Predicting distant dissemination in patients with early breast cancer

Prognostic value and distribution pattern of tumor infiltrating lymphocytes and their subsets in distant metastases of advanced breast cancer

BACKGROUND

There are significant correlations between the levels of tumor infiltrating lymphocytes (TILs) and the prognosis of primary breast cancer. While little is known about immunological mechanisms in the distant metastasis of advanced breast cancer.

PATIENTS AND METHODS

A total of 106 patients with advanced metastatic breast cancer were enrolled in this study between 2016 and 2022. Hematoxylin and eosin staining and immunohistochemistry were used to assess the densities of stromal TILs (sTILs), intratumoral TILs (iTILs) and invasive marginal TILs (imTILs) and CD4+, CD8+, CD20+, FOXP3+ TILs in the primary tumor and metastasis (bone, lung, liver, and distant lymph node) of advanced breast cancer.

RESULTS

Higher levels of sTILs at metastatic sites were associated with better progression-free survival (PFS), postmetastasis survival (PMS) and overall survival (OS) (p = .026, .001 and .005, respectively). The levels of iTILs were significantly lower than those of sTILs and imTILs in both primary tumor (p< .001, both) and metastasis (p< .001, both). The level of CD4+ T cells was higher than those of CD8+ T cells and CD20+ B cells in both primary tumor (p < .001) and metastasis (p < .001). The levels of sTILs (p=0. 001) and imTILs (p< .001) in the primary tumor were generally higher than those in the metastasis.

CONCLUSION

The levels of TILs and their subsets can predict the survival and prognosis of patients with advanced breast cancer. The distributions of TILs and their subsets are similar between the primary tumor and metastasis. The metastases have a lower degree of lymphocytes infiltration than its corresponding primary tumor.

Model-based inference of metastatic seeding rates in de novo metastatic breast cancer reveals the impact of secondary seeding and molecular subtype

We present a stochastic network model of metastasis spread for de novo metastatic breast cancer, composed of tumor to metastasis (primary seeding) and metastasis to metastasis spread (secondary seeding), parameterized using the SEER (Surveillance, Epidemiology, and End Results) database. The model provides a quantification of tumor cell dissemination rates between the tumor and metastasis sites. These rates were used to estimate the probability of developing a metastasis for untreated patients. The model was validated using tenfold cross-validation. We also investigated the effect of HER2 (Human Epidermal Growth Factor Receptor 2) status, estrogen receptor (ER) status and progesterone receptor (PR) status on the probability of metastatic spread. We found that dissemination rate through secondary seeding is up to 300 times higher than through primary seeding. Hormone receptor positivity promotes seeding to the bone and reduces seeding to the lungs and primary seeding to the liver, while HER2 expression increases dissemination to the bone, lungs and primary seeding to the liver. Secondary seeding from the lungs to the liver seems to be hormone receptor-independent, while that from the lungs to the brain appears HER2-independent.

Prediction of distant metastatic recurrence by tumor-infiltrating lymphocytes in hormone receptor-positive breast cancer

BACKGROUND

Breast cancer subtypes are known to have different metastatic recurrence sites. Distant metastases are often observed during the post-operative course in patients with human epidermal growth factor receptor 2 (HER2)-enriched breast cancer and triple-negative breast cancer, but are relatively rare in those with hormone receptor-positive and HER2-negative (HR+/HER2-) breast cancer. Tumor-infiltrating lymphocytes (TILs) serve as an index to monitor tumor immune microenvironment and may possibly predict the prognosis and therapeutic effect in breast cancer. This study aimed to investigate the correlation between TIL density and recurrence site in HR+/HER2- breast cancer.

METHODS

In stages I-II of HR+/HER2- breast cancer patients who underwent surgery as the first treatment and received adjuvant endocrine therapy (except adjuvant chemotherapy), forty-two patients relapsed after surgery. TILs were evaluated using needle biopsy specimens for the diagnosis of breast cancer. Morphological assessment was conducted using conventional hematoxylin and eosin staining.

RESULTS

Six patients had no TILs density. In them, local recurrence was significantly less (p = 0.022), while distant metastases were significantly more (p = 0.015) compared to those in patients with TIL density. Therefore, for the prediction of distant metastases in HR+/HER2- breast cancer without chemotherapy, TILs could be used as predictors in univariate analysis (p = 0.015, odds ratio [OR] = 0.127), although not as independent factors (p = 0.285, OR = 0.144).

CONCLUSIONS

Our findings indicate that TILs may predict distant metastatic recurrence in stages I-II of HR+/HER2- breast cancer in patients who do not undergo chemotherapy.

A Clinical Decision Support System for Predicting Invasive Breast Cancer Recurrence: Preliminary Results

The mortality associated to breast cancer is in many cases related to metastasization and recurrence. Personalized treatment strategies are critical for the outcomes improvement of BC patients and the Clinical Decision Support Systems can have an important role in medical practice. In this paper, we present the preliminary results of a prediction model of the Breast Cancer Recurrence (BCR) within five and ten years after diagnosis. The main breast cancer-related and treatment-related features of 256 patients referred to Istituto Tumori “Giovanni Paolo II” of Bari (Italy) were used to train machine learning algorithms at the-state-of-the-art. Firstly, we implemented several feature importance techniques and then we evaluated the prediction performances of BCR within 5 and 10 years after the first diagnosis by means different classifiers. By using a small number of features, the models reached highly performing results both with reference to the BCR within 5 years and within 10 years with an accuracy of 77.50% and 80.39% and a sensitivity of 92.31% and 95.83% respectively, in the hold-out sample test. Despite validation studies are needed on larger samples, our results are promising for the development of a reliable prognostic supporting tool for clinicians in the definition of personalized treatment plans.

The cost-effectiveness of neoadjuvant chemotherapy in women with locally advanced breast cancer: Adriamycin and cyclophosphamide in comparison with paclitaxel and gemcitabine

Background:

A decision analysis model was developed to assess the cost-effectiveness of adriamycin and cyclophosphamide (AC) in comparison with paclitaxel and gemcitabine (PG) in women with advanced breast cancer in Iran.

Materials and Methods:

This is a cost-effectiveness analysis performed as a cross-sectional study in Namazi Hospital in Shiraz, Iran. Patients were divided into two groups by random numbers, 32 women in the AC group and 32 women in the PG group. The costs were measured using the societal perspective and effectiveness of 2 regimens were assessed using tumor response. By a decision tree, the incremental cost-effectiveness ratio was calculated. In addition, the robustness of results was examined by sensitivity analysis.

Results:

The estimated total cost of AC and PG per patient was 1565.23 ± 765.31 and 2099.08 ± 926.99, respectively. Response to treatment in AC and PG arm were 84% versus 75% respectively. The incremental cost-effectiveness ratio results showed AC is a dominate alternative.

Conclusion:

Overall, AC was a simple dominate strategy. In other words, AC was estimated to have a lower cost and greater effectiveness than PG.

A Novel Prognostic Nomogram for Predicting Risks of Distant Failure in Patients with Invasive Breast Cancer Following Postoperative Adjuvant Radiotherapy

Purpose

This study aimed to identify predictors for distant metastatic behavior and build a related prognostic nomogram in breast cancer.

Materials and Methods

A total of 1,181 patients with non-metastatic breast cancer between 2003 and 2011 were analyzed. To predict the probability of distant metastasis, a nomogram was constructed based on prognostic factors identified using a Cox proportional hazards model.

Results

The 7-year overall survival and 5-year post-progression survival of locoregional versus distant recurrence groups were 67.6% versus 39.1% (p=0.027) and 54.2% versus 33.5% (p=0.043), respectively. Patients who developed distant metastasis showed early and late mortality risk peaks within 3 and after 5 years of follow-up, respectively, but a broad and low risk increment was observed in other patients with locoregional relapse. In multivariate analysis of distant metastasis-free interval, age (≥ 45 years vs. < 45 years), molecular subtypes (luminal A vs. luminal B, human epidermal growth receptor 2, and triple negative), T category (T1 vs. T2-3 and T4), and N category (N0 vs. N1 and N2-3) were independently associated (p < 0.05 for all). Regarding the significant factors, a well-validated nomogram was established (concordance index, 0.812). The risk score level of patients with initial brain failure was higher than those of non-brain sites (p=0.029).

Conclusion

The nomogram could be useful for predicting the individual probability of distant recurrence in breast cancer. In high-risk patients based on the risk scores, more aggressive systemic therapy and closer surveillance for metastatic failure should be considered.

A Hybrid Computer-aided-diagnosis System for Prediction of Breast Cancer Recurrence (HPBCR) Using Optimized Ensemble Learning

Cancer is a collection of diseases that involves growing abnormal cells with the potential to invade or spread to the body. Breast cancer is the second leading cause of cancer death among women. A method for 5-year breast cancer recurrence prediction is presented in this manuscript. Clinicopathologic characteristics of 579 breast cancer patients (recurrence prevalence of 19.3%) were analyzed and discriminative features were selected using statistical feature selection methods. They were further refined by Particle Swarm Optimization (PSO) as the inputs of the classification system with ensemble learning (Bagged Decision Tree: BDT). The proper combination of selected categorical features and also the weight (importance) of the selected interval-measurement-scale features were identified by the PSO algorithm. The performance of HPBCR (hybrid predictor of breast cancer recurrence) was assessed using the holdout and 4-fold cross-validation. Three other classifiers namely as supported vector machines, DT, and multilayer perceptron neural network were used for comparison. The selected features were diagnosis age, tumor size, lymph node involvement ratio, number of involved axillary lymph nodes, progesterone receptor expression, having hormone therapy and type of surgery. The minimum sensitivity, specificity, precision and accuracy of HPBCR were 77%, 93%, 95% and 85%, respectively in the entire cross-validation folds and the hold-out test fold. HPBCR outperformed the other tested classifiers. It showed excellent agreement with the gold standard (i.e. the oncologist opinion after blood tumor marker and imaging tests, and tissue biopsy). This algorithm is thus a promising online tool for the prediction of breast cancer recurrence.

Metastasis to the Thyroid Gland: A Critical Review

Background

Metastasis to the thyroid gland from nonthyroid sites is an uncommon clinical presentation in surgical practice. The aim of this review was to assess its incidence management and outcomes.

Methods

A literature review was performed to identify reports of metastases to the thyroid gland. Both clinical and autopsy series were included.

Results

Metastases to the gland may be discovered at the time of diagnosis of the primary tumor, after preoperative investigation of a neck mass, or on histologic examination of a thyroidectomy specimen. The most common primary tumors in autopsy studies are from the lung. In clinical series, renal cell carcinoma is most common. For patients with widespread metastases in the setting of an aggressive malignancy, surgery is rarely indicated. However, when patients present with an isolated metastasis diagnosed during follow-up of indolent disease, surgery may achieve control of the central neck and even long-term cure. Other prognosticators include features of the primary tumor, time interval between initial diagnosis and metastasis, and extrathyroid extent of disease.

Conclusions

In patients with thyroid metastases, communication among clinicians treating the thyroid and the index primary tumor is essential. The setting is complex, and decisions must be made considering the features of the primary tumor, overall burden of metastases, and comorbidities. Careful balancing of these factors influences individualized approaches.

Assay of serum CEACAM1 as a potential biomarker for breast cancer

BACKGROUND

Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) is a widely expressed multi-functional adhesion molecule reported to serve as a serum biomarker in several types of cancer. However, the serum CEACAM1 expression in breast cancer is unclear. We investigated the serum concentrations of CEACAM1 in patients with breast cancer and determine the potential of serum CEACAM1 as a breast cancer biomarker.

METHODS

Serum specimens were obtained from 33 patients with breast cancer, 30 patients with benign breast diseases and 34 healthy donors. The serum CEACAM1 concentrations were examined by an enzyme-linked immunosorbent assay (ELISA).

RESULTS

The serum CEACAM1 concentrations in the malignant group (532 ng/ml) were significantly higher than those of the benign group (423 ng/ml) and healthy control group (386 ng/ml) (both p<0.001). Based on univariable logistic regression, serum CEACAM1 concentrations significantly predicted breast cancer versus normal controls or benign breast diseases. Area under receiver operating characteristic curve (ROC) for serum CEACAM1 was 0.925(95% CI: 0.866-0.984). The optimal cut-off concentration of CEACAM1 was 475.82 ng/ml for discriminating breast cancer from normal controls.

CONCLUSION

Serum concentrations of CEACAM1 may serve as a useful indicator for the presence of breast cancer.

Expression of proliferation markers Ki67, cyclin A, geminin and aurora-kinase A in primary breast carcinomas and corresponding distant metastases

Aims

To assess the expression of the following cell cycle regulatory proteins in primary metastatic breast carcinomas (MBCs) and on availability in matched distant metastases (DMs): Ki67, cyclin A, geminin and aurora-kinase A (aurkA); and to compare the expression of these markers in early MBC (EMBC) and late MBC separated into groups according to median time point on metastatic event occurred (28 months).

Methods

The expression of the above mentioned markers was analysed in a total of 47 primary MBCs and 59 DMs (out of which 37 were pairs) by immunohistochemistry. Fourteen breast carcinomas with no relapse over a 10-year follow-up period were utilised as control cases (CBC).

Results

Among the MBCs, 22 metastasised to the bone, 4 to the lung and 21 to the central nervous system (CNS). Geminin (p<0.001) and Ki67 (p=0.001) were increased in the MBCs while aurkA and cyclin A showed no difference when compared with CBCs. There were no differences between aurkA, cyclin A and geminin expression in MBCs and DMs in general. Expression of Ki67 was, however, elevated (p=0.027) in DMs. In CNS metastases all markers showed elevated expression as compared to MBCs. In bone metastases, geminin was lower (p<0.001) compared with primary MBCs. In the metastases of the lung, the evaluated markers did not show different expression. According to the median follow-up until the metastatic event, Ki67 was found to be significantly elevated in EMBC (p=0.018).

Conclusions

Ki67 index and geminin distinguish a fraction of MBC with worse prognosis, showing increased levels in the latter in comparison to CBC being tumour-free over a 10-year follow-up period. Ki67 could possibly identify a group of MBCs that develop early DMs.

Calponin-h2: a potential serum marker for the early detection of human breast cancer?

Early diagnosis is the key for the successful treatment of breast cancer. A serum marker for the early detection of breast cancer could significantly reduce breast cancer morbidity and mortality by bringing the time of diagnosis at an earlier and therefore still curable stage. So far, no biomarker for the early detection is available for the clinical routine. The aim of the present study was to evaluate the use of calponin-h2 as a blood-based biomarker for the early diagnosis of this disease. Using two monoclonal antibodies against calponin-h2, we developed a sandwich ELISA to analyze the serum levels of calponin-h2. In order to evaluate the diagnostic potential of this biomarker, patients with breast cancer (n = 76), benign diseases of the breast (n = 51) and healthy females (n = 24) were analyzed. Serum levels above 10 ng/ml were only observed in patients with breast cancer (n = 8; 10.5%). Further large-scale studies and preanalytic evaluations are necessary to clarify the definite role of calponin-h2 as a biomarker in breast cancer management.

Antiproliferation and induction of caspase-8-dependent mitochondria-mediated apoptosis by β-tocotrienol in human lung and brain cancer cell lines

The pure vitamin isomer, β-tocotrienol has the least abundance among the other vitamin E isomers that are present in numerous plants. Hence, it is very scarcely studied for its bioactivity. In this study, the antiproliferative effects and primary apoptotic mechanisms of β-tocotrienol on human lung adenocarcinoma A549 and glioblastoma U87MG cells were investigated. It was evidenced that β-tocotrienol had inhibited the growth of both A549 (GI50=1.38±0.334μM) and U87MG (GI50=2.53±0.604μM) cells at rather low concentrations. Cancer cells incubated with β-tocotrienol were also found to exhibit hallmarks of apoptotic morphologies including membrane blebbing, chromatin condensation and formation of apoptotic bodies. The apoptotic properties of β-tocotrienol in both A549 and U87MG cells were the results of its capability to induce significant (P<0.05) double-strand DNA breaks (DSBs) without involving single-strand DNA breaks (SSBs). β-Tocotrienol is said to induce activation of caspase-8 in both A549 and U87MG cells guided by no activation when caspase-8 inhibitor, z-IETD-fmk was added. Besides, disruption on the mitochondrial membrane permeability of the cells in a concentration- and time-dependent manner had occurred. The induction of apoptosis by β-tocotrienol in A549 and U87MG cells was confirmed to involve both the death-receptor mediated and mitochondria-dependent apoptotic pathways. These findings could potentiate the palm oil derived β-tocotrienol to serve as a new anticancer agent for treating human lung and brain cancers.

Preoperative MRI in patients with locoregional recurrent breast cancer: influence on treatment modalities

RATIONALE AND OBJECTIVES

The purpose of this analysis was to evaluate the impact of preoperative magnetic resonance imaging (MRI) on management in patients with locoregional recurrent breast cancer.

MATERIALS AND METHODS

Forty-three patients who underwent treatment for locoregional relapse of breast cancer from 2008 through 2012 were analyzed. All patients underwent both conventional surveillance by mammography, ultrasound, and clinical examination and subsequent bilateral breast MRI.

RESULTS

Preoperative MRI detected additional tumor foci in 15 of 43 patients (34.9%). In two cases (4.7%), the diagnosis of occult sites had no influence on the subsequent treatment. Two patients (4.7%) had an unfavorable change of surgical management with unnecessary additional resection of benign foci. Eleven patients benefited from the MRI scan detecting malignant occult lesions (25.6%) resulting in either additional surgical resection or radiotherapy. Patient and tumor characteristics in primary disease did not differ significantly between patients with a favorable impact on surgical management and patients who experienced either no benefit or even disadvantage from MRI scan.

CONCLUSIONS

Preoperative breast MRI has a strong impact on the management of locoregional recurrent breast cancer. This study demonstrates that breast MRI is a powerful supplement to conventional diagnostic work-up, both during follow-up or preoperative treatment planning in recurrent disease.

Thyroid metastasectomy

Metastases to the thyroid gland are uncommon. Renal, lung, breast, and colon cancer and melanoma are the most common primary diseases implicated. Few retrospective series have been reported. Treatment decisions must be individualized, and will depend on the state of systemic disease. Selected patients could benefit from surgical treatment. Although most patients selected for surgery will not be cured, the aim of surgery is to avoid the complications of uncontrolled central neck disease.

Acalypha wilkesiana extracts induce apoptosis by causing single strand and double strand DNA breaks

ETHNOPHARMACOLOGICAL RELEVANCE

The seeds of Acalypha wilkesiana have been used empirically by traditional healers in Southwest Nigeria together with other plants as a powder mixture to treat patients with breast tumours and inflammation.

AIM OF THE STUDY

There is an increasing interest among researchers in searching for new anticancer drugs from natural resources, particularly plants. This study aimed to investigate the anticancer properties of Acalypha wilkesiana extracts and the characteristics of DNA damage against brain and lung cancer cells.

MATERIALS AND METHODS

The antiproliferative activity of Acalypha wilkesiana extracts (ethyl acetate, hexane, and ethanol) was examined on human glioma (U87MG), human lung carcinoma (A549), and human lung fibroblast (MRC5) cells.

RESULTS

Cell viability MTT assay revealed that ethyl acetate extract of the plant possessed significant antiproliferative effects against both U87MG (GI(50)=28.03 ± 6.44 μg/ml) and A549 (GI(50)=89.63 ± 2.12 μg/ml) cells (p value<0.0001). The hexane extract was found to exhibit crucial antiproliferative effects on U87MG (GI(50)=166.30 ± 30.50 μg/ml) (p value<0.0001) but not on A549 cells. Neither plant extract possessed noticeable antiproliferative effects on the non-cancerous MRC5 cells (GI(50)>300 μg/ml). The ethanol extract showed no antiproliferative effects on any cell line examined. Haematoxylin & Eosin (H & E) staining and single cell gel electrophoresis (SCGE) comet assay confirmed that plant extract-treated cells underwent apoptosis and not necrosis. SCGE comet assays confirmed that plant extracts caused both single strand (SSB) and double strand (DSB) DNA breaks that led to the execution of apoptosis.

CONCLUSION

The extracts (especially ethyl acetate and hexane) of Acalypha wilkesiana possess valuable cytotoxic effects that trigger apoptosis in U87MG and A549 cancer cells through induction of DNA SSBs and DSBs.

Non-invasive proteomics-thinking about personalized breast cancer screening and treatment

The early diagnosis of breast cancer in potentially curable stages improves prognosis and consecutively reduces mortality of breast cancer patients. Established screening programs have an unfavorable connotation due to significant rates of false negative as well as false positive results leading to overdiagnosis and overtherapy. The combination of a non-invasive breast-cancer-suspectability-biomarker with established clinical diagnostics could help to increase the acceptance of population based breast cancer screening programs by creating an individual risk profile, which is irrespective of mammography quality and interpretation. Recently, non-invasive proteomic biomarkers obtained from blood, saliva or nipple aspiration fluid have been extensively investigated and might play a future role in the personalized management of breast cancer screening. A simple, robust and inexpensive, non-invasive test for screening and diagnosis could easily be performed in every medical practice leading to an affordable, high-throughput instrument. This review describes recently investigated proteomic screening biomarkers that could improve the early diagnosis of breast cancer in the following years.

c-erbB-2 and the "triple-state" in early breast carcinomas

Although c-erbB-2 expression is, in general terms, an ominous prognostic indicator in breast carcinomas, there are suggestions that lack of this oncogene, when combined with analogous lack of estrogen (ER negative) and progesterone receptors (PgR negative)-"triple-negative phenotype", is linked with an equally poor prognosis. We investigated this hypothesis in a series of early ductal breast carcinomas. A total of 116 specimens with early breast cancer, defined as tumors of < or =2 cm in size and clinically negative axilla, were studied immunohistochemically for ER, PgR, and c-erbB-2 expression. The median follow-up was 131 months (range 62-245 months). ER positive tumors had a favorable clinical course, compared to ER negative neoplasms, but only for the first 10 years of follow-up (P = 0.04). Prognosis was poorer for the PgR negative cases, relative to PgR positive tumors (P = 0.005), but this stood true for the entire investigation period. Triple-negative breast carcinomas had a poor prognosis, while triple-positive tumors had a favorable outcome. However, if triple-positive and triple-negative cases were excluded from the original sample, the remaining c-erbB-2 positive cases were connected with poor prognosis, relative to the remaining c-erbB-2 negative tumors. c-erbB-2 oncogene has a complex biological role in early breast carcinomas for its expression characterizes subgroups of patients with both favorable (triple-positive phenotype) and unfavorable prognosis (c-erb-B2 positive cases after excluding triple-positive and triple-negative tumors)-a phenomenon presumably due to activation of different biological pathways. Elucidation of these pathways may determine subgroups of patients with tumors requiring different targeted agents.

The impact of loco-regional recurrences on metastatic progression in early-stage breast cancer: a multistate model

To study whether the effects of prognostic factors associated with the occurrence of distant metastases (DM) at primary diagnosis change after the incidence of loco-regional recurrences (LRR) among women treated for invasive stage I or II breast cancer. The study population consisted of 3,601 women, enrolled in EORTC trials 10801, 10854, or 10902 treated for early-stage breast cancer. Data were analysed in a multivariate, multistate model by using multivariate Cox regression models, including a state-dependent covariate. The presence of a LRR in itself is a significant prognostic risk factor (HR: 3.64; 95%-CI: 2.02-6.5) for the occurrence of DM. Main prognostic risk factors for a DM are young age at diagnosis (< or =40: HR: 1.79; 95%-CI: 1.28-2.51), larger tumour size (HR: 1.58; 95%-CI: 1.35-1.84) and node positivity (HR: 2.00; 95%-CI: 1.74-2.30). Adjuvant chemotherapy is protective for a DM (HR: 0.66; 95%-CI: 0.55-0.80). After the occurrence of a LRR the latter protective effect has disappeared (P = 0.009). The presence of LRR in itself is a significant risk factor for DM. For patients who are at risk of developing LRR, effective local control should be the main target of therapy.