Monoclonal Antibodies MBr1 and MBr8 as Predictors of Response to Oophorectomy in Advanced Breast Cancer

The response to oophorectomy in 40 patients with advanced breast cancer was evaluated as a function of the presence or absence of the antigens recognized by the monoclonal antibodies MBrl, MBr8, and MOv2 on the cell surface of the primary tumor. Two groups (20 patients alive 5 years after oophorectomy and 20 patients who died within 5 years) were evaluated. These groups had a) the same distribution of lymph node status, diameter of the primary, and the presence of estrogen receptors at the time of first treatment and b) a comparable extent of the disease at the time of oophorectomy. The frequency of complete response after oophorectomy was significantly higher in patients whose tumors did not express the antigens recognized by antibodies MBrl and MBr8. Fourteen of the 22 patients with tumors not reacting with MBrl and 11 of the 18 negative to MBr8 had a complete response. There was no correlation with response and the monoclonal antibody MOv2. Both MBrl and MBr8 were present in 11 patients and both were absent in another 11. The simultaneous absence of the two antigens was related to the highest complete response rate (9 out of 11 patients).

Histopathological Characterization of a Novel Monoclonal Antibody, MLuC1, Reacting with Lung Carcinomas

A monoclonal antibody (MoAb), MLuC1, derived from the fusion of P3 - X63 - Ag 8 - U1 mouse myeloma cells with spleen cells from an HR mouse immunized with the carcinoma cell line SW626, was studied to define its reactivity profile on normal and neoplastic human tissues and its potential clinical applications in lung cancer. Evaluation of paraffin sections using the ABC immunoperoxidase method showed a « pan-epithelial » reactivity; a large majority of epithelial components of organs in the respiratory, digestive and urogenital systems (except liver, rectum and ovary) were immunostained. As regard to neoplastic tissues MLuC1 recognized 84 % of lung carcinomas (82 % of small cell, 100 % of squamous cell, 74 % of adenocarcinomas), 86 % of breast and 62 % of ovarian carcinomas. On the contrary, MLuC1 was non-reactive with the other normal and tumoral non-epithelial tissues. Due to its spectrum of reactivity this MoAb could be useful for different diagnostic purposes such as differential diagnosis and lung cancer cytology.

Factors influencing acute and late toxicity in the era of adjuvant hypofractionated breast radiotherapy

PURPOSE

To evaluate toxicity in breast cancer patients treated with anthracycline and taxane based chemotherapy and whole breast hypofractionated radiotherapy, and to identify the risk factors for toxicity.

METHODS AND MATERIALS

537 early breast cancer patients receiving hypofractionated radiotherapy after conservative surgery were enrolled from April 2009 to December 2014, in an Italian cancer institute. The dose was 42.4 Gy in 16 daily fractions, 2.65 Gy per fraction. The boost to the tumor bed was administered only in grade III breast cancer patients and in patients with close or positive margins. Acute and late toxicity were prospectively assessed during and after radiotherapy according to RTOG scale. The impact of patients clinical characteristics, performed treatments and dose inhomogeneities on the occurrence of an higher level of acute skin toxicity and late fibrosis has been evaluated by univariate and multivariate analysis.

RESULTS

The mean age was 74 (range 46-91 yrs). 27% of patients received boost. 22% of cases (n = 119) received also chemotherapy. The median follow-up was 32 months. G1 and G2/G3 acute skin toxicity were 61.3% and 20.5% and G1 and G2/G3 late fibrosis 12.6% and 4.3% respectively. Chemotherapy (p = 0.04), diabetes (p = 0.04) and boost administration (p < 0.01) were found to be statistically significant on the occurrence of late fibrosis, but a multivariate analysis did not show any factors connected. The boost administration (p < 0.01), the breast volume (p = 0.05), dose inhomogeneities (p < 0.01) and boost volume (p = 0.04) were found to be statistically significant as concerns the occurrence of acute skin reaction at the univariate analysis, but only the boost administration (p = 0.02), at multivariate analysis.

CONCLUSIONS

The results of our study, according to the large randomized trials, confirmed that hypofractionated whole breast irradiation is safe, and only the boost administration seems to be an important predictor for toxicity. Chemotherapy does not impact on acute and late skin toxicity.

Abstract P5-07-11: CDCP1 as a new marker of aggressiveness in triple-negative breast cancers

Triple-negative breast cancer (TNBC) is an aggressive breast cancer subtype with high recurrences and mortality rate, for which no therapies besides chemotherapy are available to date. Lacking specific markers for an effective targeted therapy, TNBCs continue to represent the most important challenge for clinical oncologists. Here, we investigated the expression of CDCP1, a transmembrane non-catalytic receptor reportedly associated with poor prognosis in some solid tumors (e.g., lung and pancreatic cancer), and its association with tumor aggressiveness in a cohort of 115 human TNBC primary specimens obtained from women surgically treated in our Institute from the beginning of 2002 to the end of 2006 and selected based on immunohistochemical (IHC) criteria (&lt;1% cell positivity for estrogen receptor, progesterone receptor and HER2 expression classified as 0 or 1+). CDCP1 was overexpressed in 56.5% of human primary TNBCs. FISH analysis of 75 TNBCs for which material was available delineated four different genetic categories: 1) disomic, with only two copies of CDCP1 and centromere (CDCP1&lt;3, CEP3&lt;3) (50/75, 67%); 2) amplified CDCP1 (CDCP1 ≥3, CEP3&lt;3) (4/75, 5%); 3) polysomic CDCP1 (CDCP1≥3, CEP3≥3) (15/75, 20%); and 4) CDCP1 deleted of its centromere (CDCP1&lt;3 CEP3≥3) (6/75, 8%). FISH positivity (polysomy or amplification) was significantly associated with IHC positivity (p=0.003). Permutation accuracy variable importance estimated by Random Survival Forests identified both CDCP1 protein expression and FISH positivity for CDCP1 as prognostic factors for DFS (HR=2.67, 95%CI 1.25-5.71, and HR= 2.95, 95%CI 1.33-6.53, respectively) and DDFS (HR=2.40, 95%CI 1.01-5.73, and HR= 3.40, 95%CI 1.44-8.04, respectively), together with age, lymph node involvement, tumor size, DCIS and Ki67 expression. Multivariate Cox survival analysis revealed a synergistic interaction between CDCP1 FISH/IHC status and N-status in DFS and DDFS. Indeed, while the 5-year relapse probability in N-negative patients did not differ according to CDCP1 IHC expression in tumor cells (18% and 13% in CDCP1 IHC negative and positive, respectively), the probability of developing distant metastases at 5 years of follow-up was 82% in N-positive/CDCP1 IHC-positive patients versus only 29% in N-positive/CDCP1 IHC-negative patients. Similarly, the probability of developing distant metastases at 5 years in the N-positive subgroup was 88% for CDCP1 FISH-positive versus 35% for CDCP1 FISH-negative patients, but only 16% and 14% in N-negative/CDCP1 FISH negative and positive, respectively.

Together, our results strongly suggest that CDCP1 is a marker of aggressiveness able to identify cases with poorer prognosis among N-positive TNBCs and, noticeably, overexpression of CDCP1 in human primary TNBCs can reflect a CDCP1 genetic gain.

Supported by AIRC.

Citation Format: Tagliabue E, Turdo F, Bianchi F, Sandri M, Forte L, Casalini P, Gasparini P, Agresti R, Triulzi T, Sozzi G, Campiglio M. CDCP1 as a new marker of aggressiveness in triple-negative breast cancers. [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 P5-07-11.

Abstract P1-14-22: Neo-adjuvant chemotherapy for the treatment of breast cancer exterts a selection pressure toward luminal phenotype

The effect of anthracycline and taxane based chemotherapy on biological features of residual disease after neo-adjuvant therapies in breast cancer patients is poorly described.

PATIENTS AND METHODS: We collected information through the institutional clinical database on all consecutive breast cancer patients treated with neo-adjuvant chemotherapy at INT, Milan, Italy, between January 2010 and March 2015. We selected patients who did not achieve pathological complete response at final surgery. All patients had a pathological evaluation including the shrinking pattern (scattered or concentric); ER, PgR, HER2 and Ki-67 expression were evaluated both at diagnostic biopsy and at final surgery. McNemar's test was used to compare paired proportions.

RESULTS: We identified a total of 325 patients. Median age was 51 yrs (range: 23 - 85 yrs). 304 (93%) pts received anthracycline and taxane containing chemotherapy for a median number of 6 (range 2-18) cycles. Radical modified mastectomy was performed in 68% of cases. Scattered residual disease was diagnosed in 112 (34%) cases. HER2 over-expression in diagnostic biopsy was significantly associated to scattered response (OR 1.94, CI 1.13 – 3.36, p= 0.017). 11/220 pts (5%) with ER-positive diagnostic biopsy had ER-negative residual tumor; 9/54 pts (17%) with initial ER-negative tumors became ER-positive. 34/183 (19%) pts with initial positive PgR at diagnostic biopsy had PgR-negative residual tumor; whereas, 17/86 pts (20%) with negative PgR became positive. The HER2 expression changed from positive to negative in 9/49 (18%) cases and from negative to positive in 7/190 (4%) cases. The Ki-67 expression changed from &gt; or =20% to &lt;20% in 63/175 (36%) cases and vice-versa in 14/54 (26%) cases. Compared to diagnostic biopsy, the rate of PgR-positive tumors decreased from 68 to 62% (p= 0.024) and the rate of Ki67&lt;20% tumors increased from 24 to 45% (p=&lt;0.001) in surgical specimen. Subtype changes at surgery occurred in 37/245 (15%) of cases, i.e. none in triple negative, 8/20 (10%) in HER2 positive, and 29/202 (14%) in luminal tumors. 73% of cases that changed after treatment showed a trend towards luminal differentiation. There was no significant correlation between pre- and post-treatment biological characteristics and the type of tumor shrinkage.

CONCLUSION: Anthracycline and taxane-based neo-adjuvant chemotherapy induces loss of PgR and Ki-67 in breast cancer. These changes are independent of the pattern of tumor shrinkage. The subtype switching toward more luminal phenotype suggest an endocrine effect of chemotherapy and paves the way to possible combinatorial approach of chemo- and hormone-therapy.

Citation Format: Galli G, Porcu L, Baili P, Hade A, Di Salvo F, Bregni G, Agresti R, Gennaro M, De Santis MC, Ferrari B, de Braud F, Di Cosimo S. Neo-adjuvant chemotherapy for the treatment of breast cancer exterts a selection pressure toward luminal phenotype. [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 P1-14-22.

Electrochemotherapy in the Treatment of Cutaneous Metastases from Breast Cancer: A Multicenter Cohort Analysis

Background

The management of breast cancer (BC) skin metastases represents a therapeutic challenge. Electrochemotherapy (ECT) combines the administration of bleomycin with temporary permeabilization induced by locally administered electric pulses. Preliminary experience with ECT in BC patients is encouraging.

Methods

A total of 125 patients with BC skin metastases who underwent ECT between 2010 and 2013 were enrolled onto a multicenter retrospective cohort study. The treatment was administered following the European Standard Operative Procedures of Electrochemotherapy. Tumor response was clinically assessed adapting the Response Evaluation Criteria in Solid Tumors, and toxicity was evaluated according to Common Terminology Criteria for Adverse Events 4.0. Cox regression analysis was used to identify predictive factors.

Results

Response was evaluable in 113 patients for 214 tumors (median 1 per patient, range 1–3). The overall response rate after 2 months was 90.2 %, while the complete response (CR) rate was 58.4 %. In multivariate analysis, small tumor size (P < 0.001), absence of visceral metastases (P = 0.001), estrogen receptor positivity (P = 0.016), and low Ki-67 index (P = 0.024) were significantly associated with CR. In the first 48 h, 10.4 % of patients reported severe skin pain. Dermatologic toxicity included grade 3 skin ulceration (8.0 %) and grade 2 skin hyperpigmentation (8.8 %). Tumor 1-year local progression-free survival was 86.2 % (95 % confidence interval 79.3–93.8) and 96.4 % (95 % confidence interval 91.6–100) in the subgroup of those with CR.

Conclusions

In this study, small tumor size, absence of visceral metastases, estrogen receptor positivity, and low Ki-67 index were predictors of CR after ECT. Patients who experienced CR had durable local control. ECT represents a valuable skin-directed therapy for selected patients with BC.

Axillary dissection versus no axillary dissection in older T1N0 breast cancer patients: 15-year results of trial and out-trial patients

BACKGROUND

Our randomized trial found no survival advantage for axillary dissection (AD) compared observation only (no AD) in older patients with early breast cancer and a clinically negative axilla, indicating that AD is unnecessary. We compared characteristics and outcomes in out-trial patients with those in trial patients to provide indications as to whether AD can be safely omitted outside the trial setting.

METHODS

The trial started in 1996, recruiting 238 patients age 65-80 years with cT1cN0 breast cancer, randomized to conservative surgery with or without AD. Over the recruitment period, 109 eligible patients who refused to participate in the trial, also received conservative breast surgery with or without AD depending on patient preference/surgeon opinion. Trial and out-trial patients received conventionally-fractioned whole breast radiation and tamoxifen for five years. Endpoints were breast cancer mortality, overall survival, and cumulative incidence of axillary disease in patients not receiving AD.

RESULTS

After 15 years of follow-up, breast cancer mortality and overall survival did not differ between the AD and no AD arms, in either the trial or out-trial cohorts. The 15-year cumulative incidence of axillary relapse was 6% in the no AD arm of the trial group, and zero in the no AD arm of the out-trial group.

CONCLUSIONS

Outside the trial setting, older patients with T1N0 breast cancer can be safely treated by conservative surgery, postoperative radiotherapy and tamoxifen for five years (if ER-positive). Axillary surgery is appropriate only for the small proportion of patients who develop overt axillary disease during follow-up.

Hepcidin and ferritin blood level as noninvasive tools for predicting breast cancer

BACKGROUND

Currently used CA15-3 and CEA have found their clinical application particularly in the follow-up of patients with advanced disease. Novel biomarkers are urgent, especially for improving early diagnosis as well as for discriminating between benign and malignant disease.

PATIENTS AND METHODS

In the present study, we used a proteomic approach based on surface-enhanced laser desorption/ionization-time of flight-mass spectrometry screening with the aim of identifying differentially expressed 2-30 kDa proteins in plasma of patients with malignant (65 cases) and benign (88 cases) breast lesions with respect to 121 healthy controls.

RESULTS

We found that the most promising SELDI peaks were those corresponding to hepcidin-25 and ferritin light chain. We evaluated the capability of these peaks in predicting malignant and benign breast lesions using the area under the receiver operating characteristic curve (AUC). The results showed a good capacity to predict malignant breast lesions for hepcidin-25 [AUC: 0.82; 95% confidence interval (CI) 0.75-0.90] and ferritin light chain (AUC: 0.86; 95% CI 0.79-0.92). Conversely, a weak and satisfactory capability to predict benign breast lesion was observed for hepcidin-25 (AUC: 0.63; 95% CI 0.41-0.85) and ferritin light chain (AUC: 0.73; 95% CI 0.49-0.97). A significant association between HER2 status and hepcidin-25 was observed and the distribution of transferrin and ferritin were found significantly different in patients with breast cancer when compared with that of controls.

CONCLUSIONS

This study provides evidence that hepcidin and ferritin light chain level in plasma may be of clinical usefulness to predict malignant and benign disease with respect to healthy controls.

Is the risk of primary hyperparathyroidism increased in patients with untreated breast cancer?

BACKGROUND

An increased frequency of primary hyperparathyroidism (PHP) has been reported in patients with treated breast cancer (BC). PHP has been found in about 7% of BC patients after surgery and radio-, chemio- or hormonal therapy.

AIM

To evaluate the frequency of PHP in untreated BC patients.

SUBJECTS AND METHODS

We evaluated 186 women with BC and 233 women with thyroid cancer (TC, no.=122) or benign thyroid diseases (BTD, no.=111). In all patients, serum calcium, albumin, PTH, and 25-hydroxyvitamin D (25-OH vitD) were measured before any treatment.

RESULTS

Serum calcium concentrations were significantly higher in BC than in TC and BTD groups (median values 9.5 mg/dl, 9.3 mg/dl and 9.3 mg/dl, respectively) but, according to a logistic regression model, calcium was not significantly different between the 3 groups when age was taken into account. In all patients, serum calcium was in the normal range, indicating that no case of overt PHP was present. Five patients (1 in BC, 2 in TC, and 2 in BDT groups) had serum calcium close to the upper limit of normal range, high PTH and low 25-OH vitD, indicating a possible PHP with hypercalcemia masked by concomitant 25-OH vitD deficiency.

CONCLUSIONS

In untreated BC group, no patient had overt PHP and 1/186 (0.5%) presented a possible PHP masked by 25-OH vitD deficiency, a PHP frequency much lower than that observed in treated BC patients. These data suggest that the treatments of BC may be responsible for the increased frequency of PHP reported in previous studies.

Axillary lymph node metastases detection with nuclear medicine approaches in patients with newly diagnosed breast cancer

Three different tracers, Tc-99m-Sesta MIBI, In-111-Pentetreotide and F-18-FDG, were evaluated in a preliminary study in three different groups of 10 breast cancer patients programmed for breast cancer resection and axillary dissection. Planar scintigraphy and single photon emission tomography (SPET) technique were used for imaging with Tc-99m-Sesta-MIBI and In-111-Pentetreotide, positron emission tomography (PET) was used for imaging with F-18-FDG. We studied 30 breast cancer patients; their clinical stage according to the TNM classification was 30 T1-T2, 1 T4 and 1 Tx (one patient had bilateral cancer and one had bifocal cancer). The lymph nodal status ranged from NO to N2 (14 NO, 16 N1, 1 N2). Tc-99m-Sesta MIBI, In-111 Pentetreotide SPET and F-18-FDG PET were randomly performed before surgery to visualize the primary tumors and to detect axillary lymph node invasion. Tc-99m-Sesta MIBI correctly visualized 10 out of 11 primary cancers in 10 patients. In-111-Pentetreotide detected 9 out of 10 primary cancers. F-18-FDG imaged all the tumors (10). As regards the axillary nodes, Tc-99m-MIBI excluded axilla involvement in 7 out of 7 negative axillae (N-), while it was positive in 2 out of 3 positive cases (N+); In-111-Pentetreotide correctly identified 7 out of 8 negative axillae (N-), while it detected 2 of 3 positive sites. F-18-FDG visualized all positive axillary lymph nodes (4 out of 4 N+ patients) and correctly excluded involvement in all negative patients (6 out of 6 N- cases). This study demonstrated that all three tracers are adequate to be proposed as tumor seeking agents with the aim of developing non-invasive diagnostic methods for pre-operative detection of axillary metastases, so that surgical dissection can be limited to selected patients. The authors discuss the advantages and disadvantages of the different radiopharmaceuticals and conclude that in centers with PET facilities F-18-FDG is the best tumor seeking agent for the evaluation of axillary status. Between Tc-99m-Sesta MIBI and In-111-Pentetreotide the former seems to present more advantages in this kind of application, considering also its lower cost and easier availability. These results encourage further study, including the simultaneous comparison of these tracers in breast cancer staging.

PD08-07: Wound-Healing Drainage Fluids Promote Triple Negative Breast Cancer Progression

Triple negative breast cancers (TNBC) account for 15% of breast cancers. TNBCs carry a high risk of recurrence and deaths, due to the high rate of local and systemic relapse in these patients and no therapeutic options except chemotherapy are currently available. The TNBC pattern of recurrence present a distant recurrence peak at approximately 3 years and then declines rapidly thereafter, whereas in all non-TNBC types the recurrence risk seems to be constant over time. TNBC relapse risk is comparable to that of HER2−positive tumors subtype, in which growth-factors released during the healing process accelerate the early recurrences in HER2−positive patients. Thus, we speculate that also TNBC early relapse may depend on their capability to respond to wound-healing stimulation. To this aim, TNBC were treated with drainages to identify which receptors/pathways can be activated and play a driving role in TNBC progression. A pilot reverse phase protein microarray (RPMA) experiment on MDA-MB-231 TN cells drainage-fluids stimulated revealed a specific activation of PDGFR and VEGFR and their downstream pathways, whereas no significant changes were observed in other receptors, such as EGFR, IRS, Met and ERB3. The type of activated receptors suggested the involvement of endothelial receptors upon drainages stimulation and, indeed TNBC cell lines expressed endothelial molecules, such as CD34, CD31, CD146. Beside the proved role of some of these receptors in cellular proliferation, the TNBC endothelial-like phenotype prompt us to analyzed TNBC cell lines capability to form vascular-like channels when seeded on matrigel. Drainages were able to accelerate the formation of vascular channels in TNBC cell lines and, moreover to consistently increase proliferation of TNBC cells compared to non-TNBC cells. To prove whether receptors found activated by drainages play a key role in TNBC progression, we targeted PDGFR, VEGFR and other receptors possibly involved in angiogenesis and vasculogenic mimicry with sunitinib (targeting PDGFR, VEGFR, FGF and c-kit), anti-bFGF antibody (Ab)(targeting the ligand bFGF) and bevacizumab (targeting the VEGF) in TNBC cells drainage-stimulated in vitro. Sunitinib and anti-bFGF Ab halved the proliferation of TNBC cell lines and reduced of almost 60% the formation of vascular-like channels in TNBC cells, whereas bevacizumab modestly affect proliferation but not vasculogenic properties. Notably, sunitinib and anti-bFGF Ab strongly inhibited MDA-MB-231 and MDA-MB-468 xenografts tumor growth (sunitinib: 80%, and 70% Growth Index (GI), respectively; anti-bFGF Ab 70% and 60% GI, respectively) whereas bevacizumab determined no more than 30% decrease of tumor volume. Unfortunately, all these drugs did not efficiently control the development of lung metastases, that indeed significant increased compared to their control, possibly through induction of hypoxia processes. In conclusion, wound healing promotes TNBC progression by sustaining proliferation and vasculogenesis. The use of sunitinib and anti-bFGF antibody strongly inhibited tumor growth in mice models, but significantly increased lung metastases suggesting a combined use of these drugs with molecules able to interfere with hypoxia pathway.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD08-07.

Abstract P6-08-01: Endothelial-Like Phenotype of Triple-Negative Breast Carcinoma Cells and Implications for New Molecular Targets

Background. Triple Negative Breast Cancers (TNBCs) still represent a question mark in breast cancer biology and a primary issue in clinics. A promising approach for an efficient targeted treatment of TNBCs seems to be represented by antiangiogenic therapies.

Methods. Effects of different compounds on proliferation of TNBC was evaluated in vivo and in vitro respectively by xenograft tumor volume analysis and SRB assay. Vasculogenic Mimicry (VM) properties were evaluated in vitro and in vivo respectively by tube formation assay and Transmission Electron Microscopy (TEM).

Results. Treatment of triple negative (TN) MDA-MB-231 xenografts with Sunitinib induced tumor regression, versus only a slight growth inhibition in tumors derived from MCF7 luminal cell line, whereas Bevacizumab determined only a modest decrease in tumor growth in both models. Accordingly, the efficacy of Sunitinib in blocking in vitro growth of breast cancer cell lines was higher in MDA-MB-231 cells in comparison with MCF7 cells (IC50 at 72h in MDA-MB-231 was 5 uM vs 25 uM in MCF7, as evaluated by SRB), and sensitivity to Bevacizumab was comparable between the two different cell lines. Investigating the undifferentiated nature of TNBCs, we observed that these tumors present an endothelial like phenotype and behavior, as supported respectively by the expression of endothelial markers, and the formation of vascular-like channels in vitro. In fact, all six TN cell lines evaluated (MDA-MB-231, MDA-MB-157, MDA-MB-468, BT-549, BT-20 and HCC1937) were able to form vascular channels when seeded on the murine tumor-derived basement membrane (Matrigel), whereas luminal (MCF7, T47D and ZR-75-1) and HER2- positive (MDA-MB-361, BT474 and SKBr3) breast carcinoma cell lines did not exhibit vascular structures. Then, we evaluated the VM in xenograft tumors derived from MDA-MB-231, MCF7 and MDA-MB-361 using transmission electron microscopy (TEM). MDA-MB-231 xenografts displayed channel-like structures formed by tumor cells encompassing erytrocytes, whereas in MCF7 and MDA-MB-361 xenografts the endothelial lining delimiting blood vessels was clearly visible. Notably, blood vessels surrounded by tumor cells were also identified in human TN specimens processed for TEM, and these structures were significantly more frequent in TN compared to non-TN tumors. 60% reduction in TN vascular channel formation in vitro by an anti-bFGF monoclonal antibody along with no effect using anti-VEGF antibody indicated that TN breast carcinoma cells can generate vascular channels through bFGF-mediated pathway. Silencing of different receptors involved in bFGF signal (i.e. FGFR2 and PDGFR β) abrogated VM in TN cells. Finally, TNBC cells able to perform vascular-like channels were found to express significantly higher (p= 0.003) levels of FGFR related genes, described associated with basal-like BC aggressiveness, compared to all the other tested cell lines. Conclusions. Our findings point to the possibility that TNBC cells are maintained by proangiogenic signals and that increased sensitivity to Sunitinib probably relies on the specific impairment of PDGFRβ and FGFR2-mediated pathways, which might represent a possible specific therapeutic target. Partially supported by AIRC and Italian Bureau of Health.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-08-01.

Absence of interference of serum IgGs from patients with breast cancer and thyroid autoimmunity on the function of human iodide symporter gene stably transfected in CHO cells

The cause of the association between breast cancer (BC) and thyroid autoimmunity is still unknown. Na+/I- symporter (NIS) is highly expressed in BC cells, and previous studies demonstrated that iodine content in BC is lower than in remote normal breast tissue, suggesting a disorder of iodide uptake in BC. In this study, we evaluated the presence of putative serum autoantibodies able to block the function of NIS in BC patients with thyroid autoimmunity. IgGs were obtained from: a) 11 patients with BC and high antithyroglobulin (TgAb) and antithyroperoxidase (TPOAb) autoantibodies serum concentration; b) 34 patients with Hashimoto's thyroiditis (HT) (1 was euthyroid, 4 had subclinical hypothyroidism and 29 were overtly hypothyroid); c) 15 control subjects. The biological activity of NIS was studied using a chinese hamster ovary (CHO) cell line stably expressing NIS (NIS-CHO). The course of iodide accumulation in NIS-CHO was studied after addition of Na125 I in culture medium. The accumulation of iodide linearly increased between 2 and 10 min, reaching a plateau at 45 min. The preincubation of NIS-CHO with IgGs purified from sera of BC with the highest levels of TPOAb and TgAb caused an inhibition of iodine uptake of no more than 5%. Similar results were obtained using IgGs purified from patients with HT and control subjects. Our data showed no interference of autoantibodies on iodine uptake in patients with BC and thyroid autoimmunity and the very low percentage of inhibition of iodine uptake cannot explain the lower content of iodine in BC tissue.

HER2 overexpression in various tumor types, focussing on its relationship to the development of invasive breast cancer

To date, poor standardization in HER2 status evaluation has precluded reliable comparison of overexpression rates in different tumors. However, standardized methodologies have been introduced recently for these analyses, and have identified frequencies of 51%, 44%, 26% and 25% in Wilm's tumor, bladder, pancreatic and breast carcinoma, respectively. Other tumors tested had frequencies below 20%. The frequency was greater than that predicted by gene amplification data in some tumor types, which may indicate overexpression due to gene deregulation, rather than gene amplification. Analysis of a large retrospective series of breast carcinomas demonstrated an association between HER2 positivity and a number of other prognostic markers. Together, these variables identify a subset of tumors with poor prognosis and early relapse post-surgery. HER2 expression is relatively stable, with 95% concordance between the HER2 status of primary and metastatic lesions. However, contralateral tumors are unrestricted with regard to HER2 status. Preliminary data indicate that the HER2 status of a hormone receptor-positive tumor may fluctuate according to the menstrual cycle. It is anticipated that the emerging wealth of standardized data for HER2 status will help to elucidate the role of HER2 in tumor progression.

HER2 overexpression in various tumor types, focussing on its relationship to the development of invasive breast cancer

To date, poor standardization in HER2 status evaluation has precluded reliable comparison of overexpression rates in different tumors. However, standardized methodologies have been introduced recently for these analyses, and have identified frequencies of 51%, 44%, 26% and 25% in Wilm's tumor, bladder, pancreatic and breast carcinoma, respectively. Other tumors tested had frequencies below 20%. The frequency was greater than that predicted by gene amplification data in some tumor types, which may indicate overexpression due to gene deregulation, rather than gene amplification. Analysis of a large retrospective series of breast carcinomas demonstrated an association between HER2 positivity and a number of other prognostic markers. Together, these variables identify a subset of tumors with poor prognosis and early relapse post-surgery. HER2 expression is relatively stable, with 95% concordance between the HER2 status of primary and metastatic lesions. However, contralateral tumors are unrestricted with regard to HER2 status. Preliminary data indicate that the HER2 status of a hormone receptor-positive tumor may fluctuate according to the menstrual cycle. It is anticipated that the emerging wealth of standardized data for HER2 status will help to elucidate the role of HER2 in tumor progression.

HER2 as a prognostic factor in breast cancer

HER2 amplification/overexpression is a marker of poor prognosis in breast cancer. The prognostic impact of HER2 positivity is lower in node-negative compared with node-positive women. The only significant, independent prognostic factors in breast cancer are node status, HER2 status and menopausal status. HER2-positive tumors also contain p53 abnormalities, tend to be hormone receptor and bcl-2 negative, have lymphoid infiltration (LI) and a high mitotic index. Patients with LI who are HER2 positive have a better prognosis than those who are HER2 negative, whereas HER2-positive patients without LI have a significantly worse prognosis than HER2-negative patients. Morphological and biological alterations appear to identify two categories of breast tumor. Two hypotheses may explain the progression to two tumor types: (1) atypical ductal hyperplasia (ADH) is a precursor of ductal carcinoma in situ (DCIS), which is a precursor of invasive ductal carcinoma (IDC); or (2) ADH is a precursor of HER2-negative IDC whereas DCIS is a precursor of HER2-positive IDC. The second theory fits well with two breast cancer subsets and the characteristics of ADH and DCIS. The first type of IDC occurs in older patients, progresses slowly due to estrogen dependency but is aggressive long term. The other type progresses rapidly, is HER2 positive and is more likely to occur in young patients.

Axillary lymph node staging in breast cancer by 2-fluoro-2-deoxy-D-glucose-positron emission tomography: clinical evaluation and alternative management

BACKGROUND

Surgical removal of axillary lymph node and histologic examination for metastases are used to determine whether adjuvant treatment is necessary for patients with breast cancer. Axillary lymph node dissection (ALND) is a costly procedure associated with various side effects, and 80% or more of patients with tumors of 20 mm or less are lymph node negative and might avoid ALND. In this study, we evaluated whether an alternative, noninvasive method--i.e., positron emission tomography (PET) with 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG)-- could be used to determine axillary lymph node status in patients with breast cancer.

METHODS

One hundred sixty-seven consecutive patients with breast cancers of 50 mm or less (range = 5-50 mm; mean = 21 mm) scheduled for complete ALND were studied preoperatively with FDG-PET, and then PET and pathology results from ALND were compared. All statistical tests were two-sided.

RESULTS

The overall sensitivity, specificity, and accuracy of lymph node staging with PET were 94.4% (PET detected 68 of 72 patients with axillary involvement; 95% confidence interval [CI] = 86.0% to 98.2%), 86.3% (82 of 95 patients without axillary involvement; 95% CI = 77.8% to 91.9%), and 89.8% (150 of 167 patients with breast cancer; 95% CI = 84.2% to 93.6%), respectively. Positive- and negative-predictive values were 84.0% (68 patients with histologically positive lymph nodes of 81 patients with positive FDG-PET scan; 95% CI = 74.2% to 90.5%) and 95.3% (82 patients with histologically negative lymph nodes of 86 patients with negative FDG-PET scan; 95% CI = 88.2% to 98.5%), respectively. When PET results for axillary metastasis were analyzed by tumor size, the diagnostic accuracy was similar for all groups (86.0%-94.2%), with higher sensitivity for tumors of 21-50 mm (98.0%) and higher specificity for tumors of 10 mm or less (87.8%), and the range was 93.5%-97.3% for negative-predictive values and 54.5%-94.1% for positive-predictive values. Among the 72 patients with axillary involvement, PET detected three or fewer metastatic lymph nodes in 27 (37.5%) patients, about 80% of whom had no clinically palpable axillary lymph nodes.

CONCLUSIONS

Noninvasive FDG-PET appears to be an accurate technique to predict axillary status in patients with breast cancer and thus to identify patients who might avoid ALND. These results should be confirmed in large multicenter studies.

Expression of protein tyrosine phosphatase alpha (RPTPalpha) in human breast cancer correlates with low tumor grade, and inhibits tumor cell growth in vitro and in vivo

Tyrosine phosphorylation is controlled by a balance of tyrosine kinases (PTKs) and protein tyrosine phosphatases (PTPs). Whereas the contribution of PTKs to breast tumorigenesis is the subject of intense scrutiny, the potential role of PTPs is poorly known. RPTPalpha is implicated in the activation of Src family kinases, and regulation of integrin signaling, cell adhesion, and growth factor responsiveness. To explore its potential contribution to human neoplasia, we surveyed RPTPalpha protein levels in primary human breast cancer. We found RPTPalpha levels to vary widely among tumors, with 29% of cases manifesting significant overexpression. High RPTPalpha protein levels correlated significantly with low tumor grade and positive estrogen receptor status. Expression of RPTPalpha in breast carcinoma cells led to growth inhibition, associated with increased accumulation in G0 and G1, and delayed tumor growth and metastasis. To our knowledge, this is the first example of a study correlating expression level of a specific bona fide PTP with neoplastic disease status in humans.

Impact of nodal status on indication for adjuvant treatment in clinically node negative breast cancer. Istituto Nazionale per lo Studio e las Cura dei Tumori

We addressed the problem of the need for axillary dissection in clinically node-negative breast cancer by determining how the information provided by the dissection suggests a different treatment to that indicated by primary tumour characteristics and age alone. We examined retrospectively 260 cases of clinically node negative early breast cancer all of whom underwent breast surgery, radiotherapy and axillary dissection. We assigned adjuvant therapy according to accepted guidelines with and without consideration of pathological node status and compared the difference. Fifty-six patients had involved axillary nodes. There was no change in adjuvant chemotherapy indication for the 44 cases over 65 years. The change in indication for the remaining 216 cases was 18.5% to 6%, depending on whether none or all of the intermediate risk patients were originally assigned chemotherapy (all were originally assigned tamoxifen). Since the trend is for most intermediate risk patients is to be assigned adjuvant chemotherapy, and since tamoxifen is anyway considered effective therapy for low and intermediate risk patients, we conclude that the information provided by axillary dissection is probably not necessary if guidelines recommending wide application of systemic adjuvant chemotherapy are applied. Satisfactory prognostic information can be obtained by consideration of primary tumour characteristics, while new prognostic markers are likely to further refine prognostic precision in the near future.

Breast cancer patients treated without axillary surgery: clinical implications and biologic analysis

OBJECTIVE

To evaluate the impact of breast carcinoma (T1-2N0) surgery without axillary dissection on axillary and distant relapses, and to evaluate the usefulness of a panel of pathobiologic parameters determined from the primary tumor, independent of axillary nodal status, in planning adjuvant treatment.

METHODS

In a prospective nonrandomized pilot study, 401 breast cancer patients who underwent breast surgery without axillary dissection were accrued from January 1986 to June 1994. At surgery, all patients were clinically node-negative and lacked evidence of distant metastases after clinical or radiologic examination. A precise 4-month clinical and radiologic follow-up was performed to detect axillary or distant metastases. Patients with clinical evidence of axillary nodal relapse were considered for surgery as salvage treatment. Biologic characteristics of primary carcinomas were investigated by immunohistochemistry, and four pathologic and biologic parameters (size, grading, laminin receptor, and c-erbB-2 receptor) were analyzed to determine a prognostic score.

RESULTS

The 5-year follow-up of these patients revealed a low rate of nodal relapses (6.7%), particularly for T1a and T1b patients (2% and 1.7%, respectively), whereas T1c and T2 patients showed a 10% and 18% relapse rate, respectively. Surgery was a safe and feasible salvage treatment without technical problems in all 19 cases of progressive disease at the axillary level. The low rate of distant metastases in T1a and T1b groups (<6%) increased to 15% in T1c and 34% in T2 patients. Analyzing the primary tumor with respect to the panel of pathologic and biologic parameters was predictive of metastatic spread and therefore can replace nodal status information for planning adjuvant treatment.

CONCLUSIONS

Middle-term follow-up shows that the rate of axillary relapse in this patient population is lower than expected, suggesting that only a minimal number of microembolic nodal metastases become clinically evident. Avoidance of axillary dissection has a negligible effect on the outcome of T1 patients, particularly in T1a and T1b tumors with no palpable nodes, because the rate of axillary node relapse is very low for both. In T1 breast carcinoma, postsurgical therapy should be considered on the basis of biologic characteristics rather than nodal involvement. The authors' prognostic score based on the primary tumor identified patients who required postsurgical treatment, providing a practical alternative to axillary status for deciding on adjuvant treatment. Conversely, in the T2 group, the high rate of salvage surgery for axillary relapses, which is expected in tumors larger than 2.5 cm or 3.0 cm, represents a limit for avoiding axillary dissection. Preoperative evaluation of axillary nodes for modification of surgical dissection in this subgroup would be more useful more than in T1 breast cancer because of the high risk. Complete dissection is feasible without technical problems if precise follow-up detects progressive axillary disease.

Fluctuation of HER2 expression in breast carcinomas during the menstrual cycle

The hormonal milieu at time of tumor surgery seems to have a significant impact on survival in premenopausal breast cancer patients. Indeed, surgery performed during the follicular phase of the menstrual cycle was suggested to correlate with a poor prognosis. To investigate the relationship between prognosis and menstrual cycle at time of surgery, we analyzed the expression of some markers associated with tumor aggressiveness, such as the hormone receptors, HER2, p53, Bcl2, and cathepsin D in breast carcinomas obtained from 198 premenopausal women who underwent surgery during different phases of the menstrual cycle. HER2 overexpression was found to fluctuate in hormone receptor-positive tumors. In actual fact, 20% of the tumors removed during the follicular phase scored HER2-positive, versus 8% of those removed during the luteal phase. Similarly, a number of hormone receptor-positive tumor specimens, obtained from the same patients during follicular and luteal phases, were scored HER2-positive when the sample was removed during the follicular phase and HER2-negative when removed in the luteal phase. Southern blot analysis of the HER2 gene indicated that, in hormone receptor-positive cases, the overexpression of HER2 is often not associated with gene amplification. The finding that overexpression of the HER2 gene, associated with tumor aggressiveness, can fluctuate according to the hormonal milieu may explain the increased survival of patients operated during the luteal phase. It is also relevant to the selection and treatment of patients most likely to benefit from anti-HER2 antibody therapy.

Association between [18F]fluorodeoxyglucose uptake and postoperative histopathology, hormone receptor status, thymidine labelling index and p53 in primary breast cancer: a preliminary observation

To investigate the possible role of positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose (FDG) in the prognostic evaluation of primary breast cancer, we studied 86 patients with T1-3 (TNM classification) breast tumours before surgery and compared the tumour FDG uptake, calculated as a standardized uptake value (SUV), with postoperative histopathological findings, steroid hormone receptor status of the tumour, thymidine labelling index (LI) and tissular expression of p53. SUV was significantly higher in infiltrating ductal carcinomas (n = 68; median SUV = 5.6) than in lobular ones (n = 18; median SUV = 3.8), and in grade 3 carcinomas (n = 26; median SUV = 6.2) than in grade 1-2 ones (n = 60; median SUV = 4.9). Moreover, SUV was significantly higher in carcinomas with high levels of p53 (n = 12; median SUV = 9.5) than in those with low levels (n = 48; median SUV = 4.25). By contrast, there was no significant correlation between SUV and the steroid hormone receptor status or LI of tumours. Our data demonstrate that FDG uptake, expressed as SUV, is associated with certain prognostic factors in breast cancer, such as histopathological grading and p53 expression, which can be assessed only by means of postoperative in vitro examinations. Hence, the information provided by FDG-PET is to some extent related to relevant information on tumour biology. The clinical value of these data will have to be confirmed by analysis of the independence of SUV from other prognostic factors by means of a multivariate analysis performed on a larger series of patients with adequate follow-up. If SUV is confirmed as an independent variable, FDG-PET could assume an important role in the determination of appropriate therapeutic strategies for primary breast cancer.

S100 protein serum levels in cutaneous malignant melanoma

We investigated the utility of serum S100 determined by means of immunoradiometric assay in a cohort of 438 patients affected by cutaneous melanoma (126 untreated and 312 previously treated). Using 0.2 microg/l cut-off value, determined in 134 healthy blood donors, the sensitivity was 4.2% in stage I patients (4/94), 5.3% in stage II patients (1/19), and 38.5% in stage III patients (5/13). Even though the sensitivity increased progressively from stage I to stage II and III, these differences were not statistically significant. The prognostic significance of S100 evaluation at diagnosis was investigated in terms of survival but no statistical correlation between S100 basal levels and survival was found. In the 312 previously treated patients serum S100 levels were correlated to disease extent, high levels of the marker were observed in 42.8% (9/21) of patients with local recurrence, in 32% (16/50) of patients with lymph node and/or in-transit metastases, in 77.3% (17/22) of patients with distant metastases, and in patients with NED, the specificity of the marker was 96.8% (212/219). The difference between these groups were statistically significant. In conclusion, S100 protein was abnormally high in patients with metastatic malignant melanoma. Serial S100 measurements in a follow-up study are necessary to test the importance of the protein in the management of patients with metastatic malignant melanoma.

Evaluation on serum 2'-5'oligoadenylate synthetase (2'-5'oligoAS) and beta 2 microglobulin (B2M) in patients with nodal metastases from cutaneous malignant melanoma treated with rIFN-alpha 2A

IFN-alpha is a promising adjuvant agent in patients with regional melanomatous metastases (stage IIIB). The aim of this study was to verify whether serum evaluation of the interferon induced proteins 2'-5'oligoAS and B2M can predict the clinical response to rIFN-alpha 2A therapy.

PATIENTS AND METHODS

Forty-two patients who had undergone radical dissection of nodal metastases were evaluated. All patients received adjuvant rIFN-alpha 2A (3 million units s.c. three times weekly) for 3 years or until progression. The patients were followed for a medium period of 43 months (range 19-46). During follow-up 22 of the 42 patients had disease progression. In all patients blood samples were obtained before starting adjuvant therapy and after 1 and 6 months of therapy with rIFN-alpha 2A. 2'-5' oligoAS and B2M were measured by radioimmunoassay.

RESULT

During the first month of adjuvant therapy with rIFN-alpha 2A the serum levels of 2'- 5' oligoAS increased 10-fold, and this trend was maintained in the following 6 months. Similar results were obtained for B2M serum levels. However, we did not find any significant difference in AS and B2M serum levels between responders and non-responders.

CONCLUSION

Our results, therefore, indicate that AS and B2M are markers of the biological activity of administered IFN but that they have little efficacy in predicting the clinical outcome of the treated patients.

Impact of the diagnostic methods on the therapeutic strategies

Over the last 25 years the diagnostic approaches and therapeutic strategies of breast cancer have dramatically changed. The relationship between diagnosis and therapy has gradually become more complex due to the ever more sophisticated diagnostic tools (mammographic screening, digital mammography, magnetic resonance, SPECT scan and FDG-PET), which have improved resolution limits and accuracy, and also due to the different therapeutic planning applied to breast cancer in these years (conservative surgery, neo-adjuvant chemotherapy, axillary dissection or not). Thus, in this paper, we have briefly analyzed the many open questions in breast cancer management and the clinical challenges of present diagnostic tools in relation to pre-, peri- and postoperative phases, and to therapeutic strategies in general. The main goal of mammographic screening is to detect early invasive cancers and to treat them at the first useful moment. However, at which age should one begin screening, and what is the impact on overall survival, the cost-effectiveness, and, most of all, the best operative approach to suspect lesions? Can digital mammography give a better quality of imaging with respect to conventional mammography? Does unexpected multicentricity and/or multifocality, which is sometimes showed by magnetic resonance, have any clinical relevance? Is this technique really better than traditional methods for the identification of local recurrence? Is scintimammography able to improve the low diagnostic accuracy of mammography on non-palpable breast lesions? Moreover, at present, the need for axillary dissection and its therapeutic and staging value is deeply debated: however, clinical detection of axillary metastases is not a reliable diagnostic tool and there are no conventional radiologic techniques to be used: recently nuclear medicine imaging has provided various approaches, such as SPECT scan with different tracers, FDG-PET, or lymphoscintigraphy with gamma probe sentinel biopsy: there are not only methodologic but also phylosophic differences in using these techniques. Neo-adjuvant chemotherapy has allowed a dramatic reduction of primary breast cancer with a replanning of the surgical approach to large breast tumours but, at the same time, has posed new questions such as the adequacy of diagnostic pre- and perioperative revaluation. Finally, does postoperative follow-up take advantage of intensive diagnostic programs and are there therapeutic margins which would improve survival of patients with metastatic disease? This paper is an attempt to analyze the answers given in the literature. Nevertheless, at present, this matter is globally in progress and a scientific debate will provide, in the near future, a new promising scenario for breast cancer management.

Nuclear medicine approaches for detection of axillary lymph node metastases

In breast cancer patients the detection of axillary lymph node involvement is a very critical issue, in view of the earlier diagnosis of the disease in recent years, and the increased frequency of very small tumors at first presentation. The size of cancer is related to the risk of axillary metastases, and this may affect the prognosis and the therapeutic strategies. Axillary lymph node involvement is generally recognized as an index of distant microdiffusion, and as it affects overall and disease-free survival, represents the basis for adoption of adjuvant chemotherapy. Routine axillary lymph node dissection (ALND) is expensive, and does not benefit about 70% of early breast cancer patients which are node negative (pN-). Today most of these patients have to sustain the potential morbidity and the economic costs of ALND. The clinical approach is known to be an unreliable diagnostic tool, and for the detection of axillary metastases, conventional X-ray techniques are also unable to solve the problem. By contrast, nuclear medicine procedures have revealed a very interesting diagnostic potential in recent years. This paper analyzes the numerous studies conducted in the field of lymph node visualization and the heterogeneity of the published experiences, taking into account the different approaches proposed in the literature: a) imaging with gamma-emitting tumor seeking agents; b) radioimmunoscintigraphy intravenous (i.v.) or by the interstitial route; c) lymphoscintigraphy with colloids and gamma probe sentinel biopsy; d) positron emission tomography (PET). Although it is very difficult to make a definitive statement about the clinical efficacy of all these methods, this paper reports the most important series of patients examined in the literature as well as the author's own experiences. This can serve as the basis for a better understanding of the potential of nuclear medicine procedures, and gives the reader the opportunity to weigh advantages and drawbacks of each method. At present, lymphoscintigraphy with gamma probe sentinel biopsy and FDG-PET are the nuclear medicine approaches with the best diagnostic performance. However, a correct comparison of the methods will not be possible, until their careful assessment in the same patients is performed. In addition, a final statement today should consider also the increasing need to carry out an economic analysis by evaluating the cost-effectiveness of the examinations.

Prospective evaluation of fluorine-18-FDG PET in presurgical staging of the axilla in breast cancer

METHODS

The presurgical, noninvasive staging of axillary nodes for metastases was prospectively investigated in 68 patients who were diagnosed with primary breast cancer using PET with 18F-fluorodeoxyglucose (FDG). Four patients had bilateral nodules; therefore, the total number of evaluable cases was 72. Visual analyses of attenuation-corrected PET images and standardized uptake values (SUVs) of FDG uptake in carcinomas were compared with histopathological surgical findings. The SUV distribution differences between carcinomas with and without axillary metastases were evaluated by means of statistical and receiver operating characteristics analyses.

RESULTS

PET correctly classified 64 of the 72 cases; four false-positive and four false-negative PET results were found. The overall sensitivity, specificity and accuracy of PET for axillary metastases were 85%, 91% and 89%, respectively. With respect to the clinical axillary stage of the patients (TNM, or tumor-node-metastasis, classification), we obtained the following results: N0 patients, sensitivity = 70%, specificity = 92%, accuracy = 86%; N1a patients, sensitivity = 85.5%, specificity = 100%, accuracy = 95%; and N1b-2 patients, sensitivity = 100%, specificity = 67%, accuracy = 87%. The median SUV in carcinomas with axillary metastases (4.6) was significantly higher than that in carcinomas without metastases (2.9), but there was a great SUV overlap between the two groups (interquartile ranges = 2.7-7.2 and 1.9-4.5, respectively). Analysis of the receiver operating characteristics curve showed that a high sensitivity of SUV in predicting axillary metastases was associated with a very low specificity and vice versa. With the best SUV cutoff value of 2.9, the sensitivity and specificity were 74% and 56%, respectively.

CONCLUSION

PET showed good overall diagnostic accuracy in the detection of axillary metastases (86%). The very high accuracy (95%) in N1a patients is of particular importance. False-negative PET findings, however, can be encountered. SUVs of breast carcinoma cannot predict the spread of the disease to the axilla, even if higher values are often associated with axillary metastases. Any decision on the use of PET in the presurgical staging of breast cancer should be incorporated into a more general debate on axillary management. In selected patients with a very low probability of axillary metastases (T1a), in whom axillary surgery can already be avoided according to data from follow-up studies, 18F-FDG PET could be proposed as a noninvasive imaging modality to improve the diagnosis of axillary relapses.

Pilot study of primary chemotherapy with doxorubicin plus paclitaxel in women with locally advanced or operable breast cancer

A pilot study of primary chemotherapy with bolus doxorubicin plus paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) infused over 3 hours was performed in 38 women with locally advanced and 41 with stage II/III breast cancer. Patients received four cycles of primary chemotherapy followed by surgery and treatment with cyclophosphamide/methotrexate/5-fluorouracil for six cycles. Preliminary data are available on 73 patients. Doxorubicin plus paclitaxel was well tolerated. Primary toxicity consisted of grade 1 or 2 reversible peripheral neuropathy and grade 3 alopecia. After a median follow-up of 13 months, none of the patients have developed cardiac toxicity or any significant alteration of the left ventricular ejection fraction, which was measured before treatment, at each cycle of doxorubicin plus paclitaxel, and every 3 months thereafter. Major clinical response of the breast tumor was observed in 88% of patients. At pathologic examination of the surgical specimen, 40% were pT1, 15% had no macroscopic tumor residue, and 7% had complete disappearance of invasive neoplastic cells. After a median follow-up of 17 months for patients with locally advanced breast cancer, freedom from progression was 67%, disease-free survival was 71%, and overall survival was 74%. The same end points were 100% for patients with stage II/III disease, with a shorter median follow-up of 10 months. In conclusion, doxorubicin plus paclitaxel is safe, feasible, and effective, and can be used as primary or adjuvant chemotherapy to assess its actual therapeutic role in women with early breast cancer.

Breast cancer staging using technetium-99m sestamibi and indium-111 pentetreotide single-photon emission tomography

We evaluated the clinical usefulness of single-photon emission tomography (SPET) with technetium-99m sestamibi and indium-111 pentetreotide in breast cancer staging. Fifteen patients with clinical and/or mammographic findings suggesting T1-2N0-1 breast cancer were studied. SPET images were acquired 20 min after 99mTc-sestamibi injection and 4 and 24 h after 111In-pentetreotide injection. Patients underwent surgery the day after the later 111In-pentetreotide acquisition. Pathological examination showed 16 tumours in the 15 patients, with one bilateral carcinoma. The mean tumour diameter was 18.7 mm. Metastatic axillary involvement was found in 6/16 tumours, with a mean of five metastatic nodes per axilla. Both tracers correctly identified 15/16 primary tumours and five of the six cases of metastatic axillary node involvement. No difference between the tracers was observed in breast cancer staging. 99mTc-sestamibi seems to be the better tracer in terms of physical characteristics, execution time and cost-effectiveness. Our data suggest the future possibility of using nuclear medicine imaging to avoid axillary dissection in patients with T1 breast cancer.