Abstract P1-07-14: Real-life analysis evaluating >1000 N0/N1mi estrogen receptor (ER)+ breast cancer patients for whom treatment decisions incorporated the 21-gene recurrence score (RS) result: Clinical outcomes with median follow up of > 9 years

Background: The 21-gene Recurrence Score (RS) Assay (Oncotype DX®) is a validated prognosticator and predictive of chemotherapy (CT) benefit in patients with hormone receptor (HR)+ human epidermal growth factor receptor 2 (HER2)-negative breast cancer. In Israel, the RS assay has been reimbursed by Clalit Health Services (CHS, the largest HMO in Israel) since 2006, and the assay is widely used in eligible estrogen receptor (ER)+ patients. Notably, ER+ breast cancer patients have a protracted risk of recurrence with approximately half of all distant recurrences occurring after 5 years from diagnosis. The goal of the current ongoing analysis was to investigate early (≤5 years) and late (>5 years) distant recurrence in N0/N1mi ER+ HER2-negative breast cancer patients who were RS-tested through CHS.

Methods: This analysis of the CHS registry included breast cancer patients with ER+ HER2-negative N0/N1mi disease who underwent RS testing from 1/2006 (CHS approval of the assay) through 1/2009. Data sources included CHS claims arms (for patient/tumor characteristics), Teva Pharmaceuticals (for tumor characteristics, RS result), and medical records (for treatment/recurrence/survival). The study was approved by the institutional review boards of the CHS Community Division and was granted a waiver for obtaining patient consent.

Results: The analysis included 1026 patients with median (interquartile range) follow up of 9.3 (8.8-10.2) years. Most patients were females (99%). Median (range) age was 59 (25-84) years; 92% had N0 and 8% had N1mi disease; 14%, 52%, and 16% had grade 1, 2, and 3 tumors, respectively (grade information was not available for 18% of patients); median (range) tumor size was 1.5 (0.3-6.5) cm. The majority of patients (78%) had invasive ductal carcinoma and 12% had invasive lobular carcinoma. Overall, 489 patients (48%) had RS<18, 434 (42%) had RS 18-30, and 103 (10%) had RS≥31. The use of adjuvant CT was consistent with the RS result: 3%, 27%, and 90% of RS<18, RS 18-30, and RS≥31 patients, respectively. Overall, 25 distant recurrences were reported within 5 years of RS testing: 5 (1.0%) in RS<18 patients, 9 (2.1%) in RS 18-30 patients, and 11 (10.6%) in RS≥31 patients. In the first 5 years, breast cancer-specific death was reported in 8 patients including 3 (0.7%) with RS 18-30 and 5 (4.9%) with RS≥31 results. Among N0 patients with RS 11-25 who did not receive adjuvant CT (n = 540), 5 (0.9%) distant recurrences and one (0.2%) breast cancer death were reported within 5 years of RS testing. Analysis of 'late' recurrences and breast cancer-specific death (from 5 to 9.3 years of follow-up) is ongoing.

Conclusions: These will be the first late recurrence data from over 1000 patients for whom the RS result was used in real-life clinical decision making. Consistent with previous analyses of the CHS registry, CT use was appropriately based on the RS result, and the recurrence/survival outcomes (for the first 5 years) demonstrated the prognostic performance of the RS. Distant recurrence and breast cancer death data beyond 5 years will be presented at the meeting.

Citation Format: Stemmer SM, Rizel S, Steiner M, Geffen DB, Soussan-Gutman L, Bareket-Samish A, McCullough D, Svedman C, Nisenbaum B, Ryvo L, Peretz T, Fried G, Rosengarten O, Liebermann N, Ben Baruch N. Real-life analysis evaluating >1000 N0/N1mi estrogen receptor (ER)+ breast cancer patients for whom treatment decisions incorporated the 21-gene recurrence score (RS) result: Clinical outcomes with median follow up of > 9 years [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-14.

Pazolimus: pazopanib plus sirolimus following progression on pazopanib, a retrospective case series analysis

Background

To explore the activity of pazopanib (P) + sirolimus (S) in patients who progressed after previous clinical benefit on pazopanib.

Methods

Eight patients with progressing metastatic high grade soft tissue sarcoma (STS) whose disease advanced on P following a response duration of at least 4 months were offered re-challenge of P supplemented by off-label S and a single patient with progressing metastatic chondrosarcoma was offered the combination as compassionate treatment. Patients were treated in two centers: Hadassah Medical Center and Tel Aviv Medical Center. Patients received oral P 200–600 mg once a day supplemented by S 3–4 mg taken separately, 12 h after the P dose.

Results

Patients received treatment from December 2012 to February 2016. Four progressed on the combination and their treatment was terminated. Two patients were undergoing treatment when data was summarized. Best Response Evaluation Criteria in Solid Tumour (RECIST) responses were: one partial response (PR), four stable disease (SD), and four progressive disease (PD), corresponding to five PR and four PD on the Choi criteria. Median progression free survival was 5.5 months (range 4–17).

Conclusions

Our series showed that the combination of P + S has activity in STS patients selected by previous response to P and in a patient with chondrosarcoma, suggesting this can serve as a mechanism to reverse resistance to P and extend the chemotherapy-free window.

A multiparous pregnant woman receiving chemotherapy for breast cancer

Cancer is the second leading cause of death in women during the childbearing years. Breast can cer is the most common malignancy presenting during pregnancy and lactation. Treatment with antineoplastic agents in this group of patients is problematic due to their potential teratogenicity. A case report is presented of a pregnant woman who received neo-adjuvant chemotherapy for locally advanced carcinoma of the breast. The patient received a total of four courses of cyclophospha mide, doxorubicin and 5-fluorouracil, before deliv ery of a child healthy in all systems. We discuss the use of cytotoxic drugs during pregnancy and indi cate some of the dilemas facing the treating physi cian. The authors join in the call for the establish ment of an international registry of children born to mothers who receive cytotoxic drugs during pregnancy.

Messenger RNA encoding constitutively active Toll-like receptor 4 enhances effector functions of human T cells

Adoptive T cell therapy of cancer employs a large number of ex-vivo-propagated T cells which recognize their targets either by virtue of their endogenous T cell receptor (TCR) or via genetic reprogramming. However, both cell-extrinsic and intrinsic mechanisms often diminish the in-vivo potency of these therapeutic T cells, limiting their clinical efficacy and broader use. Direct activation of human T cells by Toll-like receptor (TLR) ligands induces T cell survival and proliferation, boosts the production of proinflammatory cytokines and augments resistance to regulatory T cell (Treg) suppression. Removal of the TLR ligand-binding region results in constitutive signalling triggered by the remaining cytosolic Toll/interleukin-1 receptor (TIR) domain. The use of such TIR domains therefore offers an ideal means for equipping anti-tumour T cells with the arsenal of functional attributes required for improving current clinical protocols. Here we show that constitutively active (ca)TLR-4 can be expressed efficiently in human T cells using mRNA electroporation. The mere expression of caTLR-4 mRNA in polyclonal CD8 and CD4 T cells induced the production of interferon (IFN)-γ, triggered the surface expression of CD25, CD69 and 4-1BB and up-regulated a panel of cytokines and chemokines. In tumour-infiltrating lymphocytes prepared from melanoma patients, caTLR-4 induced robust IFN-γ secretion in all samples tested. Furthermore, caTLR-4 enhanced the anti-melanoma cytolytic activity of tumour-infiltrating lymphocytes and augmented the secretion of IFN-γ, tumour necrosis factor (TNF)-α and granulocyte-macrophage colony-stimulating factor (GM-CSF) for at least 4 days post-transfection. Our results demonstrate that caTLR-4 is capable of exerting multiple T cell-enhancing effects and can potentially be used as a genetic adjuvant in adoptive cell therapy.

Abstract P4-05-08: Oncotype Dx assay in BRCA positive ER positive breast cancer patients

Background:

Oncotype DX is a 21-gene RT-PCR assay which quantifies the likelihood of breast cancer recurrence and the potential benefit of chemotherapy in patients with early stage, ER positive, Tamoxifen treated breast cancer. Breast cancer in BRCA carriers is considered more aggressive. The aim of our study was to evaluate whether Oncotype Dx recurrence score distribution is different in breast cancer patients with inherited BRCA mutation.

Methods:

The Oncotype DX assay has been used at Hadassah Medical Center since 2004 on specimens from over 450 patients. We analyzed and compared clinicopathological characteristics and Oncotype Dx recurrence scores of BRCA carriers versus non- BRCA or unknown status of BRCA patients.

Results:

Ten patients had validated inherited BRCA mutation, five of them are BRCA1 carriers and five BRCA2 carriers. There were no significant differences in the clinicopathological characteristics between the two groups. Oncotype Dx recurrence score distribution between low, intermediate and high risk groups was not significantly different. The mean recurrence score was 18.48 for the non- BRCA or unknown status of BRCA patients and 22.8 for the BRCA carriers patients. This difference was not statistically significant.

Conclusion:

Estrogen receptor positive breast cancer tumors from BRCA carriers does not display a significantly different Oncotype Dx recurrence score result distribution.

These preliminary data suggest Oncotype Dx assay might be used to help tailor treatment in this subset of patients, although further follow up is needed.

All patients evaluated for oncotype_DX  All evaluated (except BRCA+) n = 456BRCA positiveP valueAgeMean57.4557.60.7 Median5857  Range56 (25-81)34 (42-76) T stageT167.7%70%0.9 T230.7%30%  T31.6%0% Tumor sizeMean1.71.360.2 Median1.51.26  Range7.8 (0.2-8)1.3 (0.7-2) GradeGrade 1-278.8%60%0.15 Grade 321.2%40% RSLow50%40%0.57 Intermediate39.8%40%  High10.2%20% RSMean18.4822.80.16 Median17.522.5  Range64 (0-64)27 (12-39) 

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-05-08.

EZH2 promotes a bi-lineage identity in basal-like breast cancer cells

The mechanisms regulating breast cancer differentiation state are poorly understood. Of particular interest are molecular regulators controlling the highly aggressive and poorly differentiated traits of basal-like breast carcinomas. Here we show that the Polycomb factor EZH2 maintains the differentiation state of basal-like breast cancer cells, and promotes the expression of progenitor associated and basal-lineage genes. Specifically, EZH2 regulates the composition of basal-like breast cancer cell populations by promoting a ‘bi-lineage’ differentiation state, in which cells co-express basal- and luminal-lineage markers. We show that human basal-like breast cancers contain a subpopulation of bi-lineage cells, and that EZH2-deficient cells give rise to tumors with a decreased proportion of such cells. Bi-lineage cells express genes that are active in normal luminal progenitors, and possess increased colony-formation capacity, consistent with a primitive differentiation state. We found that GATA3, a driver of luminal differentiation, performs a function opposite to EZH2, acting to suppress bi-lineage identity and luminal-progenitor gene expression. GATA3 levels increase upon EZH2 silencing, mediating a decrease in bi-lineage cell numbers. Our findings reveal a novel role for EZH2 in controlling basal-like breast cancer differentiation state and intra-tumoral cell composition.

Abstract P2-14-04: Co-Administration of GnRH-Agonists with Adjuvant Chemotherapy in Young Breast Cancer Patients: The Effect on Ovarian Function and on Clinical Outcome

Background: Loss of fertility is a major concern for young breast cancer (BC) patients who require adjuvant chemotherapy. The risk of ovarian failure depends on patient's age and chemotherapy regimen. Use of GnRH agonists (GnRHa) has been proposed as a mean for ovarian function preservation but has been investigated mainly in small single arm studies. Objectives: To evaluate ovarian function preservation and disease free survival (DFS) in young breast cancer patients following GnRHa and adjuvant chemotherapy co-administration. Methods: In this multicenter retrospective study, we reviewed medical records of 560 breast cancer patients diagnosed before the age of 40, from 1990 through 2006. All patients were treated in one of 5 Israeli cancer centers with standard adjuvant or neoadjuvant chemotherapy regimens with curative intent. GnRHa were prescribed at the discretion of the treating physician. Ovarian function preservation was determined by resumption of menses, premenopausal hormonal profile or pregnancy during follow up. Multivariate analysis was applied in order to determine whether coadministration of GnRHa with chemotherapy affects DFS. Results: Data was available for 71 patients who received GnRHa during chemotherapy (group A), 60 of those were evaluable for fertility and 68 were evaluated for DFS. The group not receiving GnRHa included 460 patients (group B). Of those 207 were evaluable for fertility and 370 for DFS. Data concerning patients’ characteristics and outcome in each group are presented in the table 1. In a Cox regression model including age, stage, ER/PR status and GnRHa administration, the latter variable predicted a better DFS rate (RR 0.31; 95% CI 0.16-0.70; p=0.003), excluding the subgroup with ER/PR positive tumors (p=0.128). This probably reflects selection bias of prognostic factors not included in the analysis and not a real anti neoplastic hormonal effect. Conclusions: Patients who received GnRHa were younger and had less advanced disease. Fertility was preserved independent of GnRHa administration and regardless of cumulative doses of cyclophosphamide or taxans. This observation suggests that GnRHa are unnecessary for fertility preservation in patients younger than 40yrs. No detrimental effect of GnRHa during chemotherapy was observed on disease outcome.

Preimplantation genetic diagnosis for BRCA1/2--a novel clinical experience

OBJECTIVE

To describe our 2-year experience with preimplantation genetic diagnosis (PGD) for carriers of mutations in the genes BRCA1 and BRCA2, the dilemmas incurred and the lessons learned.

METHODS

We collected data on those carriers of BRCA1/2 mutations who applied for PGD counseling and who decided to proceed. We describe the PGD procedures that were conducted and their outcome.

RESULTS

Ten carriers of BRCA1/2 mutations applied for PGD counseling, seven were healthy, and three were BC survivors. Eight women needed in vitro fertilization (IVF) because of coexisting infertility. After counseling, six opted for the procedure and five of them underwent PGD for the BRCA mutation. In one of these PGD, fluorescence in situ hybridization (FISH) analysis for chromosomes 21, X and Y was also performed. Three women conceived, each in the first treatment attempt. One of them gave birth to twins, the second to a singleton and the third is currently pregnant. During the pregnancies, dilemmas concerning PGD confirmation were discussed.

CONCLUSIONS

PGD is an acceptable reproductive option for BRCA mutation carriers, especially for those who require IVF due to fertility problems. Discussion of this option should be carried out with sensitivity, taking into account the age of the woman, her health, fertility status and emotional state. Confirmatory prenatal diagnosis may not always be encouraged.

Fertility and pregnancy in patients under age 38 following chemotherapy for breast cancer

e11541

Background: Chemotherapy improves breast cancer outcome, but may impact fertility. Post chemotherapy fertility rates range between 10–90% among studies. Fertility post chemotherapy is most often assessed by rate of menstruation resumption- an indirect method of evaluating childbearing potential. It is noteworthy that future pregnancy is a woman's first concern not menses preservation. Variability in fertility rates along with limited data on post chemotherapy pregnancies led us to undertake this single institute retrospective study evaluating fertility and pregnancy post chemotherapy in ≤ 38 y old breast cancer patients. Methods: We reviewed medical records of 222 consecutive stage II-IIIB breast cancer patients diagnosed, treated and followed at Sharette Institute of Hadassah-Hebrew University Medical Center from 1990–2004. Inclusion criteria included age ≤ 38 years, ≥3 cycles of standard metothrexate or adriamycine based chemotherapy, metastasis-free 12 months post chemotherapy initiation or one year following GnRH analog withdrawal. Patients diagnosed with infertility prior to breast cancer diagnosis (data present for part of patients), bilateral oophorectomy or patients surviving ≤3 years from diagnosis were excluded. Patient pregnancy preference was not recorded. Fertility was defined as resumption of recurrent menses or pregnancy anytime during follow up. In case of recurrence, date of recurrence diagnosis was assigned as date of last follow up. Results: Cohort included 65 patients. Mean age 32.5±4 ys (20.3–38.5) Almost all patients (95.4%), 38 ys or younger, preserve menses following chemotherapy, and 33.9% become pregnant. Most of patients who did not conceive post chemotherapy (66.1%), were under a familial status not promoting pregnancy; 44% of all women who did not give birth post chemotherapy had at least 3 offspring at the time of diagnosis and 83% out of all women who did not have any offspring by the end of follow up were single. Conclusions: This data suggest that pregnancy potential may be even higher than our actual finding, since pregnancy is most probably not attempted by multiparous or most single patients, whom cultural constrains affect their decisions. It seems prudent to offer the subgroup of unmarried women fertility preservation.

No significant financial relationships to disclose.

Prelimenary results of a phase I/II of a combination of cetuximab and taxane for triple negative breast cancer patients

e12018

Background: The triple negative subtype of breast cancer is currently only treated with chemotherapeutic agents. It has been demonstrated that over 50% of this kind of tumors express EGFR (HER-1). Cetuximab is a humanized antiEGFR IgG1 antibody. In colon cancer there are also high percentage of EGFR expression and addition of Cetuximab to chemotherapy results in renewed sensitivity to treatments. We therefore hypothesized that in a similar manner addition of Cetuximab to taxanes which are among the most potent anti breast cancer drugs will result in increased effectiveness in this subset of breast cancer patients. Methods: From January 2007 to January 2009, we treated 12 breast cancer patients with either paclitaxel 80 mg/m2, (10 patients) or docetaxel (30 mg mg/m2) (2 patients), with cetuximab weekly. Patients had a pathology sample of breast cancer with triple negative components, metastatic disease and up to two prior chemotherapy lines in the metastatic settings. Results: Patient characteristics (median): age 60 (31–69) years, prior taxane therapy 9/12 pts. Toxicity: Dermatologic grade 2 9/12 grade 3 3/12, nail disease grade 2 10/12 evaluable patients. One patient developed severe swallowing difficulties after 19 month of therapy which may or may not be linked to the treatment. Response is evaluable for 11/12 patients. Response which includes clinical response, tumor marker decrease, and a metastasis size decrease was noted in 9/11 patients. Including tumor marker normalization and nearly a roentgoenolgic CR in a young patient previously treated with several chemeotherapietic lines. Three patients developed brain metastasis during treatments. Molecular pathology is now performed. We continue accrual. Conclusions: Administration of taxane-cetuximab weekly therapy for triple negative breast cancer patients is possible. Toxicity is the cumulated expected toxicity of each of the agents — special care should be taken for nail disease which occurred in most of the patients. Some impressive clinical responses were obtained even in taxane pretreated patients.

[Table: see text]

Glutathione-S-transferase M1, T1 and P1 polymorphisms, and breast cancer risk, in BRCA1/2 mutation carriers

Variation in penetrance estimates for BRCA1/2 carriers suggests that other environmental and genetic factors may modify cancer risk in carriers. The GSTM1, T1 and P1 isoenzymes are involved in metabolism of environmental carcinogens. The GSTM1 and GSTT1 gene is absent in a substantial proportion of the population. In GSTP1, a single-nucleotide polymorphism that translates to Ile112Val was associated with lower activity. We studied the effect of these polymorphisms on breast cancer (BC) risk in BRCA1/2 carriers. A population of 320 BRCA1/2 carriers were genotyped; of them 262 were carriers of one of the three Ashkenazi founder mutations. Two hundred and eleven were affected with BC (20 also with ovarian cancer (OC)) and 109 were unaffected with BC (39 of them had OC). Risk analyses were conducted using Cox proportional hazard models adjusted for origin (Ashkenazi vs non-Ashkenazi). We found an estimated BC HR of 0.89 (95% CI 0.65-1.12, P=0.25) and 1.11 (95% CI 0.81-1.52, P=0.53) for the null alleles of GSTM1 and GSTT1, respectively. For GSTP1, HR for BC was 1.36 (95% CI 1.02-1.81, P=0.04) for individuals with Ile/Val, and 2.00 (95% CI 1.18-3.38) for carriers of the Val/Val genotype (P=0.01). An HR of 3.20 (95% CI 1.26-8.09, P=0.01), and younger age at BC onset (P=0.2), were found among Val/Val, BRCA2 carriers, but not among BRCA1 carriers. In conclusion, our results indicate significantly elevated risk for BC in carriers of BRCA2 mutations with GSTP1-Val allele with dosage effect, as implicated by higher risk in homozygous Val carriers. The GSTM1- and GSTT1-null allele did not seem to have a major effect.

Improvement in survival of breast cancer patients with synchronous metastases

1063

Background: Less than 10% of breast cancer patients are diagnosed with metastatic disease upon initial diagnosis. Once metastases are detected, median survival ranges between 18 and 24 months. Many new chemotherapy agents, hormonal therapy, monoclonal antibodies and supportive care options were presented during the last decade. Although a few randomized trials have demonstrated improvement in survival for various agents, it has not been clear whether the overall survival of these patients has improved. In this study, we analyzed the survival of patients diagnosed with metastatic breast cancer in during the 1990’s Methods: We have analyzed 874 patients diagnosed with breast cancer at our Institute in the years 1991–1994 and 1102 patients in 1996–1999. Tumor characteristics, treatments, and the outcomes of these patients were compared. We used Kaplan-Meier, Wilcoxon test and Cox proportional hazard in order to investigate variants between the 2 groups. Results: After excluding all women with no evidence of metastatic disease at diagnosis, we analyzed 96 patients. No major difference in tumor characteristics was found between the group of patients diagnosed in the early 1990’s and the group diagnosed in the late 1990’s. We found a significant relationship between the period of diagnosis of metastatic breast cancer and survival: median survival was 19 months for the first group and 35 months for the second group (p=0.0398, 95% C.I), with 5-year overall survival rates 8% for patients diagnosed in the early 1990’s and 25% for patients diagnosed in the late 1990’s, p=0.0497. Two years survival was 25% and 60% respectively, although insignificant, p = 0.0941. Although there was no significant difference in number of chemotherapy courses given in the 2 groups, many more new generation treatments were used for the late 90th group. The Hazard of death within 5 years for patients treated with at least one new generation protocol was 0.53, p= 0.004. Conclusions: This study suggests that there has been significant survival improvement in breast cancer patients diagnosed with synchronous metastasis during the second half of the 1990’s. This improvement can be explained by the introduction of new treatments agents and strategies during the last decade

No significant financial relationships to disclose.

Superior survival of breast cancer BRCA1 /2 mutation carriers harboringG/G at the -309 position at the MDM2 promoter compared to those harboring T/T or G/T at this SNP

10600

Background: A germ line single polymorphism in the promoter of the gene encoding the important modulator of P53, MDM2 has been described. The findings of G/G nucleotides at this position in contrast to G/Tor T/T were demonstrated to increase MDM2 transcriptional levels and were correlated with younger onset of cancers in patients with the Li-Fraumeni syndrome. Furhtermore gastric cancer patients harboring T/T at this position and treated with chemotherapy were found to have decresed survival compared to the other SNP carriers. P53 mutations appear in high frequency in tumors associated with BRCA1/2 mutations. Indeed it has been suggested that mutations in the p53 gene are a necessary step in tumorigenesis in BRCA tumors. Methods: Here we investigate the effect of the MDM2 SNP309 on overall survival and age of onset in breast cancer patients. MDM2 SNP309 was evaluated in Breast cancer Ashkenazy patients analyzed for the three common mutations in BRCA1/2- 180 patients who are positive for either of these mutation and 272 negative ones. 194 negative, Disease onset age and survival were analyzed for the different subgroups Results: Around a quarter of the whole population analyzed were identified as carriers of G/G at the -309 MDM2. There was no correlation between age of disease onset in either BRCA1/2mutation carriers and the specific genotype. In the BRCA1/2 mutation carriers we found a survival advantage in patients harboring the SNP309 G/G genotype(p-0.001 log rank test). Such an effect was not demonstrated in patients tested negative for the known Ashkenazy mutations Conclusions: In specific subgroups of breast cancer patients SNP309 G/G is associated with improved patient survival. A possible explanation for this finding could be the presence of a P53 which can be reactivated in the MDM2 SNP309 G/G carriers.

No significant financial relationships to disclose.

The margins effect: Residual tumor after breast conserving surgery

11045

Background: Resection of breast cancer with good surgical margins is one of the fundamental aspects of breast conserving surgery. Most studies have shown that women with positive margins after breast conserving surgery (BCS) fared worse compared to those with negative margins, regardless of chemotherapy or radiation therapy. Nowadays, when partial breast irradiation is gaining popularity, understanding the natural history of positive or close margins is particularly important. We studied the surgical process in a large cohort of Israeli women with breast cancer to estimate the frequency of tumor margin involvement in the primary and subsequent surgical procedure. Methods: The National Israeli Breast Cancer Detection Programs has been monitoring the detection process of all new cases of breast cancer in Israel since 1996. Full data on tumor histology and surgical procedures, including indication of margins in the pathology report were available for 16,925 malignant breast tumors. Margins were classified as positive margins (PM), close (= 2mm) (CM) or negative margins (greater then 2mm)(NM). Results: BCS was identified in 14,815 women with invasive cancer and 2,110 with pure ductal carcinoma in situ (DCIS). Only 7,751 (52.3%) of the 14,815 women with invasive cancer had NM, while 2,868 (19.4%) had CM and 4,196 (28.3%) had PM. Among those with PM, 2,276 (54.6%) had a re-operation within 6 months from the index surgery and 1,265 (55.6%) of them were found to be malignant; 58% of them were invasive cancers and 42% DCIS. Among the invasives on re-operation, 24.4% still had PM and another 12.1% had CM while among the DCIS 14.4% had PM and 17.6% had CM. Of the 717 women with DCIS and positive margins at first surgery, 67.9% had a second operation. Of them, 59.8% had malignancy, 8.8% of them invasive. Overall 10.6% of all invasive cancers and 3.7% of all DCIS had PM on relumpectomy within 6 month regardless of initial margin status. Conclusions: A relatively high proportion of all women undergoing BCS were found to have positive or close margins, even after re-operations. If a failure to reach clean margins is a reflection of an aggressive tumor phenotype, special attention should be given to these patients and treatment should be adjusted accordingly.

No significant financial relationships to disclose.

Rapid development of post-radiotherapy sarcoma and breast cancer in a patient with a novel germline 'de-novo' TP53 mutation

AIMS

Germline mutations in the TP53 tumour suppressor gene are associated with Li-Fraumeni syndrome, which is characterised by a spectrum of neoplasms occurring in children and young adults that predominantly include early-onset breast cancer, a variety of sarcomas, brain tumours and adrenocortical tumours. The identification of patients carrying TP53 mutations is primarily based on a positive family history of these early-onset characteristic cancer types. The aim of this study is to emphasize the importance of TP53 molecular testing in patients with very early onset breast cancer and no family history of cancer.

MATERIALS AND METHODS

A young woman with no family history of cancer presented with bilateral breast cancer at the age of 27 years. Forty months later she developed malignant fibrous histiocytoma of the right clavicle and another primary left breast cancer. Molecular testing of mutations 185delAG, 5382insC in BRCA1 gene and 6174delT in BRCA2 gene was performed using multiplex PCR and separation on a denaturing polyacrylamide gel. TP53 molecular analysis was performed by PCR-SSCP analysis of the whole coding region of the TP53. Exon 8 PCR products were sequenced using an ABI dye terminator kit and examined on an ABI 3100 automated sequencer.

RESULTS

Molecular testing of peripheral blood DNA did not reveal mutations in BRCA1 or BRCA2 genes. A novel germline TP53 mutation, c.G841C, p.D281N, was identified. The detected mutation is a missense substitution, c.G841C, resulting in the substitution of the amino acid aspartate to asparagine, p.D281N. Molecular analysis in her parents showed that neither of them carried the mutation.

CONCLUSIONS

We describe a novel 'de novo'TP53 mutation and discuss the importance of molecular testing in early-onset breast cancer patients and its effect on the management and outcome of the disease.

The changing face of cancer in the elderly—Only a demographic change?

18597

Background: In industrial countries, the cancer burden of the elderly is high and is increased. One reason is longer life expectancy. Increasing age standardized rates of cancer in this age group compared to younger groups may also explain this phenomenon. Methods: Two age groups were examined, above and below 65 years. Each age group was further divided into men and women. The age standardized rates for all cancers combined among the Jewish population in Israel were identified through the Israel Cancer Registry during the years 1973–2002. In addition, lung and colorectal cancers according to sexes, prostate cancer in men and breast cancer in women were examined. Results: Between the first 5 years of the study (1973–1977) and the last 5 years (1998–2002) the age standardized rates for all cancers combined were raised by about one third in the two age groups. In males, the overall change was higher in the older group (42% in men aged 65 years and older compared to 31% in men younger than 65). However, the rise in the younger group was more prominent in females (42% in women younger than 65 years compared to 33 % in women aged 65 and older). The most outstanding increase was in prostate cancer in men, but mainly in the younger group (176% in the older group and 368% in the younger group) followed by breast cancer in women, more prominent in the older group (64% in the older group and 50% in the younger group). In both sexes, more noticeable increases were noted in the older groups in colorectal cancer and in lung cancer. Between the years 1993–1997 and 1998–2002 shifts towards stabilization and even a decrease was noted in some of the cancers that were examined. In men aged 65 years and older rates for all cancers combined were decreased by 2.5%, among the specific tumors and a decrease was noted in lung cancer (6.7%) and prostate cancer (5.8%). The rates for all cancers combined among the older women were slightly decreasing (2.0%). No decrease was noted in the specific tumors in this group. Among the younger groups in both sexes, no decrease (defined >0.5%) was noted. Conclusions: These data argue against the hypothesis that the overall change in the cancer burden in the aged could be also explained by differences changes in the risk of developing cancer between these two age groups.

No significant financial relationships to disclose.

Multimarker RT-PCR assay for the detection of minimal residual disease in sentinel lymph nodes of breast cancer patients

The presence of metastases in lymph nodes is the most powerful prognostic factor in breast cancer patients. Routine histological examination of lymph nodes has limited sensitivity for the detection of breast cancer metastases. The aim of the present study was to develop a multimarker reverse transcriptase-polymerase chain reaction (RT-PCR) assay for the detection of minimal residual disease in sentinel nodes of breast cancer patients. RNA was extracted from 30 sentinel lymph nodes (SLN) obtained from 28 patients, three primary breast cancers (positive controls), three lymph nodes from patients with benign diseases, and peripheral blood lymphocytes of 10 healthy volunteers (negative controls). RT-PCR was performed using the following markers; cytokeratin (CK)-19, NY-BR-1 and mammaglobin B. RT-PCR results were compared to enhanced histopathologic examination and immunohistochemistry (IHC). All three positive controls showed strong PCR amplification for all three markers. None of the 13 negative controls was amplified by any of the three markers. Among the 30 SLN analysed, breast cancer metastases were detected in six SLNs by routine histology, in eight by IHC and in 15 by RT-PCR. We conclude that a multimarker RT-PCR assay probing for NY-BR-1, mammaglobin-B, and CK-19 is more sensitive compared to enhanced pathologic examination. This method may prove to be of value in breast cancer staging and prognosis evaluation.

Tumor suppressor p53 regulates heparanase gene expression

Mammalian heparanase degrades heparan sulfate, the most prominent polysaccharide of the extracellular matrix. Causal involvement of heparanase in tumor progression is well documented. Little is known, however, about mechanisms that regulate heparanase gene expression. Mutational inactivation of tumor suppressor p53 is the most frequent genetic alteration in human tumors. p53 is a transcription factor that regulates a wide variety of cellular promoters. In this study, we demonstrate that wild-type (wt) p53 binds to heparanase promoter and inhibits its activity, whereas mutant p53 variants failed to exert an inhibitory effect. Moreover, p53-H175R mutant even activated heparanase promoter activity. Elimination or inhibition of p53 in several cell types resulted in a significant increase in heparanase gene expression and enzymatic activity. Trichostatin A abolished the inhibitory effect of wt p53, suggesting the involvement of histone deacetylation in negative regulation of the heparanase promoter. Altogether, our results indicate that the heparanase gene is regulated by p53 under normal conditions, while mutational inactivation of p53 during cancer development leads to induction of heparanase expression, providing a possible explanation for the frequent increase of heparanase levels observed in the course of tumorigenesis.

Use of tranquilizers and sleeping pills among cancer patients is associated with a poorer quality of life

PURPOSE

To evaluate the association between sleeping pill/tranquilizer (SP/T) use and quality of life (QOL) among cancer patients.

PATIENTS AND METHODS

Oncology patients (n = 909) in three Israeli hospitals were interviewed in clinics, day centers and in-patient departments regarding SP/T use in the previous week. Crude and adjusted QOL scores, measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30), were compared in users vs. non-users.

RESULTS

Sleeping pill/tranquilizer use was self-reported by 234 (25.7%) participants, but rarely documented in medical charts. Factors associated with SP/T use were female gender (adjusted Odds ratio, OR: 1.79; 95% Confidence interval, CI: 1.22-2.62, age (OR: 4.6; 95% CI: 1.66-12.53 for age 70+), place of birth (OR: 1.97; 95% CI: 1.19-3.26 for Eastern Europe compared with Israel), concomitant use of painkillers (OR: 2.88; 95% CI: 1.97-4.20) and presence of cardiovascular disease (OR: 2.41; 95% CI: 1.48-3.91). Controlling these factors as well as disease status, users had a poorer QOL on all functional scales (p < 0.001) as well as global QOL. Furthermore, users reported increased severity of symptoms, especially fatigue, insomnia, pain, dyspnea and constipation (p < 0.01), compared to non-users.

CONCLUSIONS

Use of SP/T, reported by one fourth of cancer patients, was associated with substantially poorer QOL and increased severity of symptoms. Causal inference is not possible given the cross-sectional design. Periodic inquiry regarding use of these medications in the Oncology Clinic is recommended since it may identify patients with poor QOL and unmet needs.

Production and purification of melanoma gp100 antigen and polyclonal antibodies

gp100 is a melanoma-associated antigen found to carry immunogenic epitopes that can induce a CTL response against tumor cells. Production and purification of large quantities of this polypeptide may be important in the context of diagnosis and vaccinating against melanoma. To overcome the hydrophobic nature of gp100, we cloned and expressed only a part of the protein, and obtained a hydrophilic recombinant polypeptide (HR-gp100) that contained most of the immunogenic peptides. High yield was achieved in an Escherichia coli expression system. The protein was purified by AKTA Prime using anionic-columns. Polyclonal antibodies developed in chicken against HR-gp100 were efficient at detecting gp100 in melanoma cells, as determined by Western blot analysis and by immunohistochemistry. HR-gp100 can be used to develop a vaccine against melanoma. Antibodies to HR-gp100 may be used to detect tumors of melanocytic origin or to determine the level of gp100 expression in tumors prior to immunotherapy with the protein or one of its peptides.

A single-nucleotide polymorphism in the RAD51 gene modifies breast cancer risk in BRCA2 carriers, but not in BRCA1 carriers or noncarriers

Variation in the penetrance estimates for BRCA1 and BRCA2 mutation carriers suggests that other genetic polymorphisms may modify the cancer risk in carriers. The RAD51 gene, which participates in homologous recombination double-strand breaks (DSB) repair in the same pathway as the BRCA1 and BRCA2 gene products, is a candidate for such an effect. A single-nucleotide polymorphism (SNP), RAD51-135g → c, in the 5′ untranslated region of the gene has been found to elevate breast cancer (BC) risk among BRCA2 carriers. We genotyped 309 BRCA1/2 mutation carriers, of which 280 were of Ashkenazi origin, 166 noncarrier BC patients and 152 women unaffected with BC (a control group), for the RAD51-135g → c SNP. Risk analyses were conducted using COX proportional hazard models for the BRCA1/2 carriers and simple logistic regression analysis for the noncarrier case–control population. BRCA2 carriers were also studied using logistic regression and Kaplan–Meier survival analyses. The estimated BC hazard ratio (HR) for RAD51-135c carriers adjusted for origin (Ashkenazi vs non-Ashkenazi) was 1.28 (95% CI 0.85–1.90, P=0.23) for BRCA1/2 carriers, and 2.09 (95% CI 1.04–4.18, P=0.04) when the analysis was restricted to BRCA2 carriers. The median BC age was younger in BCRA2-RAD51-135c carriers (45 (95% CI 36–54) vs 52 years (95% CI 48–56), P=0.05). In a logistic regression analysis, the odds ratio (OR) was 5.49 (95% CI 0.5–58.8, P=0.163). In noncarrier BC cases, carrying RAD51-135c was not associated with BC risk (0.97; 95% CI 0.47–2.00). These results indicate significantly elevated risk for BC in carriers of BRCA2 mutations who also carry a RAD51-135c allele. In BRCA1 carriers and noncarriers, no effect for this SNP was found.

Targeting pulmonary metastases of renal cell carcinoma by inhalation of interleukin-2

INTRODUCTION

Pulmonary metastases of renal cell carcinoma (RCC) are associated with poor prognosis. Inhalation therapy with interleukin-2 (IL-2) is thus an appealing method for palliation. This multicenter study summarizes the national experience of IL-2 inhalation in patients with lung metastases of RCC.

PATIENTS AND METHODS

Forty patients (median, 66.5 years of age) with radiologically documented progressing pulmonary metastases were enrolled. All patients had to be able to comply with inhalation technique, and were not candidates for other treatment options. Twenty-eight patients were systemic treatment-naïve. The protocol included three daily inhalations of IL-2 to a total dose of 18 MU. Treatment had to be continued until one of the following occurred: progression; a complete response; a life threatening toxicity; or patient refusal. Response was assessed using the Response Evaluation Criteria in Solid Tumors (RECIST) system.

RESULTS

The disease-control rate reached 57.5%, with a partial response rate of 2.5% and a disease stabilization rate of 55%. Median time to progression was 8.7 months. The main side-effects were cough and weakness.

CONCLUSIONS

Inhalation of IL-2 for the treatment of pulmonary metastases in RCC is feasible, tolerable and beneficial in controlling progressive disease for considerable periods of time. The definition of response of biological therapy may need to be re-assessed and modified: stable disease should be regarded as a favorable response.

Interleukin-2 improves tumour response to DNP-modified autologous vaccine for the treatment of metastatic malignant melanoma

This paper is a report of response rate (RR) and survival of 34 metastatic melanoma patients who received a dinitrophenyl (DNP)-modified autologous melanoma cell vaccine. In all, 27 patients started the vaccine as a primary treatment for metastatic melanoma and seven started it as an adjuvant, with no evidence of disease at the time, but had developed new metastases. Interleukin-2 (IL-2) was administered in 24 out of the 34 patients: 19 who progressed on vaccine alone and five who had the combination from start. Interleukin-2 was administered in the intravenous, bolus high-dose regimen (seven patients) or as subcutaneous (s.c.) low-dose treatment (17). Overall response for the entire group was 35% (12 patients out of 34), 12% having a complete response (CR) and 23% a partial response (PR). However, only two patients had tumour responses while on the vaccine alone, whereas the other 10 demonstrated objective tumour regression following the combination with IL-2 (two CR, eight PR), lasting for a median duration of 6 months (range 3–50 months). Of the 12 responding patients, 11 attained strong skin reactivity to the s.c. injection of irradiated, unmodified autologous melanoma cells. None of the patients with a negative reactivity experienced any tumour response. Patients with positive skin reactions survived longer (median survival – 54 months). The results suggest enhanced RRs to the combination of IL-2 and autologous melanoma vaccine. Skin reactivity to unmodified autologous melanoma cells may be a predictor of response and improved survival, and therefore a criterion for further pursuing of immunotherapeutic strategies.

Population attributes affecting the prevalence of BRCA mutation carriers in epithelial ovarian cancer cases in israel

OBJECTIVE

The objective was to evaluate the prevalence of BRCA1/2 mutations in selected categories of ovarian cancer patients in Israel.

METHODS

Blood samples and specimens of ovarian tumors were obtained in the course of a national case control study of women with ovarian cancer in Israel. Eight hundred ninety-six patients with epithelial ovarian cancer, 40 cases with nonepithelial ovarian cancer, and 68 with primary peritoneal cancer were tested for the BRCA mutations. Analysis of the three common BRCA mutations in Israel (185delAG, 5382insC in BRCA1, and 6174delT in BRCA2) was done using a multiplex polymerase chain reaction assay. A multivariate logistic regression model was used to assess the association of mutation carrier status and other factors (age, origin, family history, and clinical variables).

RESULTS

Of the 779 invasive epithelial ovarian cancer cases, 29.4% were mutation carriers. The prevalence of the mutations was higher among women below age 60 and in more advanced cases. The prevalence was low in mucinous tumors. There was almost a twofold excess of mutations among women with positive family history (45.7%), but still 26.5% of the family history negative cases were carriers. As expected, we found a higher rate of mutation carriers among the Ashkenazi group (34.2%) and 55% among Ashkenazi women with positive family history. No subjects born in North Africa were mutation positive.

CONCLUSION

BRCA mutations are strongly associated with ovarian cancer and they are present in variable rates in distinct age, ethnic, and histopathologic categories.

Autologous cell vaccine as a post operative adjuvant treatment for high-risk melanoma patients (AJCC stages III and IV). The new American Joint Committee on Cancer

This study evaluates the overall survival and disease free survival of melanoma patients that were treated with an autologous melanoma cell vaccine, administered as a post-operative adjuvant. Included are 43 patients with totally resected metastatic melanoma (28-AJCC stage III, 15-AJCC stage IV), with a median follow up of 34 months (6-62). The treatment consisted of eight doses of a vaccine made of 10-25x10(6) autologous melanoma cells either released from the surgical specimen or grown in cell cultures. Tumour cells were conjugated with hapten dinitrophenyl, mixed with Bacille Calmette Guérin and irradiated to 110 Gy. Both disease free survival and overall survival were found to be correlated with intensity of evolving delayed type hypersensitivity to subcutaneous injection of unmodified melanoma cells. Patients with a delayed type hypersensitivity reaction of > or =10 mm had a median disease free survival of 17 months (mean 35 months) and a mean overall survival of 63 months (median not reached). In contrast, patients with a negative or weak delayed type hypersensitivity had a median disease free survival of 9 months (relative risk of recurrence=4.5, P=0.001), and a median overall survival of 16 months (relative risk of death=15, P=0.001). Stage III patients with a positive delayed type hypersensitivity reaction had an improved disease free survival of 16 months and a mean overall survival of 38 months, whereas patients with a negative delayed type hypersensitivity had a median disease free survival of 7 months (relative risk=4.5, P=0.02) and a median overall survival of 16 months (relative risk=9.5, P=0.005). The adjuvant administration of autologous melanoma vaccine was associated with improved disease-free and overall survival to selected patients who successfully attained anti-melanoma reactivity as detected by positive delayed type hypersensitivity reactions to unmodified melanoma cells.

Haplotype analysis of BRCA2 8765delAG mutation carriers in French Canadian and Yemenite Jewish hereditary breast cancer families

The BRCA2 8765delAG mutation was previously reported in hereditary breast cancer families of French Canadian and Yemenite Jewish descent. Haplotype analysis, using six microsatellite markers that span BRCA2 and two intragenic polymorphisms, was performed on 8765delAG mutation carriers to determine if there was evidence that the mutations were identical by descent. The alleles of the microsatellite markers most closely flanking BRCA2 (D13S1697 and D13S1701) were found to be identical in state in all the mutation carriers. However, the disease-associated allele of one of the intragenic markers differed between the Yemenite Jews and French Canadian families, indicating that the 8765delAG mutation has independent origins in these two geographically and ethnically distinct populations.

Psychological intervention in cancer patients: a randomized study

We examined the long-term effects of a behavioral intervention on the psychological distress of patients recently diagnosed with localized cancer, who were being treated at Hadassah University Hospital. All 116 patients who met the inclusion criteria (49 men and 67 women) were randomized into an intervention group and a control group on a 3:1 basis. The intervention chosen was Progressive Muscle Relaxation with Guided Imagery, which is intended to decrease psychological distress and increase the patient's sense of internal control. The Brief Symptom Inventory (BSI) and the Impact of Events Scale (IES) were used to assess psychological distress within 1 month of diagnosis, 3 months later (shortly before starting intervention), and 6 months after the end of the intervention. At the final assessment, the effect of the behavioral intervention on psychological distress was positive. The effect was relatively modest but statistically significant when assessed in terms of the Global Severity Index (GSI) (a decrease of 2.3 points in the GSI of the treatment group as compared to an increase of 1.2 points in the GSI of the control group P=.005). Despite these moderately positive findings, we suggest that the results might be more meaningful if cancer patients are first screened for psychological distress to exclude those with a low distress level that does not justify intervention, and only then randomized for participation in the study.

CAG and GGC repeat polymorphisms in the androgen receptor gene and breast cancer susceptibility in BRCA1/2 carriers and non-carriers

Variation in the penetrance estimates for BRCA1 and BRCA2 mutations carriers suggests that other genetic polymorphisms may modify the cancer risk in carriers. A previous study has suggested that BRCA1 carriers with longer lengths of the CAG repeat in the androgen receptor (AR) gene are at increased risk of breast cancer (BC). We genotyped 188 BRCA1/2 carriers (122 affected and 66 unaffected with breast cancer), 158 of them of Ashkenazi origin, 166 BC cases without BRCA1/2 mutations and 156 Ashkenazi control individuals aged over 56 for the AR CAG and GGC repeats. In carriers, risk analyses were conducted using a variant of the log-rank test, assuming two sets of risk estimates in carriers: penetrance estimates based on the Breast Cancer Linkage Consortium (BCLC) studies of multiple case families, and lower estimates as suggested by population-based studies. We found no association of the CAG and GGC repeats with BC risk in either BRCA1/2 carriers or in the general population. Assuming BRCA1/2 penetrance estimates appropriate to the Ashkenazi population, the estimated RR per repeat adjusted for ethnic group (Ashkenazi and non-Ashkenazi) was 1.05 (95%CI 0.97-1.17) for BC and 1.00 (95%CI 0.83-1.20) for ovarian cancer (OC) for CAG repeats and 0.96 (95%CI 0.80-1.15) and 0.90 (95%CI 0.60-1.22) respectively for GGC repeats. The corresponding RR estimates for the unselected case-control series were 1.00 (95%CI 0.91-1.10) for the CAG and 1.05 (95%CI 0.90-1.22) for the GGC repeats. The estimated relative risk of BC in carriers associated with > or =28 CAG repeats was 1.08 (95%CI 0.45-2.61). Furthermore, no significant association was found if attention was restricted to the Ashkenazi carriers, or only to BRCA1 or BRCA2 carriers. We conclude that, in contrast to previous observations, if there is any effect of the AR repeat length on BRCA1 penetrance, it is likely to be weak.