 to 2 months) Leydig cells are the predominant cell types showing intense staining which reaches its nadir at 3 months. Subsequently both Sertoli cells as well as Leydig cells show equal intensity of inhibin staining. Testicular inhibin is likely to play a vital role in cell to cell communication.

Prostate--an extrapituitary source of follicle-stimulating hormone (FSH): occurrence, localization, and de novo biosynthesis and its hormonal modulation in primates and rodents

A comparative study on the immunocytochemical localization, de novo biosynthesis, and hormonal modulation of follicle-stimulating hormone (FSH) was carried out in the prostates of man, monkey, dog, guinea pig, hamster, rat, and mouse. FSH was localized in the cytoplasm of the prostatic epithelial cells. In some specimens, staining was also observed in the nucleus. Both pituitary as well as prostatic FSH were coeluted on a Sephadex G-100 column and high-performance liquid chromatography (HPLC) indicating physicochemical similarities of FSH in both the tissues. Surprisingly, the modulation of pituitary and prostatic FSH by inhibin and its related peptides were comparable. The intensity and grandularity of FSH staining was stronger in the case of benign prostatic hyperplasia as compared with normal prostatic specimens. In view of the well-known effects of FSH on the cellular growth, differentiation, and function of gonadal tissues, a similar role for FSH in pathophysiology of prostate is postulated.

Primary intramuscular cold abscess in the left deltoid region: a case report

A case of primary intramuscular cold abscess in the left deltoid region is described. There was no underlying bone lesion in relation to cervical or thoracic spine, shoulder joint or upper humerus, and clavicle. It is postulated that the cold abscess might have developed as a result of reactivation of BCG lesion when the patient received a fresh dose of tubercular bacilli which produced only lymph node enlargement in the mediastinum because of the partial immunity the patient had.