Abstract P2-11-13: High PD-L2 Protein Expression in Cancer Cells is an Independent Marker of Unfavorable Prognosis in Luminal Breast Tumors

Background PD-1 inhibitors have shown significant efficacy in triple negative breast cancer (BC), however, durable responses are less common in estrogen receptor-positive (ER+) BC. Better markers are therefore needed that will identify likely responders to PD-1 inhibitors among patients with luminal BC. While most efforts have focused on the immune checkpoint protein PD-L1, the alternative PD-1 ligand, PD-L2, has been largely overlooked. We aimed to determine if PD-L2 is associated with unfavorable prognosis in ER+ BC. Methods PD-L2 protein levels in cancer cells and stromal cells were measured retrospectively by quantitative immunofluorescence histocytometry in tissue microarrays of therapy-naïve, localized or locoregional ER+ BC and correlated with progression-free survival (PFS). Evaluable tumor PD-L2 data were derived from a main study cohort A diagnosed between 1988-2005 (n=684) with extensive clinical and outcome data and from an independent validation cohort B diagnosed between 1992-2012 (n=273). Patients received standard-of-care adjuvant therapy without immune checkpoint inhibitors after tumor resection. Results Univariate analysis of the main cohort A revealed that high PD-L2 expression in cancer cells was associated with shorter PFS (HR=1.8; 95%CI:1.3-2.6; p=0.001), an observation that was validated in an independent cohort B (HR=2.3, 95%CI:1.1-4.8; p=0.026). Approximately one third of ER+ BC cases were classified as high PD-L2. After multivariable adjustment for common clinicopathological variables, high cancer cell levels of PD-L2 remained independently predictive of early recurrence (HR=2.0; 95%CI:1.4-2.9; p< 0.001). Sub-analysis of ER+ BC cases treated with adjuvant chemotherapy (n=197) suggested that high PD-L2 levels in cancer cells was associated with particularly increased risk of progression (multivariable HR=3.4; 95%CI:1.9-6.2; p< 0.001). The observed frequent expression of PD-L2 protein in BC provided scientific rationale for the design of our ongoing phase II clinical trial (NCT04243616) of neoadjuvant combined PD-1 inhibitor (cemiplimab; Regeneron Pharmaceuticals Inc) and chemotherapy in patients diagnosed with PD-L1+ and/or PD-L2+ BC. The primary objective of this trial is to assess pathologic responses to neoadjuvant treatment with secondary objective of assessing the correlation between PD-L1/PD-L2 status and tumor responses. Pathologist review of PD-L1 and PD-L2 expression in an initial set of ER+ tumors (n=15) screened for trial eligibility revealed frequent discordance between cancer cell positivity for PD-L1 and PD-L2 protein (PD-L1: median=0%; range 0-2% vs. PD-L2: median=18%; range < 1-60%) as well as immune cell positivity (PD-L1: median=5%; range 0-50% vs. PD-L2: median=0; range 0-50%). Conclusions In treatment-naïve ER+ breast tumors, high cancer cell expression of PD-L2 protein was an independent predictor of poor clinical outcome, with evidence of further elevated risk of progression in patients who received adjuvant chemotherapy. Preliminary analyses of ER+ tumors from our ongoing clinical trial showed frequent discordance between baseline PD-L1 and PD-L2 protein expression in both cancer cells and immune cells. Collectively, our analyses indicate that PD-L2 has prognostic value for ER+ BC, and our progress justify further studies to determine whether PD-L2, alone or in combination with PD-L1, may serve as a predictive marker of response to PD-1 inhibitors.

Citation Format: Lubna N. Chaudhary, Inna Chervoneva, Amy R. Peck, Yunguang Sun, Misung Yi, John F. Langenheim, Julie M. Jorns, Sailaja Kamaraju, Yee Chung Cheng, John Burfeind, Christopher R. Chitambar, Jeffrey A. Hooke, Albert J. Kovatich, Craig Shriver, Hai Hu, Juan P. Palazzo, Marluce Bibbo, Terry Hyslop, Richard Pestell, Edith P. Mitchell, Hallgeir Rui. High PD-L2 Protein Expression in Cancer Cells is an Independent Marker of Unfavorable Prognosis in Luminal Breast Tumors [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-11-13.

Abstract 5861: Insurance and survival among lung cancer patients: Comparison of the US military health system and the surveillance, epidemiology, and end results (SEER) program

Accessibility to medical care is related health insurance. The U.S. military health system (MHS) provides beneficiaries with universal health care. Our previous studies showed improved survival of the MHS patients with lung cancer compared to those in the US general population covered by the Surveillance, Epidemiology, and End Results (SEER) program. This study expanded the previous studies by further comparing MHS patient with SEER patients with different insurances to provide evidence on the effects of insurance status on survival. The MHS patients were identified from the Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR). The SEER patients were identified from the 18 cancer registries of the SEER program. All patients were diagnosed with histologically confirmed lung cancer between 2007 and 2013. The SEER program defines insurance type as insured (private insurance, Medicare administered through a managed care plan or private supplement), insured/no specifics (Medicare NOS, insurance NOS), any Medicaid (Indian/Public health Service, Medicaid, Medicaid administered through a managed care plan, Medicare with Medicaid eligibility), and uninsured (no insurance, self-pay). The results showed that compared to ACTUR, SEER patients with non-small cell lung cancer exhibited increased risk of mortality regardless of their insurance type. Specifically, the adjusted HR (95% CI) was 1.08 (1.03-1.13), 1.22 (1.16-1.28), 1.40 (1.33-1.47), 1.49 (1.41-1.58), for SEER insured, insured/no specifics, Medicaid, and uninsured, respectively. This pattern was consistently observed in subgroups by age, gender, race, and tumor stage. Among small-cell lung cancer patients, the higher HR compared to ACTUR was significant only for Medicaid (HR=1.24, 95% CI=1.11-1.38) and uninsured (HR=1.28, 95% CI=1.13-1.45). Furthermore, compared to ACTUR, the likelihood of receiving surgery was significantly lower in SEER with odds ratios (95% CIs) of 0.85 (0.76-0.95), 0.64 (0.57-0.72), 0.40 (0.36-0.45), and 0.34 (0.29-0.39) for insured, insurance/no specifics, Medicaid, and uninsured, respectively, and was observed regardless of tumor stage. Our study suggests that the MHS lung cancer patients had survival advantage over the SEER patients and the advantage was even larger when compared to Medicaid or uninsured patients. In addition, the SEER patients were less likely to receive surgery regardless of tumor stage, especially for Medicaid or uninsured patients. Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, opinions, or policies of the USUHS, HJF, the DoD or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Citation Format: Jie Lin, Craig Shriver, Kangmin Zhu. Insurance and survival among lung cancer patients: Comparison of the US military health system and the surveillance, epidemiology, and end results (SEER) program [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5861.

Abstract 5860: Five-year survival of patients with late stage prostate cancer: Comparison of the military health system with the US general population

While the five-year survival for local and regional prostate cancer is nearly 100%, it decreases dramatically for advanced (stages III and IV) prostate cancer. Access to health care is an important factor that affects cancer prognosis. The Military Health System (MHS) provides universal health care to beneficiaries. However, it is unclear whether the universal care translates into improved survival among patients with advanced prostate cancer. We compared survival of patients with advanced prostate cancer between the MHS and the U.S. general population. The MHS patients (N= 5,379) were identified from the Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR). Patients in the U.S. general population (N=21,516) were identified from the Surveillance, Epidemiology, and End Results (SEER) program. All patients were diagnosed between January 1, 1987 and December 31, 2013. The two populations were matched on age (within 5 years), race, and diagnosis year. Multivariable Cox regression hazard model was used to estimate hazard ratios (HRs) for ACTUR compared to SEER. ACTUR patients exhibited longer 5-year survival than matched SEER patients (HR=0.74, 95% CI=0.67-0.83), after adjustment for the potential confounders. In stratified analysis, the improved survival was observed for ages 50 years or older, both white and black races, all tumor stages, and grades. In stratified analysis by treatment receipt, the improved survival of ACTUR patients compared to SEER patients remained regardless of the receipt of surgery or radiation treatment. Our results suggested that MHS beneficiaries with advanced prostate cancer had longer survival than their counterparts in the U.S. general population. Universal health care in the MHS might translate into improved survival for advanced prostate cancer.

Disclaimers: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, opinions, or policies of the USUHS, HJF, the DoD or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Citation Format: Jie Lin, Darryl Nousome, Jiji Jiang, Gregory Chesnut, Craig Shriver, Kangmin Zhu. Five-year survival of patients with late stage prostate cancer: Comparison of the military health system with the US general population [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5860.

Abstract P3-14-04: Genetic testing in non-Hispanic Black women with breast cancer treated within an equal-access healthcare system

Purpose: Identification of women with hereditary forms of cancer allows for use of precision medicine approaches to improve survival. Non-Hispanic Black (NHB) women in the US general population are less likely to undergo genetic testing or utilize risk-reducing strategies. Whether these disparities exist within the equal-access military healthcare system of the Department of Defense is not known. Methods: Genetic test information and surgical procedures were extracted for all NHB and Non-Hispanic Whites (NHW) with invasive breast cancer who were diagnosed and treated at the Murtha Cancer Center at Walter Reed National Military Medical Center and enrolled in the Clinical Breast Care Project. National Comprehensive Cancer Network criteria from the year of diagnosis were assessed for all patients. Data were analyzed using chi-square analysis with p<0.05 defining significance. Results: NHB were significantly (p=0.009) more likely to meet criteria for genetic testing compared to NHW, however, test uptake did not differ significantly between populations (p=0.292). Pathogenic variant frequency (p=0.597), prophylactic mastectomy (p=0.915) and oophorectomy (p=0.076) did not differ significantly between populations. Conclusion: These data demonstrate that when barriers, such as cost and lack of insurance barriers were removed, NHB were as willing to pursue testing and risk-reducing strategies as their NHW counterparts. Increasing the availability of testing and clinical management for NHB with hereditary forms of cancer may help reduce disparate survival seen in the US general population. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of Defense (DoD) or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Citation Format: Rachel Ellsworth, Ashlee Vargason, Clesson Turner, Craig Shriver. Genetic testing in non-Hispanic Black women with breast cancer treated within an equal-access healthcare system [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-14-04.

Abstract PS7-38: Pathologic characteristics of African American women with breast cancer treated at the DoD’s Murtha Cancer Center: Understanding why survival cancer is not disparate to European American women when treated within the US Military Healthcare System

Background: In the United States, breast cancer mortality rates in African American women (AAW) are significantly higher than in European American women (EAW). In contrast, within the Department of Defense Military Healthcare System (DoD MHS) healthcare system, overall survival did not differ significantly between AAW and EAW with early-stage breast cancer. In this study, we evaluated pathological factors of AAW treated within the Murtha Cancer Center at Walter Reed National Military Medical Center to identify factors associated with this lack of disparate outcomes within the DoD MHS. Methods: Between 2001-2018, 345 AAW and 759 EAW treated at MCC/WRNMMC enrolled in the Clinical Breast Care Project (CBCP). Extracted demographic data included BMI, Charlson comorbidity index (CCI), education level and marital and smoking status. All diagnoses were performed by a single breast pathologist and included stage, grade, size, lymph node, hormone receptor and HER2 status. Statistical analyses included odds ratio (OR) and log-rank analyses. Results: Within this cohort, AAW were not at increased risk for having higher CCI scores, cigarette use or a college education, however, AAW were significantly more likely to be obese (OR 2.07, 95% CI 1.5, 2.9) and unmarried (OR 2.4, 95% CI 1.8, 3.2). The average age at diagnosis was 56.1 years in AAW and 57.5 years in EAW with 11% of AAW and 8% of EAW diagnosed <40 years of age. AAW were more likely to have higher stage (OR 1.6, 95% CI 1.3, 2.1), high-grade (OR 2.6, 95% CI 1.9, 3.6), larger (OR 1.6, 95% CI 1.2, 2.1) tumors. AAW were at increased risk for having triple negative tumors (OR 2.1, 95% CI 1.5, 2.9). Neither 5-year nor 10-year survival differed significantly between populations. Conclusion: While a previous study found no overall survival difference in early-stage AAW and EAW treated within the DoD MHS, this study found that across all stages of breast cancer breast cancer-specific survival was not inferior for AAW treated at MCC/WRNMMC. Critically, AAW did not have disparate survival despite having tumors with less favorable pathological characteristics, similar to those seen in the US general population. Evaluation of pre- and post-diagnostic care within DoD MHS should be performed to determine how breast care is provided to AAW within an equal-access healthcare setting and the results used as a model of care template to reduce breast cancer disparities within the US general population. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of Defense (DoD) or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Citation Format: Rachel Ellsworth, Leann Lovejoy, Craig Shriver. Pathologic characteristics of African American women with breast cancer treated at the DoD’s Murtha Cancer Center: Understanding why survival cancer is not disparate to European American women when treated within the US Military Healthcare System [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-38.

Abstract 4624: Should genetic testing for cancer predisposition be standard-of-care for women with invasive breast cancer: The Murtha Cancer Center experience

Background: Currently, genetic testing is recommended to those patients diagnosed with breast cancer at a young age, with triple negative disease, Ashkenazi ancestry and/or a significant family history of breast, ovarian, prostate or pancreatic cancer. This precludes the opportunity to apply precision medicine approaches to women who do not meet these criteria. Timing and uptake of testing in high-risk patients and frequency of mutation detection in low-risk patients was evaluated in a cohort of women with invasive breast cancer treated at the Murtha Cancer Center of the Walter Reed National Military Medical Center (MCC/WRNMMC), the largest hospital of the Department of Defense health-care system.

Methods: 1,231 women enrolled in the Clinical Breast Care Project of the MCC/WRNMMC 2001-2018 with invasive breast cancer. Genetic risk status was estimated using NCCN BRCA1/2 Testing Criteria. Panel testing was performed in the research laboratory for 1,043 women who had genomic (blood) DNA available. Genetic variants across 94 cancer predisposition genes were classified as pathogenic, variant of unknown significance (VUS) or benign using the ClinVar database.

Results: Using NCCN version 1.2018 criteria, 57.8% of patients were eligible for genetic testing. Uptake of testing within the high-risk group was 40.0%; those who pursued genetic testing were significantly (p<0.001) younger and more likely to be college educated. Time-to-testing ranged from 0 to 15.3 years post-diagnosis and 6.3% of women pursued clinical testing only after a second tumor event. 19.3% of the high-risk women with clinical testing, 7.5% of high-risk women who did not pursue clinical testing and 4.4% of low-risk women carried a pathogenic or likely pathogenic mutation.

Conclusions: More than 4% of breast cancer patients who chose not to pursue or were ineligible for genetic testing harbored pathogenic mutations in cancer predisposition genes. These data suggest that inclusion of panel testing at the time of diagnosis would allow for appropriate surveillance and treatment strategies to be employed to reduce the risk of secondary tumors and improve patient outcome. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of Defense (DoD), the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Citation Format: Seth Rummel, Leann Lovejoy, Clesson Turner, Craig Shriver, Rachel Ellsworth. Should genetic testing for cancer predisposition be standard-of-care for women with invasive breast cancer: The Murtha Cancer Center experience [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4624.

Twenty-five-Year Follow-up of a Prospective Randomized Trial Comparing Preoperative Versus Postoperative FLAC/Granulocyte Colony-Stimulating Factor Chemotherapy for Stage II Breast Cancer

BACKGROUND

Preoperative chemotherapy is important in the management of women with breast cancer, with the ability to downstage the breast primary tumor and axillary lymph nodes. Long-term studies are needed to identify late toxicities, recurrence patterns, and equivalency with postoperative chemotherapy for recurrence-free survival (RFS) and overall survival (OS).

PATIENTS AND METHODS

We conducted a single-institution prospective randomized control trial comparing preoperative or postoperative fluorouracil, leucovorin calcium, doxorubicin, and cyclophosphamides/granulocyte colony-stimulating factor chemotherapy for women with untreated clinical stage II (T1N1, T2N0, and T2N1) breast cancer. Long-term follow-up was conducted to define toxicities, recurrence patterns and RFS and OS.

RESULTS

Fifty-three women with clinical stage II breast cancer were randomized, 26 patients to receive preoperative chemotherapy and 27 to receive postoperative chemotherapy. Long-term follow-up, with a median of 25.3 years, was obtained. Local or systemic recurrence occurred in 8 women in the preoperative group and in 10 women in the postoperative group, and recurrences were predominantly within 10 years of treatment. Late toxicities included local upper extremity paresthesia's, upper extremity edema and congestive heart failure in 1 patient each. Analysis revealed no difference in RFS (20-year RFS probabilities; preoperative: 61.3%, postoperative: 54.7%, P=0.42), or in OS between the 2 treatment groups (20-year probabilities, preoperative: 64.6%, postoperative: 62.2%, P=0.44). Twenty-five of 53 patients (47%) were alive and without disease at this follow-up.

CONCLUSION

Twenty-five-year follow-up for this prospective randomized trial confirms the equivalency of preoperative versus postoperative chemotherapy with fluorouracil, leucovorin calcium, doxorubicin, and cyclophosphamides/granulocyte colony-stimulating factor for stage II breast cancer for both RFS and OS.

Pan-cancer analysis of whole genomes

Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale1-3. Here we report the integrative analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter4; identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation5,6; analyses timings and patterns of tumour evolution7; describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity8,9; and evaluates a range of more-specialized features of cancer genomes8,10-18.

Abstract 440: Use of longitudinal samples from the DOD serum repository to identify candidate biomarkers for HNSCC

The Department of Defense Serum Repository (DODSR) represents a unique resource enabling longitudinal studies of cancer risk, progression, and response to therapy. The DODSR was initiated in 1989, initially as a means for HIV surveillance, and is comprised of serum samples from active and reserve military personnel drawn at enlistment and annually or biennially throughout the service members' participation in the Military Health System, accompanied by the service member’s electronic health records. This enables the identification of serum samples for all service members with a particular diagnosis, such as Head and Neck Squamous Cell Carcinoma (HNSCC), a cancer significantly represented in the military population with substantial impact on military operations. For HNSCC, 175 cases diagnosed between 2003 and 2013 were identified, as well as 175 corresponding healthy controls matched for age at the time of diagnosis, gender, and ethnicity. Serum samples drawn at the time of diagnosis, 2 and 4 years prior to diagnosis, and 2 years after diagnosis were retrieved and analyzed by targeted mass spectrometry analysis using a panel of 148 qualified selected reaction monitoring (SRM) assays selected from the curated literature and discussions with military oncologists at the Murtha Cancer Center. Initial analyses of 212 samples (38 cases and 38 matched controls, each with 2-4 longitudinal samples) from the total 978 samples available focused on comparisons of pre-diagnosis and at diagnosis serum proteins. Preliminary results identified proteins that were differentially abundant between serum samples taken from HNSCC cases at the time of diagnosis, compared to age-matched controls. Proteins such as A2GL displayed a trend of gradually increasing abundance as a function of time to diagnosis, in HNSC cases, suggesting behavior that may be proven useful for early detection of HNSCC, prior to overt symptoms. These preliminary results suggest that the DODSR can be used to provide serum samples of sufficiently high quality for extensive proteomic analysis, and form cohorts sufficiently large to enable meaningful statistics. Access to longitudinal samples representing years prior to diagnosis enables the identification of serum factors that predict the risk of cancer and may also enable early diagnosis. Access to post-treatment serum samples accompanied with data indicating the clinical response to treatment enables the development of algorithms predicting response to treatment and may eventually contribute to the selection of appropriate therapies.

Citation Format: Ju Yeon Lee, Tujin Shi, Vladislav Petyuk, Athena Schepmoes, Thomas Fillmore, Wayne Cardoni, George Coppit, Joseph Goodman, Shiv Srivastava, Craig Shriver, Tao Liu, Karin Rodland. Use of longitudinal samples from the DOD serum repository to identify candidate biomarkers for HNSCC [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 440.

Correction to: Phase 2 Open-Label Trial Investigating Percutaneous Laser Ablation for Treatment of Early-Stage Breast Cancer: MRI, Pathology, and Outcome Correlations

The article "Phase 2 Open-Label Trial Investigating Percutaneous Laser Ablation for Treatment of Early-Stage Breast Cancer: MRI, Pathology, and Outcome Correlations", written by Barbara Schwartzberg et al., was originally published electronically on the publisher's internet portal (currently SpringerLink) on July 9, 2018, without open access.

Phase 2 Open-Label Trial Investigating Percutaneous Laser Ablation for Treatment of Early-Stage Breast Cancer: MRI, Pathology, and Outcome Correlations

Background

An institutional review board-approved, multicenter clinical trial was designed to determine the efficacy and outcome of percutaneous laser ablation (PLA) in the treatment of invasive ductal breast carcinoma (IDC). Post-ablation magnetic resonance imaging (MRI) was compared with surgical pathology in evaluation of residual post-ablation IDC and ductal carcinoma in situ.

Methods

Patients with a single focus of IDC 20 mm or smaller by pre-ablation MRI were treated with PLA. The patients underwent a 28-day post-ablation MRI, followed by surgical resection. Cell viability criteria were applied to pre- and post-ablation pathology specimens, which evaluated hematoxylin–eosin (H&E), cytokeratin (CK) 8/18, estrogen receptor, and Ki67 staining patterns.

Results

In this study, 61 patients were reported as the intention-to-treat cohort for determination of PLA efficacy. Of these 61 patients, 51 (84%) had complete tumor ablation confirmed by pathology analysis. One subject’s MRI imaging was not performed per protocol, which left 60 subjects evaluable for MRI pathology correlation. Five patients (8.3%) had residual IDC shown by both MRI and pathology. Post-ablation discordance was noted between MRI and pathology, with four patients (6.7%) false-positive and four patients (6.7%) false-negative. The negative predictive value (NPV) of MRI for all the patients was 92.2% (95% confidence interval [CI], 71.9–91.9%). Of the 47 patients (97.9%) with tumors 15 mm or smaller, 46 were completely ablated, with an MRI NPV of 97.7% (95% CI, 86.2–99.9%).

Conclusions

Percutaneous laser ablation is a potential alternative to surgery for treatment of early-stage IDC. Strong correlations exist between post-ablation MRI and pathologic alterations in CK8/18, ER, and Ki67 staining.

Diversion remains the standard of care for modern management of war-related rectal injuries

INTRODUCTION

Management of rectal injuries in war-injured patients has evolved over time.

METHODS

Retrospective review of records of patients sustaining war-related rectal injuries admitted to Walter Reed Army Medical Center from Iraq and Afghanistan.

RESULTS

From 2003 to 2011, 67 males ages 18 to 40 sustained rectal injuries after secondary blast (64%), gunshot (33%), motor vehicle crash (1%), or helicopter crash (1%). Injuries were extraperitoneal (72%), intraperitoneal (25%), or both (3%). Rectal abbreviated injury score mean was 3 ± 1. Surgical management included end colostomy (66%), loop colostomy (28%), and no diversion (4%). Distal washout (24%) and drain placement (33%) were performed. Colostomy closure occurred in 79% of patients at an average of 237 days after injury.

CONCLUSIONS

Diversion is the preferred treatment of war-related rectal injuries. Loop colostomy is acceptable unless there is potential for evolving rectal injury. Routine use of presacral irrigation and drainage was not supported.

Tissue imprints: assessing their potential for routine biobanking collection

Biomedical research depends on the availability of good quality biospecimens. Unfortunately, certain specimens are scarce due to disease rarity or size restrictions of surgical materials. To increase access to limited surgical specimens, Biobanks need to reassess and adjust their collection programs. We evaluated the feasibility of adapting "touch imprints" to gain access to limited surgical specimens as well as to maximize the use of "precious" specimens. We utilized 12 kidney samples for touch imprints on defined areas of microscope glass slides and FTA paper. DNA was isolated from glass slides on the day of preparation, Day 0, and from glass slide and FTA paper preparations after two weeks of storage at room temperature and -80°C. Yield and purity of DNA from reference kidney samples were compared to DNA from the touch imprints and the quality determined by real-time PCR using the amplification of Cyclophilin A (Cyc A) as an index. DNA quality for glass slides at Day 0 was not significantly different from DNA after two weeks at room temperature (glass at room temperature; p=0.111 and 0.097, yield and purity, respectively) and after two weeks at -80°C (glass -80°C; p=0.358 and 0.281, yield and purity, respectively). Glass slide DNA at room temperature and -80°C were not significantly different (p=0.795 and 0.146 for yield and purity, respectively). DNA from FTA paper at room temperature and from FTA paper at -80°C were significantly different from glass at room temperature and glass at -80°C (p=0.002, respectively). Threshold values for Cyc A were ≤28 for the reference DNA and ≤32 for DNA from glass and FTA paper. This study demonstrates that touch preparations on microscope glass slides and FTA paper can provide sufficient and good quality DNA suitable for PCR. Touch imprints could therefore be adopted by biobanks to collect and bank biological materials from limited surgical specimens.

Abstract A105: Identification of gene expression profiles associated with different types of breast adipose and their relationship to tumorigenesis

Background: Research over the past decade has shown the importance of the stroma in tumorigenesis, however, having long been thought to function only as an inert energy storage depot, the role of adipose tissue in tumor etiology has been largely ignored. Improved understanding of the role of adipose in tumor development and progression is crucial given the increasing rates of obesity and the use of autologous fat transfer in breast reconstruction.

Methods: Adipose, adjacent to and distant from invasive breast tumors, was laser microdissected from 20 post-menopausal women, and from 20 post-menopausal women with non-malignant breast disease. Gene expression data were generated using U133 2.0 microarrays. After quality control and visualization steps, the data were analyzed to identify significant patterns of differential expression between adipose classes, at the individual gene and molecular pathway level. A subset of genes were further analyzed by qRT-PCR in out-of-sample adipose specimens.

Results: Pathway analysis revealed significant differences in immune response between non-malignant, distant and tumor adjacent adipose. 141 genes were differentially expressed (FDR <0.05, >2-fold difference) between tumor-adjacent and non-malignant breasts including FCGR2A, FOLR2, LGMN and NLRP3. These four genes were also differentially expressed (FDR <0.05, >2-fold difference) between distant and non-malignant adipose. Within invasive breasts, no genes were differentially expressed using FDR <0.05, however, RRM2, PLA2G7, MMP9, MMP12, CHI3L1, SPP1 were expressed at >3-fold higher levels (P<0.05) in tumor-adjacent compared to distant adipose.

Conclusions: Gene expression levels differ in breast adipose, depending on presence of or proximity to tumor cells. Tumor-adjacent and distant adipose from invasive breasts both exhibit increased expression in genes involved in the M2 anti-inflammatory response, suggesting that the microenvironment in an invasive breast has a decreased immune response compared to the non-malignant microenvironment. Genes expressed at higher levels in tumor-adjacent compared to distant adipose are associated with increased cellular proliferation, invasion, migration, angiogenesis and metastasis, suggesting that tumor-adjacent adipose promotes the growth and progression of the tumor. Together, these data suggest that adipose is not an inert component of the breast microenvironment but plays an active role in tumorigenesis.

Citation Format: Lori Field, Brenda Deyarmin, Ryan van Laar, Craig Shriver, Rachel Ellsworth. Identification of gene expression profiles associated with different types of breast adipose and their relationship to tumorigenesis. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr A105.

Breast conserving surgery versus mastectomy: the influence of comorbidities on choice of surgical operation in the Department of Defense health care system

BACKGROUND

Studies on the effect of comorbidities on breast cancer operation have been limited and inconsistent. This study investigated whether pre-existing comorbidities influenced breast cancer surgical operation in an equal access health care system.

METHODS

This study was based on linked Department of Defense cancer registry and medical claims data. The study subjects were patients diagnosed with stage I to III breast cancer during 2001 to 2007. Logistic regression was used to determine if comorbidity was associated with operation type and time between diagnosis and operation.

RESULTS

Breast cancer patients with comorbidities were more likely to receive mastectomy (odds ratio [OR] = 1.27; 95% confidence interval [CI], 1.14 to 1.42) than breast conserving surgery plus radiation. Patients with comorbidities were also more likely to delay having operation than those without comorbidities (OR = 1.27; 95% CI, 1.14 to 1.41).

CONCLUSIONS

In an equal access health care system, comorbidity was associated with having a mastectomy and with a delay in undergoing operation.

Abstract 4266: Identification of gene expression profiles associated with different types of breast adipose and their relationship to tumorigenesis

Background: Research over the past decade has shown the importance of the stroma in tumorigenesis, however, having long been thought to function only as an inert energy storage depot, the role of adipose tissue in tumorigenesis has been largely ignored. Improved understanding of the role of adipose in tumorigenesis is crucial given the increasing rates of obesity and the use of autologous fat transfer in breast reconstruction. Methods: Adipose, adjacent to and distant from invasive breast tumors, was laser microdissected from 20 post-menopausal women, and from 20 post-menopausal women with non-malignant breast disease. Gene expression data were generated using U133 2.0 microarrays. After quality control and visualization steps, the data were analyzed to identify significant patterns of differential expression between adipose classes, at the individual gene and molecular pathway level. Results: Pathway analysis revealed that immune response differs between non-malignant, distant and tumor adjacent adipose; this response is seen as a gradient with the largest response closest to the tumor. Gene expression differed significantly in adipose from invasive compared to non-malignant breasts with FCGR2A, FOLR2, LGMN, MARCO and NLRP3 expressed at significantly higher levels and HLA-DQB1 and HLA-DQA1 at significantly lower levels in adipose from invasive breasts. Within the invasive breasts, MMP9, PLA2G7, RRM2 and SPP1 were expressed at >3-fold higher levels in adjacent compared to distant adipose. Conclusions: Gene expression levels differ in breast adipose, depending on presence of or proximity to tumor cells. Adipose adjacent to the tumor demonstrated the largest immune response; this response may reflect a reaction to surgical insult from the original biopsy; however, response to surgical injury has been associated with increased ability to metastasize. In addition, within breasts with invasive breast cancer, genes involved in cellular proliferation, degradation of the extracellular matrix and angiogenesis were expressed at higher levels in adjacent compared to distant adipose. Together, these data suggest that adipose is not an inert component of the breast microenvironment but plays an active role in tumorigenesis.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4266. doi:1538-7445.AM2012-4266

Analysis of matrix metalloproteinase-1 gene polymorphisms and expression in benign and malignant breast tumors

A guanine insertion polymorphism in matrix metalloproteinase-1 promoter (MMP-1 2G) is linked to early onset and aggressiveness in cancer. We determined the role of MMP-1 2G on MMP-1 expression and breast cancer severity in patients with breast diseases. We observed no significant difference in genotype distribution among different disease groups. However, MMP-1 expression was significantly higher in atypical ductal hyperplasia than in benign breast disease and in invasive breast cancer compared to in situ breast cancer. MMP-1 2G insertion polymorphism in the invasive group also correlated significantly with the expression of MMP-1 and breast cancer prognostic markers HER2 and P53.

Remote processing of pancreas can restore normal glucose homeostasis in autologous islet transplantation after traumatic whipple pancreatectomy: technical considerations

An emergency autologous islet transplant after a traumatic Whipple operation and subsequent total pancreatectomy was performed for a 21-year-old patient who was wounded with multiple abdominal gunshot wounds. After Whipple pancreatectomy, the remnant pancreas (63.5 g), along with other damaged organs, was removed by the surgeons at Walter Reed Army Medical Center (WRAMC) and shipped to Diabetes Research Institute (DRI) for islet isolation. The pancreas was preserved in UW solution for 9.25 h prior to islet isolation. Upon arrival, the organ was visually inspected; the pancreatic head was missing, the rest of the pancreas was damaged and full of blood; the tail looked normal. A 16-gauge catheter was inserted into the main duct and directed towards tail of the pancreas after the dissection of main duct in the midbody of the pancreas. The pancreas was distended with collagenase solution (Roche MTF) through the catheter. During 10 min of intraductal delivery of enzyme, the gland was distended uniformly. No leakage of the solution was observed. The pancreas was transferred to a Ricordi chamber for automated mechanical and enzymatic digestion. Islets were purified using a COBE 2991 cell processor. Islet equivalents (IEQ; 221,250) of 40% purity and 90% viability were recovered during the isolation, which were shipped back to WRAMC and infused by intraportal injection into the patient. Immediate islet function was demonstrated by the rapid elevation of serum C peptide followed by insulin independence with near normal oral glucose tolerance test (OGTT) 1 and 2 months later. It is possible to restore near normal glucose tolerance with autologous islet transplantation after total pancreatectomy even with suboptimal number of islets while confirming that islets processed at a remote site are suitable for transplantation.

Abstract B31: Molecular signature discriminating triple-negative breast tumors between African American and Caucasian women

Background: Triple negative (TN) tumors are characterized by aggressive behavior and, the negative hormone receptor and HER2 status precludes the use of personalized therapies such as tamoxifen and trastuzumab. African American women have higher rates of both breast cancer mortality as well as TN breast tumors. What remains unknown is how much of these disparities can be attributed to molecular differences between populations.

Methods: The Clinical Breast Care Project database was queried to identify African American women with triple negative, high-grade tumors. Caucasian women with highgrade TN tumors were then matched by age at diagnosis, tumor stage, size and lymph node status. RNA was isolated after laser microdissection of the tumor and hybridized to HG U133A 2.0 microarrays. Data was analyzed using Partek Genomics Suite.

Results: Principal Component Analysis accurately clustered the triple negative specimens by ethnicity. Using a false-discovery rate (FDR) p-value <0.05 with a minimum 2.0-fold change of expression, 132 probes from 117 genes were differentially expressed. Hierarchical clustering using a subset of these probes (P<0.00001) representing 23 known genes reliably partitioned all samples as African American or Caucasian. Genes differentially expressed include lower expression of AQP5, VEGF and RAD51C and higher expression of hemoglobin B, and complement factors CFD and C4A in tumors from African Americans.

Discussion: Despite matching of tumors by clinicopathological characteristics, molecular profiles of triple negative breast tumors differed between AAW and CW. These differences may serve as molecular targets for the development of novel prevention strategies and therapeutics to reduce the risk of developing and improve treatment of African American women with triple negative breast cancer.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B31.

Intrathyroidal Parathyroid Carcinoma Presenting as Asymptomatic High Normal Serum Calcium and Slightly Elevated Intact Parathyroid Hormone: A Case Report and Review of Literature

Parathyroid carcinoma is an uncommon endocrine malignancy and the probability of an intrathyroidal location is low. We report a case of intrathyroidal parathyroid carcinoma presenting as asymptomatic high normal serum calcium and slightly elevated intact parathyroid hormone (iPTH) making preoperative suspicion and diagnosis extremely difficult.

Abstract 3741: Identification of differentially expressed genes in breast tumors from African American compared with Caucasian women

Background: Breast tumors from African American women (AAW) have less favorable pathological characteristics and higher mortality rates than Caucasian women. While socioeconomic status may influence prognosis, biological factors are also likely to contribute to tumor behavior.

Methods: Patients treated within an equal-access military medical center were matched by age, grade and ER status. Tumors were subjected to laser microdissection and RNA hybridized to HG U133A 2.0 microarrays. Data was analyzed using Partek Genomics Suite using a cutoff of P<0.001, 1.5-fold change. Microarray results were validated by qRT-PCR.

Results: Twenty-six pairs of matched tumor samples were identified. Clinico-pathological factors did not differ significantly for age at diagnosis, tumor size or stage, lymph node, hormone receptor, or HER2 status. Mortality was similar between the two groups. One putative and nineteen known genes were differentially expressed between populations with five genes expressed at higher and 15 genes at lower levels in tumors from AAW; hierarchical clustering classified 23/26 AAW and 26/26 CW correctly. Differential expression was validated (P<0.001) for PSPHL (higher in AAW) and LTF and PSD3 (lower in AAW).

Conclusions: Despite matching of tumors by pathological characteristics and provision of medical care in an equal-access health care system, a molecular signature differentiating AAW from CW tumors was detected, supporting a model in which aggressive tumor phenotypes are driven by molecular differences within the tumors. These differentially expressed genes are involved in immune response, cell cycle and metastasis and thus may contribute to the poor outcome in AAW.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3741. doi:10.1158/1538-7445.AM2011-3741

Abstract P4-07-09: The Impact of Matrix Metalloproteinase-1 Promoter 1G/2G Polymorphism on Breast Diseases

Background: Matrix Metalloproteinase-1 (MMP-1) is a ubiquitously expressed interstitial collagenase. Overexpression of MMP-1 has a role in initiating mammary tumorigenesis by degrading stroma and by releasing growth factors. A single guanine insertion polymorphism in the MMP-1 promoter creates the binding site, 5'-GGAA-3', for the Ets transcription factor, and increases transcription of MMP-1. The MMP-1 2G polymorphism is linked to early onset, increased risk or aggressiveness of several cancers. Its relationship with other potential markers in invasion and metastasis of breast cancer is unknown.

Experimental Design: To study the impact of the 2G polymorphism on breast cancer we analyzed the genotypes of 109 patients (52 invasive breast cancer [IBC], 29 ductal carcinoma in situ [DCIS], 13 atypical ductal hyperplasia [ADH] and 15 benign breast disease). Immunohistochemical (IHC) data for MMP-1, HER2, ER/PR and P53 from these donors were also analyzed. IHC results for MMP-1 were scored as 0 (no expression) or increasing expression of+1, +2 or +3. Data were analyzed using Pearson's chi-square test to identify statistical significance.

Results: A significantly higher number of patients in the IBC group expressed high MMP-1 (+2 and +3; p <0.001) while the benign group had the least number of patients expressing higher MMP-1 (score +3; p = 0.0075). In the IBC group, among patients with low levels of MMP-1 (+1), 57% had the 1G/1G phenotype, and among those expressing high levels of MMP-1 (+2 and +3), over 70% were 1G/2G heterozygotes or 2G/2G homozygotes. The 2G allele frequency in the ADH group was 0.62 and these patients had higher MMP-1 expression (+2 and +3). Further analyses of HER2, ER/PR and P53 in relation to the MMP-1 polymorphism within the IBC group showed MMP-1 allelic variation in Her-2 positive group was significantly different compared with Her-2 negative group (p = 0.039), with a distribution curve shifted to a greater frequency of 2G homozygosity. A similar result was also observed in P53 positive group when compared with P53 negative group (p = 0.043).

Conclusions: 1) In the IBC group, the 2G insertion polymorphism contributes to MMP-1 over expression. 2) Increased expression of MMP-1 in ADH and higher 2G allele frequency are consistent with the hypothesis that increased MMP-1 2G polymorphism plays a role in initiation of ADH through up regulation of MMP-1 expression. 3) Earlier studies show prognostic role for the coexistence of increased expression of HER2 and P53 in breast cancer. Our observation of a significant increase in the 2G homozygotes in HER2 and P53 positive patients supports a prognostic role for this polymorphism and suggests its possible association with other breast cancer markers. Thus, the MMP-1 2G polymorphism may both contribute to breast disease onset and serve as a prognostic marker for breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-07-09.

An Approach To Correlate the Temporal Information To Facilitate Specimen Selection in the Breast Cancer Research Project

Background: Temporal information management is very important in translational research. In the Clinical Breast Care Project (CBCP), the information on subjects and their specimens may be collected at multiple time points using multiple instruments.All such information is stored in an in-house data warehouse. Currently, 4000+ subjects have been enrolled in the study following HIPAA-compliant IRB-approved protocols with 35,000+ specimens collected. Some of the patient's information is static but other data are time dependent. As a result, selecting samples for experiments is a challenge due to complicated temporal relationships between samples and information collected through various instruments.Methods and Results: In the CBCP, the clinical information, blood, and solid tissues of a subject may be collected at multiple time points, associated with the completion of a Core Questionnaire (CQ) for clinical information, and/or a Pathology Checklist (PC) for pathology and sample information. We have designed and implemented an algorithm to use a set of pre-defined flags to precisely describe each sample related to patient's clinical and pathology information in the temporal domain. Five categories (flags) were created to describe the relationship between the sample date (SD) and the CQ date based on whether SD is within 60 days of the CQ date or there is missing data or not. The relationship between blood samples and pathology information is more complicated. Within 90 days, any of the 15 surgical procedures might be performed on a patient and blood samples might be collected before, at the time of, or between any procedures. For some experiments, it is crucial to select blood samples taken before tumor is impacted or severely impacted. Thus, we defined a dozen categories to describe the relationship between the SD and the procedure date (PD), including when the SD is earlier than any PD, equals to the first PD, or between certain procedures. Using these flags we have characterized the relationships between SDs and CQ dates, and between SDs and PDs for all the samples and all the subjects, and stored all the information into two relational tables. The temporal criteria for sample selection are now represented by the relationships between these flags, and can be implemented through several filtering processes. The described algorithm drastically reduces the time needed for precise sample selection from several days for manual efforts to several hours.Discussion: We are in the process of developing a general data model for temporal information management. The method described here is a transitional solution that fulfills our current needs. As an initial effort some of the thresholds for categorizing different temporal conditions are arbitrary, and we are validating them with experimental results for future improvement. Nonetheless, this algorithm has greatly enhanced the efficiency of our subject and specimen selection for wet bench experiments. The same principle can be applied to the future temporal data model solution, for CBCP and other human disease studies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4173.

Genetic Characterization of Columnar Cellular Lesions and Atypical Ductal Hyperplasia of the Breast

Aims: Columnar cell lesions (CCL) and atypical ductal hyperplasia (ADH) frequently coexist and share molecular changes with in situ and invasive components, suggesting that CCL and ADH may be precursors to breast cancer. These conclusions are, however, largely based on studies examining CCL and/or ADH from patients diagnosed with more advanced disease. Thus, we assessed allelic imbalance (AI) in pure CCL or ADH specimens to characterize molecular changes in early breast lesions.Methods and results: DNA samples were obtained from laser microdissected lesions from CCL with (n=42) or with ADH (n=31) without concurrent in situ or invasive disease. AI was assessed at 26 chromosomal regions commonly altered in breast cancer. The average AI frequency was 6.2% (range 0-20%) in CCL and 6.1% (range 0-25%) in ADH with no significant difference in levels of AI between CCL and ADH. The highest levels of AI were on chromosomes 8q24 and 17q21 in ADH (23%) and CCL (15%), respectively.Conclusions: In conjunction with low overall levels of AI, chromosomal alterations that characterize low- and high-grade in situ and invasive disease were not frequent in pure CCL and ADH. Thus, pure lesions are not genetically advanced and are molecularly distinct from synchronous lesions.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5156.

Converting Paper Medical Records to Electronic Version To Support Breast Cancer Translational Research and Clinical Practice

Background: The healthcare system has extremely large volumes of patients' paper medical records (PMRs) scattered throughout various medical facilities. Currently the industry is transitioning to Electronic Medical Records (EMR). Although each source of information is equally important, a complete longitudinal health record is rarely available or currently attainable. The goal of this effort is to convert the existing PMRs into searchable electronic equivalents and merge them with existing EMRs to create a more complete longitudinal health record to support clinical care and biomedical research.Method: Using a subset of PMRs for subjects enrolled in the Clinical Breast Care Project at Walter Reed Army Medical Center, (WRAMC), we are developing an automated method to digitize and index the records, extract the biomedical information and prepare the data for delivery to clinicians and researchers. The electronic records were loaded into a database for immediate access by clinicians. To support translational research, MRs need to be de-identified, and information extracted and loaded into a research database; we used ten MRs to develop the operational method. Several methods were tested in the de-identification process: 1) manually, by striking out the protected health information (PHI) on paper before it was digitized and 2) “electronically”, by redacting the record electronically on the computer after it was digitized. We are in the process of testing automated data extraction tools and natural language processors to automatically de-identify and extract data from the EMR.Result: We quickly realized that only 10% of PMRs existed onsite at WRAMC; remaining MRs were held by the patients or other medical facilities. Approximately 300 PMRs, containing 66,600 pages, were scanned and digitized for this project. We have created a successful digitization process, which includes creating PDFs with hidden and searchable information. We have compared the effort and accuracy of various redaction methods. To de-identify 10 records, it took ∼10 hours manually and ∼20 hours electronically. It took longer electronically because of the preparations to ensure the removed information could not be retrieved. We expect that automated redaction tools will greatly reduce that effort. We also found that the electronic method had a 99% accuracy compared to 96% for the paper method. A portal prototype to allow access to medical records by clinicians and researchers is currently being tested and evaluated.Discussion: Conversion of non-searchable data into an explorable and computable format will enable clinicians to acquire needed information more conveniently in their clinical care including treatment plan development. Similarly, properly de-identified, complete MRs will serve as a rich source of clinical information to support translational research. Although the method we are developing will initially satisfy the CBCP need for clinical service and research, it will be further developed into a full solution to expand into other disease condition fields.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5123.

Proteomic Discrimination of Well- from Poorly-Differentiated Breast Carcinomas

Background: Pathological grade is a useful prognostic factor for stratifying breast cancer patients into favorable (well-differentiated tumors) and less favorable (poorly-differentiated tumors) outcome groups. The current system of tumor grading, however, is highly subjective and a large proportion of tumors are characterized as intermediate-grade, making determination of optimal treatments difficult.Methods: Primary breast tumor specimens from patients diagnosed with well- (n=27) and poorly-differentiated (n=51) invasive ductal carcinoma were obtained from patients enrolled in the Clinical Breast Care Project. Frozen tissues were sectioned and mounted on gold coated MALDI target plates for protein expression profiling. Hematoxylin and eosin (H&E) stained slides were prepared from serial sections for histological characterization. MALDI matrix was deposited as individual spots on the tissue sections in a histology directed manner to assay specific areas and tissue types of interest. Mass spectral data were then acquired from multiple sites across each tissue section.Results: 129 features were observed in well-differentiated and 132 in poorly-differentiated tumors. While the majority of features detected were similar between the two groups, 6 protein features were expressed at significantly lower and 12 at significantly higher levels in the poorly-differentiated tumors, including increased expression of Calgranulin A and Calgizzarin.Conclusions: Protein expression differences detected here suggest that well- and poorly-differentiated invasive breast tumors are molecularly distinct diseases and that these protein changes may contribute to the structural integrity of the tumor cell. In particular, calgranulin A and calgizzarin are members of the S100 protein family, and function in processes such as cell proliferation and differentiation. Further refinement of this differentiation protein signature may not only improve our understanding of the biological processes involved with tumor grade but provide pathologists with new molecular tools to classify breast tumors and reduce the subjectivity associated with current grading criteria.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6126.

Role for CD44 in Enhancing Invasion, Migration, and Growth of Triple Negative (TN) Breast Cancer Cells

Triple negative (TN) breast cancers are defined by a lack of expression of estrogen, progesterone, and her-2/neu receptors. It is widely recognized that TN breast cancers have a poorer prognosis than any other subtypes of breast caner. Given the lack of effective targeted therapies for TN breast cancer patients, understanding of the mechanisms of growth and invasion in the tissues provides insight into developing novel approaches to lower the mortality from TN breast cancer.Neoplastic epithelial cells in breast carcinomas interact with various components in the tissue microenvironment including extracellular matrix (ECM) and mesenchymal cells. Recent studies identified CD44 as a metastasis-related molecule with multiple functions by promoting cell-cell and cell-ECM interactions. CD44 is an integral transmembrane protein encoded by a single 20-exon gene. In the standard form (CD44s), 10 of the 20 exons are translated. Multiple variant isoforms exist (CD44v1-10) which arises from alternate mRNA splicing of the remaining 10 exons. In contrast to the ubiquitous expression of the standard form of CD44, splice variants are highly restricted in their expression in normal or malignant tissues. Indeed, CD44 variants containing v3, v5, v6, v7-8, v10 exons are expressed in malignant breast cancer tissues. However, there is limited information regarding the biological functions of these exons to promote tumor invasion and metastasis. The goal of this study is to evaluate specific exon(s) of CD44 expressed on TN breast cancer cells for promoting tumor progression and metastasis.In order to approach this goal, we utilized three TN cell lines (HCC38, HCC1937, and HCC1806) as model systems to evaluate CD44 in regulating invasion, migration, and growth in extracellular matrix (ECM) environments. Reverse transcriptase (RT)-PCR analysis using exon specific primers indicate that these cells expressed CD44v8-v10 and CD44s. We demonstrated that an inhibitory antibody against exon v10 of CD44 significantly inhibited b1 integrin-mediated migration and invasion into Matrigel and type I collagen gel. Importantly, this antibody also inhibited three dimensional (3D) growth which is a b1 integrin-independent process. The significant inhibition of these processes was also achieved when a FLAG-fusion exon v10 peptide (FLAG-v10, in which FLAG is tagged at the N-terminal of the peptide) was used as an inhibitor, implying that this exon would function to assemble molecular complexes on TN breast cancer cells that facilitate invasion, migration, and growth. Thus, these results suggest that generation of small synthetic molecules that block the functions of exon v10 of CD44 is promising approaches to inhibit invasion and metastasis of TN breast cancer cells.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6161.

Microarray Data Analysis Using Peripheral Blood Samples Suggests Differential Enrichment of Signaling Pathways between Breast Cancer Patients and Normal Subjects

Background: Breast cancer is the second most common cancer among women in the United States and the second leading cause of cancer death in women. Early and accurate diagnosis is crucial for better treatment and reduction of mortality. Diagnostics based on blood samples are being developed for many diseases including a variety of cancers.Gene expression profiling has been widely used to investigate the mechanisms of tumorigenesis with the goal of developing novel treatment strategies. We have applied microarray technology to study the gene expression signatures in blood samples from patients with invasive breast cancer, with benign breast disease and from disease free (normal) control groups to find potential diagnostic patterns. We have identified differentially expressed genes in each group and investigated the pathways these genes are involved in and how these are regulated.Material and Methods: Human blood samples from 102 invasive breast cancer patients, 57 patients with benign breast disease and 102 normal controls were collected for this study. Patients are enrolled in the Clinical Breast Care Project (CBCP) following HIPAA-compliant IRB approved protocols, with proven breast pathology diagnosis categories. Affymetrix HG-U133 Plus 2 GeneChips were used to investigate the gene expression profile. Microarray experiments were performed following Affymetrix protocols. CEL files were then analyzed with RMA algorithm for the calculation of gene expression matrix. Differentially expressed genes were identified between different groups using Wilcoxon rank sum test. We also applied Gene Set Enrichment Analysis (GSEA) to the entire gene expression profiles to investigate the gene sets or pathways enriched in different groups.Results: We identified about 2,051 differentially expressed genes between normal and invasive groups (p < 0.001 and Fold Change > 1.2). Furthermore, about 445 and 51 genes were identified in normal vs. benign and benign vs. invasive groups respectively. We performed GSEA using 395 gene sets from pathway databases, initially focusing on normal vs. invasive groups. 123 gene sets are highly expressed in the normal group and 272 gene sets are highly expressed in the invasive group. For the normal group, 10 gene sets are significantly enriched and 22 gene sets are significantly enriched in the invasive group (p < 0.05). These results show that some important pathways are down regulated in the invasive group, such as, the B-cell antigen receptor pathway, the BCR signaling pathway, the T-cell signal transduction pathway, the IL4 receptor pathway, the PIP3 pathway, the ERK pathway, etc. The pathways up regulated in the invasive group are oxidative phosphorylation pathway, ATP synthesis, etc.Discussion: Our results suggest that a list of genes differentially expressed in different groups and they may be used to compose cancer marker panels which can be integrated with currently clinical procedures for cancer diagnosis. We also find some crucial pathways enriched in each group. Most of the pathways downregulated in the blood of patients in the invasive group are related to the immune response. In contrast, most of pathways upregulated in the blood of patients in the invasive group are associated with metabolism.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3024.

Differential Benign Breast Disease Co-Occurrence with Cancer in Caucasian and African American Women

Background: Breast Cancers (BCs) in Caucasian (CA) and African American (AA) women have different characteristics. Recently, there have been reports, mostly focusing on Caucasians that Benign Breast Diseases (BBDs) may be risk factors for BCs. There are also a few reports of different co-occurring patterns of BBDs with BCs between the two populations. In the Clinical Breast Care Project (CBCP) more than 4,000 subjects have been enrolled following HIPAA-compliant, IRB-approved protocols, with more than 35,000 biospecimens collected. For patients requiring biopsies, an expanded pathology report for research is completed. The occurrences of any of the 131 pathologic conditions, including 66 BBDs, are recorded. All the results are reviewed by the same pathologist. The CBCP provides a uniformed pathology dataset for a comprehensive characterization of the association of BBDs with BCs.Method: The diagnoses were made from potentially multiple biopsies obtained over a short period of time, mostly within 60 days. CBCP subjects with BBD diagnosis and ethnicity information from their most recent visit were selected, giving a dataset totaling 1479 CA and 484 AA women. We studied the association between BBDs and BCs (including in situ, invasive, and malignant NOS) in these two groups using the chi-square test.Results: In both populations 6 BBDs are positively associated with BCs, including atypical ductal hyperplasia (ADH) (4% vs 15% for AA p<3.8E-05, meaning 4% cancer-free cases with ADH compared to 15% cancer cases co-occurring with it; 7% vs 16% for CA p<1.9E-08), microcalcifications (27% vs 56% for AA p<1.2E-09, 35% vs 53% for CA p<8.0E-12), multiple (peripheral) papillomas (6% vs 16% for AA p<0.0005, 4% vs 8% for CA p<0.0002), columnar cell hyperplasia (9% vs 21% for AA p<0.0003, 6% vs 18% for CA p<3.5E-12), and moderate intraductal hyperplasia (IDH) (14% vs 28% for AA p<0.0002, 14% vs 18% for CA p<0.03). On the contrary, 3 BBDs are negatively associated with BCs including fibroadenoma (30% vs 10% for AA p<4.9E-07; 21% vs 7% for CA p<1.0E-13), and mild IDH (10% vs 2% for AA p<0.003; 13% vs 7% for CA p<0.0002). Eight BBDs differentially co-occur with BCs between AA and CA. BCs in AA are associated with sclerosing adenosis (13% vs 31%, p<4.5E-06), fibrocystic changes (45% vs 61%, p<0.001), fibroadenomatoid nodule (6% vs 12%, p<0.042), and cysts (42% vs 57%, p<0.004). BCs in CA are positively associated with columnar cell hyperplasia with atypia (3% vs 8% p<3.6E-05), atypical lobular hyperplasia (1% vs 5%, p<6.0E-05), and radiation changes (0% vs 1.4% p<0.004), but negatively associated with duct ectasia (10% vs 2%, p<7.9E-10).Discussion Our findings are in accordance with established BC risk factors such as ADH and moderate IDH for both ethnic groups. We further found that 8 BBDs differentially co-occur with BCs between AA and CA groups, and interestingly the 4 significant BBDs detected in the AA group typically show >10% increased co-occurrence rate in cancer cases compared to cancer-free cases, whereas the 4 BBDs detected in the CA group almost always show a <10% co-occurrence rate overall. More research is undergoing to understand the implications of this distinct co-occurrence pattern.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3066.

Modern management of complex open abdominal wounds of war: a 5-year experience

BACKGROUND

Optimal management of the open abdomen remains controversial.

STUDY DESIGN

Retrospective review of patients injured during Operations Enduring Freedom and Iraqi Freedom returning to Walter Reed Army Medical Center (WRAMC) from January 2003 to October 2007 for treatment of open abdomen.

RESULTS

Three hundred fifty-four patients were evacuated to WRAMC after laparotomy, including 86 patients (24%) with open abdomen. Three transferred patients were excluded. Eighty-three patients, mean age 26 years (range 18 to 54 years), sustaining injury from secondary blast (n = 47), gunshot (n = 29), and blunt trauma (n = 7) were studied. Surgical management included early definitive abdominal closure (EDAC, n = 56; 67%), primary fascial closure (n = 15; 18%), planned ventral hernia (PVH, n = 9; 11%) and vacuum-assisted closure with AlloDerm (n = 3; 4%). EDAC closure involves serial closure with Gore-Tex Dualmesh and final closure supplemented with polypropylene mesh (62%) or AlloDerm (31%). There was no substantial difference in injury mechanism, age, length of evacuation to WRAMC, or Injury Severity Score (average 30) according to closure type. Complications included removal of infected prosthetic mesh in 4 EDAC closure patients (5%). Overall morbidity was lowest (60%) in primary repair patients (p = 0.01). Rates of deep venous thrombosis, pulmonary embolism, abdominal wall hematoma, and infection did not differ between groups. Fistula rate was increased with PVH (20%). Two patients with PVH died. PVH and EDAC mesh complications have been minimized in the last 2 years of the study.

CONCLUSIONS

Primary closure of fascia is ideal but not always possible. Early definitive closure has avoided PVH. Mesh-related complications have decreased with time.

Breast, colorectal, and skin cancer screening practices and family history of cancer in U.S. women

BACKGROUND

Several national medical organizations recommend more intensive screening or screening at an earlier age for individuals with a family history of breast, colorectal, or skin cancer. This study examined whether women with a family history of cancer were more likely to use breast, colorectal, or skin cancer screenings compared with those without such a family history.

METHODS

The data for this study came from female respondents who participated in the 2000 National Health Interview Survey. The age range of the study subjects and the definitions of cancer screening were determined based on the American Cancer Society recommendations on cancer screening.

RESULTS

When compared with women without a family history of breast cancer, women with a family history were more likely to undergo a screening mammogram. Women who had a family history of colorectal cancer were twice as likely to use colorectal cancer screening than women without a family history of colorectal cancer. The association of family history with colorectal and breast cancer screening was stronger among the younger age group for which a screening test is recommended if one has such a family history. The association between skin cancer screening and family history of skin cancer was significant only in younger women.

CONCLUSIONS

Women with a family history of cancer were more likely to have colorectal, breast, and skin cancer screening examinations. This may be a result of more physicians' recommendations and higher personal motivation for getting cancer screening, suggesting that the efficacy of national guidelines has been increasing somewhat.

Early definitive abdominal closure using serial closure technique on injured soldiers returning from Afghanistan and Iraq

BACKGROUND

Twenty-nine of 1,284 battle-injured soldiers arriving at Walter Reed Army Medical Center from Operations Enduring Freedom and Iraqi Freedom have abdominal wounds requiring delayed definitive closure with Gore-Tex (WL Gore & Assoc) mesh.

METHODS

Serial abdominal closure (SAC) leading to early definitive abdominal closure (EDAC) was achieved using Gore-Tex mesh. Inpatient records of Operations Enduring Freedom and Iraqi Freedom soldiers with open or reopened abdomens were reviewed from March 2003 to August 2005.

RESULTS

Twenty-nine soldiers, average age 27 years (range 20 to 42 years) injured by secondary blast effects (n = 19); penetrating (n = 8); motor vehicle crashes (n = 1); and crushing injury (n = 1) were included in the study. Patients arrived at Walter Reed Army Medical Center 8 days (range 3 to 56 days) after injury with Gore-Tex mesh placed 6 days (range 0 to 26 days) from arrival and 14 days (range 4 to 79 days) from injury. SAC was achieved with towel clamp tightening or excision of midline mesh and drawing fascia closer to the midline for an average of 46 days (range 15 to 160 days) before EDAC. One patient is undergoing SAC and another was transferred to another facility. EDAC was achieved in 24 of the remaining of 27 patients (89%). Four patients required early removal of the Gore-Tex mesh, resulting in three patients with planned ventral hernia. One patient underwent EDAC with primary closure and fascial release. EDAC was completed with polypropylene mesh in 17 patients and 6 patients had original Gore-Tex in place. Patients were discharged from the hospital an average of 18 days after closure (range 1 to 89 days) with total hospital days of 62 (range 17 to 197 days). Average followup of patients from placement of Gore-Tex mesh is 264 days (range 31 to 855 days).

CONCLUSIONS

SAC with Gore-Tex mesh led to EDAC in 89% of patients and proved to be a safe and effective alternative to planned ventral hernia. SAC allowed protection of abdominal contents, effective fluid management, reclamation of abdominal domain, and early rehabilitation with minimal complications and only one hernia reoccurrence.

Body mass index and use of mammography screening in the United States

BACKGROUND

Obese and underweight women may be less likely to seek cancer screening because of health status, self-perception, and body image related to non-desirable weight. This study examined the relationship between body mass index (BMI) and mammography screening, using the data from the year 2000 United States National Health Interview Survey.

METHODS

This study included 7692 white and 1496 black female participants aged 40-80, who were randomly selected. Body mass index (kg/m2), based on self-reported weight and height, was compared between women with and without a mammogram in the past 2 years using logistic regression.

RESULTS

Compared to women with normal body mass index, underweight and extremely obese women were more likely to have no screening mammograms in the past 2 years (odds ratio (OR) = 1.8, 95% confidence interval (CI), 1.2-2.6 for underweight women; odds ratio = 1.3, 95% confidence interval, 1.0-1.8 for extremely obese women). When data were analyzed by race, the odds ratio estimates were 1.8 for underweight white women (95% confidence interval, 1.3-2.7) and 1.4 for extremely obese white women (95% confidence interval, 1.0-1.9). The corresponding odds ratio estimates were close to 1.0 for black women.

CONCLUSIONS

Underweight and extreme obesity may increase the risk of underusing screening mammography. The association between body mass index especially underweight and underuse of mammography might exist primarily in white women.