A peripheral blood mononuclear cell-based in vitro model: A tool to explore indoleamine 2, 3-dioxygenase-1 (IDO1)

BACKGROUND

Proinflammatory cytokines powerfully induce the rate-limiting enzyme indoleamine 2, 3-dioxygenase-1 (IDO-1) in dendritic cells (DCs) and monocytes, it converts tryptophan (Trp) into L-kynurenine (KYN), along the kynurenine pathway (KP). This mechanism represents a crucial innate immunity regulator that can modulate T cells. This work explores the role of IDO1 in lymphocyte proliferation within a specific pro-inflammatory milieu.

METHODS

Peripheral blood mononuclera cells (PBMCs) were isolated from buffy coats taken from healthy blood donors and exposed to a pro-inflammatory milieu triggered by a double-hit stimulus: lipopolysaccharide (LPS) plus anti-CD3/CD28. The IDO1 mRNA levels in the PBMCs were measured by RT-PCR; the IDO1 activity was analyzed using the KYN/Trp ratio, measured by HPLC-EC; and lymphocyte proliferation was measured by flow cytometry. Trp and epacadostat (EP) were used as an IDO1 substrate and inhibitor, respectively. KYN, which is known to modulate Teffs, was tested as a positive control in lymphocyte proliferation.

RESULTS

IDO1 expression and activity in PBMCs increased in an in vitro pro-inflammatory milieu. The lymphoid stimulus increased IDO1 expression and activity, which supports the interaction between the activated lymphocytes and the circulating myeloid IDO1-expressing cells. The addition of Trp decreased lymphocyte proliferation but EP, which abrogated the IDO1 function, had no impact on proliferation. Additionally, incubation with KYN seemed to decrease the lymphocyte proliferation.

CONCLUSION

IDO1 inhibition did not change T lymphocyte proliferation. We present herein an in vitro experimental model suitable to measure IDO1 expression and activity in circulating myeloid cells.

Reduction of IL-6, IL-8 and β2-ADRENOCEPTOR mRNA levels in circulating polymorphonuclear leukocytes after adenotonsillectomy in children with Obstructive Sleep Apnea Syndrome

BACKGROUND

Obstructive Sleep Apnea Syndrome (OSAS) affects approximately 1-5% of children and is linked to cardiovascular, metabolic, and neurobehavioral complications. Dysregulation of inflammatory process and sympathetic nervous system overstimulation leading to increased catecholamine production may contribute to OSAS pathogenesis. Polymorphonuclear Neutrophils (PMN), key cells in the inflammatory process, express adrenergic receptors, including β2-adrenergic receptor (ADRB2), which modulate their functions through an autocrine/paracrine loop. In this pilot study, we aimed to investigate the relationship between OSAS severity, ADRB2 expression in PMN and patient's inflammatory profile before and after adenotonsillectomy.

PATIENTS/METHODS

In this pilot study we enrolled OSAS pediatric patients in which ADRB2, IL-6 and IL-8 mRNA expression levels were evaluated in circulating PMN by RT-PCR.

RESULTS

9 OSAS pediatric patients, ranged from 3 to 8 years of age, were enrolled in the study. We found that adenotonsillectomy significantly reduced ADRB2 as well as IL-6, IL-8 mRNA expression levels in PMN.

CONCLUSIONS

These findings offer valuable insights into the underlying immune and inflammatory mechanisms of OSAS and open the way for the development of novel therapeutic approaches.

Effect of Cannabidiol on Cyclooxygenase Type 1 and 2 Expression and Function in Human Neutrophils

Introduction: In this study, the effects of the cannabinoid CBD were assessed on cyclooxygenase (COX)-1 and COX-2 expression and activity in resting and activated human neutrophils (polymorphonuclear [PMN] leukocytes). Methods: COX expression was measured at the mRNA levels, whereas COX activity was assessed by enzyme-linked immunosorbent assay measurement of prostaglandin (PG)E2. In vitro experiments in a standard commercial acellular assay of COX-1/COX-2 activity completed the study. Results: Results show that CBD profoundly inhibits expression of COX-1 and COX-2 mRNA in activated PMN, however, without any significant consequences for PGE2 production. CBD, however, was able to induce a slight but significant direct inhibition of COX-2 in the acellular model. Conclusion: The effects of CBD occur in the μM concentration range, which is attained in humans with therapeutic doses of the drug, suggesting the clinical relevance of these findings.

Effect of Cannabidiol on Human Peripheral Blood Mononuclear Cells and CD4+ T Cells

Cannabidiol (CBD), the main non-psychoactive component of Cannabis sativa L., is widely used in therapy for the treatment of different diseases and as an adjuvant drug. Our aim was to assess the effects of CBD on proinflammatory cytokine production and cell proliferation in human peripheral blood mononuclear cells (PBMCs) and on CD4+ T lymphocyte differentiation, and, furthermore, to test CBD's ability to affect the functional properties of regulatory T cells (Treg). Experiments were performed on isolated PBMCs and purified CD4+ T lymphocytes obtained from the buffy coats of healthy subjects. Cytokines produced by CD4+ T cells were evaluated by flow cytometry and intracellular cytokine staining techniques. PBMC cytokine production was measured by an ELISA assay. Real-time PCR was used to assess the mRNA expression of cytokines and the key transcription factors (TFs) of CD4+ T cells. Finally, the proliferation of PBMC and CD4+ T effector cells (Teff), alone and in the presence of Treg, was assessed by flow cytometry. Results showed that CBD affects both the frequency of IL-4-producing CD4+ and of IFN-γ/IL-17-producing cells and dramatically decreases the mRNA levels of all TFs. Stimuli-induced cytokine mRNA expression was decreased while protein production was unaffected. CBD was unable to affect the ability of Treg to prevent Teff cell proliferation while it slightly increased PBMC proliferation. In conclusion, CBD may inhibit the expression of proinflammatory cytokines; however, the effect of CBD on cell proliferation suggests that this cannabinoid exerts a complex activity on human PBMCs and CD4+ T cells which deserves further investigation.

Dopaminergic Inhibition of Human Neutrophils is Exerted Through D1-Like Receptors and Affected By Bacterial Infection

BACKGROUND

Dopamine (DA) affects immune functions in healthy subjects and during disease by acting on D1-like (D1 and D5) and D2-like (D2, D3 and D4) dopaminergic receptors (DR), however its effects on human polymorphonuclear leukocytes (PMN) are still poorly defined.

METHODS

We investigated DR expression in human PMN and the ability of DA to affect cell migration and reactive oxygen species (ROS) production. Experiments were performed on cells from healthy subjects (HS) and from patients (Pts) with bacterial infections as well, during the acute phase and after recovery. Some experiments were also performed in mice KO for the DRD5 gene.

RESULTS

PMN from HS express both D1-like and D2-like DR, and exposure to DA results in inhibition of activation-induced morphological changes, migration and ROS production which depend on the activation of D1-like DR. In agreement with these findings, DA inhibited migration of PMN obtained from wild-type mice, but not from DR D5 KO mice. In Pts with bacterial infections, during the febrile phase D1-like DR D5 on PMN were downregulated and DA failed to affect PMN migration. Both D1-like DR D5 expression and DA-induced inhibition of PMN migration were however restored after recovery.

CONCLUSION

Dopaminergic inhibition of human PMN is a novel mechanism which is likely to play a key role in the regulation of innate immunity. Evidence obtained in Pts with bacterial infections provides novel clues for the therapeutic modulation of PMN during infectious disease.

Role of the Mosaic Cisternal Maturation Machinery in Glycan Synthesis and Oncogenesis

Tumorigenesis is associated with the deregulation of multiple processes, among which the glycosylation of lipids and proteins is one of the most extensively affected. However, in most cases, it remains unclear whether aberrant glycosylation is a cause, a link in the pathogenetic chain, or a mere consequence of tumorigenesis. In other cases, instead, studies have shown that aberrant glycans can promote oncogenesis. To comprehend how aberrant glycans are generated it is necessary to clarify the underlying mechanisms of glycan synthesis at the Golgi apparatus, which are still poorly understood. Important factors that determine the glycosylation potential of the Golgi apparatus are the levels and intra-Golgi localization of the glycosylation enzymes. These factors are regulated by the process of cisternal maturation which transports the cargoes through the Golgi apparatus while retaining the glycosylation enzymes in the organelle. This mechanism has till now been considered a single, house-keeping and constitutive function. Instead, we here propose that it is a mosaic of pathways, each controlling specific set of functionally related glycosylation enzymes. This changes the conception of cisternal maturation from a constitutive to a highly regulated function. In this new light, we discuss potential new groups oncogenes among the cisternal maturation machinery that can contribute to aberrant glycosylation observed in cancer cells. Further, we also discuss the prospects of novel anticancer treatments targeting the intra-Golgi trafficking process, particularly the cisternal maturation mechanism, to control/inhibit the production of pro-tumorigenic glycans.

Immune profile of hyaluronic acid hydrogel polyethylene glycol crosslinked: An in vitro evaluation in human polymorphonuclear leukocytes

Neauvia hydrogel (N-Gel) is a hyaluronic acid-based dermal filler, cross-linked with polyethylene glycol. This filler contains sodium hyaluronate at different concentrations, poly(ethylene glycol) diglycidyl ether cross-linked, glycine, and l-prolyne. Assessing any effects of N-Gel on immunity and inflammation is of crucial importance. The aim of the study was to characterize the ability of N-Gel to modulate human polymorphonuclear leukocyte (PMN) functions, including migration, oxidative metabolism, and production of proinflammatory mediators. N-Gel was tested on isolated human PMN. Spontaneous and N-formylmethionyl-leucyl-phenylalanine (fMLP)-stimulated migration were examined using the Boyden Chamber technique, whereas the oxidative metabolism was assessed through spectrofluorometric measurement of reactive oxygen species (ROS) production under resting conditions and after stimulation with fMLP. Tumor necrosis factor (TNF)-α and interleukin (IL)-8 mRNA levels were measured by real-time PCR after stimulation with fMLP or Escherichia coli lipopolysaccharide. This study showed that N-Gel reduced fMLP-induced migration and ROS production without affecting these functions in resting cells. In addition, incubation of PMN with N-Gel effectively reduced both TNF-α and IL-8 mRNA levels. N-Gel modulates critical functions of human PMN such as migration and oxidative metabolism, indicating its potential as an anti-inflammatory agent.

Beta1- and Beta2-Adrenoceptors Expression Patterns in Human Non-small Cell Lung Cancer: Relationship with Cancer Histology

Assessment of Beta-AR protein expression on tumour tissues might be a plausible strategy to select cancer patients who can benefit from Beta-blockers therapy. The aim of this study is to evaluate the differences between resected tissue specimens from primary lung cancer (adenocarcinoma (ADC) and squamous cell carcinoma (SCC)) in terms of expression pattern of Beta1- and Beta2-AR in both tumour and adjacent surrounding non-tumour tissue. This retrospective study was based on the analysis of 80 patients with histologically confirmed diagnosis of primary Non-Small Cell Lung Cancer (NSCLC) who received surgical treatment. The cases were carefully selected in order to obtain the most homogeneous sample in terms of histologic subtype (40 ADCs and 40 SCCs) and clinical stage (10 each). Beta1- and Beta2-AR expression was determined by immunohistochemistry and the staining evaluated by semi-quantitative scoring using the H-score method. In our NSCLC series, Beta1- and Beta2-AR are differentially expressed. Beta1-AR expression is present at low levels in both SCC and ADC. Likewise, when compared with the matched surrounding non-tumour tissues, Beta1-AR expression level was significantly lower in both histologic subtypes. Conversely, Beta2-AR is highly expressed in both histologic subtypes, but clearly highly expressed in ADC when compared with SCC and with their matched surrounding non-tumour tissue. Overall, this clinicopathological study highlights the differential expression of Beta1- and Beta2-AR in ADC and SCC. Repurposing non-selective Beta-blockers in oncologic setting might be a suitable therapeutic strategy for lung ADC. Graphical abstract.

Laparoscopy in Staging and Restaging of 95 Patients with Ovarian Carcinoma

The merits of laparoscopy with inspection of diaphragmatic leaves were studied in 95 patients with ovarian carcinoma. Laparoscopy was positive in 19 out of 27 new cases, 11 out of 47 patients previously treated and in apparent complete remission, and 12 out of 21 patients previously treated and with disease. Thirty-one out of 95 patients were shown to have diaphragmatic metastases alone and/or associated with other localizations of disease. In 5 out of 27 new cases the stage was modified after laparoscopy. The histologic-endoscopic correlation was correct in 28/36 positive cases (78 %) and in 31/32 negative cases (97 %). In conclusion, all patients with ovarian carcinoma should be subjected to laparoscopy as staging and restaging before undergoing laparotomy.

β2 -Adrenoceptors inhibit neutrophil extracellular traps in human polymorphonuclear leukocytes

This study tests the hypothesis that in isolated human polymorphonuclear leukocytes (PMN) adrenergic ligands can affect neutrophil extracellular trap (NET) formation. We have previously shown that, in PMN, adrenaline (A), through the activation of adrenergic receptors (AR), reduces stimulus-dependent cell activation; we have, therefore, planned to investigate if AR are involved in NET production. PMN were obtained from venous blood of healthy subject. The ability of adrenergic ligands to affect reactive oxygen species (ROS) production, NET production, and cell migration was investigated in cells cultured under resting conditions or after activation with N-formyl-methionyl-leucyl-phenylalanine (fMLP), LPS, or IL-8. Stimuli-induced NET production measured as ROS, microscopic evaluation, and elastase production was reverted by A and this effect was blocked by the selective β₂ -AR antagonist ICI-118,551. The stimulus-induced ROS generation and migration was prevented by A and by isoprenaline (ISO), and these effects were counteracted only by ICI-118,551 and not by the other two selective ligands for the β₁ and β₃ -AR. Finally, the presence of the β-ARs on PMN was confirmed, by means of microscopy and flow cytometry. The data of the present study suggest that adrenergic compounds, through the interaction of mainly β₂ -AR, are able to affect neutrophil functions. These data are suggestive of a possible therapeutic role of β₂ -AR ligands (in addition to their classical use), promoting the possible therapeutic relevance of adrenergic system in the modulation of innate immunity proposing their possible use as anti-inflammatory drugs.

Comments on a Series of 88 Invasive Microcarcinomas of the Breast

Eightly-eight women with minimal invasive breast cancer were treated at the Istituto Nazionale Tumori of Milan, in the decade 1970–1980. Their tumors were smaller than 0.5 cm in diameter and were clinically assessed as T1N0M0; surgery, consisting of radical or limited procedures, was performed, always with complete axillary dissection. Pathologic assessment showed that axillary lymph nodes presented with metastases in 21.5% of cases. In 1 of N-positive cases, more than 3 nodes were affected, and in 5 cases extracapsular invasion was observed. Five-year actuarial survival, calculated by the life table method, was as high as 90%, demonstrating that these have a favorable prognosis, even when they are treated by limited surgery followed by radiotherapy on the residual breast, provided that the axilla is completely dissected. Minimal invasive breast cancer should consequently be clearly distinguished from other pathologic entities termed as « minimal », such as lobular carcinoma in situ and intraductal carcinoma, for which complete axillary dissection is not worthwhile.

Young Age is not an Ominous Prognostic Factor in Breast Cancer Patients

Analysis of a series of 137 women 20–30 years of age, operated for breast carcinoma, excluding patients pregnant, lactating or with inflammatory cancer, showed that disease-free survival rates were similar and not lower than those reported for a large series of 716 breast cancer patients of all ages, treated and followed at the same Institute. Ten-year disease-free survival rates for the two series of 137 young women and 716 patients of all ages were 43.7% and 47.1% respectively. Even when considering the subgroups of patients with and without nodal axillary involvement, the corresponding figures for the two series considered were 72.6% vs. 72.1% (N−) and 25.1% vs. 24.5% (N+). It can be concluded that young age cannot be considered as an unfavorable prognostic factor.

Laparoscopy Combined with Peritoneal Cytology in Staging and Restaging Ovarian Carcinoma

The merits of laparoscopy, with inspection of the diaphragmatic leaves, and of peritoneal cytology (free fluid or washing) in staging and restaging were studied in 153 patients with ovarian carcinoma. Of 153 patients examined, 83 were new cases, 34 were restaging in patients without clinical and/or radiological signs of disease, and 36 in patients with evident disease. The conversion rate for diaphragmatic metastases alone was 6%. Information about the spread of disease (diaphragmatic metastases) was obtained in 33 new cases (39.7%). In pretreated patients, laparoscopy was positive in 4 of 34 NED restaging and in 24 of 36 ED restaging. The conversion rate for peritoneal cytology was 6.6%, but information about the cellular intraperitoneal spread of the disease was obtained in 31 new cases (37.8%). In pretreated patients, peritoneal cytology was positive in 4 of 34 NED restaging and in 13 of 36 ED restaging.

Preoperative Irradiation and Surgery for Esophageal Cancer: Causes of Failure

Twenty-seven patients with squamous esophageal cancer underwent small-volume, low-dose, concentrated radiotherapy followed by esophageal resection whenever possible (esophagectomy for tumors of the thoracic esophagus and esophagogastrectomy for tumors of the lower esophagus). Curative resectability was 70% (19/27) with 4 operative deaths (21%). Recurrence rate was 66% after a mean period of 16 months, and the failure pathway was nodal in 53% of the cases. Historical comparison of the data suggests that preoperative irradiation increases the curative resectability rate without changing the early recurrence rate or failure pathway. Tumors with deeper invasion of the esophageal wall, which benefit by preoperative irradiation, are probably related to greater nodal diffusion, which is partly outside of the volume that may be resected or irradiated.

Axillary web syndrome assessment using a self-assessment questionnaire: a prospective cohort study

BACKGROUND

Surgical procedure for breast cancer is not without its side effects and one such side effect is axillary web syndrome (AWS), characterized by palpable fibrotic-like cords in the operated arm. As physical evaluation is the only gold standard method used, our study aims to assess the incidence and early detection of AWS with a self-assessment questionnaire.

METHODS

From July 2013 to July 2014, 370 breast cancer patients were enrolled. AWS incidence was 51.1%, with 94.1% onset in the first 4 weeks after surgery; 43.5% of the patients did not recover in the first 8 weeks. Univariate analysis showed that BMI (P < 0.001), age (P < 0.001), educational level (P = 0.01), and exercise frequency in the eighth week of follow-up (P < 0.001) were significantly associated with the AWS detection, and multivariate analyses confirmed that younger patients (age < 50) have significantly higher AWS detection (OR = 2.38 (95%CI 1.53, 3.71) and that BMI is associated with AWS, with normal weight patients (BMI ≤ 25) having a significantly greater AWS detection with an odds ratio of 2.11 (95%CI 1.33, 3.36).

CONCLUSION

Our findings indicated that the incidence of AWS is high in breast cancer patients, particularly in the first month after surgery. Not all patients achieved recovery during our 8 week follow-up, suggesting that evaluation and treatment should be longer. Double AWS detection was found for patients who were younger (age < 50) and with normal weight.

NET amyloidogenic backbone in human activated neutrophils

Activated human neutrophils produce a fibrillar DNA network [neutrophil extracellular traps (NETs)] for entrapping and killing bacteria, fungi, protozoa and viruses. Our results suggest that the neutrophil extracellular traps show a resistant amyloidogenic backbone utilized for addressing reputed proteins and DNA against the non-self. The formation of amyloid fibrils in neutrophils is regulated by the imbalance of reactive oxygen species (ROS) in the cytoplasm. The intensity and source of the ROS signal is determinant for promoting stress-associated responses such as amyloidogenesis and closely related events: autophagy, exosome release, activation of the adrenocorticotrophin hormone/α-melanocyte-stimulating hormone (ACTH/α-MSH) loop and synthesis of specific cytokines. These interconnected responses in human activated neutrophils, that have been evaluated from a morphofunctional and quantitative viewpoint, represent primitive, but potent, innate defence mechanisms. In invertebrates, circulating phagocytic immune cells, when activated, show responses similar to those described previously for activated human neutrophils. Invertebrate cells within endoplasmic reticulum cisternae produce a fibrillar material which is then assembled into an amyloidogenic scaffold utilized to convey melanin close to the invader. These findings, in consideration to the critical role played by NET in the development of several pathologies, could explain the structural resistance of these scaffolds and could provide the basis for developing new diagnostic and therapeutic approaches in immunomediated diseases in which the innate branch of the immune system has a pivotal role.

Adrenergic modulation of migration, CD11b and CD18 expression, ROS and interleukin-8 production by human polymorphonuclear leukocytes

OBJECTIVES

Adrenergic modulation of immunity has been extensively characterized, however, few information exist regarding polymorphonuclear leukocytes (PMN), despite their key role in immunity and inflammation. We investigated the effect of adrenergic agents on human PMN migration, CD11b and CD18 expression, reactive oxygen species (ROS) and interleukin (IL)-8 production, and on adrenoceptor (AR) expression.

METHODS

Migration was measured by the Boyden chamber assay, CD11b/CD18 expression was assessed by flow cytometry, intracellular ROS were detected by spectrofluorimetry, and IL-8 was quantitated by standard ELISA assay. AR mRNA levels were measured by real-time PCR and PMN morphology was studied by scanning electron microscopy.

RESULTS

Adrenaline(A), noradrenaline and the β-AR agonist isoprenaline reduced N-formyl-Met-Leu-Phe (fMLP)-induced migration, CD11b/CD18 expression, and ROS production, without affecting IL-8. The effect of A on CD11b was antagonized by yohimbine and propranolol, and increased by prazosin. The effect on ROS production was completely abolished by propranolol. PMN expressed α(1A)-, α(1B)-, α(1D)-, α(2A)-, α(2C)-, β(1)-, β(2)-, and β(3)-AR mRNA. A prevented fMLP-induced morphological changes of PMN.

CONCLUSIONS

Adrenergic agents reduced PMN responses mainly through β-AR, although α-AR may contribute at least to CD11b expression. AR-operated pathways in PMN should be investigated in disease conditions and in the response to therapeutic agents.

Changes in PgR and Ki-67 in residual tumour and outcome of breast cancer patients treated with neoadjuvant chemotherapy

BACKGROUND

Limited data are available on the prognostic value of changes in the biological features of residual tumours following neoadjuvant therapies in breast cancer patients.

PATIENTS AND METHODS

We collected information through the institutional clinical database on all consecutive breast cancer patients treated with neoadjuvant chemotherapy at the European Institute of Oncology (IEO), Milan, Italy, between 1999 and 2011. We selected patients who did not achieve pathological complete response at final surgery. All patients had a pathological evaluation, including ER, PgR, HER2 protein and Ki-67 expression carried out at the IEO both at diagnostic core biopsy and at final surgery.

RESULTS

We identified a total of 904 patients. The 5% of patients who were ER positive at diagnostic biopsy had ER-negative residual tumour at final surgery. For PgR expression, 67% of the patients, whose tumours had a PgR >20% at diagnostic biopsy had a PgR <20% at final surgery. The Ki-67 expression changed from >20% to <20% in 40% of the patients. At the multivariate analysis, the decrease of PgR-immunoreactive cells correlated with improved outcome in terms of disease-free survival (DFS) [hazard ratio (HR) 0.73; 95% confidence interval (CI) 0.54-1.00, P 0.046]. In addition, the decrease of Ki-67 expression to <20% of the cells at final surgery was found to be associated with better outcome both in terms of DFS (HR 0.52; 95% CI 0.40-0.68 P < 0.0001) and overall survival (HR 0.45; 95% CI 0.32-0.64, P < 0.0001).

CONCLUSION

The decrease of PgR and Ki-67 expression after preoperative chemotherapy has a prognostic role in breast cancer patients with residual disease.

Isoflavone content and estrogenic activity of different batches of red clover (Trifolium pratense L.) extracts: an in vitro study in MCF-7 cells

The estrogenicity of different batches of red clover (Trifolium pratense L., Fabaceae; RCL) extracts and its relationship with the isoflavone content were assessed by measuring MCF-7 cell proliferation by flow cytometry and propidium iodide staining. RCL extracts were compared to estradiol (E2) and to the main RCL isoflavones biochanin A, daidzein, genistein and formononetin. Isoflavone content in the extracts was assayed by HPLC. E2 and isoflavones increased MCF-7 proliferation in a concentration-dependent fashion, with the following potency order: E2>>>genistein>biochanin A=daidzein>formononetin. Extracts increased MCF-7 proliferation with different potencies, which in four out of five extracts correlated with the ratios 5,7-dihydroxyisoflavones/7-hydroxyisoflavones. The efficacy of all extracts increased with decreasing genistein contents. A solution containing the main isoflavones at the average concentration of RCL extracts increased MCF-7 proliferation with higher potency and steeper concentration-response curve. The effects of E2, of RCL extracts and of the isoflavone solution were inhibited by the estrogen receptor antagonist 4-hydroxytamoxifen. Flow cytometric analysis of MCF-7 proliferation is a suitable bioassay for the estrogenicity of RCL extracts, thus expanding the characterization of individual batches beyond assessment of chemical composition and contributing to improved standardization of quality and activity.

Abstract P1-15-03: Preoperative endocrine treatment with letrozole ± triptorelin in patients with ER (estrogen receptor) and PgR (progesterone receptor) positive locally advanced breast cancer

Background: Neoadjuvant endocrine therapy demonstrated activity in endocrine responsive locally advanced breast cancer. Proper duration of neoadjuvant therapy has not yet established. We aimed to assess the efficacy and safety of longer duration of letrozole alone or combined with triptorelin in pre-or postmenopausal breast cancer patients.

Methods: Premenopausal and postmenopausal patients (pts) with ER and PgR-positive &gt; 50% of the cells, HER2-negative, T2-T4b breast cancer were considered eligible. Patients received letrozole 2,5 mg per day (plus triptorelin 3,75 mg/month in premenopausal pts) for 3-9 months. Tumor response was measured by caliper, ultrasound (US) and mammography. The primary endpoint was overall tumour response (ORR) (complete response plus partial response), during the neoadjuvant treatment period for the intention-to-treat population.

Results: Between 2009 and 2013, 54 pts were enrolled and 46 (34 pre- and 12 post-menopausal) pts were evaluable for ORR. Median age was 44 and 55 years, respectively. 44 patients are evaluable. The ORR was 77% in the premenopausal group and 67% in the postmenopausal group. One premenopausal patient had a pathological complete response (pCR). The mean time to complete/partial response was 4.9 months (95% CI: 3.8-6.0) in the premenopausal group and 3.6 months (95% CI: 0.8-6.4) in the postmenopausal group. Overall, 56% of premenopausal and 58% of postmenopausal pts underwent breast conservative surgery. Ki67-LI after surgery had a mean decrease of 33% (95% CI: 16%-50%, p-value = 0.0005) and 42% (95% CI: 18%-65%, p-value = 0.0030) in pre-and postmenopausal pts, respectively. Therapy was well tolerated in both groups with no grade 3/4 toxicity. The most common adverse events in both groups were hot flashes, fatigue, arthralgias/stiffness, and myalgias.

Conclusions: The results of this preliminary analysis support neoadjuvant endocrine therapy for a duration of up to 9 months. The combination of letrozole plus triptorelin might represent an alternative neoadjuvant treatment option for premenopausal women with early stage endocrine-responsive breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-15-03.

Abstract P3-09-06: Development and validation of a questionnaire for axillary web syndrome self-assessment

INTRODUCTION: Despite the great strides made in medical knowledge and technology, surgery still remains a necessary part of the breast cancer treatment protocol. Even with the employment of less aggressive techniques, surgical procedures still lead to post surgical sequelae and complications. The axillary web syndrome (AWS) is one such sequela which can lead to disability, reduced arm mobility and compromised quality of life. Currently, there is no diagnostic tool such as a self-validated questionnaire to detect AWS which may help the patient to seek the opportunity for immediate treatment. To improve diagnosis and patient education, the ST-AWS questionnaire was drafted and applied at the European Institute of Oncology (IEO).

MATERIALS AND METHOD: We prospectively recruited patients from October 2012 to December 2012. Groups of patients who underwent ipsilateral sentinel lymph node biopsy and/or axillary dissection with or without plastic reconstruction procedures were registered. The complete physical examination by physiotherapist was set as a gold standard to evaluate the validity and reliability of ST-AWS.

Axillary Web Syndrome general table  AWS EVALUATION CATEGORIESYES 32 (%)NO 56 (%)p-value §AGE*&lt; 5119 (59)24 (43)0.14 ≥ 5113 (41)32 (57) SCHOOLINGHigh28 (88)42 (75)0.16 Low4 (12)14 (25) BMI≤ 18,55 (16)0 (0)0.006 18,5 - 25,022 (68)32 (57)  &gt; 255 (16)24 (43) TIME OF SURGERY (min)*≤ 11912 (37)33 (59)0.05 &gt; 11920 (63)23 (41) PLASTIC RECONSTRUCTIONYes25 (78)29 (52)0.02 No7 (22)27 (48) BREAST SURGERYMastectomy25 (78)34 (61)0.10 Quadrantectomy7 (22)22 (39) AXILLARY SURGERYAxillary Dissection20 (63)29 (52)0.33 Sentinel Lymph Node Biopsy12 (37)27 (48) N STAGE09 (28)25 (45)0.07 115 (47)16 (28)  22 (6)10 (18)  36 (19)5 (9) SENSIBILITY LOSSYes15 (47)9 (16)0.002 No17 (53)47 (84) * median values were used as cut off points § Chi-square, Fisher exact and Mantel-Haenszel Chi-Square tests

RESULTS: 88 patients completed the questionnaire and the physical examinations and were included in the study. 32 patients had axillary web syndrome diagnosed, thus a 36% incidence. Median age was 51 years (range 22-78 years).

The questionnaire achieved a sensitivity of 94%, a specificity of 91%, a positive prevalence value (PPV) of 86%, a negative prevalence value (NPV) of 96% and an accuracy of 92%.

Comparing Gold Standard physical Evaluation and ST-AWS Questionnaire results PHYSICAL EVALUATION (GOLD STANDARD)  NEGATIVEPOSITIVETOTALQUESTIONNAIRE   NEGATIVE51253POSITIVE53035TOTAL563288Sensibility: 94%, Specificity: 91%, Accuracy:92%, PPV:86%, NPV:96%

CONCLUSION: Our questionnaire achieves high sensitivity and predictive values, and we would recommend it as a screening-tool for auto-diagnosis of the axillary web syndrome. Nevertheless, the results of the ST-AWS should be confirmed by a physiotherapy examination.

The main objective of the questionnaire is to enhance patient and therapist awareness of the problem, and prompt management in order to shorten the effects of this disability. Moreover, it may offer a tool to enhance body image acceptance after surgery.

Further studies whereby the efficacy of the questionnaire is investigated in a larger, heterogeneous group and in different situations are warranted.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-06.

Abstract PD03-02: A Randomized Pre-Surgical Trial of Metformin in Breast Cancer. Preliminary Feasibility and Safety Results

Background: Metformin has been associated with decreased breast cancer (BC) incidence in diabetic patients in epidemiological studies. Moreover, this drug results in initiation of an AMPK-dependent energy stress response which can adversely affect survival of breast cancer cell lines and inhibition of PI3K/Akt/mTOR signaling leading to reduced proliferation of BC cell lines.

Methods: We conducted a randomized, pre-surgical, phase IIb, placebo-controlled, biomarker trial in women with stage I-III BC candidate to elective surgery. The primary endpoint was the change in cell proliferation in malignant, dysplastic and hyperplastic tissue as measured by Ki-67 labeling index (LI). With 150 subjects, the study was 80% powered to test for the interaction between metformin activity and ER status. Two interim analyses are being planned after 100 and 200 women enrolled. Results: As of June 18, 2010, 175 subjects have been randomized and 162 have completed treatment. Here we report data on the first 100 women enrolled. At the symposium, full data on the first 200 women enrolled will be available. As of December 31, 2009, a total of 163 women were screened, 26 were not eligible and 40 refused to participate, 6 dropped out during the study for AEs (n=2) or refusal to continue treatment (n=4), thus leaving 95 subjects assessable for the primary endpoint. The main subject and tumor characteristics blinded as to the allocated arm were mean age 52 (31-77), Pre/postmenopause, 54/41, mean BMI, 23.6 (18.0-40.2). At baseline, median Ki-67LI was 18% (range 4%-65%) at biopsy and 19% (4%-70%) after 4 weeks at surgery. All adverse events except for 1 SAE were grade 1 or 2, consisting of G2 nausea and G2 diarrhea in 4% and 6% of the cases, respectively. The prevalence of ductal intraepithelial neoplasia was 91% (median Ki-67 LI, 10%) in samples both adjacent and distant from the tumor, whereas the prevalence of ductal hyperplasia was 77% (median Ki-67LI, 2%) in samples distant from the tumor. Conclusions: Our preliminary results show the feasibility, high compliance and safety of a metformin trial in breast cancer patients. Assessment of tissue and circulating biomarkers is currently ongoing to characterize the whole spectrum of metformin activity in malignant and dysplastic tissue.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD03-02.

Prognosis and adjuvant treatment effects in selected breast cancer subtypes of very young women (<35 years) with operable breast cancer

BACKGROUND

There is limited knowledge about prognosis of selected breast cancer subtypes among very young women.

PATIENTS AND METHODS

We explored patterns of recurrence by age according to four immunohistochemically defined tumor subtypes: Luminal A and Luminal B (estrogen receptor positive and/or progesterone receptor positive and either human epidermal growth factor receptor 2 (HER2) positive and/or high Ki-67), HER2-positive (and) endocrine receptor absent and Triple Negative, in 2970 premenopausal patients with pT1-3, pN0-3 and M0 breast cancer.

RESULTS

Patients <35 years of age (315, 11%) presented a significantly increased risk of recurrence and death [hazards ratio (HR) = 1.65, 95% confidence interval (CI) 1.30-2.10 and HR = 1.78, 95% CI 1.12-2.85, respectively] when compared with older patients (2655, 89%) with similar characteristics of disease. This was true considering patients with Luminal B [HR = 1.62, 95% CI 1.21-2.18 for disease-free survival (DFS) and HR = 2.09, 95% CI 0.96-4.53 for overall survival (OS)] and with Triple Negative (HR = 2.04, 95% CI 1.11-3.72 for DFS and HR = 2.20, 95% CI 1.10-4.41 for OS) breast cancer, observing the highest risk of recurrence in the younger patients with HER2-positive breast cancer (HR = 2.37, 95% CI 1.12-5.02) when compared with older patients.

CONCLUSIONS

Very young patients with Triple Negative, Luminal B or HER2-positive breast cancer have a worse prognosis when compared with older patients with similar characteristics of disease.

IART (Intra-Operative Avidination for Radionuclide Therapy) for accelerated radiotherapy in breast cancer patients. Technical aspects and preliminary results of a phase II study with 90Y-labelled biotin

BACKGROUND

Breast conserving surgery (BCS) plus external beam radiotherapy (EBRT) is considered the standard treatment for early breast cancer. We have investigated the possibility of irradiating the residual gland, using an innovative nuclear medicine approach named IART(®) (Intra-operative Avidination for Radionuclide Therapy).

AIM

The objective of this study was to determine the optimal dose of avidin with a fixed activity (3.7 GBq) of (90)Y-biotin, in order to provide a boost of 20 Gy, followed by EBRT to the whole breast (WB) at the reduced dose of 40 Gy. Local and systemic toxicity, patient's quality of life, including the cosmetic results after the combined treatment with IART(®) and EBRT, were assessed.

METHODS

After tumour excision, the surgeon injected native avidin diluted in 30 ml of saline solution into and around the tumour bed (see video). Patients received one of three avidin dose levels: 50 mg (10 pts), 100 mg (15 pts) and 150 mg (10 pts). Between 12 to 24 h after surgery, 3.7 GBq (90)Y-biotin spiked with 185 MBq (111)In-biotin was administered intravenously (i.v.). Whole body scans and SPECT images were performed up to 30 h post-injection for dosimetric purposes. WB-EBRT was administered four weeks after the IART(®) boost. Local toxicity and quality of life were evaluated.

RESULTS

Thirty-five patients were evaluated. No side effects were observed after avidin administration and (90)Y-biotin infusion. An avidin dose level of 100 mg resulted the most appropriate in order to deliver the required radiation dose (19.5 ± 4.0 Gy) to the surgical bed. At the end of IART(®), no local toxicity occurred and the overall cosmetic result was good. The tolerance to the reduced EBRT was also good. The highest grade of transient local toxicity was G3, which occurred in 3/32 pts following the completion of WB-EBRT. The combination of IART(®)+EBRT was well accepted by the patients, without any changes to their quality of life.

CONCLUSIONS

These preliminary results support the hypothesis that IART(®) may represent a valid approach to accelerated WB irradiation after BCS. We hope that this nuclear medicine technique will contribute to a better management of breast cancer patients.

Low-Dose Tamoxifen for the Treatment of Breast Ductal Intraepithelial Neoplasia: Results of a Large Observational Study

Background: The cost-benefit ratio of tamoxifen for breast ductal intraepithelial neoplasia (DIN) is unclear. Since low-dose tamoxifen showed a favorable safety profile and modulation of breast cancer biomarkers in phase II trials, we analyzed a large mono-institutional cohort of women with DIN treated with low-dose tamoxifen or no systemic treatment.Material and Methods: A total of 309 patients with ER positive DIN received either tamoxifen 5 mg/day or 20 mg/week, as part of clinical trials or institutional guidelines and were compared with 371 patients who received no systemic treatment after surgery with or without radiotherapy due to personal preference, allocation to placebo or contraindication to tamoxifen.Results: The 5-year cumulative incidence of recurrence was 14.5% (95% CI, 11.9-17.5), with a negative trend according to age. Women with ER/PgR &gt;50% DIN who were untreated had a higher incidence of breast events than women on tamoxifen (HR 1.76; 95% CI, 1.00-3.12) or women with ER/PgR&lt;50% DIN (HR 1.72; 95% CI, 1.14-2.58). Among untreated patients with ER&gt;50% DIN, recurrence was higher in PgR ≥50% DIN than in PgR &lt;50% DIN, whereas it was similar among low PgR (&lt;50%) DIN against which tamoxifen had no effect. No difference in endometrial cancer incidence was noted.Discussion: High ER and especially high PgR expression is a significant adverse prognostic indicator of DIN against which low-dose tamoxifen appears to be a safe and active treatment. Conversely, women with low expression ER or PgR DIN do not seem to benefit from tamoxifen. A definitive clinical trial is warranted.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2113.

Analysis of local and regional recurrences in breast cancer after conservative surgery

BACKGROUND

A minority of patients treated conservatively for breast cancer will develop local or regional recurrences. Our aim was to determine how their occurrence may be linked to the evolution of the disease.

PATIENTS AND METHODS

We analyzed 2784 women treated for early-stage breast cancer by quadrantectomy and whole-breast irradiation in a single institution. We evaluated the prognostic factors associated with local, regional and distant recurrences and the prognostic value of local and regional recurrences on systemic progression.

RESULTS

After a median follow-up of 72 months, we observed 33 local events, 35 regional events and 222 metastases or deaths as first events (5-year cumulative incidence 1.1%, 1.2% and 7.6%, respectively). Size, estrogen receptor status, Her2/Neu and Ki-67 were associated with all three types of events, while axillary status and vascular invasion were associated only with the occurrence of metastases or death. Young age increased the risk of local recurrence. Local and regional recurrences were associated with an increased risk of systemic progression: hazard ratios 2.5 [95% confidence interval (CI) 1.1-5.8] and 5.3 (95% CI 3.0-9.5), respectively.

CONCLUSIONS

Local and regional recurrences after breast-conserving surgery are rare events. They are markers of tumor aggressiveness and indicators of an increased likelihood of distant metastases.

Minimal axillary lymph node involvement in breast cancer has different prognostic implications according to the staging procedure

It is still controversial whether the identification of micrometastases and isolated tumor cells in the axillary lymph nodes of patients with breast cancer has any prognostic value. We evaluated the prognostic role of isolated tumor cells and micrometastases in the axillary lymph nodes in 3,158 consecutive patients pT1-2 pN0-N1mi (with a single involved lymph node) and M0, referred to the Division of Medical Oncology after surgery performed at the European Institute of Oncology from April 1997 to December 2002. Median follow-up was 6.3 years (range 0.1-11 years). Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) were performed in 2,087 and 1,071 patients, respectively. A worse metastasis-free survival was observed for patients with micrometastatic disease compared to node-negative patients, if staged with ALND (log-rank P < .0001; HR: 3.17; 95% CI 1.72-5.83 at multivariate analysis), but not for patients who underwent SLNB (log-rank P = 0.36). The presence of a single micrometastatic lymph node is associated with a higher risk of distant recurrence as compared to node-negative disease only for patients undergoing ALND for staging purposes. Treatment recommendations for systemic therapy should not take into account the presence of a single micrometastatic lymph node identified during complete serial sectioning of sentinel node(s).

Antioxidant and cytoprotective properties of infusions from leaves and inflorescences of Achillea collina Becker ex Rchb

Plants are the main source of molecules with antioxidant and radical scavenging properties that aid the natural defence systems of cells and may be involved in the preservation of human health, particularly preventing all the physiopathological conditions where oxidative damage is a hallmark. Achillea collina Becker ex Rchb. is a medicinal plant of the Achillea millefolium aggregate (yarrow) traditionally used, particularly in mountain areas, as an infusion or alcohol extract for its digestive, antiinflammatory, analgesic, antipyretic and wound healing properties. The aim of this study was to investigate the antioxidant capacity and cytoprotective activity against oxidative stress of infusions obtained from the leaves and inflorescences of Achillea collina Becker ex Rchb., assessed by chemical (free radical scavenging activity by DPPH and Folin Ciocalteu assay) and biological assays (in vitro model of cytotoxicity and lipid peroxidation in PC12 cells line). Infusions of leaves had the highest antioxidant properties and cytoprotective activity. The antioxidant capacity was significantly correlated with the total phenolic content but not with the cytoprotective profile. Achillea collina Becker ex Rchb. has good antioxidant and cytoprotective properties, suggesting further investigations on its chemical composition and potential health value, particularly for traditionally prepared infusions of leaves.

A risk score to predict disease-free survival in patients not achieving a pathological complete remission after preoperative chemotherapy for breast cancer

BACKGROUND

We aimed to predict disease-free survival (DFS) in patients who failed to achieve a pathologic complete remission (pCR) after preoperative chemotherapy (PC).

PATIENTS AND METHODS

Data from 577 patients treated with PC and operated at the European Institute of Oncology (EIO) were used to develop a nomogram using Cox proportional hazards regression model based on both categorical (pT, positive nodes, human epidermal growth factor receptor 2 (HER2) status, vascular invasion) and continuous histological variables (estrogen receptors and Ki-67 expression) at surgery. The nomogram was tested on a second patient cohort (343 patients) treated in other institutions and subsequently operated at the EIO.

RESULTS

The nomogram for DFS based on both categorical and continuous variables had good discrimination in the training and the validation sets (concordance indices 0.73, 0.67).

CONCLUSION

The use of a nomogram based on the degree of selected histopathological variables can predict DFS and might help in the adjuvant therapeutic algorithm design.

Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO)

In order to reduce mutilation, nipple-areola complex (NAC) conservation can be proposed for the treatment of breast cancer when mastectomy is indicated. To reduce the risk of retro areolar recurrence, a novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy (ELIOT) is proposed. One thousand and one nipple sparing mastectomies (NSM) were performed from March 2002 to November 2007 at the European institute of oncology (EIO), for invasive carcinoma in 82% of the patients and in situ carcinoma in 18%. Clinical complications, aesthetic results, oncological and psychological results were recorded. A comparison was performed between the 800 patients who received ELIOT and the 201 who underwent delayed one-shot radiotherapy on the days following the operation. The median follow up time was 20 months (range 1-69) for a follow up performed in 83% of the patients. The NAC necrosed totally in 35 cases (3.5%) and partially in 55 (5.5%) and was removed in 50 (5%). Twenty infections (2%) were observed and 43 (4.3%) prostheses removed. The median rate of the patients for global cosmetic result on a scale ranging from 0 (worst) to 10 (excellent) was 8. Evaluation by the surgeon in charge of the follow-up gave a similar result. Only 15% of the patients reported a partial sensitivity of the NAC. Of the fourteen (1.4%) local recurrences, ten occurred close to the tumour site, all far from the NAC corresponding to the field of radiation. No recurrences were observed in the NAC. In a group of patients characterized by a very close free margin under the areola, no local recurrence was observed. Overall, 36 cases of metastases and 4 deaths were observed. No significant outcome difference was observed between the 800 patients receiving intraoperative radiotherapy (ELIOT) and the 201 patients receiving delayed irradiation.