Epigenetic Alterations in Triple-Negative Breast Cancer-The Critical Role of Extracellular Matrix

Triple-negative breast cancer (TNBC) is an aggressive subgroup of breast cancer characterized by genomic complexity and therapeutic options limited to only standard chemotherapy. Although it has been suggested that stratifying TNBC patients by pathway-specific molecular alterations may predict benefit from specific therapeutic agents, application in routine clinical practice has not yet been established. There is a growing body of the literature supporting that epigenetic modifications comprised by DNA methylation, chromatin remodeling and non-coding RNAs play a fundamental role in TNBC pathogenesis. Extracellular matrix (ECM) is a highly dynamic 3D network of macromolecules with structural and cellular regulatory roles. Alterations in the expression of ECM components result in uncontrolled matrix remodeling, thus affecting its ability to regulate vital functions of cancer cells, including proliferation, migration, adhesion, invasion and epithelial-to-mesenchymal transition (EMT). Recent molecular data highlight the major role of tumor microenvironment and ECM alterations in TNBC and approaches for targeting tumor microenvironment have recently been recognized as potential therapeutic strategies. Notably, many of the ECM/EMT modifications in cancer are largely driven by epigenetic events, highlighting the pleiotropic effects of the epigenetic network in TNBC. This article presents and critically discusses the current knowledge on the epigenetic alterations correlated with TNBC pathogenesis, with emphasis on those associated with ECM/EMT modifications, their prognostic and predictive value and their use as therapeutic targets.

PD-L1 Expression and Tumor-infiltrating Lymphocytes in Breast Cancer: Clinicopathological Analysis in Women Younger than 40 Years Old

BACKGROUND/AIM

To evaluate the association between programmed cell death ligand 1 (PD-L1) expression on both tumor cells (TC) and inflammatory cells (IC), tumor infiltrating lymphocytes (TILs), CD3⁺ and CD8⁺ lymphocytes and other clinicopathological parameters in primary infiltrative breast cancer (IBC) of young women, a population shown to have a worse prognosis.

MATERIALS AND METHODS

A retrospective study was performed collecting data from patients younger than 40 years old. Forty-five young women with IBC were included. Whole tissue sections were used to evaluate all parameters.

RESULTS

Twenty percent (20%) of cases showed PD-L1 expression by tumor cells (PDL1TC) and 44.4% showed PD-L1 expression by immune cells (PDL1IC). Furthermore, 28.88% revealed high stromal TILs. PDL1TC and PDL1IC expression were significantly associated with tumor diameter and expression of estrogen (ER) and progesterone (PR) receptors and Ki67. PDL1TC expression was also associated with grade. High TILs were associated with tumor diameter, ER and Ki67 expression. PDL1TC, PDL1IC expression and TILs were associated with the density of CD3⁺ and CD8⁺ lymphocytes.

CONCLUSION

Our results are similar to those of other age groups, as reported in the literature.

Correlation between insulin-like peptide 3 and appendix testis length in congenital cryptorchidism

AIM

The appendix testis (AT) is a vestigial remnant of Müller's paramesonephric duct. Insulin-like 3 hormone (INSL3) is produced in the Leydig cells of the testis. We investigated the possible correlation between AT length and plasma INSL3 concentrations in patients with congenital cryptorchidism (CCO) and patients with hydrocele, who served as controls.

METHODS

A total of 40 patients with CCO and 34 patients with hydrocele and orthotopic testes were investigated. Sixteen patients presented high cryptorchidism and 24 low cryptorchidism. During surgery, AT was identified in 34 patients with CCO (high cryptorchidism:15, low cryptorchidism:19) and 28 controls. Plasma INSL3 levels were measured with a spectrophotometry enzyme immunoassay Elisa sandwich technique.

RESULTS

AT was present in 85.0% of the boys with CCO and 82.4% of the controls. A significant positive correlation was found between the AT length and INSL3 concentrations in CCO patients.

CONCLUSIONS

A longer AT may reflect better testicular function in boys with CCO, since it is correlated with higher INSL3 concentrations.

Spine ABC, A Multidimensional Case Report from A to Z: Aneurysmal Bone Cyst of the Spine

Background: Aneurysmal bone cysts (ABC) are uncommon entities which cause expansile and destructive bone lesions and are characterized by reactive proliferation of connective tissue. They usually grow rapidly with hypervascularity. ABC’s incidence on the spine is 1.5 in 10 million. Most cases present with pain of unexplained origin. The Case: Presented in this paper is an ABC case in the spinous process of the L2 vertebra of a 20-year-old Greek female patient. The main symptom was persistent back pain, without neurological symptoms, of four years’ duration. Treatment consisted of surgical curettage of the lesion. In this case report, we tried to describe not only the pathology of this disease but also the subsequent psychosocial symptoms that accompany it. We managed to accomplish that by exploiting the knowledge of an experienced pathologist, the help of the physicians responsible for this case, the interest of some sensitized medical students, and of course, the experience of the patient herself since the patient is also the lead author. Conclusion: The focal point of this article is that even though ABCs might lead to excruciating pain, this pain can be alleviated with the proper treatment, especially if the communication between physician and patient is optimal.

Lysine methyltransferase 2D regulates pancreatic carcinogenesis through metabolic reprogramming

OBJECTIVE

Despite advances in the identification of epigenetic alterations in pancreatic cancer, their biological roles in the pathobiology of this dismal neoplasm remain elusive. Here, we aimed to characterise the functional significance of histone lysine methyltransferases (KMTs) and demethylases (KDMs) in pancreatic tumourigenesis.

DESIGN

DNA methylation sequencing and gene expression microarrays were employed to investigate CpG methylation and expression patterns of KMTs and KDMs in pancreatic cancer tissues versus normal tissues. Gene expression was assessed in five cohorts of patients by reverse transcription quantitative-PCR. Molecular analysis and functional assays were conducted in genetically modified cell lines. Cellular metabolic rates were measured using an XF24-3 Analyzer, while quantitative evaluation of lipids was performed by liquid chromatography-mass spectrometry (LC-MS) analysis. Subcutaneous xenograft mouse models were used to evaluate pancreatic tumour growth in vivo.

RESULTS

We define a new antitumorous function of the histone lysine (K)-specific methyltransferase 2D (KMT2D) in pancreatic cancer. KMT2D is transcriptionally repressed in human pancreatic tumours through DNA methylation. Clinically, lower levels of this methyltransferase associate with poor prognosis and significant weight alterations. RNAi-based genetic inactivation of KMT2D promotes tumour growth and results in loss of H3K4me3 mark. In addition, KMT2D inhibition increases aerobic glycolysis and alters the lipidomic profiles of pancreatic cancer cells. Further analysis of this phenomenon identified the glucose transporter SLC2A3 as a mediator of KMT2D-induced changes in cellular, metabolic and proliferative rates.

CONCLUSION

Together our findings define a new tumour suppressor function of KMT2D through the regulation of glucose/fatty acid metabolism in pancreatic cancer.

Tumors with high-density tumor infiltrating lymphocytes constitute a favorable entity in breast cancer: a pooled analysis of four prospective adjuvant trials

BACKGROUND

Tumor infiltrating lymphocytes (TILs) are considered in the prognosis of breast cancer (BC) patients. Here, we investigated the prognostic/predictive effect of TILs in patients treated in the frame of four prospective trials with adjuvant anthracycline-based chemotherapy in the pre- and post-trastuzumab era.

METHODS

TILs density was histologically assessed as percentage of stromal area on whole routine sections of 2613 BC (1563 Luminal A/B; 477 Luminal HER2; 246 HER2-enriched; 327 triple negative [TNBC]) and were evaluated as high/low at three cut-offs (c/o; 50% [lymphocytic predominance, LP], 35% and 25%), in separate training and validation sets.

RESULTS

High TILs were present in 3.5%, 6.5% and 11.5% of all tumors, using the 50%, 35% and 25% c/o, respectively. TILs status did not interact with BC subtypes or trastuzumab treatment. LPBC patient outcome was not affected by nodal status, while high TILs were favorable in TNBC with unfavorable nodal status. When adjusted for standard clinicopathological parameters and treatment, high TILs independently predicted for favorable outcome, e.g., disease-free survival with the 35% c/o in the entire cohort (HR = 0.44, 95% CI 0.28-0.69, p < 0.001) and in specific subtypes.

CONCLUSIONS

High TILs tumors, especially LPBC seem worthy validating as a separate entity of favorable prognosis in breast cancer.

Towards tumor immunodiagnostics

Immunodiagnostic markers applicable on tissue or cytologic material may be prognostic or predictive of response to immunomodulatory drugs and may also be classified according to whether they are cell-specific or tumor-tissue-specific. Cell-specific markers are evaluated under the microscope as (I) morphological, corresponding to the assessment of tumor infiltrating immune cells on routine hematoxylin & eosin (H&E) sections; and (II) immunophenotypic, including the immunohistochemical (IHC) assessment of markers characteristic for tumor infiltrating immune cells. Tumor-tissue-specific markers are assessed in tissue extracts that may be enriched in neoplastic cells but almost inevitably also contain stromal and immune cells infiltrating the tumor. Such markers include (I) immune-response-related gene expression profiles, and (II) tumor genotype characteristics, as recently assessed with large-scale genotyping methods, usually next generation sequencing (NGS) applications. Herein, we discuss the biological nature of immunodiagnostic markers, their potential clinical relevance and the shortcomings that have, as yet, prevented their clinical application.

Gangrenous Cholecystitis Related to Transcatheter Arterial Chemoembolization (TACE) Treatment for Hepatocellular Carcinoma

A 69-year-old male with a history of hepatitis B-induced cirrhosis underwent segmental liver resection for hepatocellular carcinoma. At his 12-month follow-up, local recurrence in segment VII was diagnosed, measuring 7.8 by 6.2 cm, with irregular margins and the presence of a tumor thrombus in the portal vein. After evaluation by the multidisciplinary liver team, the patient underwent transcatheter arterial chemoembolization with drug-eluting beads. Forty-eight hours after his discharge, the patient presented with gangrenous cholecystitis and he underwent an uneventful cholecystectomy. Cholecystitis is a well-documented complication of transcatheter arterial chemoembolization due to inadvertent reflux of the embolic material into the cystic artery. However, super selective embolization significantly reduces the risk of cholecystitis. In most cases, management is conservative and only severe cases require further intervention.

Expression of Bmi1, FoxF1, Nanog, and γ-catenin in relation to hedgehog signaling pathway in human non-small-cell lung cancer

BACKGROUND

Hedgehog signaling is known to be involved in both lung organogenesis and lung carcinogenesis. The aim of this study was to examine potential downstream targets of the hedgehog signaling pathway in non-small-cell lung cancer.

METHODS

Protein expression of Bmi1, FoxF1, Nanog, and γ-catenin was examined by immunohistochemistry in 80 non-small-cell lung cancer samples. Correlations with the previously immunohistochemically recovered results for sonic hedgehog, Ptch1, Smo, Gli1, and Gli2 in the same cohort of tumors as well as the clinicopathological characteristics of the tumors were also evaluated.

RESULTS

Bmi1 was expressed in 78/80 (97.5 %) cases of non-small-cell lung cancer and correlated with male gender and expression of Gli1. Positive expression of FoxF1 was found in 62/80 (77.5 %) cases. Expression of FoxF1 correlated with lymph node metastases, Bmi1, and hedgehog pathway activation. Overexpression of Nanog was also noted in 74/80 (92.5 %) tumors and correlated with Bmi1. Cytoplasmic accumulation of γ-catenin was observed in 85 % (68/80) of the tumors and correlated with the expression of Bmi1, FoxF1, and Nanog.

CONCLUSION

Several developmental pathways seem to be implicated in non-small-cell lung cancer. It is also suggested that Bmi1 and FoxF1 may cooperate with hedgehog signaling in non-small-cell lung carcinogenesis.

Abstract P2-09-18: High VEGFR1 and VEGFR3 Protein Expression Is Associated with Improved Response to the Combination of Paclitaxel (P) and Bevacizumab (Bev) Therapy in Patients with HER2-Negative Metastatic Breast Cancer (MBC)

Background: Treatment with weekly P and 2-weekly Bev has been established as an active 1st line treatment in patients with MBC. However, robust predictive or prognostic biomarkers for this treatment have not been identified as yet.

Patients and Methods: In this retrospective analysis, we evaluated the activity of this combination in patients with HER2-negative MBC. Further, we explored the role of a panel of biomarkers on patients’ outcome. VEGF-A, VEGF-C, VEGFR1, VEGFR2, and VEGFR3 were centrally assessed by immunohistochemistry (IHC) in 70 tissue blocks. P was administered either weekly 90 mg/m2 x12 with 2-weekly Bev 10 µg/kg (86 patients) or 3-weekly 175 mg/m2 x6 with 3-weekly Bev 15µg/kg (38 patients). Bev was administered until progression in the majority of the patients.

Results: The ORR did not differ significantly between the weekly or 3-weekly P schedule (55.8% vs 55.3%). In contrast to the published literature with P monotherapy, median PFS was significantly longer in the 3-weekly compared to the weekly P schedule (20.4 months vs 10.2 months, p=0.029). Median survival has not been reached yet. 2-year survival was 76.1% and 67.3%, respectively (p=0.085). High VEGFR1 and VEGFR3 protein expression, assessed by IHC, was associated with higher response rates (p=0.010 and p=0.039, respectively).

Conclusions: This retrospective analysis confirmed the activity of P and Bev in patients with HER2-negative MBC. Protein expression of VEGFR1 and VEGFR3 was found to be of predictive value. These findings need to be validated in a larger cohort of patients treated with this combination. VEGF polymorphisms (VEGF-2578 and VEGF-1154) are currently assessed in peripheral blood DNA from our patients for possible predictive value.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-09-18.

Overexpression of hedgehog pathway molecules and FOXM1 in non-small cell lung carcinomas

The hedgehog (HH)-signaling pathway is implicated in developmental processes and its aberrant activation in adult tissues has been associated with malignancy. The aim of this study was to determine the expression pattern of HH-signaling molecules in non-small cell lung carcinomas (NSCLC), as well as the involvement of the transcription factor FOXM1, that controls cell proliferation, in this process. Paraffin-embedded tissue sections of 80 NSCLC cases and adjacent non-neoplastic lung parenchyma were immunohistochemically analyzed with anti-SHH, anti-Patched1 (PTCH1), anti-Smoothened (SMO), anti-GLI1, anti-GLI2 and anti-FOXM1 antibodies. Correlations of HH molecules with clinicopathological parameters and FOXM1 expression were evaluated. All the HH-signaling molecules examined were overexpressed in NSCLC compared with the adjacent non-neoplastic lung parenchyma. HH pathway activity and expression of PTCH1 and SMO were significantly higher in squamous cell carcinomas compared to other NSCLC histological types. Activation of HH pathway and PTCH1 expression were correlated with tumor grade being higher in low grade tumors. There was a significant correlation of lymph node metastases with expression of SMO in all NSCLC histological types and with nuclear GLI1 immunolocalization only in adenocarcinomas. Overexpression of FOXM1 in NSCLC was also significantly correlated with PTCH1, SMO and GLI1 expression. In conclusion, HH-signaling pathway is activated in NSCLC and correlates with histological type, prognostic parameters of the tumors as well as with the increased expression of FOXM1.

Paclitaxel and carboplatin as first-line chemotherapy combined with gefitinib (IRESSA) in patients with advanced breast cancer: a phase I/II study conducted by the Hellenic Cooperative Oncology Group

Paclitaxel (Taxol) and carboplatin are an effective combination regimen for treating advanced breast cancer. Gefitinib (IRESSA) is the first epidermal growth factor receptor tyrosine kinase inhibitor to be approved for cancer treatment. This multicenter phase II trial treated 68 patients with advanced breast cancer with paclitaxel (175 mg/m(2) over 3 h) and 3-weekly carboplatin (area under the curve of 6) for six cycles, and 250 mg/day gefitinib orally. Median age was 57 (range 35-77) years, patients had performance status 0 (69.1%), 1 (27.9%) 2 (2.9%), 82.4% of patients had visceral metastases and 63.2% had received adjuvant chemotherapy. Forty-eight (70.6%) patients completed six cycles of chemotherapy and 20 (29.4%) patients discontinued treatment (seven [10.3%] due to disease progression, seven [10.3%] due to toxicity, five [7.4%] withdrew consent and one [1.5%] died after the first cycle). Sixty-three (92.7%) patients were evaluable for response; nine (13.2%) had complete responses, 30 (44.1%) had partial responses, 21 (30.9%) had stable disease and three (4.4%) had disease progression. Grade 3/4 adverse events in > or =5% of patients except of alopecia, included neutropenia (17.7%), anemia (10.3%), diarrhea (7.4%), thrombocytopenia (5.9%) and peripheral neuropathy (5.9%). Of those tumor biopsies available for immunohistochemical analysis (n=60), 5.0% were positive and 35.0% negative for expression of all HER-family receptors. Comparable numbers of tumor biopsies were nuclear p27(kipl) positive and negative (39.7 and 42.7%, respectively), with the majority (72.1%) negative for cytoplasmic p27(kipl). The observed efficacy data in this study were similar to those reported for the combination of paclitaxel and carboplatin alone.

Does graded reaming affect the composition of reaming products in intramedullary nailing of long bones?

Reaming products taken during intramedullary nailing were examined to identify possible differences in their composition depending on the reaming percentage. Reaming products were taken from 39 fresh closed tibial and femoral diaphyseal fractures in patients with an average age of 29 years. According to histology, reaming products mainly consisted of bone trabeculae, viable or nonviable, and bone marrow stroma. A statistically significant reverse correlation exists between viable bone mass percentage and reaming progress. Reaming 1 mm less than the minimum canal diameter provides a higher viable bone mass percentage, which might be an important factor in the bone healing process.

Bronchial carcinoid of an accessory tracheal bronchus

We present a rare case of bronchial carcinoid tumor arising in an accessory right tracheal bronchus and involving the associated tracheal lobe in a 48-year-old man, who presented with a history of recurrent respiratory infections and recent onset of hemoptysis. Diagnosis was established on preoperative bronchoscopy and biopsy. The tumor was completely removed by right upper lobectomy with the tracheal bronchus resected flush to its origin from the right lower tracheal wall. Final histology revealed a typical carcinoid tumor.

Malignant mixed mesodermal tumors of the ovary

OBJECTIVE

To review the experience at Women & Infants Hospital and Hartford Hospital of patients with malignant mixed mesodermal tumors of the ovary, and to review the pertinent literature.

METHODS

Fourteen cases of malignant mixed mesodermal tumors of the ovary at the two hospitals over a 5-year period were identified through their tumor registries. Demographic data, pathology, treatment, and survival rates were reviewed.

RESULTS

The median survival of the patients in our series was 7 months, with 64% dead of disease in 1 year. A review of the pertinent literature indicated median survivals of 6-12 months, with more than 70% of the patients dead of disease at 1 year, despite treatment.

CONCLUSION

Further investigation is needed to determine the proper management for malignant mixed mesodermal tumors of the ovary. Meanwhile, current treatment strategies should recognize the present therapeutic limitations, so as not to diminish any further the quality of life for women with this malignancy.