Cardiac structure, function, and coronary anatomy 10 years after isolated contemporary adjuvant radiotherapy in breast cancer patients with low cardiovascular baseline risk

AIMS

The effects of isolated contemporary low-dose breast cancer (BC) radiotherapy (RT) on the heart remain poorly understood. This study aims to assess the long-term impacts of BC-RT on cardiac structure and function.

METHODS AND RESULTS

Seventy-six women (62 ± 7 years) without history of prior heart disease, who had undergone RT for either first left (n = 36) or right (n = 40) BC, without additional medical oncology therapy apart from hormonal treatment 11 ± 1 years earlier, underwent transthoracic echocardiography, cardiac magnetic resonance imaging (CMR), computed tomography coronary angiography (CTCA), NT-proBNP, and a 6-min walk test (6MWT). They were compared with 54 age-matched healthy female controls. By CTCA, 68% of BC patients exhibited no or very mild coronary disease, while only 11% had moderate stenosis (50-69%) and 3% had significant stenosis (>70%). Despite slightly reduced regional echocardiographic midventricular strains, BC patients exhibited similar global left and right ventricular volumes, ejection fractions, and global strains by echocardiography and CMR as controls. Mitral E/e' ratios were slightly higher, and mitral deceleration times were slightly lower, but NT-proBNP was similar to controls. Also, 6MWT was normal. None had late gadolinium enhancement, and extracellular volume fraction was similar in BC (28 ± 3 vs. 29 ± 3, P = 0.15) and controls. No differences were observed relative to dose or side of RT.

CONCLUSION

Aside from minor alterations of regional strains and diastolic parameters, women who received isolated RT for BC had low prevalence of coronary disease, normal global systolic function, NT-proBNP, and exercise capacity and showed no structural changes by CMR, refuting significant long-term cardiotoxicity in such low-risk patients.

Metabolic adaptation towards glycolysis supports resistance to neoadjuvant chemotherapy in early triple negative breast cancers

BACKGROUND

Neoadjuvant chemotherapy (NAC) is the standard of care for patients with early-stage triple negative breast cancers (TNBC). However, more than half of TNBC patients do not achieve a pathological complete response (pCR) after NAC, and residual cancer burden (RCB) is associated with dismal long-term prognosis. Understanding the mechanisms underlying differential treatment outcomes is therefore critical to limit RCB and improve NAC efficiency.

METHODS

Human TNBC cell lines and patient-derived organoids were used in combination with real-time metabolic assays to evaluate the effect of NAC (paclitaxel and epirubicin) on tumor cell metabolism, in particular glycolysis. Diagnostic biopsies (pre-NAC) from patients with early TNBC were analyzed by bulk RNA-sequencing to evaluate the predictive value of a glycolysis-related gene signature.

RESULTS

Paclitaxel induced a consistent metabolic switch to glycolysis, correlated with a reduced mitochondrial oxidative metabolism, in TNBC cells. In pre-NAC diagnostic biopsies from TNBC patients, glycolysis was found to be upregulated in non-responders. Furthermore, glycolysis inhibition greatly improved response to NAC in TNBC organoid models.

CONCLUSIONS

Our study pinpoints a metabolic adaptation to glycolysis as a mechanism driving resistance to NAC in TNBC. Our data pave the way for the use of glycolysis-related genes as predictive biomarkers for NAC response, as well as the development of inhibitors to overcome this glycolysis-driven resistance to NAC in human TNBC patients.

Predictive markers for pathological complete response (pCR) after neo-adjuvant chemotherapy in HER2-positive breast carcinoma

OBJECTIVES

Patients with HER2-positive invasive breast cancer that is node-positive and/or larger than 3 cm are generally treated with neoadjuvant chemotherapy (NAC). We aimed to identify predictive markers for pathological complete response (pCR) after NAC in HER2-positive breast carcinoma.

METHODS

Hematoxylin/eosin-stained slides of 43 HER2-positive breast carcinoma biopsies were histopathologically reviewed. Immunohistochemistry (IHC) was performed on pre-NAC biopsies, comprising HER2, estrogen receptor (ER), progesterone receptor (PR), Ki-67, epidermal growth factor receptor (EGFR), mucin-4 (MUC4), p53 and p63. Dual-probe HER2 in situ hybridization (ISH) was performed to study the mean HER2 and CEP17 copy numbers. ISH and IHC data were retrospectively collected for a validation cohort, comprising 33 patients.

RESULTS

Younger age at diagnosis, 3+ HER2 IHC scores, high mean HER2 copy numbers and high mean HER2/CEP17 ratios were significantly associated with an increased chance of achieving a pCR, and the latter two associations were confirmed in the validation cohort. No other immunohistochemical or histopathological markers were associated with pCR.

CONCLUSIONS

This retrospective study of two community-based NAC-treated HER2-positive breast cancer patient cohorts identified high mean HER2 copy numbers as a strong predictor for pCR. Further studies on larger cohorts are required to determine a precise cut-point for this predictive marker.

Pregnancy After Breast Cancer in Young BRCA Carriers: An International Hospital-Based Cohort Study

Importance

Young women with breast cancer who have germline pathogenic variants in BRCA1 or BRCA2 face unique challenges regarding fertility. Previous studies demonstrating the feasibility and safety of pregnancy in breast cancer survivors included limited data regarding BRCA carriers.

Objective

To investigate cumulative incidence of pregnancy and disease-free survival in young women who are BRCA carriers.

Design, Setting, and Participants

International, multicenter, hospital-based, retrospective cohort study conducted at 78 participating centers worldwide. The study included female participants diagnosed with invasive breast cancer at age 40 years or younger between January 2000 and December 2020 carrying germline pathogenic variants in BRCA1 and/or BRCA2. Last delivery was October 7, 2022; last follow-up was February 20, 2023.

Exposure

Pregnancy after breast cancer.

Main Outcomes and Measures

Primary end points were cumulative incidence of pregnancy after breast cancer and disease-free survival. Secondary end points were breast cancer-specific survival, overall survival, pregnancy, and fetal and obstetric outcomes.

Results

Of 4732 BRCA carriers included, 659 had at least 1 pregnancy after breast cancer and 4073 did not. Median age at diagnosis in the overall cohort was 35 years (IQR, 31-38 years). Cumulative incidence of pregnancy at 10 years was 22% (95% CI, 21%-24%), with a median time from breast cancer diagnosis to conception of 3.5 years (IQR, 2.2-5.3 years). Among the 659 patients who had a pregnancy, 45 (6.9%) and 63 (9.7%) had an induced abortion or a miscarriage, respectively. Of the 517 patients (79.7%) with a completed pregnancy, 406 (91.0%) delivered at term (≥37 weeks) and 54 (10.4%) had twins. Among the 470 infants born with known information on pregnancy complications, 4 (0.9%) had documented congenital anomalies. Median follow-up was 7.8 years (IQR, 4.5-12.6 years). No significant difference in disease-free survival was observed between patients with or without a pregnancy after breast cancer (adjusted hazard ratio, 0.99; 95% CI, 0.81-1.20). Patients who had a pregnancy had significantly better breast cancer-specific survival and overall survival.

Conclusions and Relevance

In this global study, 1 in 5 young BRCA carriers conceived within 10 years after breast cancer diagnosis. Pregnancy following breast cancer in BRCA carriers was not associated with decreased disease-free survival.

Trial Registration

ClinicalTrials.gov Identifier: NCT03673306.

Breast-implant Related Silicone Lymphadenopathy: Asteroid Bodies do not Always Equal Sarcoidosis!

Silicone breast implants are frequently used for breast augmentation for cosmetic purposes, as well as for breast reconstruction after prophylactic or therapeutic mastectomy. Silicone lymphadenopathy is a well-known complication of silicone breast implants. Silicone droplets are present in the breast tissue through 'silicone bleeding' of the implant or because of implant rupture. These silicone particles can migrate from the breast to the regional lymph nodes. Silicone lymphadenopathy is caused by a substantial foreign body reaction against these silicone particles, and is frequently associated with asteroid body-containing multinucleated giant cells. Similar multinucleated giant cells are often observed in the capsule surrounding the silicone breast implant, and the number of associated asteroid bodies is highly variable. Here, we discuss a series of twelve women with breast implant-related asteroid bodies in their lymph nodes and/or breast tissue. This pictorial essay illustrates that the presence of asteroid bodies in a lymph node does not necessarily suggests a diagnosis of sarcoidosis. Clinical information about the patient having (or having had) silicone breast implants is often lacking. The encounter of asteroid body-containing giant cells in lymph node cytology, biopsies or resections should therefore lead to reflex clinical-pathological correlation, before establishing a final diagnosis.

Abstract P4-07-16: B-IMMUNE final analysis: a phase Ib/II study of durvalumab combined with dose-dense EC in a neoadjuvant setting for patients with locally advanced luminal B HER2(-) or triple negative breast cancers

Background: Neoadjuvant association of immune checkpoints inhibitors (ICI) and dose dense chemotherapy is promising for triple negative breast cancers (TNBC). However, response rates vary from one study to another. Timing, best chemotherapy partner and efficacy in less immunogenic breast cancer (BC), like luminal B tumors, should be further investigated. This study evaluates for TNBC and luminal B HER2(-) BC the neoadjuvant treatment with paclitaxel followed by a short combination of an anti-PD-L1 antibody with anthracyclines. Method B-IMMUNE (NCT03356860), a multicentric phase Ib/II prospective trial, included patients with stage I to III luminal B HER2(-) or TNBC treated with paclitaxel 80mg/m2 weekly from week 1 to 12 followed by 4 cycles of epirubicine 90mg/m2 and cyclophosphamide 600 mg/m2 (EC) Q2W in a neoadjuvant setting. Phase Ib evaluated a single infusion of durvalumab (anti-PD-L1) combined with the 3rd cycle of EC. Phase II evaluated infusions of durvalumab with the 1st and 3rd EC cycles. Surgery was planned 3 weeks after the last EC cycle. Primary objectives were safety and pathological complete response (pCR) rate compared to a historical control. Secondary endpoint was the overall response rate (ORR) based on breast MRI. Eleven patients were enrolled in a control arm without durvalumab, exclusively for translational research purposes. Based on a 2-stage Simon design with an α = 0.1 and β = 0.1, 22 TNBC patients were needed in the phase II to test a null hypothesis of 30% pCR rate against a one-side alternative of 60%, and 24 luminal B BC patients to test a null hypothesis of 15% pCR rate against a one-side alternative of 40% (including an additional accrual margin of 10% for eventual dropouts). At least 9 pCRs had to be observed among the first 20 evaluable TNBC patients and 6 among the first 22 evaluable luminal B patients to rule out the null hypothesis. Results This analysis concerns the 50 patients treated with the experimental treatment, 3 from the phase Ib and 47 from the phase II part. Median age was 51 y-old (31 to 72y), tumor subtypes were 24 TNBC, 25 Luminal B and one sarcoma excluded from the efficacy analysis. Seven (14%) patients had a stage I tumor, 17 (34%) a stage IIA, 13 (26%) a stage IIB, 8 (16%) a stage IIIA, 4 (8%) a stage IIIB and 1 (2%) a stage IIIC. Concerning safety, 232 AEs were reported on 39/50 patients and 34 (14,6%) were graded ≥ 3. The 5 most frequent all-grade AEs were fatigue (8,2%), diarrhea (5,6%), neutropenia (5,2%), anemia and nausea (4,3%). Most frequent grade 3 AEs were anemia and neutropenia (14,7%). Among 4 immune-related adverse events, all were thyroid disorders. One patient died 10 months after the end of treatment due to progressive disease in the liver. Forty-six of the 47 phase II patients were evaluable for efficacy. pCR was reported in 12/22 TNBC patients (55%) and 8/24 luminal B HER2(-) patients (33%). Subgroup analyses based on PD-L1 expression and TILs score are planned. Conclusions The B-IMMUNE study met its primary objective showing a significant improvement in pCR versus the historical control in both TNBC and in Luminal B HER2(-) BC cohorts with the addition of only 2 doses of durvalumab to the anthracyclines. The safety profile is comparable to those previously described with reported immune related adverse events limited to thyroid endocrine disorders.

Citation Format: Alix Devaux, Gabriela Beniuga, Claire Quaghebeur, Stéphanie Henry, Mieke Van Bockstal, Christine Galant, Paul Delrée, Jean-Luc Canon, Brigitte Honhon, Dominique Korman, Vincent Verschaeve, Christophe Lonchay, Sarah Lefevre, Lionel D’Hondt, Martine Berlière, Sophie Delmarcelle, Jean-Michel Mine, Timour Willems, Gebhard Müller, Nathalie Myant, Isabelle Bar, Sandy Haussy, Pierre G. Coulie, François P. Duhoux, Javier Carrasco. B-IMMUNE final analysis: a phase Ib/II study of durvalumab combined with dose-dense EC in a neoadjuvant setting for patients with locally advanced luminal B HER2(-) or triple negative breast cancers. [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 P4-07-16.

Predictive Biomarkers of Response to Neoadjuvant Chemotherapy in Breast Cancer: Current and Future Perspectives for Precision Medicine

Pathological complete response (pCR) after neoadjuvant chemotherapy in patients with early breast cancer is correlated with better survival. Meanwhile, an expanding arsenal of post-neoadjuvant treatment strategies have proven beneficial in the absence of pCR, leading to an increased use of neoadjuvant systemic therapy in patients with early breast cancer and the search for predictive biomarkers of response. The better prediction of response to neoadjuvant chemotherapy could enable the escalation or de-escalation of neoadjuvant treatment strategies, with the ultimate goal of improving the clinical management of early breast cancer. Clinico-pathological prognostic factors are currently used to estimate the potential benefit of neoadjuvant systemic treatment but are not accurate enough to allow for personalized response prediction. Other factors have recently been proposed but are not yet implementable in daily clinical practice or remain of limited utility due to the intertumoral heterogeneity of breast cancer. In this review, we describe the current knowledge about predictive factors for response to neoadjuvant chemotherapy in breast cancer patients and highlight the future perspectives that could lead to the better prediction of response, focusing on the current biomarkers used for clinical decision making and the different gene signatures that have recently been proposed for patient stratification and the prediction of response to therapies. We also discuss the intratumoral phenotypic heterogeneity in breast cancers as well as the emerging techniques and relevant pre-clinical models that could integrate this biological factor currently limiting the reliable prediction of response to neoadjuvant systemic therapy.

BRCA1 Mutation: An Insidious Enemy with Multiple Facets…

Epidemiological studies suggest that around 10% of breast cancers are due to hereditary predisposition. The risk of cancer is exponentially increased in patients harboring BRCA1 or BRCA2 mutations. Cumulative breast cancer risk by age 80 is estimated to 72% for BRCA1 mutation carriers and 69% for BRCA2. The cumulative risk estimates for developing ovarian cancer by age 80 are 44% for BRCA1 mutation carriers and 17% for BRCA2. We present here the case of a 59-year-old woman who developed a left breast cancer in 2014 treated by conservative surgery, radiotherapy, and endocrine therapy with letrozole. The diagnosis of BRCA1 mutation was performed in 2015. In 2018, the patient was referred to our institution for treatment of an aggressive angiosarcoma developed in the same breast. She had undergone radical hysterectomy by the age of 49 years for a benign uterine pathology. In 2020, she developed a tumor in the gastric wall; histological analysis confirmed a serous papillary carcinoma of ovarian origin. She was treated − after gastrectomy and lymphadenectomy − with 6 courses of carboplatin and paclitaxel followed by olaparib therapy. In 2021, she suffered from a chest recurrence of high grade angiosarcoma. New resection with free margins was performed. We discuss the link between angiosarcomas and BRCA mutations, the therapeutic options for angiosarcoma and ovarian cancer of extra ovarian origin and the follow-up modalities.

Severe Gestational Gigantomastia: from Mastectomy to Staged Autologous Breast Reconstruction. A Case Report

Gestational gigantomastia (GGM) is a rare condition characterized by a massive overgrowth of breast tissue during pregnancy. Surgical sanction may be required when conservative measures fail. In this study, we report the case of a 29-year-old woman who presented with an evolutive GGM responsible for physical and emotional distress, despite medical treatment. A multidisciplinary decision was made to induce delivery at 32 weeks. In the postdelivery period, the patient developed breast wounds, complicated with septic cardiomyopathy. An emergency bilateral mastectomy was then carried out, together with banking of both nipple-areola complexes. Thereafter, delayed bilateral 2-stage breast reconstruction was started at 12 months with subcutaneous tissue expanders, later on followed by implants removal and autologous reconstruction with bilateral deep inferior epigastric artery perforator flaps and bilateral nipple replantation.

Artefactual Epithelial Displacement in a Papilloma with Extensive Usual Duct Hyperplasia Mimics a Solid Papillary Carcinoma with Invasive Growth

Mammary solid papillary carcinoma and usual duct hyperplasia (UDH) of the breast are morphological look-alikes, characterized by cellular streaming, solid growth, and a lack of high-grade nuclear atypia. Here, we report a challenging papillary lesion in the breast of a 48-year-old woman that presented with a double pitfall. A core needle biopsy showed a solid papillary proliferation of epithelial cells with oval to round overlapping nuclei, surrounded by a sclerotic stroma. This distorted lesion contained peripheral clefts and cellular streaming, without high-grade nuclear atypia. Immunohistochemistry showed diffuse heterogenous immunoreactivity for estrogen receptor and cytokeratin 5, and no immunoreactivity for chromogranin and synaptophysin. The immunohistochemical profile distinguished this sclerosed papilloma with extensive UDH from a solid papillary carcinoma. The lumpectomy specimen revealed a second challenge, where multiple epithelial islets without surrounding myoepithelial cells were observed near the papilloma, mimicking an invasive carcinoma. These islets displayed the same immunohistochemical profile as the sclerosed papilloma and they were surrounded by steatonecrosis and reactive fibroblasts, indicating epithelial displacement within the biopsy needle tract. A sclerosed papilloma with extensive UDH is a morphologically challenging mimic of a solid papillary carcinoma. Immunohistochemistry is helpful to distinguish both entities from one another. Extensive epithelial displacement in the biopsy tract made this case particularly challenging, as the displaced epithelial islets mimicked an invasive carcinoma. Pathologists should be aware of this uncommon double pitfall to prevent misdiagnosis.

Morphological intratumor heterogeneity in ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast is a heterogeneous disease in terms of morphological characteristics, protein expression profiles, genetic abnormalities, and potential for progression. Molecular heterogeneity has been extensively studied in DCIS. Yet morphological heterogeneity remains relatively undefined. This study investigated morphological intratumor heterogeneity in a series of 51 large DCIS. Nuclear atypia, DCIS architecture, necrosis, calcifications, stromal architecture, and stromal inflammation were assessed in one biopsy slide and three representative slides from each corresponding resection. For each histopathological feature, a histo-score was determined per slide and compared between the biopsy and the resection, as well as within a single resection. Statistical analysis comprised of Friedman tests, post hoc Wilcoxon tests with Bonferroni corrections, Mann-Whitney U tests, and chi-square tests. Despite substantial morphological heterogeneity in around 50% of DCIS, the histopathological assessment of the biopsy did not statistically significantly differ from the resection. Morphological heterogeneity was not significantly associated with patient age, DCIS size, or type of surgery, except for a weak association between heterogeneous stromal inflammation and smaller DCIS size. At the group level, the degree of heterogeneity did not significantly affect the representativity of a biopsy. At the individual patient level, however, the presence of necrosis, intraductal calcifications, myxoid stromal changes, and high-grade nuclear atypia was underestimated in a minority of DCIS patients. This study confirms the presence of morphological heterogeneity in DCIS for all six evaluated histopathological features. This should be kept in mind when taking biopsy-based treatment decisions for DCIS patients.

Interobserver Variability in Ductal Carcinoma In Situ of the Breast

OBJECTIVES

Since most patients with ductal carcinoma in situ (DCIS) of the breast are treated upon diagnosis, evidence on its natural progression to invasive carcinoma is limited. It is estimated that around half of the screen-detected DCIS lesions would have remained indolent if they had never been detected. Many patients with DCIS are therefore probably overtreated. Four ongoing randomized noninferiority trials explore active surveillance as a treatment option. Eligibility for these trials is mainly based on histopathologic features. Hence, the call for reproducible histopathologic assessment has never sounded louder.

METHODS

Here, the available classification systems for DCIS are discussed in depth.

RESULTS

This comprehensive review illustrates that histopathologic evaluation of DCIS is characterized by significant interobserver variability. Future digitalization of pathology, combined with development of deep learning algorithms or so-called artificial intelligence, may be an innovative solution to tackle this problem. However, implementation of digital pathology is not within reach for each laboratory worldwide. An alternative classification system could reduce the disagreement among histopathologists who use "conventional" light microscopy: the introduction of dichotomous histopathologic assessment is likely to increase interobserver concordance.

CONCLUSIONS

Reproducible histopathologic assessment is a prerequisite for robust risk stratification and adequate clinical decision-making. Two-tier histopathologic assessment might enhance the quality of care.

Predictive markers for pathological complete response after neo-adjuvant chemotherapy in triple-negative breast cancer

A combination of Sox10 and GATA3 was previously identified as a marker for metastatic triple-negative breast cancer (TNBC), but it is uncertain whether their expression is associated with pathological complete response (pCR) after neoadjuvant chemotherapy (NAC). This study investigates the predictive value of clinicopathological characteristics, as well as protein expression of Sox10, GATA3, p53 and p63, in a consecutive series of TNBC patients treated with NAC. Archived hematoxylin & eosin stained slides of core biopsies and resection specimens from 35 TNBC patients were reviewed. The following clinicopathological characteristics were determined at the biopsy level: age at diagnosis, cancer type, Nottingham grade, lympho-vascular invasion, syncytial growth, necrosis, clear cell differentiation, myxoid peritumor stroma, stromal tumor-infiltrating lymphocytes (sTILs) and presence of an in situ component. The MD Anderson residual cancer burden (RCB) score and corresponding RCB class were determined. Immunohistochemistry for Sox10, p53, GATA3 and p63 was performed at the biopsy level. sTILs, either as a continuous or as a dichotomous variable, were the only parameter that was significantly associated with pCR in univariable and multivariable analyses. Assessment of sTILs showed moderate to good interobserver agreement. High sTILs (≥40%) were significantly associated with increased pCR rates, and this association was observer-independent. This retrospective study of a consecutive community-based cohort of TNBC patients confirms that sTILs are a robust, observer-independent predictor for therapeutic response after NAC. The combination of Sox10, GATA3 and p53 immunoreactivity is unlikely to harbor any predictive value for pCR in TNBC.

Pregnancy After Breast Cancer in Patients With Germline BRCA Mutations

PURPOSE

Young women with germline BRCA mutations have unique reproductive challenges. Pregnancy after breast cancer does not increase the risk of recurrence; however, very limited data are available in patients with BRCA mutations. This study investigated the impact of pregnancy on breast cancer outcomes in patients with germline BRCA mutations.

PATIENTS AND METHODS

This is an international, multicenter, hospital-based, retrospective cohort study. Eligible patients were diagnosed between January 2000 and December 2012 with invasive early breast cancer at age ≤ 40 years and harbored deleterious germline BRCA mutations. Primary end points were pregnancy rate, and disease-free survival (DFS) between patients with and without a pregnancy after breast cancer. Pregnancy outcomes and overall survival (OS) were secondary end points. Survival analyses were adjusted for guarantee-time bias controlling for known prognostic factors.

RESULTS

Of 1,252 patients with germline BRCA mutations (BRCA1, 811 patients; BRCA2, 430 patients; BRCA1/2, 11 patients) included, 195 had at least 1 pregnancy after breast cancer (pregnancy rate at 10 years, 19%; 95% CI, 17% to 22%). Induced abortions and miscarriages occurred in 16 (8.2%) and 20 (10.3%) patients, respectively. Among the 150 patients who gave birth (76.9%; 170 babies), pregnancy complications and congenital anomalies occurred in 13 (11.6%) and 2 (1.8%) cases, respectively. Median follow-up from breast cancer diagnosis was 8.3 years. No differences in DFS (adjusted hazard ratio [HR], 0.87; 95% CI, 0.61 to 1.23; P = .41) or OS (adjusted HR, 0.88; 95% CI, 0.50 to 1.56; P = .66) were observed between the pregnancy and nonpregnancy cohorts.

CONCLUSION

Pregnancy after breast cancer in patients with germline BRCA mutations is safe without apparent worsening of maternal prognosis and is associated with favorable fetal outcomes. These results provide reassurance to patients with BRCA-mutated breast cancer interested in future fertility.

Periductal Stromal Tumors and Phyllodes Tumors Represent a Spectrum of Fibroepithelial Lesions: What Is in a Name?

Periductal stromal tumors (PSTs) of the breast are considered as a rare subtype of phyllodes tumors. These rare fibroepithelial lesions display a biphasic morphology, characterized by a cellular stroma surrounding benign ducts. Unlike phyllodes tumors, they do not present with a leaflike architecture, rendering a biopsy diagnosis of a PST very challenging. In this report, we compare the histopathological features of a PST with those of a borderline phyllodes tumor. We discuss the differences and similarities between both entities, and we highlight the potential pitfalls of the respective biopsies. Both cases illustrate that PSTs and phyllodes tumors are part of the same spectrum. This biological spectrum implies that "hybrid" lesions do exist, which can be hard to classify.

Tumor sequencing is useful to refine the analysis of germline variants in unexplained high-risk breast cancer families

Background

Multigene panels are routinely used to assess for predisposing germline mutations in families at high breast cancer risk. The number of variants of unknown significance thereby identified increases with the number of sequenced genes. We aimed to determine whether tumor sequencing can help refine the analysis of germline variants based on second somatic genetic events in the same gene.

Methods

Whole-exome sequencing (WES) was performed on whole blood DNA from 70 unrelated breast cancer patients referred for genetic testing and without a BRCA1, BRCA2, TP53, or CHEK2 mutation. Rare variants were retained in a list of 735 genes. WES was performed on matched tumor DNA to identify somatic second hits (copy number alterations (CNAs) or mutations) in the same genes. Distinct methods (among which immunohistochemistry, mutational signatures, homologous recombination deficiency, and tumor mutation burden analyses) were used to further study the role of the variants in tumor development, as appropriate.

Results

Sixty-eight patients (97%) carried at least one germline variant (4.7 ± 2.0 variants per patient). Of the 329 variants, 55 (17%) presented a second hit in paired tumor tissue. Of these, 53 were CNAs, resulting in tumor enrichment (28 variants) or depletion (25 variants) of the germline variant. Eleven patients received variant disclosure, with clinical measures for five of them. Seven variants in breast cancer-predisposing genes were considered not implicated in oncogenesis. One patient presented significant tumor enrichment of a germline variant in the oncogene ERBB2, in vitro expression of which caused downstream signaling pathway activation.

Conclusion

Tumor sequencing is a powerful approach to refine variant interpretation in cancer-predisposing genes in high-risk breast cancer patients. In this series, the strategy provided clinically relevant information for 11 out of 70 patients (16%), adapted to the considered gene and the familial clinical phenotype.

Abstract P5-03-03: Tumor sequencing is useful to reclassify germline variants in unexplained high-risk breast cancer families

BACKGROUND Multigene panels are routinely used to search for predisposing mutations in families considered at high risk of breast cancer. The number of variants of unknown significance (VUS) thereby identified increases with the number of sequenced genes. We aimed to determine whether tumor sequencing can help reclassify germline VUS based on second events hitting the same gene. METHODS Whole-exome sequencing (WES) was performed on whole-blood DNA from 70 unrelated breast cancer patients referred for genetic testing and without BRCA1, BRCA2, TP53 or CHEK2 mutations. Rare variants considered as a VUS based on ACMG guidelines were retained in a list of 735 genes. WES was performed on matched tumor DNA to look for somatic second hits (copy number alteration or second mutation) in the same genes. RESULTS Sixty-eight patients (97%) carried at least one germline VUS (4.7 ± 2.0 variants per patient). Of the 329 VUS, 55 (17%) presented a somatic second hit in the paired tumor tissue. Two were a second somatic mutation, whereas 53 were copy number alterations. This resulted in relative tumor enrichment or depletion of the germline variant for 28 and 25 VUS, respectively. Estimation of tumor mutation burden and homologous recombination deficiency through mutational signatures and allelic imbalance analysis could highlight bi-allelic gene inactivation in relevant cases. Clinical measures were proposed for six patients carrying a germline variant on PALB2, PMS2, PMS1, MUTYH or NTHL1. Variant disclosure without clinical measures was proposed for five patients carrying a variant on MRE11A, ATM, WRN or TP53 (functional testing ongoing for the latter). Germline and tumor DNA analysis of an affected relative of the patient carrying the germline MRE11A variant demonstrated the co-segregation of the variant as well as the presence of the same somatic second hit. Seven VUS on clinically actionable breast cancer predisposing genes (PALB2, BRCA2, CDH1, ATM and BARD1) were downgraded to probably benign variants as the germline variant was depleted in the tumor. One patient presented a significant tumor enrichment of a germline VUS in the C-terminal domain of the oncogene ERBB2. In vitro expression of this variant caused downstream signaling pathway activation. CONCLUSION Tumor sequencing is a powerful approach to refine VUS in cancer-predisposing genes in high-risk breast cancer patients. In this series, the strategy provided clinically relevant information for 11 out of 70 patients (16%).

Citation Format: Cedric Van Marcke, Raphaël Helaers, Céline A Schoonjans, Martine Berlière, Anne De Leener, Jean-Luc Canon, Peter Vuylsteke, Jean-Pascal Machiels, Nisha Limaye, Miikka Vikkula, Francois P Duhoux. Tumor sequencing is useful to reclassify germline variants in unexplained high-risk breast cancer families [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-03-03.

Abstract P5-03-04: Co-segregation of rare possibly-damaging variants in cancer-related genes correlates with phenotypic homogeneity in familial breast cancer

BACKGROUND Breast cancer (BC) is a complex disease. While Mendelian mutations in high-penetrance genes predispose to some familial forms, others are due to multiple common low-penetrance polymorphisms. However, it is unclear if the combination of some rare coding variants has an effect. As some Mendelian forms demonstrate genotype-phenotype correlations, we hypothesized co-segregation of rare variants in cancer-related genes would be more frequent in high-risk families with a uniform BC phenotype among relatives. METHODS Whole-exome sequencing was performed on germline DNA from unrelated BC patients referred for genetic testing but without a causative mutation and for which DNA was available from at least one second relative with BC. We retained rare (< 1.5% in ExaC) in silico possibly damaging variants (splice alteration, nonsense or frameshift mutation, or missense variant considered deleterious by at least 2 different algorithms) in a list of 735 cancer or DNA repair related genes. We assessed correlation between segregation of these variants in affected relatives (studied by Sanger sequencing) and tumor phenotypes. A familial uniform BC phenotype was denoted as sharing the same BC histology and the same clinical molecular classification, based on the expression of the hormone receptors and HER2. RESULTS Of the 54 families, 23 (43%) presented a uniform phenotype across the affected relatives. We identified 251 variants. The mean number of variants tested did not differ between families with a similar BC phenotype and families with different BC phenotypes (4.3 vs 4.9 respectively, two-sided T-test p=0.19). The proportion of disease co-segregating variants inside each family was however significantly higher in families with a uniform BC phenotype than in families with a heterogeneous BC phenotype (57.8% vs 30.2%, p<0.01 adjusted for the number of relatives and meioses within each family). Sequencing of matched tumor DNA, obtained for 44 probands, revealed co-segregating variants were more frequently enriched by a somatic event (18.6 vs 4.5%, Mann-Whitney test p=0.042 and 8.3 vs 1.1%, p=0.031 for the families with a uniform or a heterogeneous breast cancer phenotype, respectively). CONCLUSION In this cohort of families at high risk of BC, the proportion of co-segregating variants was significantly higher in the families in which the affected relatives shared a uniform BC phenotype. Investigation of oligogenic models could be more pertinent in this subgroup of families. The theory of bi-allelic gene inactivation required to drive cancer, shown for several Mendelian genes, could also be pertinent in the oligogenic model of inheritance. This study should be replicated in an independent cohort for confirmation.

Citation Format: Cedric Van Marcke, Raphaël Helaers, Céline A Schoonjans, Jérôme Ambroise, Martine Berlière, Jean-Luc Canon, Peter Vuylsteke, Jean-Pascal Machiels, Miikka Vikkula, Francois P Duhoux. Co-segregation of rare possibly-damaging variants in cancer-related genes correlates with phenotypic homogeneity in familial breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-03-04.

Potential Benefit of Intra-operative Administration of Ketorolac on Breast Cancer Recurrence According to the Patient's Body Mass Index

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) are currently used in some countries as analgesics in primary cancer surgery. Retrospective studies suggest that NSAIDs could reduce breast cancer recurrences. Because NSAIDs also act on biological mechanisms present in patients with increased adiposity, we aimed at assessing whether the intra-operative administration of ketorolac or diclofenac would be associated with a reduction of recurrence in patients with elevated body mass index (BMI).

Methods

We considered two institutional retrospective series of 827 and 1007 patients evaluating the administration of ketorolac (n = 529 with, n = 298 without) or diclofenac (n = 787 with, n = 220 without). The BMI subgroups were defined as less than 25 kg/m2 (lean) and 25 or more kg/m2 (overweight and obese). Cumulative incidence estimation of distant metastases as well as Fine-Gray and Dixon-Simon models was used. These analyses were adjusted for clinico-pathological variables. All statistical tests were two-sided.

Results

The administration of ketorolac was statistically significantly associated with decreased incidence of distant recurrences (adjusted hazard ratio [aHR]= 0.59, 95% confidence interval [CI] = 0.37 to 0.96, P = .03). In particular, the association was evident in the high-body mass index (BMI) group of patients (aHR = 0.55, 95% CI = 0.31 to 0.96, P = .04). The administration of diclofenac was not statistically significantly associated with decreased incidence of distant recurrences, either in the global population or in the BMI subgroups.

Conclusions

These results show that the intra-operative administration of ketorolac, but not diclofenac, is statistically significantly associated with a reduction of distant recurrences in patients with increased BMI. Altogether, this study points to a potentially important repositioning of ketorolac in the intra-operative treatment of patients with elevated BMI that, if prospectively validated, might be as impactful as and cheaper than adjuvant systemic anticancer therapies.

Abstract P4-04-10: Early-stage breast carcinomas are infiltrated by oligoclonal T cell populations highly enriched relative to the blood

BACKGROUD: The immunogenicity of some human tumors towards T lymphocytes is well established. Recently, encouraging results have been obtained with immunotherapies inhibiting immune checkpoints in cancers such as melanoma, NSCLC and bladder cancer. Fewer studies explored these treatments in breast cancer (BC) as these tumors are often considered to be poorly immunogenic.

METHODS: We analysed the T cell receptor β-chains variable genes (TCRBV) repertoires of tumor-infiltrating T cells in 17 early BC. We looked for clonally amplified T cells as their presence is an expected consequence of tumor immunogenicity. RNA was extracted and reverse-transcribed from formalin-fixed, paraffin-embedded tumor tissues. A short random sequence was added to the cDNA and used as a unique molecular identifier (UMI) for each cDNA molecule. cDNA encoding TCRBV genes was then amplified and sequenced using high throughput sequencing. Usage of UMIs during this procedure strongly improved the accuracy of the analysis by avoiding amplification biases inherent to the construction of the TCRBV library and by allowing an absolute quantification of TCRBV mRNA molecules normalized with the RPP30 housekeeping gene. TCRBV sequences were aligned using IMGT/HighV-QUEST. The Simpson's index was used to evaluate TCRBV repertoires diversity (ranging from 0 = infinite diversity to 1 = no diversity). For 3 patients, the same procedure was applied on blood T cells collected a few days before tumor resection and the analysis was also carried out on 3 normal tissues obtained from breast reduction surgery.

RESULTS: T cell infiltration varied strongly from one tumor to another ranging from 5 to 2498 TCRBV/103 RPP30 mRNA molecules. TCRBV repertoires analysis indicated that infiltrated T cells corresponded to oligoclonal populations. We observed 3 clonotypes in the smaller repertoire and 74 in the largest one and the Simpson's index ranged from 0.01 to 0.65. Most tumors (16/17) contained at least one clonotype that made up ≥10% of the infiltrating T cells, with the highest observed proportions reaching 80%. Normal breast samples were infiltrated by a more diverse repertoire: 130 to 368 clonotypes were identified in those tissues and Simpson's index ranged from 0.002 to 0.008. Highest observed frequency among those clonotypes was 2%. For 3 BC patients, the frequencies of the most prevalent clonotypes in the tumor were compared to those of the same clonotypes in blood prior to surgery. These T cell clones were 250 to >34000 times more frequent in the tumor than in the blood.

CONCLUSIONS: Some early BC are infiltrated by oligoclonal T cell populations that are highly enriched relative to the blood. Quantitative T cell repertoire analysis allows to distinguish 3 types of BC: (1) tumors without T cell infiltration, (2) tumors with a high T cell infiltration and a small T cell repertoire, and (3) tumors with a high T cell infiltration and a large repertoire. Our observations suggest that anti-tumor T cell responses are ongoing in some early BC and this warrants boosting such responses with immune checkpoint inhibitors in selected patients. T cell repertoire evaluation could be used as a predictive biomarker to identify patients who will benefit from this treatment.

Citation Format: Carrasco J, Schröder D, Coulie PG, Godelaine D, Berlière M, Theate I, Delrée P, Vannuffel P, Galant C, Duhoux FP, Machiels J-P, Canon J-L. Early-stage breast carcinomas are infiltrated by oligoclonal T cell populations highly enriched relative to the blood. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-04-10.

Abstract P4-04-08: Presence of tumor-specific cytolytic T cells in human primary breast carcinoma: Consequences for immunotherapy

Background: Immunotherapy through stimulatory antibodies targeting the CTLA-4 or PD-1 pathways has a clear clinical efficacy in a fraction of patients with various cancers. It is likely that the main immune effectors of these therapies are CD8+ cytolytic T lymphocytes (CTL) recognizing tumor-specific antigens. The antigenicity of human tumors has been demonstrated with studies conducted mostly on melanomas. However the genetic mechanisms leading to antigenicity, notably point mutations in the tumor cells, apply to all cancer types. Thus primary breast carcinoma cells do certainly bear tumor-specific antigens, even though the extent of this antigenicity is unknown. Most melanomas, which are highly antigenic tumors, are also immunogenic, i.e. they stimulate spontaneous anti-tumor CTL responses. This immunogenicity, of which the presence of tumor-infiltrating T cells (TILs) is probably a surrogate marker, might be a predictive marker for clinical benefit to immunostimulatory antibodies. Whether primary breast carcinomas are immunogenic is not known, mainly due the absence of autologous tumor cell lines to analyze patients' T cells. However even in the absence of T-cell aimed immunotherapy the amounts of TILs have been positively correlated with patients' survival. Here we wished to obtain evidence for the presence of tumor-specific CD8+ T cells in TILs from primary breast carcinomas.

Methods: From each tumor we isolated TILs and derived a random set of ±100 CD8+ clones maintained in culture by stimulation with anti-CD3 antibodies, thus irrespective of their antigenic specificity. We screened these clones for recognition of tumor-specific antigens present on the autologous tumor. In the absence of autologous tumor lines we restricted our analysis to mutated antigens selected on the basis of tumor exome sequencing and gene expression profiling. Indels and non-synonymous base substitutions were selected to synthesize candidate mutated peptides.

Results: Thus far we have analyzed two hormone receptor-positive HER2-negative primary carcinomas. For one patient we screened 144 T cell clones for recognition of 40 candidate mutated peptides, without any positive result. For the other patient, 6 out of 98 T cell clones recognized 4 out of 119 candidate mutated peptides. Two peptides were recognized by two different T cell clones, i.e. with different T cell receptor sequences. These 4 'antigenic' mutations appear to be passenger, i.e. the four genes have a low published mutation frequency.

Conclusions: We conclude that some human primary breast carcinomas are immunogenic, as one tumor contained at least 6% of tumor-specific T cells among the CD8+ TILs. It suggests that the corresponding patient could benefit from the currently used immunostimulatory antibodies. More work is required to understand the reasons for the negative results in the first patient. We are pursuing the work on 2 HER2-positive and 2 triple-negative tumors, in which TILs are better correlated with prognosis. Our results warrant more investigations on the activation or inhibition of tumor-specific T cells at early stages of human breast cancer development.

Citation Format: Schröder DJ, Bricard O, Hames G, Remy N, Carrasco J, Canon J-L, Berlière M, Galant C, Coulie PG. Presence of tumor-specific cytolytic T cells in human primary breast carcinoma: Consequences for immunotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-04-08.

Perioperative ketorolac in high risk breast cancer patients. Rationale, feasibility and methodology of a prospective randomized placebo-controlled trial

Ketorolac, a NSAID routinely used during surgery proposed to have anticancer effects, is a promising way to improve postoperative oncological outcome. This effect may be particularly prominent in patients with elevated preoperative inflammatory scores, like the neutrophil:lymphocyte ratio. In this paper, we describe the rationale, the preliminary analyses in our patients, the feasibility and the methodology of a prospective randomized trial called "Ketorolac in Breast Cancer trial" (KBCt) (NCT01806259).

Genomic grade adds prognostic value in invasive lobular carcinoma

BACKGROUND

The prognostic value of histologic grade (HG) in invasive lobular carcinoma (ILC) remains uncertain, and most ILC tumors are graded as HG2. Genomic grade (GG) is a 97-gene signature that improves the prognostic value of HG. This study evaluates whether GG may overcome the limitations of HG in ILC.

METHODS

Gene expression data were generated from frozen tumor samples, and GG calculated according to the expression of 97 genes. The prognostic value of GG was assessed in a stratified Cox regression model for invasive disease-free survival (IDFS) and overall survival (OS).

RESULTS

A total of 166 patients were classified by GG. HG classified 33 (20%) tumors as HG1, 120 (73%) as HG2 and 12 (7%) as HG3. GG classified 106 (64%) tumors as GG low (GG1), 29 (17%) as GG high (GG3) and 31 (19%) as equivocal (cases not classified as GG1 or GG3). The median follow-up time was 6.5 years. In multivariate analyses, GG was associated with IDFS [HR(GG3 vs GG1) 5.6 (2.1-15.3); P < 0.001] and OS [HR(GG3 vs GG1) 7.2, 95% CI (1.6-32.2); P = 0.01].

CONCLUSIONS

GG outperformed HG in ILC and added prognostic value to classic clinicopathologic variables, including nodal status.

[Contribution of MRI for monitoring response to neoadjuvant chemotherapy in the management of breast cancer]

In the management of breast neoplasms, two breast MR examinations are performed, one before initiation of neoadjuvant chemotherapy (NAC) and one at the end. However, a third MR exam may be performed between two courses of chemotherapy in order to assess tumor response to treatment. The assessment criterion currently used is measurement of tumor diameter according to RECIST (Response Evaluation Criteria In Solid Tumors) and WHO. But according to the preliminary results of the American College of Radiology Imaging Network protocol, using measurement of tumor volume as a reference may be valuable. Larger series are therefore necessary to estimate the value of diffusion MR, spectroscopy and diffusion studies.

[Contribution of sonoelastography to the characterization of breast lesions]

We evaluate the performances of sonoelastography in the characterization of breast nodules with histologic correlation. Elastosonography was performed immediately after mode B sonography in 59 patients (65 nodules) by two radiologists, independently. All sequences of elastosonography were recorded. An intra and inter -observers correlation was calculated. Each nodule was classified with BI-RADS lexicon and with Ueno elastography classification. The scores 1-3 were considered as benign and 4-5 as malignant. A cytologic/histologic diagnosis was available for all nodules. At histology, 16 nodules were malignant and 49 nodules were benign. The intra and inter-observer correlations of elastosonography were excellent. The sensitivity, specificity, PPV, NPV of sonoelastography were 87.5%, 98%, 93.3%, 96%, respectively comparing with 100%, 93.9%, 84%, 100% of Mode B sonography. Thus, 95% (36/38 nodules) of BI-RADS 3 nodules were reclassified score 2 or 1 with elastosonography, decreasing the rates of fine needle aspiration and short-term follow-up. Elastosonography is a simple, rapid and complementary method to mode B sonography that can improve the specificity in the characterization of breast nodules and the management of BI-RADS 3 nodules, leading to a decrease of false-positive and short term follow-up rates.

Breast tuberculosis imaging

We report unusual magnetic resonance images of breast tuberculosis before and after treatment. Magnetic resonance imaging may assess the efficiency of treatment of breast tuberculosis.

Papillomatose juvénile mammaire

The authors report a patient with juvenile papillomatosis of the breast presenting with a palpable mass and illustrate the correlation between mammographic, sonographic and pathologic features.

Osteomalacia due to chemotherapy-induced Fanconi syndrome in an adult patient

BACKGROUND

Chemotherapy-induced Fanconi syndrome is a dangerous condition that could lead to severe electrolyte disturbances and rarely to osteomalacia.

CASE

A patient treated with ifosfamide for a metastatic cervix squamous-cell carcinoma was admitted for diffuse, symmetric bilateral pain in bones and articulations. The diagnosis work-up revealed that she suffered from osteomalacia due to a chemotherapy-induced Fanconi syndrome. The patient recovered completely with oral calcitriol supplements.

CONCLUSIONS

This very rare chemotherapy-complication suggests that detection of potential tubular dysfunction, by regular serum electrolyte monitoring of patients receiving ifosfamide, may be a reasonable approach to diagnose early chemotherapy-induced Fanconi syndrome, even in adults.

Focal expression and final activity of matrix metalloproteinases may explain irregular dysfunctional endometrial bleeding

Irregular dysfunctional bleeding of the endometrium (ie, metrorrhagia without organic lesion) is common in women, whether treated or not with ovarian hormones. Several matrix metalloproteinases (MMPs) become normally expressed and/or activated at menstruation and cause extracellular matrix breakdown. We therefore explored whether episodes of irregular dysfunctional bleeding could be associated with untimely MMP activity. By histology, foci of stromal breakdown were exclusively found in the endometrium of metrorrhagic women at bleeding. In these foci, 1) expression of estrogen receptor-alpha and progesterone receptor was altered; 2) collagenase-1 (MMP-1), stromelysin-1 (MMP-3), and gelatinase B (MMP-9) became detected in stromal cells, together with MMP-9 in neutrophils; and 3) gelatinase A (MMP-2) was more expressed and immunolocalized at the membrane of stromal cells. By biochemistry, endometrial lysates from nonbleeding metrorrhagic patients contained more latent and active MMP-2 and -9 than age-matched controls; at bleeding, collagenase activity, MMP-9, and active MMP-2 were strikingly increased whereas tissue inhibitor of metalloproteinases-1 (TIMP-1) was considerably decreased. As a functional assay, in situ gelatin zymography revealed large areas of gelatinolytic activity only in endometrium of bleeding patients. Altogether, these results strongly suggest that inappropriate focal expression and activation of several MMPs, combined with decreased inhibition, trigger irregular dysfunctional endometrial bleeding.

LH-RH agonists offer very good protection against the adverse gynaecological effects induced by tamoxifen

This study was initiated to evaluate the efficacy of luteinizing hormone-releasing hormone (LH-RH) agonists in protecting premenopausal patients against the adverse gynaecological effects induced by tamoxifen. Between January 1998 and January 2000, 85 premenopausal breast cancer patients were included in this prospective study. All were to receive LH-RH agonists and tamoxifen for a minimum of two years. All patients underwent a pretreatment gynaecological evaluation and annual follow-up. Bone density was also measured at the start of treatment and then after 2, 3 and 4 years. Pretreatment evaluation revealed 2 polyps. At one and two years of follow-up, no abnormal symptoms were noted and echographic findings were normal. At three years of follow-up, a polyp associated with adnexal masses was discovered. Histology revealed ovarian and endometrial metastases of infiltrating lobular breast carcinoma. Bone density evaluation after 2, 3 and 4 years of treatment showed no significant bone loss. LH-RH agonists offer safe protection against the gynaecological side-effects of tamoxifen in premenopausal breast cancer patients.

Neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy in patients with primarily unresectable, advanced-stage ovarian cancer

OBJECTIVE

The aim of this review is to report our experience and the feasibility of neoadjuvant chemotherapy in patients with advanced-stage ovarian cancer.

METHODS

Forty-five patients with primarily unresectable advanced-stage epithelial ovarian cancer were treated in our center between 1995 and 2002 by platinum-based neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy. Their files were reviewed retrospectively.

RESULTS

At the end of neoadjuvant chemotherapy, according to RECIST criteria, 1 patient (2.2%) had achieved a clinical complete response (CR), 33 (73.4%) a partial response (PR), and 8 (17.8%) had stable disease (SD). Only 3 (6.6%) patients showed disease progression (PD). Surgery was performed in patients with objective response or SD after a median number of 4 courses (range: 2-6) of induction chemotherapy. A complete macroscopic debulking was achieved in 24 (53.3%) out of 39 patients in whom cytoreductive surgery was performed. For the entire group, median overall survival was 29 months. Survival was significantly improved in patients with optimal debulking compared to patients with persistent tumor after surgery: 41 months versus 23 months (P = 0.0062). Median survival for patients responding to neoadjuvant chemotherapy (CR and PR) was 44 months compared to 27 months for patients with SD or PD after initial chemotherapy (P = 0.01). Neither treatment-related deaths nor significant toxicities were observed.

CONCLUSION

Neoadjuvant chemotherapy followed by optimal debulking may be a safe and valuable treatment alternative in patients with primarily unresectable advanced-stage bulky ovarian cancer. Patients with an objective response to chemotherapy or absence of macroscopic residual tumor after surgery have a better outcome. This approach is currently being tested in large, prospective randomized clinical trials.

Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density

OBJECTIVE

Our purpose was to determine the contribution of mammography followed by sonography for the detection of nonpalpable breast cancers in Breast Imaging Reporting and Data System (BI-RADS) density grades 1-4 breasts, in grades 1 and 2 breasts, and in grades 3 and 4 breasts.

MATERIALS AND METHODS

The results of physical, mammographic, and sonographic examinations performed in 4236 patients were reviewed to determine the sensitivities of mammography and sonography for the detection of nonpalpable breast cancers and to calculate the relative risk for detecting nonpalpable breast cancers using sonography in comparison with mammography in density grades 1-4, grades 1 and 2, and grades 3 and 4 breasts. Sonography was performed after mammographic interpretation.

RESULTS

Sensitivities of mammography and subsequent sonography for the detection of nonpalpable breast cancers were 69% and 88% in grades 1-4, 80% and 88% in grades 1 and 2, and 56% and 88% in grades 3 and 4 breasts, respectively. The relative risk for detecting nonpalpable breast cancers using sonography was statistically significantly greater than that for detecting nonpalpable breast cancers using mammography in grades 1-4 (relative risk, 1.29; p = 0.024) and in grades 3 and 4 (relative risk, 1.57; p = 0.013) but not in grades 1 and 2 (relative risk, 1.1; p = 0.445) breasts.

CONCLUSION

Sonography is a useful adjunct after mammography for the detection of nonpalpable breast cancer, particularly in the dense breast.

A new, liquid-based cytology technique

OBJECTIVE

To evaluate a new liquid-based cytology technique, Papspin (Thermo Shandon, Pittsburgh, Pennsylvania, U.S.A.).

STUDY DESIGN

Three thousand cervical samples were examined. Each cervix was sampled with a Cervex Brush (Roche, Oss, the Netherlands), used first for a Pap smear and afterwards for a Papspin. One cytospin was prepared from each vial.

RESULTS

An identical rate of epithelial cell abnormalities (3.8%) was detected with the two methods. Diagnostic concordance was observed in 86% of the 114 cases. Differences in diagnoses occurred in 168 of 3,000 cases (5.6%) concerning fungal infection (22 cases), epithelial cell abnormalities (24 cases) and minimal differences within the nonneoplastic Bethesda category (122 cases). Endocervical cells were absent from 158 Papspins (5.3%) and 66 Pap smears (2.2%), while they were present in the respective Pap smear or Papspin. Seven Papspins were considered "satisfactory, but limited by ..." (SBLB) as compared to 33 Pap smears given the absence of endocervical cells.

CONCLUSION

Discordances concerning epithelial cell abnormalities were observed in 24 of 3,000 cases (0.8%). Fungal infections were more easily diagnosed on Papspin. The absence of endocervical cells in 5.3% of Papspins is due to a bias of methodology. Quality improvement was evident on Papspin for SBLB specimens. HPV testing could be performed with good results.

Immunolocalisation of cytochrome P-450 3A enzymes in human breast carcinoma: relationship with tumour differentiation and steroid receptors

Cytochrome P-450 3A enzymes belong to the most abundant subfamily of the cytochrome P-450 system. They are predominantly found in the liver where they metabolize numerous drugs and endogenous substances such as oestrogens. However, they are also expressed by normal and tumoural extrahepatic tissues. Accordingly, immunolocalization was assessed in malignant breast tumours (n=32) and normal counterparts, by using a monoclonal antibody that recognizes all human CYP3A proteins. We investigated a potential relation between expression of CYP3A protein expression, the degree of tumour differentiation assessed by the histological grade and the proliferation index assessed by Ki-67 immunostaining. Immunodetection of CYP3A was observed in 27 of the 32 tumours analyzed (84%). A focal staining was also observed in the adjacent normal breast tissue in 33% of the samples, but expression was always fainter than in tumours. A significant negative association was found between CYP3A and the proliferation index, but there was no relation with receptor status or tumour differentiation. While CYP3A protein expression can be found in normal breast tissues, these data highlight higher and more frequent CYP3A in malignant breast cells. Such expression in malignant breast cells appears inversely related to the proliferation index whereas no relation is found with tumour differentiation.

[Localization of non-palpable breast lesions with black carbon powder (experience of the Catholic University of Louvain)]

PURPOSE

The authors report their experience in presurgical localization of non palpable lesions with black carbon powder.

MATERIALS AND METHODS

153 cases of primary tumorectomies and mastectomies have been reviewed. The suspension is prepared in the hospital's pharmacy, the procedure is performed days or weeks before scheduled surgery without diffusion in the surrounding tissues.

RESULTS

In 92% of cases, the carbon marker was observed less than 5 mm from the target and no significant interference with the pathologic diagnosis has been observed.

CONCLUSION

Patient tolerance is good and providing close collaboration between the different members of the treating team, the authors believe that this technique may be a good alternative to wire localization.

The potential oncogenic effect of tamoxifen on the endometrium

We report the case of an in-situ endometrial adenocarcinoma with severe atypical hyperplasia which developed while the patient was on tamoxifen only 1 year after endometrial resection for benign pathology. A 55-year-old woman received tamoxifen as adjuvant therapy for breast cancer treated in 1994. At that time, a benign endometrial polyp was also removed before initiating tamoxifen treatment. In 1997, endometrial resection was performed for benign pathology (atrophic cystic endometrium). In 1998, an endometrial adenocarcinoma was diagnosed. This case illustrates that endometrial resection does not protect women taking tamoxifen against subsequent development of severe atypical lesions.

[Endometrial evaluation prior to tamoxifen: preliminary results of a prospective study]

The objective of this study was to try to identify, by pretreatment screening, a group of patients at higher risk of developing endometrial carcinoma on tamoxifen. Between January 1993 and January 1997, 360 postmenopausal patients with breast cancer were enrolled in this prospective study. Basal screening included gynaecologic examination with a Papanicolaou smear and endovaginal sonography. In the case of an abnormal ultrasound (endometrial thickness greater than 4 mm), an outpatient hysteroscopy with an endometrial biopsy was carried out. These examinations were repeated annually. By means of this preliminary evaluation, two groups of patients were identified: patients without initial lesions (group I) and patients with initial endometrial lesions (group II). These two groups of patients were followed up separately exactly in the same way. Endometrial lesions taken into account were: adenocarcinomas (in situ and invasive), polyps with or without atypia, myomas and adenomyotic lesions with irregular mucosa. After 3 years and after 4 years of follow-up, the percentage of atypical lesions was significantly higher in the group with initial lesions than in the group without initial lesions. This study suggests that a group of high risk patients more sensitive to the carcinogenic effect of tamoxifen can be identified by pretreatment evaluation.

Uterine side effects of tamoxifen: a need for systematic pretreatment screening

OBJECTIVE

To determine the effect of tamoxifen on the endometrium in postmenopausal women with breast cancer and to try to identify, by pretreatment screening, subjects at higher risk of developing endometrial cancer.

METHODS

Between January 1993 and January 1996, 264 postmenopausal women with breast cancer were studied prospectively with pelvic ultrasonography. Outpatient hysteroscopy and endometrial biopsy were done if ultrasound abnormalities were detected. Initial endometrial evaluation was done before treatment with tamoxifen was started, 20 mg daily, and annually thereafter. Attention was focused on endometrial lesions and, especially, endometrial hyperplasia, which was defined according to World Health Organization classification. Endometrial hyperplasia was subdivided into two broad categories: hyperplasia without cytological atypia and hyperplasia with cytological atypia. Adenocarcinoma in situ was defined as a well-differentiated endometrial carcinoma confined to the endometrial mucosa without myometrial invasion.

RESULTS

Forty-six women (17.4%) had asymptomatic endometrial lesions diagnosed before starting tamoxifen, and two of these were atypical lesions. Patients with initial lesions and those without initial lesions were followed separately. At 3 years of follow-up, the incidence of atypical lesions was significantly higher in women with lesions initially than in those without (three lesions among nine women versus one lesion among 51 women, P = .009).

CONCLUSION

It appears that a group of high-risk subjects can be defined on the basis of endometrial evaluation before tamoxifen therapy; these women should be followed carefully because of the high incidence of severe atypical lesions.

Thrombopoietic effects and toxicity of interleukin-6 in patients with ovarian cancer before and after chemotherapy: a multicentric placebo-controlled, randomized phase Ib study

Recombinant human interleukin-6 (IL-6) has previously been shown to increase platelet counts in normal and sublethally irradiated mice, dogs, and primates. To assess its tolerance and efficacy in clinical use, we performed a randomized phase Ib study in patients with ovarian carcinoma. IL-6 was administered during an initial 7-day cycle before any chemotherapy. Beginning 7 days later, six cycles of chemotherapy containing carboplatin were administered every 3 weeks. During chemotherapy cycles 2 to 6, IL-6 was administered from day 4 through day 17 at escalating dose levels from 0.5 to 10 micrograms/kg/d. At each level, three patients received IL-6 and one patient received a placebo. During the prechemotherapy cycle of IL-6, a dose-dependent increase in platelet count was observed from day 12 to 15 and was maximal on day 15 (r = .77; P < .01). The median ploidy of bone marrow megakaryocytes shifted from 16 N to 32 N after 7 days of the initial prechemotherapy IL-6 administration. Dose-dependent increases in C-reactive protein (CRP) and fibrinogen levels were observed on day 8 (P < .0001 for both). A significant decrease in hemoglobin level occured rapidly after initiation of IL-6 therapy and was maximal on day 8 (P < .001). When given after chemotherapy, IL-6 accelerated platelet recovery after chemotherapy cycles 2 to 6. Postponements of scheduled chemotherapy due to thrombocytopenia were less frequent in patients treated with IL-6. No difference in either neutrophils or peripheral blood progenitor assays was observed during or after IL-6 treatment. Toxicity of IL-6 appeared mild and was not dose-limiting up to 10 micrograms/kg/d. Systemic symptoms such as fever, headache, and myalgia were the main side effects and were easily relieved by acetaminophen administration. No biologic toxicity was observed. The data indicate that IL-6 is a well-tolerated cytokine and capable of accelerating platelet recovery in patients receiving chemotherapy.

Histologic study of peritoneal endometriosis in infertile women

The present study included 118 patients undergoing a laparoscopy for infertility. In 86 patients with laparoscopically diagnosed endometriosis (group I), biopsies were taken from areas of apparent endometriosis (n = 86) and from a visually normal peritoneum (n = 52). Histology reveals the presence of endometriosis in 93% of positive sites and in 13% of negative sites. In 32 patients without endometriosis at laparoscopy (group II), biopsies were taken from normal uterosacral ligaments (n = 32). Endometriosis was observed in 6% of cases. Despite the increased ability to detect pigmented and nonpigmented endometriotic lesion, histological study revealed the presence of endometriosis in normal peritoneum in 13% (group I) and 6% (group II) of cases.