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Haynes BP, Ginsburg O, Gao Q, Folkerd E, Afentakis M, Buus R, Quang LH, Thi Han P, Khoa PH, Dinh NV, To TV, Clemons M, Holcombe C, Osborne C, Evans A, Skene A, Sibbering M, Rogers C, Laws S, Noor L, Smith IE, Dowsett M. Menstrual cycle associated changes in hormone-related gene expression in oestrogen receptor positive breast cancer. NPJ Breast Cancer 2019; 5:42. [PMID: 31754627 PMCID: PMC6858333 DOI: 10.1038/s41523-019-0138-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/24/2019] [Indexed: 01/25/2023] Open
Abstract
The major changes in hormone levels that occur through the menstrual cycle have been postulated to affect the expression of hormone-regulated and proliferation-associated genes (PAGs) in premenopausal ER+ breast cancer. Whilst previous studies have demonstrated differences in gene expression, here, we investigated if there are within patient changes in the expression of oestrogen- and progesterone-regulated genes (ERGs and PRGs) and PAGs in ER+ breast cancer during the menstrual cycle. Samples from 96 patients in two independent prospective studies of the effect of menstrual cycle on ER+ breast cancer were used. Plasma hormone measurements were used to assign tumours to one of three pre-defined menstrual cycle windows: W1 (days 27-35 and 1-6; low oestradiol and low progesterone), W2 (days 7-16; high oestradiol and low progesterone) and W3 (days 17-26; intermediate oestradiol and high progesterone). RNA expression of 50 genes, including 27 ERGs, 11 putative PRGs and seven PAGs was measured. The AvERG (geomean of PGR, GREB1, TFF1 and PDZK1) was used as a composite measure of ERG expression and showed significant changes between the three windows of the menstrual cycle increasing over 2.2-fold between W1 and W2 and decreasing between W2 and W3 and between W3 and W1. Proliferation gene expression also varied significantly, following the same pattern of changes as ERG expression, but the changes were of lower magnitude (1.4-fold increase between W1 and W2). Significant changes in the expression of eight individual ERGs, including GREB1, PGR and TFF1, and two PAGs were observed between W1 and either W2 or W3 with all genes showing higher levels in W2 or W3 (1.3-2.4-fold; FDR 0.016-0.05). The AvProg, a composite measure of PRG expression, increased significantly (1.5-fold) in W3 compared to W1 or W2 but no significant changes were observed for individual PRGs. In conclusion, we observed significant changes in ERG, PRG and PAG expression in ER+ breast tumours during the menstrual cycle that may affect the assessment and interpretation of prominent biomarkers (e.g. PgR) and commonly used multigene prognostic signatures in premenopausal ER+ breast cancer.
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Affiliation(s)
- Ben P. Haynes
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Ophira Ginsburg
- Perlmutter Cancer Center and the Department of Population Health, NYU Langone Health, New York, USA
| | - Qiong Gao
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, UK
| | - Elizabeth Folkerd
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Maria Afentakis
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Richard Buus
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, UK
| | - Le Hong Quang
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Pham Thi Han
- Department of Pathology, National Cancer Hospital, Hanoi, Vietnam
| | - Pham Hong Khoa
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Nguyen Van Dinh
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Ta Van To
- Department of Pathology, National Cancer Hospital, Hanoi, Vietnam
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Chris Holcombe
- Royal Liverpool University Hospital, Prescott Street, Liverpool, UK
| | | | | | - Anthony Skene
- Royal Bournemouth Hospital, Castle Lane East, Bournemouth, Dorset UK
| | | | - Clare Rogers
- Doncaster Royal Infirmary, Armthorpe Road, Doncaster, South Yorkshire UK
| | - Siobhan Laws
- Royal Hampshire County Hospital, Winchester Hampshire, UK
| | - Lubna Noor
- University Hospital North Tees, Hardwick Road, Stockton-on-Tees, UK
| | - Ian E. Smith
- The Breast Unit, Department of Medicine, Royal Marsden Hospital, Fulham Road, London, UK
| | - Mitch Dowsett
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, UK
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Haynes BP, Ginsburg O, Gao Q, Folkerd E, Afentakis M, Quang LH, Han PT, Khoa PH, Dinh NV, To TV, Clemons M, Smith IE, Dowsett M. Molecular changes in premenopausal oestrogen receptor-positive primary breast cancer in Vietnamese women after oophorectomy. NPJ Breast Cancer 2017; 3:47. [PMID: 29214214 PMCID: PMC5703856 DOI: 10.1038/s41523-017-0049-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/20/2017] [Accepted: 11/01/2017] [Indexed: 12/16/2022] Open
Abstract
For premenopausal women with primary ER + breast cancer, oophorectomy (OvX) is an evidence-based cost-effective option and is standard treatment in many countries. However, there is virtually no data describing the effects of OvX on breast tumour biology. We therefore, characterised the endocrine and genome-wide transcriptional impact of OvX in 56 premenopausal women with ER + breast cancer for 2 weeks prior to mastectomy. Plasma estradiol concentrations decreased from 406 ± 41 to 20.7 ± 2.6 pmol/l (mean ± sem) 24 h after OvX, and to 8.1 ± 0.8 pmol/l 2 weeks later at mastectomy. Ki67 decreased in 33/36 (91.7%) tumours. The expression of 655 genes changed significantly (FDR < 1%) with an absolute mean fold-change (FC) ≥ 1.25 (257 up, 398 down). Archetypal oestrogen-regulated genes (TFF1, GREB1, PGR and PDZK1) showed large decreases in expression (FC = 0.20–0.69; p < 1e-6-1e-7). Proliferation-associated genes (e.g. TOP2A, AURKA and UBE2C) were also strongly downregulated (FC = 0.38–0.56; p < 1e-7) along with putative progesterone-regulated genes (e.g. FKBP4, MYB; FC = 0.64–0.68; p < 1e-4-1e-7). The gene expression changes did not differ according to HER2 status and correlated strongly with the changes reported previously after aromatase inhibitor (AI) treatment in postmenopausal women (rho = 0.55, p < 1e-04). However, after OvX the mean FC was significantly higher compared to AI (p < 1e-04). In conclusion, changes in tumoural gene expression after OvX were largely similar, but of a greater magnitude to those observed after AI in postmenopausal patients; however, OvX appeared to have a greater effect on progesterone-regulated genes than AI. Surgical removal of the ovaries alters the expression of hundreds of genes in the tumour cells of premenopausal women with breast cancer. Ben Haynes from Royal Marsden Hospital in London, UK and colleagues characterised molecular changes in 56 premenopausal women from Vietnam with oestrogen receptor-positive breast cancer who underwent oophorectomies, a standard treatment for this patient population. They showed that blood levels of the hormone estradiol dropped precipitously following ovary-removal surgery. Levels of a protein that was indicative of tumour growth also went down, as did genes involved in regulating hormone signalling and cell proliferation. The results are consistent with those seen in postmenopausal women following treatment with an oestrogen-blocking drug, but oophorectomy had a more dramatic effect. The data could aid the search for predictive biomarkers of who stands to benefit most from ovary removal.
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Affiliation(s)
- Ben P Haynes
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Ophira Ginsburg
- Department of Medicine, University of Toronto, Toronto, Canada.,Department of Population Health, NYU School of Medicine/Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, USA
| | - Qiong Gao
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, UK
| | - Elizabeth Folkerd
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Maria Afentakis
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK
| | - Le Hong Quang
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Pham Thi Han
- Department of Pathology, National Cancer Hospital, Hanoi, Vietnam
| | - Pham Hong Khoa
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Nguyen Van Dinh
- Department of Breast Surgery, National Cancer Hospital, Hanoi, Vietnam
| | - Ta Van To
- Department of Pathology, National Cancer Hospital, Hanoi, Vietnam
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Ian E Smith
- The Breast Unit, Department of Medicine, Royal Marsden Hospital, Fulham Road, London, UK
| | - Mitch Dowsett
- The Ralph Lauren Centre for Breast Cancer Research, Royal Marsden Hospital, Fulham Road, London, UK.,The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, UK
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Abdel-Hafiz HA, Horwitz KB. Post-translational modifications of the progesterone receptors. J Steroid Biochem Mol Biol 2014; 140:80-9. [PMID: 24333793 PMCID: PMC3923415 DOI: 10.1016/j.jsbmb.2013.12.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 11/30/2013] [Accepted: 12/02/2013] [Indexed: 01/21/2023]
Abstract
Progesterone plays a key role in the development, differentiation and maintenance of female reproductive tissues and has multiple non-reproductive neural functions. Depending on the cell and tissue, the hormonal environment, growth conditions and the developmental stage, progesterone can either stimulate cell growth or inhibit it while promoting differentiation. Progesterone receptors (PRs) belong to the steroid hormone receptor superfamily of ligand-dependent transcription factors. PR proteins are subject to extensive post-translational modifications that include phosphorylation, acetylation, ubiquitination and SUMOylation. The interplay among these modifications is complex with alteration of the receptors by one factor influencing the impact of another. Control over these modifications is species-, tissue- and cell-specific. They in turn regulate multiple functions including PR stability, their subcellular localization, protein-protein interactions and transcriptional activity. These complexities may explain how tissue- and gene-specific differences in regulation are achieved in the same organism, by the same receptor protein and hormone. Here we review current knowledge of PR post-translational modifications and discuss how these may influence receptor function focusing on human breast cancer cells. There is much left to be learned. However, our understanding of this may help to identify therapeutic agents that target PR activity in tissue-specific, even gene-specific ways.
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Affiliation(s)
- Hany A Abdel-Hafiz
- Division of Endocrinology, Department of Medicine, Anschutz Medical Campus, University of Colorado Denver, Aurora, CO 80045, USA.
| | - Kathryn B Horwitz
- Division of Endocrinology, Department of Medicine, Anschutz Medical Campus, University of Colorado Denver, Aurora, CO 80045, USA; Department of Pathology, Anschutz Medical Campus, University of Colorado Denver, Aurora, CO 80045, USA
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Tanos T, Rojo L, Echeverria P, Brisken C. ER and PR signaling nodes during mammary gland development. Breast Cancer Res 2012; 14:210. [PMID: 22809143 PMCID: PMC3680919 DOI: 10.1186/bcr3166] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The ovarian hormones estrogen and progesterone orchestrate postnatal mammary gland development and are implicated in breast cancer. Most of our understanding of the molecular mechanisms of estrogen receptor (ER) and progesterone receptor (PR) signaling stems from in vitro studies with hormone receptor-positive cell lines. They have shown that ER and PR regulate gene transcription either by binding to DNA response elements directly or via other transcription factors and recruiting co-regulators. In addition they cross-talk with other signaling pathways through nongenomic mechanisms. Mouse genetics combined with tissue recombination techniques have provided insights about the action of these two hormones in vivo. It has emerged that hormones act on a subset of mammary epithelial cells and relegate biological functions to paracrine factors. With regards to hormonal signaling in breast carcinomas, global gene expression analyses have led to the identification of gene expression signatures that are characteristic of ERα-positive tumors that have stipulated functional studies of hitherto poorly understood transcription factors. Here, we highlight what has been learned about ER and PR signaling nodes in these different systems and attempt to lay out in which way the insights may converge.
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Costa-Rodrigues J, Moniz KA, Teixeira MR, Fernandes MH. Variability of the paracrine-induced osteoclastogenesis by human breast cancer cell lines. J Cell Biochem 2012; 113:1069-79. [PMID: 22274920 DOI: 10.1002/jcb.23439] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Breast cancer frequently metastasizes to the bone, often leading to the formation of osteolytic lesions. This work compares the paracrine-induced osteoclastogenesis mediated by four human breast cancer cell lines, the estrogen-receptor positive T47D and MCF-7 and the estrogen-negative SK-BR-3 and Hs-578T cell lines. Human osteoclast precursor cells were cultured in the presence of conditioned media from the breast cancer cell lines (10% and 20%), collected at different culture periods (48 h, 7 days, and 14 days). Cultures performed in the absence or the presence of M-CSF and RANKL served as negative and positive control, respectively. Results showed that the cell lines differentially expressed several osteoclastogenic genes. All cell lines exhibited a significant osteoclastogenic potential, evidenced by a high TRAP activity and number of osteoclastic cells, expression of several osteoclast-related genes, and, particularly, a high calcium phosphate resorption activity. Differences among the osteoclastogenic potential of the cell lines were noted. T47D and MCF-7 cell lines displayed the highest and the lowest osteoclastogenic response, respectively. Despite the variability observed, MEK and NF-κB signaling pathways, and, at a lesser extent, PGE2 production, seemed to have a central role on the observed osteoclastogenic response. In conclusion, the tested breast cancer cell lines exhibited a high osteoclastogenic potential, although with some variability on the cell response profile, a factor to be considered in the development of new therapeutic approaches for breast cancer-induced bone metastasis.
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Affiliation(s)
- João Costa-Rodrigues
- Laboratório de Farmacologia e Biocompatibilidade Celular, Faculdade de Medicina Dentária, Universidade do Porto, Porto, Portugal
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Hassan MI, Waheed A, Yadav S, Singh TP, Ahmad F. Zinc alpha 2-glycoprotein: a multidisciplinary protein. Mol Cancer Res 2008; 6:892-906. [PMID: 18567794 DOI: 10.1158/1541-7786.mcr-07-2195] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Zinc alpha 2-glycoprotein (ZAG) is a protein of interest because of its ability to play many important functions in the human body, including fertilization and lipid mobilization. After the discovery of this molecule, during the last 5 decades, various studies have been documented on its structure and functions, but still, it is considered as a protein with an unknown function. Its expression is regulated by glucocorticoids. Due to its high sequence homology with lipid-mobilizing factor and high expression in cancer cachexia, it is considered as a novel adipokine. On the other hand, structural organization and fold is similar to MHC class I antigen-presenting molecule; hence, ZAG may have a role in the expression of the immune response. The function of ZAG under physiologic and cancerous conditions remains mysterious but is considered as a tumor biomarker for various carcinomas. There are several unrelated functions that are attributed to ZAG, such as RNase activity, regulation of melanin production, hindering tumor proliferation, and transport of nephritic by-products. This article deals with the discussion of the major aspects of ZAG from its gene structure to function and metabolism.
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Affiliation(s)
- Md Imtaiyaz Hassan
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi 110025, India
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Mackay A, Urruticoechea A, Dixon JM, Dexter T, Fenwick K, Ashworth A, Drury S, Larionov A, Young O, White S, Miller WR, Evans DB, Dowsett M. Molecular response to aromatase inhibitor treatment in primary breast cancer. Breast Cancer Res 2007; 9:R37. [PMID: 17555561 PMCID: PMC1929101 DOI: 10.1186/bcr1732] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 04/26/2007] [Accepted: 06/07/2007] [Indexed: 11/10/2022] Open
Abstract
Background Aromatase inhibitors such as anastrozole and letrozole are highly effective suppressants of estrogen synthesis in postmenopausal women and are the most effective endocrine treatments for hormone receptor positive breast cancer in such women. Little is known of the molecular effects of these agents on human breast carcinomas in vivo. Methods We randomly assigned primary estrogen receptor positive breast cancer patients to treatment with anastrozole or letrozole for 2 weeks before surgery. Expression profiling using cDNA arrays was conducted on pretreatment and post-treatment biopsies. Sample pairs from 34 patients provided sufficient RNA for analysis. Results Profound changes in gene expression were seen with both aromatase inhibitors, including many classical estrogen-dependent genes such as TFF1, CCND1, PDZK1 and AGR2, but also many other genes that are likely to represent secondary responses; decrease in the expression of proliferation-related genes were particularly prominent. Many upregulated genes are involved in extracellular matrix remodelling, including collagens and members of the small leucine-rich proteoglycan family (LUM, DCN, and ASPN). No significant differences were seen between letrozole and anastrozole in terms of molecular effects. The gene changes were integrated into a Global Index of Dependence on Estrogen (GIDE), which enumerates the genes changing by at least twofold with therapy. The GIDE varied markedly between tumours and related significantly to pretreatment levels of HER2 and changes in immunohistochemically detected Ki67. Conclusion Our findings identify the transcriptional signatures associated with aromatase inhibitor treatment of primary breast tumours. Larger datasets using this approach should enable identification of estrogen-dependent molecular changes, which are the determinants of benefit or resistance to endocrine therapy.
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Affiliation(s)
- Alan Mackay
- The Breakthrough Breast Cancer Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
| | - Ander Urruticoechea
- Academic Department of Biochemistry, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | | | - Tim Dexter
- The Breakthrough Breast Cancer Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
| | - Kerry Fenwick
- The Breakthrough Breast Cancer Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
| | - Alan Ashworth
- The Breakthrough Breast Cancer Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
| | - Suzanne Drury
- Academic Department of Biochemistry, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | - Alexey Larionov
- The Edinburgh Breast Unit, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - Oliver Young
- The Edinburgh Breast Unit, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - Sharon White
- The Edinburgh Breast Unit, Western General Hospital, Edinburgh, EH4 2XU, UK
| | - William R Miller
- The Edinburgh Breast Unit, Western General Hospital, Edinburgh, EH4 2XU, UK
| | | | - Mitch Dowsett
- The Breakthrough Breast Cancer Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
- Academic Department of Biochemistry, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
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Smith JM, Shen Z, Wira CR, Fanger MW, Shen L. Effects of Menstrual Cycle Status and Gender on Human Neutrophil Phenotype. Am J Reprod Immunol 2007; 58:111-9. [PMID: 17631004 DOI: 10.1111/j.1600-0897.2007.00494.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PROBLEM The effects of gender and fluctuating ovarian hormones on neutrophil phenotype have yet to be characterized. METHOD OF STUDY Neutrophils from females at days 7, 14, 21, and 28 of the menstrual cycle were analyzed by flow cytometry for surface receptor, granule protein, and intracellular cytokine expression. Comparisons were made to neutrophils from males isolated at 7-day intervals during 1 month. RESULTS Decreased MMP-9 and TNF-alpha expression by neutrophils from females was observed during the periovulatory period. Comparing the genders, cells from females during the periovulatory period expressed less CD11b and CD18 than those from males. CXCR1 surface levels were higher on neutrophils from female donors. CONCLUSIONS Neutrophil phenotype varies minimally during the menstrual cycle and between the genders. Our data provide support for a potential anti-inflammatory effect of ovarian hormones on neutrophils.
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Affiliation(s)
- Jennifer M Smith
- Department of Microbiology & Immunology, Dartmouth Medical School, Lebanon, NH 03756, USA
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Abstract
Although the relationship between breast cancer and hormones has been known for almost two centuries, it is only during the last 16 years that evidence suggesting the hormonal profile of the patient at the time of surgery can affect the outcome, came to light. A series of studies investigated the hypothesis that unopposed estrogen (observed during the follicular phase of the cycle) may adversely affect the overall and/or disease-free survival of women operated on at that time. The findings have been, at times, contradictory. The retrospective nature of the studies, poor recording of last menstrual period, small study size, and the possible effect of the timing of the diagnostic procedures (cytology or core biopsy) on the outcome may be responsible for the conflicting results. Despite this, more sophisticated studies based on pathological or hormonal observations/measurements, confirmed the relation of luteal phase surgery to better outcome. Estrogen-induced increased protease activity activates a cascade of proteolysis and allows the more discohesive tumor cells to gain access to the circulation. Moreover, disseminated cells might be able to proliferate easier because of several estrogen-dependent growth factors. Diminished immune function during the follicular phase, because of natural killer cell activity and mononuclear cell phagocytic activity down-regulation may also be implicated in the dissemination of viable tumor cells. Taken together these findings provide a framework for explaining the observation that luteal phase surgery can lead to an improved outcome. By altering the perioperative hormonal milieu it may be possible to reduce deaths from breast cancer in a simple and nontoxic manner.
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Affiliation(s)
- Michael Kontos
- Hedley Atkins Breast Unit, Guy's and St Thomas' NHS Trust, London, United Kingdom
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