Abstract P3-13-01: Determining the breast tumor margin through genomics of the cancer-stromal interaction

This abstract was withdrawn by the authors.

Abstract P5-04-09: Redefining the breast tumor margin through genomics of the tumor-stromal interaction

Objectives: Emerging data suggest that breast tumors enact gene expression changes in the surrounding stroma, facilitating future recurrence, cancer progression/invasion, metastasis, and altering therapeutic response. The extent to which this alteration penetrates the surrounding breast tissue has not been characterized. It is important to understand both the genomics of the tumor and the tissue that remains following surgery. This relationship could ultimately impact treatment decisions for effective surgery and adjuvant therapy based on the biological impact of the tumor on its anatomical surroundings.Methods: 32 patients undergoing mastectomy for invasive cancer from 2009-2012, had 9 tissue samples placed in RNA later: tumor, and stroma every 5 mm to 20 mm in two directions. A pathologist verified that the stroma was devoid of cancer cells. 108 tissues were analyzed for genome-wide mRNA expression by Affymetrix U133A 2+ arrays: 27 tumor, 29 5mm, 21 10mm, 11 15mm, and 20 20mm regions. RNA was purified by RNeasy chromatography (Qiagen) and assayed for integrity and concentration by Agilent Bioanalysis. SVM, ANOVA and PCA were performed to establish gene expression patterns, clustering and FDR in all tumor sets.Results We propose a gene expression profile/ map of the impact of the breast tumor on non-cancer stromal tissue in the breast. SVM analysis showed paired gene significance based on stromal proximity at all distances, which decreased in similarity with radial distance (closer stromal tissue to tumor had fewer differentially expressed genes). Analysis of gene expression patterns, PCA, unsupervised and supervised clustering demonstrate that the 5 mm region are significantly related to tumor gene expression profiles in almost all of the patients.In contrast, stromal tissue at 10mm, 15mm, and 20mm from the tumor-free margin display gene expression profiles that are similar to each other.But, with reduced similarity to tumor and 5mm. In a small number of patients, stroma at 10-15mm also displayed gene expression profiles significantly consistent with a tumor-like signature. Further analysis for the highest ranked 300 transcripts with the lowest FDR scores based on ANOVA are fully shared by the tumor and 5mm regions in over 30% the patients. A genomic signature is emerging that occurs in the stroma in both the tumor like and non-tumor like regions. Conclusion: These results show that breast tissue devoid of tumor cells is genomically highly related to the tumor at the 5mm, and even from regions 10, 15, and 20mm beyond cancer-free margins in some patients,, corresponding to regions considered histologically “normal”. We suggest that in a subset of patients, cancer-free stromal tissue is highly similar to the tumor. This implicates tumor imprinting as a means of genetically altering stromal tissues in a manner that is consistent with a potential for increased recurrence and de novo cancer development. In order to improve the effectiveness of breast cancer therapy, further determination of tumor/stromal interaction (determining optimal disease free tissue based on genomics and tumor promoting tissue), could directly impact both surgical and disease outcomes.Fig 1. Heatmap-Gene Expression in tumor&5mm are similar, but different from 10, 15, 20.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-04-09.

Abstract P2-01-02: The Incidence of Mammographically-Occult Breast Cancer in Women Older than Seventy Years

Background: Mammographic density generally decreases over time, which increases the sensitivity of screening mammography. However a significant proportion of older women have persistently dense breast tissue. This raises the question of how best to screen older women, particularly those with mammographically dense tissue or other risk factors. Little information exists about the accuracy of screening mammography in women older than seventy years. Additionally, the frequency of older women with mammographically-occult breast cancer is also unknown. The purpose of this study was to report the incidence of mammographicallyoccult breast cancer in women older than seventy and to describe the clinical factors that may be associated with this presentation.

Methods:

A retrospective chart review was conducted of women older than seventy diagnosed with breast cancer (intraductal carcinoma, invasive ductal carcinoma and invasive lobular carcinoma) at NYU Langone Medical Center from 2002-2009. Data collected included age, presentation, stage, mammographic density, BI-RADS results, breast ultrasound (US) and MRI results, and risk factors. Breast density was categorized according to BI-RADS definitions: 1. predominantly fatty, 2. scattered fibroglandular elements, 3. heterogeneously dense, or 4. extremely dense. Descriptive analyses were applied.

Results: A total of 401 women older than seventy years were diagnosed with breast cancer at our institution. A cohort of 20 (5%) had mammographically occult disease. The median age was 77 years (range 71 to 89 yrs). Of the 20 mammographically occult cases, the majority (75%) were detected as a palpable mass, one was detected by screening US and four were detected by screening MRI. The majority of the cohort (65%) had been screened regularly with mammography prior to diagnosis. When we examined mammographic density, 60% had heterogeneously dense or extremely dense tissue. Nineteen out of twenty were diagnosed with early stage disease. There were 4 cases of DCIS, 10 (50%) were stage 1, and 5 (25%) were stage 2. Seven (35%) had invasive lobular carcinoma on final histopathology. Nine (45%) patients also had an antecedent history of breast cancer; 4 had ipsilateral recurrences and 5 had contralateral new primaries. Only 4 (20%) had a history of HRT use and 7 (35%) had a family history of breast cancer.

Discussion: A meaningful proportion of women older than age seventy diagnosed with breast cancer at our institution had mammographicallyoccult disease. A majority (60%) of these patients had heterogeneously dense or extremely dense breast tissue, potentially limiting the sensitivity of mammographic screening in this cohort. In previous work, we evaluated a large number of screening mammograms and reported an incidence of 37% dense breast tissue in women of the same age group. This suggests that increased mammographic density, even in older women, may increase the potential for mammographically occult breast cancer. Particularly for women with increased risk based on a personal or family history of breast cancer, the addition of other imaging modalities may be of value in the presence of mammographically dense tissue regardless of patient age.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-01-02.

Sucess of Brochure/One Page Universal Consent for Biospecimen Donation

Background: Accrual of biospecimens to biorepositories is a challenge and has been recognized as a critical barrier for translational research. HIPAA mandates that patients sign a separate Informed ConsentForm (ICF) for donating biospecimens for research. This poses a significant challenge to the medical staff and may negatively impact accrual to biorepositoriesMaterials and Methods: At NYU Cancer Institute, the ten page ICF was reformatted as a tri-fold brochure and one page ICF in 2005. The brochure is given to patients during the office visit or at time of registration and the triplicate one-page ICF on the day of surgery. The brochure contains information regarding biospecimen banking.The triplicate, one page consent is signed by the patient on the day of surgery.Results: In a 3-year period (2003-2005), the 10-page ICF was used to consent 433 patients from Breast, Gynecologic Oncology and GI Oncology, with an average of 2.77 patients per week. After the implementation of the novel brochure and single page ICF format, 1,426 patients were consented in the next 3- year period (2006-2008), with an average of 9.14 patients per week (10)Patients in the Breast Surgical Oncology Clinic at NYUCI were initially targeted. This was done in close cooperation with the breast surgical oncologists, nurses and operating room staff. The brochure/1-page ICF method doubled the accrual of patients from 141 to 304 patients in the first year (2005-6). However, the number of patients who consented did not increase in the next two years in spite of a significant increase in the total number of patients in the breast surgical oncology service.A root cause analysis was performed and it was determined that either the patients were not approached in the physician's office or the consenting process was not followed. It was concluded that a dedicated consenting professional was required to overcome these hurdles, who will primarily works in the operating room, where patients with diagnosis of cancer are targeted. This has yielded a significant increase in number of patients consenting for biospecimen donation. shows a significant increase in accrual since her recruitment in February 2009.Conclusions: A novel consenting mechanism with a brochure and one page consent has been successfully implemented at NYU Cancer Institute and has resulted in a significant increase in patients consenting for biospecimen donation. The process is being replicated institute wide for accrual to all biorepositories at NYULMC. This novel method can be widely employed to accrue specimens for clinical trials.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6081.

Mammographic Density and Lobular Involution in Older Women with Abnormal Breast Imaging

Mammographic density has been established as an independent risk factor for breast cancer, and there is data to suggest that the degree of lobular involution in the breast tissue may also function as an independent risk factor for the disease. The present study was designed to investigate the relationship between mammographic density and lobular involution in a population of mature women undergoing open biopsy for non-palpable breast lesions.A total of 199 women over the age of 60 who underwent breast biopsy with image-guided localization in 2008 at NYU Langone Medical Center formed the study population. Variables of interest included age, breast density, degree of involution, use of hormone replacement therapy (HRT) and biopsy histology (invasive ductal and lobular carcinoma and intraductal carcinoma vs. benign). Breast density was categorized according to BI-RADS classification as less dense (predominantly fatty and scattered fibroglandular elements) vs more dense (heterogeneously dense and extrememely dense). Degree of involution was classified as none (0%), partial (1-74%) and complete (>75%). All specimens were reviewed by a single pathologist who used the criteria of Hartmann, et al in evaluating degree of involution. Statistical analysis was performed using Pearson's Chi-square test and logistic regression analyses.In agreement with our previously presented data, we found an inverse relationship between breast density and age (p=0.02). In our cohort of women over 60 with abnormal breast imaging, we found a trend toward an inverse relationship between age and degree of lobular involution, but this did not achieve statistical significance. 129 of our patients had biopsies yielding malignant histology. There was no significant relationship between degree of lobular involution and biopsy histology. Use of HRT did not correlate with breast density in our cohort. There was no discernable relationship between degree of involution and history of prior or current HRT use.Association of lobular involution with age, density, histology, and HRT  INVOLUTION TOTALP-VALUE NONEPARTIALCOMPLETEN (%) AGE (YRS)      60-696337617 (9%)0.18270-797202959 (29%) 80-894618123 (62%) DENSITY     Less Dense143477125 (63%)0.177More Dense3254674 (37%) HISTOLOGY     Benign5194670 (35%)0.690Malignant124077129 (65%) HRT     Never11246398 (70%)0.774Ever3112741 (30%)  Our study reinforces the general observation that breast density decreases with age. Our data do not permit us to comment on the validity of lobular involution as a risk factor for breast cancer. However, the degree of lobular involution did not predict malignant histology in our cohort. There was a trend toward an inverse relationship between mammographic density and lobular involution. This observation suggests that other factors such as stromal features may be responsible for the increased mammographic density in these older patients. Further study is warranted to better understand the significance of lobular involution and its relationship with mammographic density in all age groups of women undergoing breast cancer screening.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6072.

Association of low P27 with loss of hormone receptors in small (T1a/b) breast cancers

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Background: P27kip1 is a nuclear protein that controls the cell cycle by inhibiting cyclin dependent kinases. In breast cancer cell lines, both estrogen and her-2/neu degrade p27 through the ubiquitin-proteasome pathway. T1N0M0 breast cancers with high p27 expression have excellent long-term survival (Loda et al, Cancer Research 1998), now we examine the association of low p27 and other prognostic factors in these patients. Methods: 122 T1N0M0 infiltrating ductal carcinoma were examined using immunohistochemistry. Specific monoclonal antibodies were used against estrogen receptor (ER), progesterone receptor (PR), Her-2/neu, p53 and p27. Percentage of cells stained were considered negative (or low for p27) if: ER <10%, PR <10%, p53<40%, her-2/neu DAKO score ≤ 1+, p27 (nuclear stain) <50%. Results: In T1a/bN0M0 tumors, 4/5 (80%) of low p27 tumors were also hormone receptor negative, while only 5/63 (8%) of the high p27 tumors were hormone receptor negative (P< 0.001, Fisher’s exact test). Although T1cN0M0 tumors showed a similar trend [4/12 (33%) of low p27 vs. 7/42 (17%) of high p27 tumors were hormone receptor negative], the difference was not statistically significant. No correlation was seen between low p27, her-2/neu, or p53 mutation. Conclusion: There is an association of low p27 and loss of hormone receptors in T1a/bN0M0 breast cancers, which may identify a subset of patients with a worse prognosis. Exploring the causes of p27 dysregulation (e.g., ubiquitin ligase overexpression) may shed further light on the significance of these associations.

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No significant financial relationships to disclose.

Morphological and biological characteristics of mammogram-detected invasive breast cancer

Thirty-nine mammographically detected, (M-detected) small invasive carcinomas of the breast (< or = 5 mm) were compared with 78 consecutive clinical cancers (> or = 10 mm) for a variety of morphological and biological markers of prognostic importance. There were more tubular carcinomas in the M-detected group (12.8% v 3.8%), but this did not reach statistical significance. Incidences of other histological types were similar. The types of associated in situ component were similar in the two groups. M-detected cancers were of lower overall grade (P < .001), lower architectural and nuclear grades (P = .0164 and P < .0001 respectively), and had fewer mitotic cells (P < .0001). None showed positive lymph nodes (P < .0001). Estrogen and progesterone receptor expression was similar in both groups. M-detected cancers expressed p53 nuclear protein less frequently than clinical cancers (P = .0398), had lower levels of microvessel density (P = .0001), and were more often diploid (P = .0131). S-phase of diploid tumors in the two groups was similar, but S-phase of aneuploid tumors was lower in the M-detected group (P = .0057). Ki67 expression was lower in M-detected cancers (P < .0001). In conclusion, M-detected small breast cancers, although invasive, represent an evolutionary phase of breast cancer that generally lacks morphological and biologic markers of aggressive behavior. The presence or absence of these markers, collectively, may explain the influence of tumor size on survival in patients with breast cancer.

Relationship between immune response to melanoma vaccine immunization and clinical outcome in stage II malignant melanoma

The authors investigated whether there was a relationship between the induction of a delayed-type hypersensitivity (DTH) response to melanoma vaccine immunization and disease recurrence. They studied prospectively 94 evaluable patients with surgically resected Stage II malignant melanoma who were immunized to a partially purified, polyvalent, melanoma antigen vaccine. The DTH response to skin tests to the vaccine was measured before treatment and at the fourth vaccine immunization. Vaccine treatment induced a strong DTH response in 29 (31%) patients, an intermediate response in 24 (25%), and no response in 41 (44%). The median disease-free survival (DFS) of patients with a strong, intermediate, and no DTH response to vaccine immunization was more than 72 months, 24 months, and 15 months, respectively. The relationship between an increase in the DTH response and a prolonged DFS was statistically significant (P = 0.02); clinically meaningful (the median DFS of patients with a strong DTH response was 4.7 years longer than that of nonresponders); and, by multivariate analysis, independent of disease severity or overall immune competence. These findings suggest, but do not prove, that vaccine treatment can slow the progression of melanoma in some patients.

Preparation and characterization of a polyvalent human melanoma antigen vaccine

A polyvalent melanoma tumor antigen vaccine was prepared from antigens shed by a pool of human melanoma cells cultured in serum-free medium. The vaccine contained multiple melanoma associated antigens (MAAs) and was free of detectable fetal calf serum (FCS) proteins and Dr antigens. Three batches of vaccine prepared several months apart contained the same spectrum of tumor antigens. Thirteen patients with metastatic malignant melanomas were immunized intradermally with escalating doses of the vaccine in a Phase I study. There was no toxicity other than transient urticaria at the injection site. Humoral immunity, assayed by indirect immunoprecipitation, was augmented in five (38%) patients. Cellular immunity, assayed by delayed-type cutaneous hypersensitivity, was induced in four (31%) patients. Skin tests to a control vaccine prepared from pooled allogeneic lymphocytes were negative. Cutaneous metastases regressed completely in one patient who is now disease free after 2 years, and multiple cutaneous metastases have remained stable for 14 months in another patient. These results indicate that active immunization to a partially characterized polyvalent melanoma antigen vaccine is safe and can increase immunity to melanoma in some patients.

Prospective evaluation of cardiotoxicity during a six-hour doxorubicin infusion regimen in women with adenocarcinoma of the breast

In order to test the possible cardiac-sparing effect of doxorubicin administered by six-hour intravenous infusion and to prospectively evaluate the role of resting left ventricular ejection fraction in monitoring these patients, 33 women with advanced breast cancer were treated with combination chemotherapy containing 5-fluorouracil, cyclophosphamide, and doxorubicin. Doxorubicin was administered via a femoral catheter as a six-hour infusion. Cardiac function was monitored prior to therapy and at intervals during therapy by history and physical examination and by measurement of resting left ventricular ejection fraction with gated pool radionuclide angiography. Twenty-six responses were observed (complete response, seven [21 percent]; partial response, 19 [57 percent]). Systemic toxicity included alopecia, myelosuppression, and nausea and vomiting. There was a progressive fall in resting left ventricular ejection fraction during treatment from a median baseline value of 0.63. Mean fall from baseline left ventricular ejection fraction at a cumulative doxorubicin dose of 200 to 300 mg/m2 was 0.06 (p less than 0.005); at 301 to 449 mg/m2 it was 0.09 (p less than 0.0005); and at 450 mg/m2 or greater it was 0.15 (p less than 0.0005). Clinical congestive heart failure developed in three patients. Even though the decrease in left ventricular ejection fraction was often within the "normal range" (left ventricular ejection fraction 0.50 or greater), these changes were progressive and appeared to be part of a continuum of doxorubicin-induced myocardial damage. Steady-state infusion levels of doxorubicin in plasma ranged from 90 to 120 nM. They confirm the hypothesis that lower concentrations can be achieved by continuous infusion rather than by bolus infusion. In this study, however, administration of doxorubicin by six-hour infusion did not appear to have a major cardiac-sparing effect. Studies of anthracycline cardiac toxicity should include determination of baseline left ventricular ejection fraction and serial observations during therapy. Failure to include deteriorations in function above an arbitrary cutoff point or to make observations only at higher cumulative doses may underestimate drug-induced myocardial damage.

Single-dose dacarbazine and dactinomycin in advanced malignant melanoma

Twenty-one patients with advanced malignant melanoma were treated with dacarbazine at a dose of 800 mg/m2 as a single infusion and dactinomycin at a dose of 1.2 mg/m2 every 3 weeks. Hematologic toxicity was mild and gastrointestinal toxicity was tolerable. The response rate for evaluable patients was 22%, which included both men and women with visceral disease. Three of the four responses were complete. Durations of response were 4, 6, 9, and 48+ months. We conclude that dacarbazine can be safely and effectively given as a single dose along with dactinomycin. The possibility that this combination may be more effective than single agents in obtaining complete responses in patients with visceral disease must be explored further.