The role of progestins and progesterone receptors in the treatment of breast cancer

Human versus non-human sex steroid use in hormone replacement therapies part 1: Preclinical data

Prior to 2002, hormone replacement therapy (HRT) was considered to be an important component of postmenopausal healthcare. This was based on a plethora of basic, epidemiological and clinical studies demonstrating the health benefits of supplementation with human sex steroids. However, adverse findings from the Women's Health Initiative (WHI) studies that examined the 2 major forms of HRT in use in the US at that time - Premarin (conjugated equine estrogens; CEE) and Prempro (CEE + medroxyprogesterone acetate; MPA), cast a shadow over the use of any form of HRT. Here we review the biochemical and physiological differences between the non-human WHI study hormones - CEE and MPA, and their respective human counterparts 17β-estradiol (E₂) and progesterone (P₄). Preclinical data from the last 30 years demonstrate clear differences between human and non-human sex steroids on numerous molecular, physiological and functional parameters in brain, heart and reproductive tissue. In contrast to CEE supplementation, which is not always detrimental although certainly not as optimal as E₂ supplementation, MPA is clearly not equivalent to P₄, having detrimental effects on cognitive, cardiac and reproductive function. Moreover, unlike P₄, MPA is clearly antagonistic of the positive effects of E₂ and CEE on tissue function. These data indicate that minor chemical changes to human sex steroids result in physiologically distinct actions that are not optimal for tissue health and functioning.

Progesterone receptor targeting with radiolabelled steroids: an approach in predicting breast cancer response to therapy

Steroid receptors have demonstrated to be potentially useful biological targets for the diagnosis and therapy follow-up of hormonally responsive cancers. The over-expression of these proteins in human cancer cells as well as their binding characteristics provides a favourable mechanism for the localization of malignant tumours. The need for newer and more selective probes to non-invasively assess steroid receptor expression in hormone-responsive tumours has encouraged the synthesis and the biological evaluation of several steroidal derivatives labelled with positron and gamma emitters. The physiological effects of the steroid hormone progesterone are mediated by the progesterone receptor (PR). Since PR expression is stimulated by the oestrogen receptor (ER), PR status has been considered as a biomarker of ER activity and its value for predicting and monitoring therapeutic efficacy of hormonal therapy has been studied. Imaging of PR-expressing breast cancer patients under hormonal therapy may be advantageous, since the response to therapy can be more accurately predicted after quantification of both ER and PR status. Thus, ligands for PR targeting, although much less explored than ER ligands, have gained some importance lately as potential PET and SPECT tumour imaging agents. In this review, we present a brief survey of explored approaches for progesterone targeting using radiolabelled progestins as potential clinical probes to predict responsiveness to breast cancer therapy. This article is part of a Special Issue entitled "Synthesis and biological testing of steroid derivatives as inhibitors".

Orbital metastasis: clinical features, management and outcome

PURPOSE

To review the clinical features, treatment, outcome and survival of metastatic tumors of the orbit.

MATERIALS AND METHODS

Retrospective, non-comparative, chart review of 80 patients with orbital metastasis treated in four tertiary orbital centres in Australia.

RESULTS

The study included 80 patients of which, 44 were male with a mean age of 60 years. Orbital involvement commonly presented late in a multisystemic disease; however, the orbit was the first presentation in 15% of the cases. Diplopia (48%), pain (42%), and visual loss (30%) were the commonest symptoms at presentation; whereas proptosis (63%), strabismus (62%), and visual loss (41%) were the most frequent clinical signs. Computed tomography commonly showed a solid enhancing mass (42 cases) located within the orbital fat (43%), or enlarging an extraocular muscle (28%). Breast carcinoma (29%), melanoma (20%), and prostatic cancer (13%) were the most frequent histological types. Treatment was often multi-disciplinary and modalities included radiotherapy, chemotherapy, hormone therapy, surgery, and immunotherapy. Survival was limited to 1.5 years after diagnosis independent of the histological type, with 29% of patients alive after 17 months follow-up.

CONCLUSIONS

A high index of suspicion and appropriate intervention with histological diagnosis can help in the management and quality of life in patients with metastatic orbital disease. Overall survival is limited and we encountered statistical limitations proving differences in the survival based on the sub-type of primary tumour involved. Metastatic orbital melanoma presented a higher incidence when compared with previous studies, probably due to the increase frequency of skin found in the Australian population.

EGCG stabilizes p27kip1 in E2-stimulated MCF-7 cells through down-regulation of the Skp2 protein

Loss of p27Kip1 is associated with a poor prognosis in breast cancer. According to previous findings, a decrease in p27Kip1 levels is mainly the result of enhanced proteasome-dependent degradation mediated by its specific ubiquitin ligase subunit S-phase kinase protein 2 (Skp2). Epigallocatechin-3-gallate (EGCG), the main constituent of green tea, was found to stabilize p27Kip1 levels in breast cancer, but whether this effect is mediated through changes in Skp2 expression remains unclear. Here we investigated the mechanisms involved in EGCG's growth inhibition of estrogen-responsive human breast cancer MCF-7 cells. In our results, EGCG increased p27Kip1 and decreased Skp2 in a time- and dose-dependent manner, suggesting that p27Kip1 and Skp2 may be involved in the growth inhibition by EGCG in estrogen-stimulated MCF-7 cells. Interestingly, mRNA levels of p27Kip1 and Skp2 did not significantly change in estrogen-stimulated MCF-7 cells after EGCG treatments. Moreover, overexpression of Skp2 in MCF-7 cells prevented accumulation of p27Kip1 and promoted resistance to the antiproliferative effects of EGCG. This suggests that the down-regulation of the F-box protein Skp2 is the mechanism underlying p27Kip1 accumulation. Furthermore, both tamoxifen and paclitaxel significantly and synergistically enhanced the growth inhibition of MCF-7 cells by EGCG through the down-regulation of Skp2 protein. However, the down-regulation of Skp2 was not always correlate with the up-regulation of p27, suggesting that EGCG-dependent Skp2 down-regulation can influence cell growth in several ways. The therapeutic strategies designed to reduce Skp2 may therefore play an important clinical role in treatment of breast cancer cells.

Pentagalloylglucose inhibits estrogen receptor alpha by lysosome-dependent depletion and modulates ErbB/PI3K/Akt pathway in human breast cancer MCF-7 cells

Estrogens and estrogen receptors (ER) play important roles in estrogen-dependent and ER-positive breast cancer development. Inhibitors against estrogen biosynthesis or anti-estrogens have been used in breast cancer treatment for many years. The aim of this study was to determine whether pentagalloylglucose (5GG) has inhibitory effects on ER function. In the present study, we found that 5GG significantly reduced the growth of estrogen-responsive human breast cancer MCF-7 cells, and suppressed the phosphorylation and protein level of estrogen receptor alpha (ERalpha). Interestingly, 5GG decreased ERalpha protein levels by promoting the degradation of ERalpha protein in the lysosome. The ERalpha can be activated through a ligand-dependent and/or a ligand-independent pathway. The activated Akt kinase was shown to directly phosphorylate ERalpha at its serine residues and cause ligand independent activation. Our results showed that 5GG might inhibit the phosphatidylinositol 3-kinase (PI3K)/Akt pathway either through directly inhibiting Akt kinase activity or through inhibiting phosphorylation of the upstream receptor tyrosine kinases. The depletion of ErbB family receptors, including epidermal growth factor receptor (EGFR), ErbB2, and ErbB3, was also observed. 5GG treatment also led to a dose-dependent decrease in the expression of the estrogen-activated cyclin D1 expression. These findings suggested that 5GG might be a useful chemopreventive or therapeutic agent for hormone-dependent breast cancer through suppressing the functions of ERalpha by lysosome-dependent depletion and modulating the ErbB/PI3K/Akt pathway.

Expression analysis and prognostic significance of human kallikrein 11 in prostate cancer

BACKGROUND

Kallikrein 11 (KLK11) is a newly discovered human kallikrein gene that is mainly expressed in the central nervous system and endocrine tissues. KLK11 has two alternative splicing isoforms, known as the brain type and prostate type. Many members of the human kallikrein gene family are differentially expressed in cancer and a few have potential as diagnostic/prognostic markers.

METHODS

In the present study, the expression of prostate type variant of KLK11 gene was analyzed by RT-PCR in 66 prostate cancer tissues. Tumors were pulverized, total RNA was extracted, and cDNA was prepared by reverse transcription. KLK11 was amplified by PCR using gene specific primers and its identity was verified by sequencing. Prostate tissues were then classified as KLK5 positive or negative based on eithidium bromide staining in agarose gels and image analysis.

RESULTS

KLK11 was found to be highly expressed in 43/66 (65%) of prostate cancer samples. We found a significant negative relationship between KLK11 expression and Gleason score (p = 0.004) and disease stage (p = 0.038). Serum total PSA concentration was found to be lower in patients with overexpression of KLK11 (p = 0.044).

CONCLUSIONS

We conclude that down-regulation of the KLK11 gene in advanced and more aggressive tumors may open the possibility of being used as a future biological marker distinguishing the tumor aggressiveness as well as a useful prognostic biomarker for prostate cancer.

Black tea polyphenol theaflavins inhibit aromatase activity and attenuate tamoxifen resistance in HER2/neu-transfected human breast cancer cells through tyrosine kinase suppression

The aromatase enzyme, which converts androstenedione to oestrone, regulates the availability of oestrogen to support the growth of hormone-dependent breast tumours. In this study, we investigated the inhibitory effects of black tea polyphenols on aromatase activities. We found that black tea polyphenols, TF-1, TF-2 and TF-3, significantly inhibited rat ovarian and human placental aromatase activities. In addition, using an in vivo model, these black tea polyphenols also inhibited the proliferation induced by 100 nM dehydroepiandrosterone (DHEA) in MCF-7 cells. Transfection of HER2/neu in MCF-7 breast cancer cells appeared to be associated with an increased resistance of the cells to hormonal therapy. Interestingly, unlike the selective oestrogen receptor modulator (SERM) tamoxifen, black tea polyphenols had antiproliferation effects in breast cancer cells with hormonal resistance. The inhibitory effect of black tea polyphenols on hormone-resistant breast cancer cells suppressed the basal receptor tyrosine phosphorylation in HER2/neu-overexpressing MCF-7 cells. These findings suggest the use of black tea polyphenols may be beneficial in the chemoprevention of hormone-dependent breast tumours and represent a possible remedy to overcome hormonal resistance of hormone-independent breast tumours.

HDLG5/KIAA0583, encoding a MAGUK-family protein, is a primary progesterone target gene in breast cancer cells

The steroid hormone progesterone is known to have profound effects on growth and differentiation of normal and malignant breast epithelial cells. The biologic actions of progesterone are exerted through the nuclear progesterone receptor-mediated control of target gene transcription. We utilized differential display polymerase chain reaction (DD-RT-PCR) to identify genes whose expression is altered in response to progestins in cultured breast cancer cells. Here we report identification of a gene encoding a member of the MAGUK protein family, hDlg5 (also known as KIAA0583 and P-dlg), as being the primary progestin target gene in MCF-7 breast cancer cells. Quantitative real-time RT-PCR analysis showed a rapid and strong upregulation of hDlg5 mRNA in cells treated with synthetic progestin medroxyprogesterone acetate (MPA) in the presence of estrogen in MCF-7, T47D and ZR-75-1 cells. The induction was abrogated by antiprogestin RU486. hDlg5 mRNA was also upregulated by progesterone, R5020 and dexamethasone. Protein synthesis inhibitor cycloheximide failed to block progestin-mediated induction of the hDlg5 gene. hDlg5 is a member of the growing family of MAGUKs (membrane-associated guanylate kinase homologs) and is to our knowledge the first member of the family reported to be hormonally regulated. hDlg5 is one of the human homologs of the Drosophila gene dlg [lethal(1)discs-large], which was initially identified as a tumor suppressor gene. The Dlg has a well-established role in cell growth control and maintenance of cell adhesion and cell polarity. Domain profile analysis revealed that hDlg5 has 2 additional PDZ domains than previously reported.

Human kallikrein gene 13 (KLK13) expression by quantitative RT-PCR: an independent indicator of favourable prognosis in breast cancer

Kallikreins are a group of serine proteases with diverse physiological functions. KLK13 (previously known as KLK-L4) is a novel kallikrein gene located on chromosome 19q13.4 and shares a high degree of homology with other kallikrein family members. Many kallikrein genes were found to be differentially expressed in various malignancies, and their regulation is controlled by steroid hormones in prostate and breast cancer cell lines. We studied the expression of KLK13 by quantitative reverse transcriptase-polymerase chain reaction in 173 patients with epithelial breast carcinoma. An optimal cutoff point equal to the 40th percentile was defined, based on the ability of KLK13 to predict disease-free survival. KLK13 values were then associated with other established prognostic factors and with disease-free survival and overall survival. Higher positivity for KLK13 expression was found in older, oestrogen receptor positive patients. In univariate analysis, KLK13 expression is a significant predictor of improved disease-free survival and overall survival (P<0.001 and P=0.009, respectively). Cox multivariate analysis indicated that KLK13 was an independent prognostic variable in the subgroups of patients with Grade I-II tumours and in patients who were oestrogen receptor and progesterone receptor positive, and node positive. Hazard ratios derived from Cox analysis, related to disease-free survival and overall survival were 0.22 (P=0.001) and 0.24 (P=0.008), respectively, for the Grade I-II group; 0.36 (P=0.008) and 0.44 (P=0.038), respectively, for the node positive group and 0.36 (P=0.008) and 0.18 (P=0.008), respectively, for the oestrogen receptor positive group. The adjusted hazard ratio for progesterone receptor positive patients for disease-free survival was 0.25 (P=0.012). For patients in the node positive and oestrogen receptor positive subgroup (n=51) the adjusted hazard ratio was 0.25 (P=0.006) and for the node positive and progesterone receptor positive subgroup (n=46) the hazard ratio was 0.24 (P=0.008). Taken together, these data suggest that higher KLK13 expression in these subgroups of breast cancer patients is associated with an approximately 55 to 80% reduction in the risk of relapse or death. We conclude that KLK13 expression, as assessed by quantitative reverse transcriptase-polymerase chain reaction, is an independent favourable prognostic marker for breast carcinoma.

The Role of Hormonal Therapy in Breast Cancer

This review reassesses the role of hormonal therapy in breast cancer specifically the sequential or concurrent use of endocrine therapy and the combined use of chemotherapy with endocrine therapy. In advanced disease the sequential use of hormone therapies is generally recommended rather than the combined use of various hormonal agents, though combination hormonal therapy offers advantages in certain subsets of patients. The efficacy of combined chemo-endocrine therapy is questionable. Chemotherapy with estrogenic recruitment is an attractive but still experimental concept. However, in an adjuvant setting there is evidence that combined chemo-endocrine therapy causes a significant increase in disease-free and/or overall survival, particularly in postmenopausal patients with estrogen receptor(ER)-positive tumors. While hormonal treatment strategies have clearly benefitted from randomized studies, data regarding optimal endocrine therapy are still insufficient.

Endocrine therapy in metastatic breast cancer

Endocrine therapy represents a mainstay of effective, minimally toxic, palliative treatment for metastatic breast cancer. Research focusing on the mechanism of action of endocrine agents will provide new insights leading to new hormonal approaches in breast cancer treatment. Development of new agents, especially the 'pure' antiestrogens, is of great interest. Combining endocrine therapy with biologic agents, especially antiproliferative compounds, may lead to more effective treatment in the adjuvant as well as the advanced setting. Tables 4 and 5 summarize response rates to the different groups of endocrine agents used in metastatic breast cancer and doses of commonly used agents, respectively. At present, tamoxifen is the drug of choice as first-line endocrine therapy for metastatic breast cancer with no or minimal symptoms in premenopausal or postmenopausal women. Second-line therapy usually consists of megace. Aromatase inhibitors may be used as second- or third-line therapy in postmenopausal women. In premenopausal women, LHRH analogues are a reasonable choice. The other hormonal agents may be beneficial as salvage therapy. More effective endocrine approaches are under development.

Progesterone receptor variants found in breast cells repress transcription by wild-type receptors

Progesterone, through its nuclear receptors (PR), regulates the development and growth of breast cancers. PR also serve as markers of hormone dependence and prognosis in patients with this disease, and functional PR are required to mediate the antiproliferative effects of progestin therapies. We find that normal and malignant breast cells and tissues can express anomalous forms of PR transcripts. We have isolated four variant PR mRNAs that contain precise deletions of exons encoding sections of the DNA- and hormone-binding domains. The transcripts lack exon 2 (PRdelta2), exon 4 (PRdelta4), exon 6 (PRdelta6), or exons 5 and 6 (PRdelta5,6). On immunoblots, PRdelta4, delta6. and delta5, 6 cloned into the background of the PR A-isoform comigrate with similar proteins present in breast tumor extracts; delta6 and delta5, 6 are dominant-negative transcriptional inhibitors of wild-type A- and B-receptors. We propose that expression of variant PR can compromise the accuracy of receptor measurements as markers of hormone-dependent cancers, and can modify the responses of tumors to progestin therapies.

Expression of human prostatic acid phosphatase correlates with androgen-stimulated cell proliferation in prostate cancer cell lines

Androgen plays a critical role in regulating the growth and differentiation of normal prostate epithelia, as well as the initial growth of prostate cancer cells. Nevertheless, prostate carcinomas eventually become androgen-unresponsive, and the cancer is refractory to hormonal therapy. To gain insight into the mechanism involved in this hormone-refractory phenomenon, we have examined the potential role of the androgen receptor (AR) in that process. We have investigated the expression of AR and two prostate-specific androgen-responsive antigens, prostatic acid phosphatase (PAcP) and prostate-specific antigen (PSA), for the functional activity of AR in LNCaP and PC-3 human prostate carcinoma cells. Our results are as follows. (i) Clone 33 LNCaP cells express AR, PAcP, and PSA, and cell growth is stimulated by 5alpha-dihydrotestosterone (DHT). Stimulation of cell growth correlates with decreased cellular PAcP activity. (ii) In clone 81 LNCaP cells, the expression of PAcP decreases with a concurrent decrease in the degree of androgen stimulation of cell growth, whereas the expression of PSA mRNA level is up-regulated by DHT, as in clone 33 cells. Conversely, in PAcP cDNA-transfected clone 81 cells, an additional expression of cellular PAcP correlates with an increased stimulation by androgen, higher than the corresponding control cells. (iii) PC-3 cells express a low level of functional AR with no detectable PAcP or PSA, and the growth of PC-3 cells is not affected by DHT treatment. Nevertheless, in two PAcP cDNA-transfected PC-3 sublines, the expression of exogenous cellular PAcP correlates with androgen stimulation. This androgen stimulation of cell growth concurs with an increased tyrosine phosphorylation of a phosphoprotein of 185 kDa. In summary, the data indicate that the expression of AR alone is not sufficient for androgen stimulation of cell growth. Furthermore, in AR-expressing prostate cancer cells, the expression of cellular PAcP correlates with androgen stimulation of cell proliferation.

Use of aromatase inhibitors in postmenopausal women with advanced breast cancer

Surgeons have been involved in the management of metastatic breast cancer since the technique of ovarian ablation was introduced in 1896. However, as newer hormonal and chemotherapeutic regimens were developed, drug therapy gradually replaced surgery as the preferred treatment for metastatic breast cancer. Thus, management of metastatic breast cancer has largely shifted from surgeons to medical oncologists. Advances in hormonal pharmacology have placed hormonal therapy alongside surgery and radiation therapy as a standard treatment option for women with advanced breast cancer. The purpose of this article is to update surgeons on the current use of hormonal agents for treatment of advanced breast cancer in postmenopausal women, and to review the aromatase inhibitors, a new line of hormonal agents for the treatment of advanced breast cancer.

Biphasic regulation of breast cancer cell growth by progesterone: role of the cyclin-dependent kinase inhibitors, p21 and p27(Kip1)

Depending on the tissue, progesterone is classified as a proliferative or a differentiative hormone. To explain this paradox, and to simplify analysis of its effects, we used a breast cancer cell line (T47D-YB) that constitutively expresses the B isoform of progesterone receptors. These cells are resistant to the proliferative effects of epidermal growth factor (EGF). Progesterone treatment accelerates T47D-YB cells through the first mitotic cell cycle, but arrests them in late G1 of the second cycle. This arrest is accompanied by decreased levels of cyclins D1, D3, and E, disappearance of cyclins A and B, and sequential induction of the cyclin-dependent kinase (cdk) inhibitors p21 and p27(Kip1). The retinoblastoma protein is hypophosphorylated and extensively down-regulated. The activity of the cell cycle-dependent protein kinase, cdk2, is regulated biphasically by progesterone: it increases initially, then decreases. This is consistent with the biphasic proliferative increase followed by arrest produced by one pulse of progesterone. A second treatment with progesterone cannot restart proliferation despite adequate levels of transcriptionally competent PR. Instead, a second progesterone dose delays the fall of p21 and enhances the rise of p27(Kip1), thereby intensifying the progesterone resistance in an autoinhibitory loop. However, during the progesterone-induced arrest, the cell cycling machinery is poised to restart. The first dose of progesterone increases the levels of EGF receptors and transiently sensitizes the cells to the proliferative effects of EGF. We conclude that progesterone is neither inherently proliferative nor antiproliferative, but that it is capable of stimulating or inhibiting cell growth depending on whether treatment is transient or continuous. We also suggest that the G1 arrest after progesterone treatment is accompanied by cellular changes that permit other, possibly tissue-specific, factors to influence the final proliferative or differentiative state.

The effects of cyclosporin A, tamoxifen, and medroxyprogesterone acetate on the enhancement of adriamycin cytotoxicity in primary cultures of human breast epithelial cells

Adriamycin (Adr), the single most active agent used in the treatment of breast cancer, may become ineffective as treatment progresses due to the development of multidrug resistant (MDR) tumors. A major mechanism associated with MDR is increased P-glycoprotein (Pgp) expression. This study examined the abilities of the anti-estrogen tamoxifen (TAM) and the progestin medroxyprogesterone acetate (MPA) as well as cyclosporin A (CsA), a known resistance modifier, to enhance the cytotoxic effects of Adr on human breast epithelial cells (HBEC) in primary culture. Pgp and estrogen receptor (ER) expression were determined in each of the cultures by immunocytochemical assays using the monoclonal antibodies C219 and H222 Sp gamma, respectively. The Adr-sensitive, Pgp-, ER+ MCF-7 cell line and the Adr-resistant, Pgp+, ER- MCF7-AdrR cell line were used as controls. Primary cultures were categorized as HBEC from tissues with or without previous chemotherapy. Pgp was detected in 1 of the 15 cell cultures from tissues without previous chemotherapy and in 5 of the 6 cell cultures from tissues previously exposed to chemotherapy. Incubation with either CsA or MPA plus Adr enhanced Adr toxicity in Pgp+ but not Pgp- cell cultures, whereas TAM had no effect on the sensitivity of any of the cultures. Of the 21 primary cultures of HBEC, 3 were ER+. There was no correlation between the enhancement of Adr cytotoxicity and ER status. The data suggest that MPA as well as CsA may be useful as modifying agents in overcoming Pgp-associated multidrug resistance.

Novel mechanisms of antiprogestin action

Endocrine therapy used either prophylactically or therapeutically for the treatment of locally advanced or metastatic breast cancers offers many advantages to patients whose tumors contain functional estrogen (ER) and progesterone (PR) receptors. The range of treatments defined as endocrine include surgical ablation of endocrine glands, administration of pharmacologic doses of steroid hormones, chemical blockade of steroid hormone biosynthesis, and inhibition of endogenous steroid hormone action at the tumor with synthetic antagonists. The last of these approaches is the most widely used, making the antiestrogen tamoxifen the preferred first-line therapeutic agent for treatment of hormone-dependent metastatic breast cancer. The wide-spread use of tamoxifen reflects its efficacy and low toxicity, and the fact that it makes good physiological sense to block the local proliferative effects of estrogens directly at the breast. But are estrogens the only hormones with a proliferative impact on the breast and on breast cancers? This chapter focuses on evidence that progesterone also has proliferative actions in the breast; on preliminary data showing that progesterone antagonists may be new tools for the management of metastatic breast cancer; and on recent data suggesting that antiprogestin-occupied PR have novel mechanisms of action that bear on tissue specificity and development of hormone resistance.

Mechanisms of action of endocrine treatment in breast cancer

Endocrine treatment plays an important role in the therapy of breast cancer. While the basic mechanisms are understood, additional mechanisms may be of importance to their action and they may also contribute to the mechanism(s) of acquired resistance. Currently, several novel drugs are entering into clinical trials. Observations of the absence or presence of cross resistance to novel 'pure' steroidal antiestrogens and the non-steroidal tamoxifen may add important information to our understanding of the mechanisms of action of both classes of drugs. Similarly, exploration of different aromatase inhibitors in sequence or concert, as well as the combining of different endocrine treatment options may be warranted. Additionally, alterations in different biochemical parameters such as growth factors should not only be carefully explored in relation to treatment options but should also be followed during the course of treatment to asess alterations over time and in relation to the development of drug resistance.

Molecular biology of breast carcinoma

During the last several years basic research has resulted in the identification of many of the factors involved in signal transduction pathways, leading us to a greater understanding of the mechanisms of growth control in breast cancer cells. Many of these factors are the products of proto-oncogenes or suppressor genes. This review describes the role of some of these factors in breast cancer development, progression, and metastasis and discusses implications for future directions.

High-dose progestin therapy for metastatic breast cancer

Progestin therapy has become an established endocrine modality for the treatment of metastatic breast cancer, with medroxyprogesterone acetate and megestrol acetate being the most widely used agents. Both drugs display similar effectiveness as initial and secondary therapy for patients with advanced disease, with combined complete and partial response rates of approximately 30% to 40%. Uncontrolled trials have suggested that high doses of medroxyprogesterone may be more effective than lower doses, but randomized trials have yielded conflicting results. Clinical trials of megestrol acetate have demonstrated it to be an affective, well-tolerated oral progestin, and a recent randomized trial has suggested that higher megestrol acetate doses may be associated with not only improved response but also improved time to disease progression and survival. Further trials of high-dose megestrol acetate for both initial and secondary therapy are under way, and their results will provide valuable information concerning the role of such treatment.

Endocrine therapy for advanced breast cancer: a review

More than 45,000 women will die of metastatic breast cancer in the United States in 1991. Endocrine therapy remains a major option for treatment of such patients, and results in complete plus partial response rates of 30% with a median duration of approximately one year. Postmenopausal status, increased age, a prolonged disease-free interval, bone and soft tissue metastases, and positive estrogen and progesterone receptors are all associated with an increased response to endocrine therapy. The use of additive hormonal therapy, specifically antiestrogens, progestins, and aromatase inhibitors, have replaced surgical ablative procedures in the majority of patients; response rates to antiestrogen therapy, progestin therapy, and aromatase inhibitors are similar, but antiestrogens have generally been associated with the most favorable therapeutic index. At present, there is no convincing evidence that either combinations of endocrine therapies or endocrine therapy combined with chemotherapy are associated with an improvement in survival for patients with metastatic disease. Future research efforts directed at defining the molecular mechanisms of endocrine activity should facilitate clinical trials of newer and potentially more effective agents. All patients with metastatic breast cancer should be considered for at least one trial of endocrine therapy provided their metastatic disease is not rapidly progressive or life-threatening.

Progestins in breast cancer treatment. A review

The two most widely used synthetic progestins in breast cancer treatment, medroxyprogesterone acetate (MPA) and megestrol acetate (MA), are reviewed with regard to pharmacological, endocrinological and clinical aspects. In high oral doses as second- or first-line endocrine therapy in advanced breast cancer, they give a similar response rate as tamoxifen (TAM) and aminoglutethimide (AG). The mechanism of action is probably complex. Considerable changes in serum levels of different hormones are induced by progestin treatment. The decrease of serum estrone sulfate (E1S) may be part of the therapeutic mechanism. Some studies suggest that the two drugs, MPA and MA, have a different mode of action, and possibly a low cross resistance. Randomized studies using the two progestins with a cross-over design may answer these questions. Further studies on the influence of progestin on different receptors and growth factors are warranted. To determine the most effective clinical dose of the two progestins, studies with increasing therapeutic doses are needed.

Phase I clinical and pharmacokinetics study of high-dose toremifene in postmenopausal patients with advanced breast cancer

Toremifene is an antiestrogen that binds strongly to estrogen receptors (ER). A total of 19 previously treated postmenopausal women with metastatic breast cancer whose performance status was good and whose ER status was positive or unknown were studied to determine the maximum tolerated dose of toremifene. Cohorts of patients received 200, 300, or 400 mg/m2 p.o. daily until relapse or unacceptable toxicity had occurred. Nausea, vomiting, and dizziness were dose-related. Three of five patients receiving 400 mg/m2 experienced moderate or severe vomiting and another developed reversible disorientation and hallucinations. Mild sweating, peripheral edema, vaginal discharge, and hot flushes were encountered at all doses. Reversible corneal pigmentation was identified in seven cases but was not of clinical importance. The pharmacokinetics of toremifene was studied weekly and in detail on day 42 using a high-performance liquid chromatographic (HPLC) assay that identified the parent compound and three active metabolites, N-desmethyltoremifene, (deaminohydroxy)toremifene, and didemethyltoremifene. Steady state was achieved at 1-3 weeks. The toremifene area under the curve and the maximal concentration were dose-dependent at high doses. The recommended phase II dose is 300 mg/m2 p.o. daily.

Tumors metastatic to the orbit: a changing picture

Clinical characteristics of tumors metastatic to the orbit are related to primary tumor biology, and vary substantially among the various primary types. Common known primary sites include breast, lung, prostate, and melanoma. Tumor presentations can be classified into four generalized syndromes of mass, infiltrative, inflammatory, and functional effects. We found the infiltrative syndrome of presentation to be more common than for other types of orbital neoplasm. Accurate diagnosis often depends on recognition of the types of clinical syndromes and on the use of diagnostic modalities such as computed tomography, magnetic resonance imaging, fine needle aspiration biopsy, and open biopsy. Special histologic techniques are often useful in determining the origin of these often poorly differentiated tumors, and can provide a basis for specific hormonal therapy. Ophthalmologists play a vital role in the diagnosis of metastatic cancer; the orbital tumor was the presenting sign of systemic cancer in 42% of the cases reviewed. Although the overall prognosis for patients with metastatic cancer is quite poor, specific therapy is available for a growing number of cancers. Timely intervention based on accurate diagnosis can dramatically improve the duration and quality of life with selected tumors.

Influence of progestins on serum hormone levels in postmenopausal women with advanced breast cancer--II. A differential effect of megestrol acetate and medroxyprogesterone acetate on serum estrone sulfate and sex hormone binding globulin

Serum estradiol, estrone, estrone sulfate and sex hormone binding globulin were measured in 10 postmenopausal patients with advanced breast cancer receiving sequential treatment with medroxyprogesterone acetate and megestrol acetate. Treatment with megestrol acetate caused a non-significant reduction in serum estradiol (mean reduction of 19%, 0.05 less than P less than 0.1) but significant reductions in serum estrone (mean reduction of 20%, P less than 0.02) and serum estrone sulfate (mean reduction of 54%, P less than 0.005) compared to treatment with medroxyprogesterone acetate. In contrast, treatment with medroxyprogesterone acetate reduced serum sex hormone binding globulin more compared to treatment with megestrol acetate (mean reduction of 69%, P less than 0.01). These findings suggest that the two progestins have differential effects on serum hormone levels. The finding that treatment with megestrol acetate causes a significant reduction in serum estrone sulfate level warrants further investigations of this potentially important mechanism of action of this drug in advanced breast cancer.

The significance of hormone receptors to predict the endocrine responsiveness of human breast cancer

The paper reviews clinical data on the correlation between the response of human breast cancer to endocrine therapy and the tumour cell content of receptors of e.g. oestrogen (OeR), progesterone (PgR), androgens (AR) and the epidermal growth factor (EGFR). In advanced disease there is a well established correlation between OeR content and the rate of objective response to all types of endocrine therapy. However, if selection of first-line salvage therapy based on OeR status will result in prolonged survival or improved quality of life remains controversial. Assays of PgR, AR, and EGFR--in addition to OeR--increase the predictive ability but no study has been able to define an entirely unresponsive subgroup of patients on the basis of receptor status. In the adjuvant setting conflicting relationships have been reported. Some authors have found a benefit with tamoxifen also among OeR negative patients whereas others have concluded that adjuvant tamoxifen is ineffective in such patients. Prospective randomized trials are warranted to further assess the predictive value of hormone receptors, particularly in view of the increased frequency of thrombotic events and endometrial cancer associated with long-term adjuvant tamoxifen.

Megestrol acetate versus aminoglutethimide for metastatic breast cancer

In this prospective, randomized study the clinical response and toxicity of megestrol acetate (MA) and aminoglutethimide (AG) as second-line treatment in patients with metastatic breast cancer was compared. 176 patients were included, and 150 received treatment greater than 8 weeks and are evaluable for treatment response. The two groups did not differ with regard to prognostic factors. Response rate for the AG and MA groups were 34% and 31% respectively, with duration of response of 13.1 and 13.0 months. Stable disease was obtained in 33% and 35% respectively. No difference was observed in survival. Side effects occurred more frequently in the AG group (42%) than in the MA group (18%).

Immunohistochemical analysis of the topographical relationship between the estrogen- and progesterone receptor in five human breast cancers. A simultaneous demonstration of both nuclear receptors in the same section by using a computer-assisted image processing

A technique is described which allows precise assessment of the topographical relationship between the estrogen receptor (ER) and the progesterone receptor (PR) in the same histological section. It is based on the analysis of the results of immunohistochemical double staining by computer-assisted image processing. Five human ductal breast cancers were examined. The simultaneous demonstration of both receptors consists in the following principal steps: The primary antisera against the ER (monoclonal rat antibody) and the PR (monoclonal mouse antibody) are incubated simultaneously, but only the anti-ER antibody is demonstrated in the first staining step by using a goat anti-rat antibody as the linking antibody and the PAP complex from the rat, both antisera from the ER-ICA kit. The result is stored as a digitized grey image ("1. object image"). Then the colored end product and the residual peroxidase activity of the PAP complex are removed. In the second staining sequence the anti-PR-antibody is demonstrated by using a rabbit anti-mouse antibody as the linking antibody and the PAP complex from the mouse. The result is exactly positioned and also stored as a digitized grey image ("2. object image"). Though antibodies raised in different species were used, cross-reactivity could not be avoided. Grey values generated by cross-reactivity between the different antibody systems are evaluated in negative controls and are eliminated in the object images. The remaining (specifically stained) structures of both object images are copied into a final image so that the topographical relationship of the ER and the PR becomes obvious. The results show that in the five carcinomas investigated three types of receptor-positive tumour cells can be distinguished: Cells which coexpress the ER and the PR (1), cells which express either the ER (2) or the PR (3). The number of tumour cells showing one of these expression patterns varies from tumour to tumour.

Oral high-dose progestins as treatment for advanced breast cancer

Fifty-two postmenopausal, previously treated advanced breast cancer patients who received oral high-dose progestins (medroxyprogesterone acetate [MPA] and/or megestrol acetate [MA]) were retrospectively reviewed. MPA was given to 45 patients and MA to 17 (10 earlier treated with MPA); 48 were evaluable for clinical response to progestin treatment, 43 for MPA and 5 for MA. Two complete responses and 10 partial responses (25%) with median duration of 9.5 months were seen. Forty percent of the patients obtained stable disease greater than or equal to 6 months with a median duration of 8.0 months. In patients with estradiol receptor positive (n = 31) and estradiol and progesterone receptor positive (n = 19) tumors the response rates were 35% and 37% respectively. No differences in serum levels of MPA or MA were observed in the different responding groups. The serum levels of MA were twice as high as MPA in spite of a dose of 160 mg/day of MA compared to 1,000 mg/day of MPA. A long disease-free interval, and positive receptor status of primary or metastatic lesions seemed to predict response to endocrine therapy even late in a therapeutic sequence. Side effects occurred in 11/45 (24%) of MPA treated patients and in 1/15 (7%) of MA treated patients. No difference in serum levels of MPA was found between patients with side effects and patients without side effects.

Progestin regulation of EGF-receptor mRNA accumulation in T-47D human breast cancer cells

Incubation of T-47D human breast cancer cells with the synthetic progestin, medroxyprogesterone acetate (MPA), resulted in a time and dose-dependent increase in epidermal growth factor-receptor (EGF-R) mRNA. Concentrations of MPA as low as 1 nM resulted in a greater than five fold increase in EGF-R mRNA. A significant increase (2-3 fold) in EGF-R mRNA was apparent 12 hr after exposure to MPA and a further increase was seen 12-48 hr after addition of MPA to the cultures. From these studies it is concluded that the increased EGF binding in progestin-treated T-47D cells results at least in part from increased EGF-R gene expression. We believe this is the first report of a steroid hormone modulating expression of this growth factor receptor gene.

Role of receptor occupancy in the transition from responsive to unresponsive states in cultured breast tumor cells

Progression from a steroid sensitive to insensitive state is characteristic of breast tumors, but little is known about the molecular mechanisms involved. Changes in steroid receptor can be associated with the progression. This paper reviews the cell culture data pertaining to loss of response and concludes that loss of receptor is a consequence rather than a cause of insensitivity. This view is based on evidence that loss of all response parameters occurs despite the presence of fully functional receptors as determined by transfection experiments. The postreceptor defect appears to be at the level of the hormone response element of the responsive genes and may involve DNA methylation. The implications of the model for human breast cancer biology are discussed.

Progression to steroid insensitivity can occur irrespective of the presence of functional steroid receptors

A major problem in treatment of cancers arising in steroid-sensitive cells is their inevitable progression to a steroid-insensitive state; current therapies are based on the assumption that hormone insensitivity is associated with loss of receptor. We demonstrate for the first time that breast tumor cells can progress to steroid insensitivity in spite of functional steroid receptors. Transfection of the steroid-inducible LTR-C3 gene into unresponsive S115 mouse mammary tumor cells results in full inducibility of that gene with both androgen and glucocorticoid. Thus, although all known endogenous inducible parameters are lost, the steroid sensitivity of a transfected exogenous gene demonstrates that the machinery for steroid responsiveness is still fully functional. Furthermore, these transfected genes retain steroid sensitivity only while steroid is present; on prolonged withdrawal of steroid, they lose responsiveness, implying an epigenetic mechanism is involved.

Progesterone receptor activity and the response to the first endocrine therapy in advanced breast cancer

The predictive value of the progesterone receptor activity (PgR) was studied in a group of 84 patients with estradiol receptor (ER) positive advanced breast cancer who received their first endocrine treatment (tamoxifen or ovariectomy), with special emphasis on the timing of the receptor analysis. All patients were treated at 1 center and receptor analyses performed in 1 laboratory. In the group of 27 patients with PgR analysis performed immediately prior to the start of treatment, 14 out of 18 PgR+ve and only 2 out of 9 PgR-ve patients responded (P less than 0.02). In contrast, when PgR was analysed greater than 6 months prior to the start of treatment, the response rates for PgR+ve and PgR-ve patients did not differ significantly: 55% vs. 33% respectively. With regard to quantitative rather than qualitative PgR data, PgR levels exceeding 100 fmol/mg protein irrespective of ER levels, are an excellent indicator of hormonal responsiveness with a response rate of more than 80%, even if PgR analyses are performed long before the start of treatment.

Modulation of the progesterone receptor in the fetal uterus of the progesterone-primed guinea pig in vivo and in organ culture

Guinea pig fetuses were treated with progesterone for 7 days before placing fetal uteri in organ culture to see if progesterone pre-treatment of fetuses in utero would permanently inhibit the spontaneous rise in progesterone receptor which occurs in organ culture. The data show that: the basal level of progesterone receptor in fetal uteri was not affected by the progesterone treatment and progesterone receptor concentrations in vitro were also not inhibited. When guinea pig fetuses were treated sequentially with progesterone and estradiol, estradiol failed to provoke an uterotrophic effect but it retained its ability to stimulate progesterone receptor concentrations.