Recent advances and current controversies in the management of DCIS of the breast

Surgical De-Escalation for Re-Excision in Patients with a Margin Less Than 2 mm and a Diagnosis of DCIS

The current surgical guidelines recommend an optimal margin width of 2 mm for the management of patients diagnosed with ductal carcinoma in situ (DCIS). However, there are still many controversies regarding re-excision when the optimal margin criteria are not met in the first resection. The purpose of this study is to understand the importance of surgical margin width, re-excision, and treatments to avoid additional surgery on locoregional recurrence (LRR). The study is retrospective and analyzed surgical margins, adjuvant treatments, re-excision, and LRR in patients with DCIS who underwent breast-conserving surgery (BCS). A total of 197 patients were enrolled. Re-operation for a close margin rate was 13.5%, and the 3-year recurrence was 7.6%. No difference in the LRR was reported among the patients subjected to BCS regardless of the margin width (p = 0.295). The recurrence rate according to margin status was not significant (p = 0.484). Approximately 36.9% (n: 79) patients had resection margins < 2 mm. A sub-analysis of patients with margins < 2 mm showed no difference in the recurrence between the patients treated with a second surgery and those treated with radiation (p = 0.091). The recurrence rate according to margin status in patients with margins < 2 mm was not significant (p = 0.161). The margin was not a predictive factor of LRR p = 0.999. Surgical re-excision should be avoided in patients with a focally positive margin and no evidence of the disease at post-surgical imaging.

Revisiting surgical management of breast cancer in a geriatric population

OBJECTIVE

Breast cancer is a leading cause of death not only in the young population but also in the elderly. There are no consensus treatment guidelines for elderly breast cancer patients. We purposed to discuss surgical treatment options for breast cancer cases over 80 years concerning morbidity and mortality.

METHODS

This retrospective study includes 58 patients over 80 years of age at the time of surgery for breast cancer between 2006 and 2017. A sum of 58 cases (54 females and 4 males), over 80 years of age, with an average age of 84.5±4.07 (80-94) years were included in the study. The modified radical mastectomy was the most common surgical modality in 30 (51.7%) cases, and the axillary intervention was performed on 41 (70.7%). Axillary dissection and sentinel lymph node biopsy were performed for 30 (51.7%) and 11 (18.9%) cases, respectively.

RESULTS

Minor and major complications were observed in 8 (13.8%) cases. The average follow-up period of the patients was 37.5 (1-120) months. During the follow-up period, breast cancer-related mortality was observed in 9 (15.52%) cases. No statistical differences were detected in mortality with/without axillary intervention and chosen surgical modality.

CONCLUSIONS

Comorbidity, the American Society of Anesthesiologists score, and life expectancy should be considered in the management and surgical planning of patients over 80 years of age with breast cancer. Minimally invasive approaches should be preferred for the elderly whenever feasible and applicable in the light of oncologic surgery principles in order to reduce complications and mortality rates.

The significance of dual-mode elastography in the diagnosis of breast lesions by physicians with different levels of experience

BACKGROUND

This study aimed to assess the diagnostic value of dual-mode elastography for benign and malignant breast lesions and determine whether this technique can improve the diagnostic ability of physicians with different levels of experience.

METHODS

One hundred and eighty-three breast lesions were analyzed retrospectively, and the following values were calculated for the lesions with various shells: shear modulus (G), Young's modulus (E), shear wave velocity (Cs), and strain ratio (SR). A random forest algorithm was used to select the optimal modes for elastography. A receiver operating characteristic curve was used to assess the diagnostic efficacy for benign and malignant breast lesions. Sensitivity and specificity values were calculated to evaluate any improvements in the diagnostic efficacy of physicians with different levels of experience (junior, intermediate-level, and senior) in the evaluation of malignant breast lesions using dual-mode elastography.

RESULTS

The best-performing mode of shear wave elastography (SWE) in the diagnosis of breast lesions was the A'min 1.0 (Cs) mode (minimum shear wave velocity of the area of interest and 1.0 mm around the area of interest), and the best-performing mode of strain elastography (SE) was the B/A' 0.5 (ratio of fat to the elasticity of the area of interest and 0.5 mm around the area of interest). When the two methods were used in series, results showed high specificity (98%), positive likelihood ratio (PLR) (21.2), and positive predictive value (PPV) (95%). Series means that if SE and SWE were malignant, the result in series was malignant, and that if either SE or SWE was benign, the result in series was benign. When the methods were used in parallel, the results showed high sensitivity (91%), negative likelihood ratio (NLR) (0.15), and negative predictive value (NPV) (89%). Parallel means that if SE and SWE were benign, the result in parallel was benign, and that if either SE or SWE was malignant, the result in parallel was malignant. When conventional ultrasound was combined with dual-mode elastography, the intermediate-level and junior physicians' diagnoses of breast lesions showed a higher sensitivity, specificity, and area under the curve than conventional ultrasound diagnosis alone.

CONCLUSIONS

Dual-mode elastography is effective in the diagnosis of breast lesions. The sensitivity and specificity values in this study show that diagnoses made by junior and intermediate-level physicians improve when dual-mode elastography is used, although diagnoses made by senior physicians do not improve significantly.

Mammary Development and Breast Cancer: a Notch Perspective

Mammary gland development primarily occurs postnatally, and this unique process is complex and regulated by systemic hormones and local growth factors. The mammary gland is also a highly dynamic organ that undergoes profound changes at puberty and during the reproductive cycle. These changes are driven by mammary stem cells (MaSCs). Breast cancer is one of the most common causes of cancer-related death in women. Cancer stem cells (CSCs) play prominent roles in tumor initiation, drug resistance, tumor recurrence, and metastasis. The highly conserved Notch signaling pathway functions as a key regulator of the niche mediating mammary organogenesis and breast neoplasia. In this review, we discuss mechanisms by which Notch contributes to breast carcinoma pathology and suggest potentials for therapeutic targeting of Notch in breast cancer. In summary, we provide a comprehensive overview of Notch functions in regulating MaSCs, mammary development, and breast cancer.

Surgical management of ductal carcinoma in situ of the breast: A large retrospective study from a single institution

BACKGROUND

Management of breast ductal carcinoma in situ (DCIS) has various approaches with distinct institutional specific practice. Here, we review DCIS management in a single institution with emphasize on re-operation rates and outcome.

METHODS

Breast ductal carcinoma in situ cases diagnosed at the Nottingham Breast Institute between 1987 and 2017 were identified (n = 1249). Clinicopathological data were collected. Cases were histologically reviewed, and different factors associated with primary operation selection, re-excision, presence of residual tumor in the re-excision specimens, use of radiotherapy and ipsilateral recurrences were analyzed.

RESULTS

34% of DCIS patients were initially treated by mastectomy and were more frequently symptomatic, of high nuclear tumor grade, size >40 mm, and associated with comedo necrosis and Paget's disease of the nipple. Further surgery was due to involved or narrow surgical margins. Residual tumor tissue was detected in 53% of the re-excision specimens. Re-excision rates of patients treated with breast-conserving surgery (BCS) were reduced from approximately 70% to 23%, and the final mastectomy rates decreased from 60% to 20%. Changes in surgical practice with acceptance of smaller excision margins and more frequent use of local radiotherapy have led to a significant decrease not only in the re-excision rate but also in the final mastectomy rate together with non-significant reduction in 5- and 10-year local recurrence rates.

CONCLUSION

Although BCS is increasingly the preferred primary surgical option for DCIS management, a proportion of low-risk DCIS patients continue to undergo re-excision surgery or completion mastectomy. Despite acceptance of smaller margins, recurrence rate is decreasing.

Accuracy of Breast Magnetic Resonance Imaging Compared to Mammography in the Preoperative Detection and Measurement of Pure Ductal Carcinoma In Situ: A Retrospective Analysis

RATIONALE AND OBJECTIVES

Ductal carcinoma in situ (DCIS) hinders imaging detection due to multifocal appearance and discontinuous growth. Preoperative determination of its extent is therefore challenging. Aim of this study was to investigate the additional benefit of breast magnetic resonance imaging (MRI) to mammography (MG) in the diagnosis of DCIS according to size and grading.

MATERIALS AND METHODS

Retrospective analysis of 295 patients with biopsy-proven, pure DCIS. Mean patient age was 57.0 years (27-87 years). All patients obtained MG. Additional MRI was performed in 41.7% (123/295). Mammographic breast density, background parenchymal enhancement (BPE), tumor size and grading were analysed. Tumor size on MG and MRI were compared to histopathological size of the surgical specimen.

RESULTS

Mean tumor size was 39.6 mm. DCIS was occult on MG in 24.4% (30/123) and on MRI in 1.6% (2/123). Size was underestimated by 4.6 mm (mean) mammographically. DCIS was high grade in 54.5% (67/123), intermediate grade in 40.7% (50/123) and low grade in 4.9% (6/123). MG was exact regarding tumor size in low grade DCIS, underestimated intermediate grade DCIS by 1 mm (median) and high grade DCIS by 10.5 mm. MRI overestimated low grade DCIS by 1 mm (median), was exact regarding intermediate grade DCIS and underestimated high grade DCIS by 1 mm. BPE did not influence tumor detection and measurement.

CONCLUSION

MRI outperforms MG in the detection and size estimation of DCIS and can reduce positive margin rates.

Improved synergetic therapy efficiency of cryoablation and nanoparticles for MCF-7 breast cancer

AIM

Current cryoablation therapy easily induces a high tumor recurrence, it is therefore necessary to develop an effective method to enhance its antitumor efficacy.

MATERIALS & METHODS

We solve the aforementioned problem by introducing doxorubicin (DOX) loading methoxy polyethylene glycol-polylactic-co-glycolic acid-poly-L-lysine-cyclic arginine-glycine-aspartic acid peptide nanoparticles (DOX nanoparticles) in the process of cryoablation.

RESULTS

The combination of cryoablation and DOX nanoparticles greatly decreases the recurrence rate of breast cancer, which is owing to the specific targeting therapy of DOX nanoparticles for residuary breast cancer cells after cryoablation. Therefore, the survival time of MCF-7 breast cancer bearing mice significantly increases.

CONCLUSION

The synergetic therapy of cryoablation and DOX nanoparticles is an effective therapy means for breast cancer. This strategy provides new means for treating breast cancer.

Value of shear wave elastography in discriminating malignant and benign breast lesions: A meta-analysis

The analysis was aimed to evaluate the diagnostic accuracy of shear wave elastography (SWE) for malignant breast lesions through a meta-analysis.Related articles were searched from Pubmed, Embase, and Cochrane library. Overall sensitivity and specificity were analyzed with DerSimonian and Laird random effects model. Area under curve with corresponding 95% confidence interval (were calculated to evaluate the diagnostic accuracy of SWE. Sensitivity and publication bias were assessed as well.A total of 25 articles including 4128 patients and 4546 breast lesions were included in the pooled analysis. In the subgroup analysis, diagnostic sensitivity and specificity of SWE in Asian population were 0.84 (0.79-0.88) and 0.87 (0.84-0.90), respectively, whereas they were 0.92 (0.86-0.96) and 0.89 (0.84-0.92) in Caucasian population. The diagnostic accuracy of SWE was a little higher for Caucasians than for Asians (0.95 vs. 0.92). The diagnostic sensitivity and specificity of virtual touch tissue quantification were 0.85 (0.77-0.91) and 0.93 (0.88-0.96), respectively. It showed a little higher value in specificity and summary ROC curve than SWE (0.93 vs. 0.87; 0.95 vs. 0.93). In addition, maximum stiffness exhibited higher detection sensitivity than that of mean stiffness (0.91 vs. 0.85).SWE serves as an accurate diagnostic technology for discriminating between malignant and benign breast lesions.

Benign and malignant breast lesions identification through the values derived from shear wave elastography: evidence for the meta-analysis

Objective

The analysis was aimed to evaluate the diagnostic accuracy of shear wave elastography (SWE) for malignant breast lesions through a meta-analysis.

Materials and Methods

Related articles were searched in databases of Pubmed, Embase and Cochrane library. Overall sensitivity and specificity were analyzed with DerSimonian and Laird random effects model. Area under curve (AUC) with corresponding 95% confidence interval were also analyzed to evaluate the diagnostic accuracy of SWE. P value < 0.05 predicted the significant heterogeneity between study. Sensitivity and publication bias were assessed as well.

Results

According to the inclusion criteria, 25 articles were selected. In the subgroup analysis, diagnostic sensitivity and specificity of SWE in Asian population were 0.84 (0.79-0.88) and 0.87 (0.84-0.90), respectively, while they were 0.92 (0.86-0.96) and 0.89 (0.84-0.92) in Caucasian population. The diagnostic accuracy of SWE was a little higher for Caucasians than for Asians (0.95 vs. 0.92). The diagnostic sensitivity and specificity of virtual touch tissue quantification (VTTQ) were 0.85 (0.77-0.91) and 0.93 (0.88-0.96), respectively. It showed a little higher value in specificity and summary receiver operating curve (sROC) than that of SWE (0.93 vs. 0.87; 0.95 vs. 0.93). In addition, maximum stiffness exhibited higher detection sensitivity than that of mean stiffness (0.91 vs. 0.85).

Conclusions

SWE serves as an accurate diagnostic technology for discriminating malignant and benign breast lesions.

Docking of CDK1 with antibiotic drugs revealed novel therapeutic value in breast ductal cancer in situ

The aim of our research is to identify potential genes associated with Ductal carcinoma in situ (DCIS) through microarrays. The microarray dataset GS54665 were downloaded from the GEO(Gene Expression Omnibus) database. Dysregulated genes were screened and their associations with DCIS was analyzed by comprehensive bioinformatics tools. A total of 649 differential expression genes were identified between normal and DCIS samples, including 224 up-regulated genes and 425 down-regulated genes. Biological process annotation and pathway enrichment analysis identified several DCIS-related signaling pathways. Finally, PPI network was constructed with String website in order to get the hub codes involved in Ductal carcinoma in situ. We thus concluded that Five genes: CDK1, CCNB2, MAD2L1, PPARG, ACACB were finally identified to participate in the regulation and serve as potential diagnosis signatures in in Ductal carcinoma in situ. Finally, complmentarity between CDK1 and three drugs, Aminophenazone, Pomalidomide and the Rosoxacin, implies novel pharmacological value of those drugs in breast cancer.

Factors influencing local control in patients undergoing breast conservation surgery for ductal carcinoma in situ

BACKGROUND

The aim of our study was to assess various predictors for local recurrence (LR) in patients undergoing breast conservation surgery (BCS) for ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

An audit was performed of 582 consecutive patients with DCIS between Jan 1975 to June 2008. In patients undergoing BCS, local guidelines reported a margin of ≥10 mm during the above period. Guideline with regard to margin of excision changes soon after this period. We retrospectively analysed clinical and pathological risk factors for local recurrence in patients undergoing BCS. Statistical analysis was carried out using SPSS version 19, and a cox regression model for multivariate analysis of local recurrence was used.

RESULTS

Overall 239 women had BCS for DCIS during the above period. The actuarial 5-year recurrence rate was 9.6%. The overall LR rate was 17% (40/239. LR was more common in patients ≤50 years: (10/31 patients, 32%) compared to patients > 50 years (30/208, 14%, P = 0.02). Forty three per cent of patients (6/14) with <5 mm margin developed LR which was significantly higher compared to patients with 5-9 mm margin (12%, 3/25) and with ≥10 mm margin (14%, 27/188, P = 0.01). On multivariate analysis age ≤50 years, <5 mm pathological margin were independent prognostic factors for local recurrence.

CONCLUSION

Our study shows that younger age (≤50 years) and a margin < 5 mm are poor prognostic factors for LR in patients undergoing breast conservation surgery for DCIS.

Design and synthesis of pyrimidinyl acyl thioureas as novel Hsp90 inhibitors in invasive ductal breast cancer and its bone metastasis

Invasive ductal carcinoma is the most common breast malignancies tumors and has tendency to bone metastases. Many oncogenic client proteins involved in formation of metastatic pathways. Stabilization, regulation, and maintenance of these oncogenic client proteins are provided with Heat Shock Protein 90 (Hsp90). Hsp90 perform these processes through its ATP binding and subsequent hydrolysis energy. Therefore, designing Hsp90 inhibitors is a novel cancer treatment method. However, many Hsp90 inhibitors have solubility problems and showed adverse effects in clinical trials. Thus, we designed and synthesized novel pyrimidinyl acyl thiourea derivatives to selectively inhibit Hsp90 alpha in human invasive ductal breast (MCF-7) and human bone osteosarcoma (Saos-2) cell lines. In vitro experiments showed that the compounds inhibited cell proliferation, ATP hydrolysis, and exhibited cytotoxic effect on these cancer cell lines. Further, gene expression was analyzed by microarray studies on MCF-7 cell lines. Several genes that play vital roles in breast cancer pathogenesis displayed altered gene expression in the presence of a selected pyrimidinyl acyl thiourea compound. Molecular docking studies were also performed to determine interaction between Hsp90 ATPase domain and pyrimidinyl acyl thiourea derivatives. The results indicated that the compounds are able to interact with Hsp90 ATP binding pocket and inhibit ATPase function. The designed compounds powerfully inhibit Hsp90 by an average of 1 μM inhibition constant. And further, the compounds perturb Hsp90 N terminal domain proper orientation and ATP may not provide required conformational change for Hsp90 function as evidenced by in silico experiments. Therefore, the designed compounds effectively inhibited both invasive ductal breast carcinoma and bone metastasis. Pyrimidinyl acyl thiourea derivatives may provide a drug template for effective treatment of invasive ductal breast carcinoma and its bone metastasis as well as new therapeutic perspective for drug design.

Breast Ductal Carcinoma In Situ: A Literature Review of Adjuvant Hormonal Therapy

This review paper analyzed publications of adjuvant tamoxifen and aromatase inhibitor use following surgery for breast ductal carcinoma in situ (DCIS). Key endpoint analyses were risk of invasive and noninvasive malignancies and new contralateral breast cancers. Metaanalysis of three studies showed a relative risk of 0.69 (95% confidence interval, 0.60-0.79, P<0.05) for breast malignancies with tamoxifen treatment in a mixed radiotherapy treatment/naïve cohort. Subgroup analysis of DCIS populations in multiple studies showed a trend to benefit with aromatase inhibitor treatment.

Effect of radiotherapy on survival of women with locally excised ductal carcinoma in situ of the breast: a Surveillance, Epidemiology, and End Results population-based analysis

BACKGROUND

Although it has been previously reported that radiotherapy (RT) effectively reduced the incidence of local recurrence of ductal carcinoma in situ (DCIS) following breast-conserving surgery (BCS), little is known about the effect of RT on survival of patients with locally excised DCIS.

PATIENTS AND METHODS

Using Surveillance, Epidemiology, and End Results registry data, we selected 56,968 female DCIS patients treated with BCS between 1998 and 2007. Overall survival (OS) and breast cancer-specific survival (BCSS) were compared among patients who received RT or no RT using the Kaplan-Meier methods and Cox proportional hazards regression models.

RESULTS

Median follow-up was 91 months. In the multivariable model, patients receiving postoperative RT had better OS than those undergoing BCS alone (hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.53-0.67, P<0.001). This pattern remained after stratification by estrogen receptor (ER) status and age. In contrast, RT delivery was not significantly associated with improved BCSS (HR 0.71, 95% CI 0.48-1.03, P=0.073). However, after stratifying by the above two variables, RT contributed to better BCSS in ER-negative/borderline patients (HR 0.41, 95% CI 0.19-0.88, P=0.023) and younger patients (≤50 years old; HR 0.37, 95% CI 0.15-0.91, P=0.030).

CONCLUSION

Our analysis confirms the beneficial effect of RT on OS in women with locally excised DCIS and reveals the specific protective effect of RT on BCSS in ER-negative/borderline and younger patients.

A potential role for human UDP-glucuronosyltransferase 1A4 promoter single nucleotide polymorphisms in the pharmacogenomics of tamoxifen and its derivatives

Tamoxifen (Tam) is a selective estrogen receptor modulator used to inhibit breast tumor growth. Tam can be directly N-glucuronidated via the tertiary amine group or O-glucuronidated after cytochrome P450-mediated hydroxylation. In this study, the glucuronidation of Tam and its hydroxylated and/or chlorinated derivatives [4-hydroxytamoxifen (4OHTam), toremifene (Tor), and 4-hydroxytoremifene (4OHTor)] was examined using recombinant human UDP-glucuronosyltransferases (UGTs) from the 1A subfamily and human hepatic microsomes. Recombinant UGT1A4 catalyzed the formation of N-glucuronides of Tam and its derivatives and was the most active UGT enzyme toward these compounds. Therefore, it was hypothesized that single nucleotide polymorphisms (SNPs) in the promoter region of UGT1A4 have the ability to significantly decrease the glucuronidation rates of Tam metabolites in the human liver. In vitro activity of 64 genotyped human liver microsomes was used to determine the association between the UGT1A4 promoter and coding region SNPs and the glucuronidation rates of Tam, 4OHTam, Tor, and 4OHTor. Significant decreases in enzymatic activity were observed in microsomes for individuals heterozygous for -163G/A and -217T/G. These alterations in glucuronidation may lead to prolonged circulating half-lives and may potentially modify the effectiveness of these drugs in the treatment of breast cancer.

Effect of low-dose tamoxifen after surgical excision of ductal intraepithelial neoplasia: results of a large retrospective monoinstitutional cohort study

BACKGROUND

Postsurgical treatment of ductal intraepithelial neoplasia (DIN) with standard doses of tamoxifen has not reached a consensus yet. Given positive results of low-dose tamoxifen on breast cancer biomarkers modulation, we analyzed a large cohort of DIN patients treated with low-dose tamoxifen or no treatment as per institutional guidelines.

PATIENTS AND METHODS

All consecutive women operated on at the European Institute of Oncology for estrogen receptor (ER)-positive DIN (474 treated with low-dose tamoxifen and 509 untreated patients) were followed up for a median of 7 years.

RESULTS

Compared with untreated patients, a significant 30% reduction in breast cancer risk was observed on low-dose tamoxifen with an adjusted hazard ratio (HR) = 0.70 [95% confidence interval (CI) 0.51-0.94], with a greater benefit in postmenopausal (HR = 0.57; 95% CI 0.34-0.94) than in premenopausal women (HR = 0.79; 95% CI 0.54-1.17). Treated patients with ER and progesterone receptor (PgR) >50% DIN had a lower incidence of breast events than untreated ones (HR = 0.61; 95% CI 0.40-0.94), whereas no protective effect has been observed in patients with ER or PgR <50% DIN. Drug discontinuation resulted in a doubled risk of recurrence in premenopausal women only (HR = 1.95; 95% CI 0.98-3.89). No excess of endometrial cancer occurred.

CONCLUSIONS

Low-dose tamoxifen is a promising and safe strategy for highly endocrine responsive DIN. Treatment adherence is crucial in premenopausal women. A definitive trial is ongoing.

Combined inhibition of ErbB1/2 and Notch receptors effectively targets breast ductal carcinoma in situ (DCIS) stem/progenitor cell activity regardless of ErbB2 status

Pathways involved in DCIS stem and progenitor signalling are poorly understood yet are critical to understand DCIS biology and to develop new therapies. Notch and ErbB1/2 receptor signalling cross talk has been demonstrated in invasive breast cancer, but their role in DCIS stem and progenitor cells has not been investigated. We have utilised 2 DCIS cell lines, MCF10DCIS.com (ErbB2-normal) and SUM225 (ErbB2-overexpressing) and 7 human primary DCIS samples were cultured in 3D matrigel and as mammospheres in the presence, absence or combination of the Notch inhibitor, DAPT, and ErbB1/2 inhibitors, lapatinib or gefitinib. Western blotting was applied to assess downstream signalling. In this study we demonstrate that DAPT reduced acini size and mammosphere formation in MCF10DCIS.com whereas there was no effect in SUM225. Lapatinb reduced acini size and mammosphere formation in SUM225, whereas mammosphere formation and Notch1 activity were increased in MCF10DCIS.com. Combined DAPT/lapatinib treatment was more effective at reducing acini size in both DCIS cell lines. Mammosphere formation in cell lines and human primary DCIS was reduced further by DAPT/lapatinib or DAPT/gefitinib regardless of ErbB2 receptor status. Our pre-clinical human models of DCIS demonstrate that Notch and ErbB1/2 both play a role in DCIS acini growth and stem cell activity. We report for the first time that cross talk between the two pathways in DCIS occurs regardless of ErbB2 receptor status and inhibition of Notch and ErbB1/2 was more efficacious than either alone. These data provide further understanding of DCIS biology and suggest treatment strategies combining Notch and ErbB1/2 inhibitors should be investigated regardless of ErbB2 receptor status.

RNA-Seq of human breast ductal carcinoma in situ models reveals aldehyde dehydrogenase isoform 5A1 as a novel potential target

Breast ductal carcinoma in situ (DCIS) is being found in great numbers of women due to the widespread use of mammography. To increase knowledge of DCIS, we determined the expression changes that are common among three DCIS models (MCF10.DCIS, SUM102 and SUM225) compared to the MCF10A model of non-tumorigenic mammary epithelial cells in three dimensional (3D) overlay culture with reconstituted basement membrane (rBM). Extracted mRNA was subjected to 76 cycles of deep sequencing (RNA-Seq) using Illumina Genome Analyzer GAIIx. Analysis of RNA-Seq results showed 295 consistently differentially expressed transcripts in the DCIS models. These differentially expressed genes encode proteins that are associated with a number of signaling pathways such as integrin, fibroblast growth factor and TGFβ signaling, show association with cell-cell signaling, cell-cell adhesion and cell proliferation, and have a notable bias toward localization in the extracellular and plasma membrane compartments. RNA-Seq data was validated by quantitative real-time PCR of selected differentially expressed genes. Aldehyde dehydrogenase 5A1 (ALDH5A1) which is an enzyme that is involved in mitochondrial glutamate metabolism, was over-expressed in all three DCIS models at both the mRNA and protein levels. Disulfiram and valproic acid are known to inhibit ALDH5A1 and are safe for chronic use in humans for other disorders. Both of these drugs significantly inhibited net proliferation of the DCIS 3D rBM overlay models, but had minimal effect on MCF10A 3D rBM overlay models. These results suggest that ALDH5A1 may play an important role in DCIS and potentially serve as a novel molecular therapeutic target.

Choices in surgery for older women with breast cancer

Breast cancer is a major cause of mortality worldwide. As the population ages and life expectancy increases, the burden of cancer on health services will increase. Older patients with breast cancer are becoming more suitable for surgery; tailored surgical techniques and increasing healthy life expectancy alongside improved assessment of patients are aiding this trend. Surgery is also becoming a favoured treatment of personal choice for older patient with breast cancer. Evidence shows that surgery is almost always feasible for the older patient with outcomes (survival, progression, and recurrence rates) comparable to younger groups and superior to non-surgical treatments. We aim to describe the current status of surgery for the older patient with breast cancer, showing it is an option that should not be denied. Surgery should always be considered regardless of age, after evaluation of co-morbidities.

MRI of the breast in patients with DCIS to exclude the presence of invasive disease

OBJECTIVES

Core biopsy underestimates invasion in more than 20% of patients with preoperatively diagnosed ductal carcinoma in situ (DCIS) without evidence of invasion (pure DCIS). The aim of the current study was to evaluate the efficacy of preoperative magnetic resonance imaging (MRI) to discriminate between patients with DCIS who are at high risk of invasive breast cancer and patients at low risk.

METHODS

One hundred and twenty-five patients, preoperatively diagnosed with pure DCIS (128 lesions; 3 bilateral) by core-needle biopsy, were prospectively included. Clinical, mammographic, histological (core biopsy) and MRI features were assessed. All patients underwent breast surgery. Analyses were performed to identify features associated with presence of invasion.

RESULTS

Eighteen lesions (14.1%) showed invasion on final histology. Seventy-three lesions (57%) showed suspicious enhancement on MRI with a type 1 (n = 12, 16.4%), type 2 (n = 19, 26.0%) or type 3 curve, respectively (n = 42, 57.5%). At multivariate analysis, the most predictive features for excluding presence of invasive disease were absence of enhancement or a type 1 curve on MRI (negative predictive value 98.5%; A(Z) 0.80, P = 0.00006).

CONCLUSION

Contrast medium uptake kinetics at MRI provide high negative predictive value to exclude presence of invasion and may be useful in primary surgical planning in patients with a preoperative diagnosis of pure DCIS.

KEY POINTS

It is important to determine invasion in breast DCIS. • MRI contrast medium uptake kinetics can help exclude the presence of invasion. • However, the positive predictive value for the presence of invasion is limited. • MRI features were more accurate at predicting invasion than mammographic features alone.

Progression of ductal carcinoma in situ to invasive breast cancer is associated with gene expression programs of EMT and myoepithelia

Ductal carcinoma in situ (DCIS) is a precursor lesion that can gives rise to invasive breast cancer (IBC). It has been proposed that both the nature of the lesion and the tumor microenvironment play key roles in progression to IBC. Here, laser capture microdissected tissue from pure DCIS and pure IBC were employed to define key gene expression profiles in either the epithelial or stromal compartment associated with disease progression. Each tissue had distinct gene expression profiles, and a DCIS/IBC classifier accurately distinguished DCIS versus IBC in multiple independent data sets. However, contrary to other studies that profiled DCIS associated with invasive disease, we found that the most significant alterations in gene expression were observed in the epithelial compartment rather than in the stroma. In particular, genes associated with epithelial-to-mesenchymal transition and myoepithelial cell-specific genes were enriched in invasive cancer relative to pure DCIS. Such alterations in transcript levels were associated with all subtypes of breast cancer, but were particularly indicative of poor outcome in ER-negative breast cancer. Together, these studies indicate that lesion-specific differences in gene expression associated with invasive phenotype are particularly relevant in the progression of DCIS to invasive breast cancer.

Comparative analysis of loss of heterozygosity and expression profile in normal tissue, DCIS and invasive breast cancer

INTRODUCTION

Ductal carcinoma in situ (DCIS) is considered to be related to the development of invasive breast cancer. The aim of molecular biological research of preinvasive breast lesion characteristics and comparison with normal tissues and tissue of invasive tumours is to identify patients at high risk of developing invasive tumour on the basis of already established preinvasive lesions, and thus influence clinical decision-making. The aim of our study was to analyse several key molecules involved in different cellular pathways important for cancer development and progression in different types of breast tissue and to describe similarities and differences between premalignant and malignant lesions.

MATERIAL AND METHODS

Genetic material isolated from both the tumour and healthy tissue was examined by loss of heterozygosity (LOH) analysis and real-time PCR using collagen 2A as a house-keeping gene.

RESULTS

We analysed 65 samples of healthy mammary gland, 25 DCIS and 42 invasive ductal breast cancer samples. We analysed the LOH in three genes: BRCA1, BRCA2 and p53; and the gene expression of the VEGF gene and Bcl-2 gene. LOH in the BRCA1 gene was present in 44.74% of invasive samples and in 8.69% of DCIS (p=0.026); LOH in the BRCA2 gene in 45.0% of invasive samples and in 9.52% of DCIS (p=0.036); LOH in the p53 gene in 32.5% of invasive samples and in 31.82% of DCIS (p=0.97). No LOH was observed in normal tissue samples. VEGF was overexpressed in 14.3% of invasive cancers and in 12.0% of DCIS. Overexpression of Bcl-2 was observed in 11.9% of invasive cancers and in 8.0% of DCIS.

CONCLUSION

We have confirmed that some of the molecular characteristics of DCIS are identical to those of invasive carcinoma. This approach could lead to the identification of molecular markers as indicators for the potential development of DCIS into invasive carcinoma or identification of DCIS subgroups with latent invasion.

Clinical applications of sentinel lymph node biopsy in ductal carcinoma in situ of the breast: a dilemma

Breast cancer is the fifth most common cause of cancer deaths in the world, which often spreads first to the axillary lymph nodes (ALN) from the primary tumor. ALN helps clinician stage breast cancer. In addition, it is one of the key prognostic factors for patients with invasive breast cancer. The sentinel lymph node (SLN) is defined as the first regional lymph node to receive lymphatic fluid from a malignant tumor. As a result, it seems possible to assess the complete nodal status with sentinel lymph node biopsy (SLNB), which is attractive and reliable approach for identifying lymph node metastasis. Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. However, the role of SLNB in DCIS is controversial because DCIS does not cause invasion and metastasis theoretically. In this review, clinical applications of SLNB in DCIS will be discussed. The potential benefit of accurately upstaging patients with DCIS and the minimal invasiveness of SLNB justify use of SLNB in selected high-risk DCIS patients. At least DSIS with microinvasion, have DCIS of sufficient extent on mammography or MRI, or indicated invasive or microinvasive focus by final histological examination, are recommended for SLNB. Moreover, large randomized trials to evaluate the usefulness of SLNB in DCIS patients after long-term follow-up on local control and survival are required for further evaluation.

Association of RB/p16-pathway perturbations with DCIS recurrence: dependence on tumor versus tissue microenvironment

The prevalence of ductal carcinoma in situ (DCIS) diagnoses has significantly increased as a result of active radiographic screening. Surgical resection and hormone and radiation therapies are effective treatments, but not all DCIS will progress to invasive breast cancer. Therefore, markers are needed to define tumors at low risk of recurrence and progression that can be treated by surgery alone rather than by adjuvant therapies. Initial analyses indicate that retinoblastoma (RB)-pathway perturbations occur at high frequency in DCIS and mirror the molecular alterations observed in invasive breast cancer. Particularly, the elevated expression of p16ink4a in DCIS was associated with loss of RB function and estrogen receptor-negative biology. Furthermore, high expression of p16ink4a in conjunction with Ki-67 was associated with increased risk of DCIS recurrence and progression to invasive disease in multivariate analyses. These data are consistent with a functional role for RB in modulating the invasive behavior of mammary epithelial cells. The tissue microenvironment is particularly relevant to the behavior of DCIS, and, surprisingly, elevated expression of p16ink4a in nonproliferative stroma was observed in a substantial fraction of cases. In this tissue compartment, p16ink4a expression was strongly associated with disease recurrence, independent of standard histopathologic features. Together, the data herein describe dual aspects of RB-pathway biology that are associated with disease recurrence through the epithelial or stromal compartment of DCIS.

KX-01, a novel Src kinase inhibitor directed toward the peptide substrate site, synergizes with tamoxifen in estrogen receptor α positive breast cancer

KX-01 is the first clinical Src inhibitor of the novel peptidomimetic class that targets the peptide substrate site of Src providing more specificity toward Src kinase. The present study was designed to evaluate the effects of KX-01 as a single agent and in combination with tamoxifen (TAM) on cell growth and apoptosis of ERα positive breast cancer in vitro and in vivo. Flow cytometry demonstrated that KX-01 induced cell cycle arrest in G2/M phase. Immunofluorescent staining for mitotic phase markers and TUNEL staining indicated that cells had arrested in the mitotic phase and mitotic arrested cells were undergoing apoptosis. KX-01 induced nuclear accumulation of cyclin B1, and activation of CDK1, MPM2, and Cdc25C that is required for progression past the G2/M checkpoint. Apoptosis resulted from activation of caspases 6, 7, 8, and 9. Combinational index analysis revealed that combinations of KX-01 with TAM resulted in synergistic growth inhibition of breast cancer cell lines. KX-01 combined with TAM resulted in decreased ERα phosphorylation at Src-regulated phosphorylation sites serines 118 and 167 that were associated with reduced ERα transcriptional activity. Orally administered KX-01 resulted in a dose dependent growth inhibition of MCF-7 tumor xenografts, and in combination with TAM exhibited synergistic growth inhibition. Immunohistochemical analysis revealed that combinational treatment reduced angiogenesis, and ERα signaling in tumors compared to either drug alone that may underlie the synergistic tumor growth inhibition. Combinations of KX-01 with endocrine therapy present a promising new strategy for clinical management of ERα positive breast cancer.

Identification of early molecular markers for breast cancer

Background

The ductal carcinoma in situ (DCIS) of the mammary gland represents an early, pre-invasive stage in the development of invasive breast carcinoma. Since DCIS is a curable disease, it would be highly desirable to identify molecular markers that allow early detection. Mice transgenic for the WAP-SV40 early genome region were used as a model for DCIS development. Gene expression profiling was carried out on DCIS-bearing mice and control animals. Additionally, a set of human DCIS and invasive mammary tumors were analyzed in a similar fashion. Enhanced expression of these marker genes in human and murine samples was validated by quantitative RT-PCR. Besides, marker gene expression was also validated by immunohistochemistry of human samples. Furthermore in silico analyses using an online microarray database were performed.

Results

In DCIS-mice seven genes were identified that were significantly up-regulated in DCIS: DEPDC1, NUSAP1, EXO1, RRM2, FOXM1, MUC1 and SPP1. A similar up-regulation of homologues of the murine genes was observed in human DCIS samples. Enhanced expression of these genes in DCIS and IDC (invasive ductal carcinoma) was validated by quantitative RT-PCR and immunohistochemistry.

Conclusions

By comparing murine markers for the ductal carcinoma in situ (DCIS) of the mammary gland with genes up-regulated in human DCIS-samples we were able to identify a set of genes which might allow early detection of DCIS and invasive carcinomas in the future. The similarities between gene expression in DCIS and invasive carcinomas in our data suggest that the early detection and treatment of DCIS is of utmost relevance for the survival of patients who are at high risk of developing breast carcinomas.

Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial

BACKGROUND

Initial results of the UK/ANZ DCIS (UK, Australia, and New Zealand ductal carcinoma in situ) trial suggested that radiotherapy reduced new breast events of ipsilateral invasive and ductal carcinoma in situ (DCIS) compared with no radiotherapy, but no significant effects were noted with tamoxifen. Here, we report long-term results of this trial.

METHODS

Women with completely locally excised DCIS were recruited into a randomised 2×2 factorial trial of radiotherapy, tamoxifen, or both. Randomisation was independently done for each of the two treatments (radiotherapy and tamoxifen), stratified by screening assessment centre, and blocked in groups of four. The recommended dose for radiation was 50 Gy in 25 fractions over 5 weeks (2 Gy per day on weekdays), and tamoxifen was prescribed at a dose of 20 mg daily for 5 years. Elective decision to withhold or provide one of the treatments was permitted. The endpoints of primary interest were invasive ipsilateral new breast events for the radiotherapy comparison and any new breast event, including contralateral disease and DCIS, for tamoxifen. Analysis of each of the two treatment comparisons was restricted to patients who were randomly assigned to that treatment. Analyses were by intention to treat. All trial drugs have been completed and this study is in long-term follow-up. This study is registered, number ISRCTN99513870.

FINDINGS

Between May, 1990, and August, 1998, 1701 women were randomly assigned to radiotherapy and tamoxifen, radiotherapy alone, tamoxifen alone, or to no adjuvant treatment. Seven patients had protocol violations and thus 1694 patients were available for analysis. After a median follow-up of 12·7 years (IQR 10·9-14·7), 376 (163 invasive [122 ipsilateral vs 39 contralateral], 197 DCIS [174 ipsilateral vs 17 contralateral], and 16 of unknown invasiveness or laterality) breast cancers were diagnosed. Radiotherapy reduced the incidence of all new breast events (hazard ratio [HR] 0·41, 95% CI 0·30-0·56; p<0·0001), reducing the incidence of ipsilateral invasive disease (0·32, 0·19-0·56; p<0·0001) as well as ipsilateral DCIS (0·38, 0·22-0·63; p<0·0001), but having no effect on contralateral breast cancer (0·84, 0·45-1·58; p=0·6). Tamoxifen reduced the incidence of all new breast events (HR 0·71, 95% CI 0·58-0·88; p=0·002), reducing recurrent ipsilateral DCIS (0·70, 0·51-0·86; p=0·03) and contralateral tumours (0·44, 0·25-0·77; p=0·005), but having no effect on ipsilateral invasive disease (0·95, 0·66-1·38; p=0·8). No data on adverse events except cause of death were collected for this trial.

INTERPRETATION

This updated analysis confirms the long-term beneficial effect of radiotherapy and reports a benefit for tamoxifen in reducing local and contralateral new breast events for women with DCIS treated by complete local excision.

FUNDING

Cancer Research UK and the Australian National Health and Medical Research Council.

Increased SIAH expression predicts ductal carcinoma in situ (DCIS) progression to invasive carcinoma

Hyperactivated HER2/Neu/EGFR/RAS signaling is a major growth-promoting pathway known to drive cellular transformation and oncogenesis in breast cancers. HER2 amplification is detected in ~20% of all human breast cancer and is quite prevalent (up to 49%) in ductal carcinoma in situ (DCIS). The E3 ubiquitin ligase SIAH is considered a key downstream "gatekeeper" required for proper HER2/EGFR/RAS signal transduction. Formalin-fixed, paraffin-embedded resection specimens from 65 patients with DCIS treated with wide excision only were stained with an anti-SIAH antibody, and the percentage of tumor and normal adjacent tissue cells positive for SIAH nuclear staining were recorded. Statistical analysis was performed comparing SIAH staining in tumor cells to disease recurrence, histologic type, necrosis, hormone receptor status, and Her2/neu status, as well as nuclear grade. Correlation of SIAH expression in tumor cells with SIAH expression in normal adjacent tissue and age was also examined. Expression levels of SIAH in tumor cells was significantly higher in specimens from patients with recurrence (median = 19%) as compared to patients without recurrence (7%) (P < 0.001). There was also significantly increased SIAH expression in tumors with more aggressive features including comedo morphology (13.5% in comedo vs. 7% in other histologic types, P = 0.014). No significant association was observed between SIAH expression and estrogen receptor, progesterone receptor, and Her2/neu status. There was a significant correlation between SIAH expression in tumors and normal adjacent tissue (Spearman correlation = 0.58, P < 0.001) as well as between SIAH expression in normal adjacent tissue and patient age (Spearman correlation = -0.59, P < 0.001). No significant correlation was identified between patient age and SIAH expression in tumors (Spearman correlation = -0.23, P = 0.067). In conclusion, SIAH may represent a useful prognostic biomarker that predicts DCIS progression to invasive breast cancer.

Update on DCIS outcomes from the American Society of Breast Surgeons accelerated partial breast irradiation registry trial

BACKGROUND

Since the initial reports on use of MammoSite accelerated partial breast irradiation (APBI) for treatment of ductal carcinoma in situ (DCIS), additional follow-up data were collected. We hypothesized that APBI delivered via MammoSite would continue to be well tolerated, associated with a good cosmetic outcome, and carry a low risk for recurrence in patients with DCIS.

MATERIALS AND METHODS

From 2002-2004, 194 patients with DCIS were enrolled in a registry trial to assess the MammoSite. Follow-up data were available for all 194 patients. Median follow-up was 54.4 months; 63 patients had at least 5 years of follow-up. Data obtained included patient-, tumor-, and treatment-related factors, and recurrence incidence.

RESULTS

Of the 194 patients, 87 (45%) had the MammoSite placed at lumpectomy; 107 patients (55%) had the device placed postlumpectomy. In the first year of follow-up, 16 patients developed a breast infection, though the method of device placement was not associated with infection risk. Also, 46 patients developed a seroma that was associated with applicator placement at the time of lumpectomy (P = 0.001). For patients with at least 5 years of follow-up, 92% had favorable cosmetic results. There were 6 patients (3.1%) who had an ipsilateral breast recurrence, with 1 (0.5%) experiencing recurrence in the breast and axilla, for a 5-year actuarial local recurrence rate of 3.39%.

CONCLUSIONS

During an extended follow-up period, APBI delivered via MammoSite continued to be well tolerated for patients with DCIS. Use of this device may make lumpectomy possible for patients who would otherwise choose mastectomy because of barriers associated with standard radiation therapy.

Aromatase and in situ estrogen production in DCIS (ductal carcinoma in situ) of human breast

Ductal carcinoma in situ or DCIS belongs to intraductal proliferative lesions, which are a group of cytologically and architecturally diverse ductal proliferations, typically originating from the terminal duct-lobular units. In these intraductal proliferative diseases, estrogens are considered to be involved in the progression of the disease especially from ductal non-neoplastic hyperplasia to DCIS and possibly development of invasive carcinoma from DCIS. Estrogen receptor (ER) alpha is abundantly expressed in atypical ductal hyperplasia and low grade DCIS. Suppression of estrogenic actions using tamoxifen resulted in inhibition of recurrence of DCIS and/or of progression into invasive carcinoma. Intratumoral estrogen concentration in DCIS determined by liquid chromatography/electrospray tandem mass spectrometry is significantly higher than that in non-neoplastic breast tissues with statistically not lower than that in invasive carcinoma. Aromatase mRNA expression in both stromal and parenchymal cells of DCIS determined by quantitative RT-PCR following laser capture microdissection was also much higher than that in non-neoplastic breast, although lower than that in invasive carcinoma. Immunohistochemistry of aromatase also revealed the similar patterns of immunolocalization as in invasive carcinoma. Aromatase is overexpressed in noninvasive breast malignancies including DCIS and results in elevated concentrations of intratumoral estradiol. These findings could provide the scientific rationale as to employing aromatase inhibitors in the management of ER positive DCIS patients.

Lobular and ductal intraepithelial neoplasia

Lobular and ductal intraepithelial neoplasias reflect proliferations of immunophenotypically variable, biologically and morphologically diverse cells with a potential, not always realized, for progression to carcinoma by breaking through the barriers of the myoepithelial cell layer and basement membrane, ultimately invading the stroma. Starting with the lobular and then the ductal proliferations, this review will address the evolution of our understanding of these lesions; the problems associated with the conventional terminology of ductal hyperplasia, atypical hyperplasia, and carcinoma in situ; and reasons for and advantages of the intraepithelial neoplasia terminology.