A prospective analysis of two studies that used the 5-mm interval slices and 5-mm margin-free method for ipsilateral breast tumor recurrence after breast-conserving surgery without radiotherapy

BACKGROUND

Breast-conserving surgery with radiotherapy is one of standard treatments for early breast cancer. However, it is regarded as an option to treat elderly patients with small hormone receptor-positive breast cancer with breast-conserving surgery and hormone therapy without radiotherapy. We conducted two sequential prospective studies to examine the feasibility of breast-conserving surgery without radiotherapy since 2002 and present the results.

PATIENTS AND METHODS

Primary female breast cancer patients who fulfilled the strict eligibility criteria were prospectively enrolled in two sequential studies named WORTH 1 and 2. The surgical materials were sliced in 5-mm intervals and all slices were examined microscopically. Postoperative radiotherapy was not allowed, but tamoxifen or anastrozole was administered for 5 years. Ipsilateral breast tumor recurrence (IBTR)-free survival was the primary outcome.

RESULTS

The data of the two studies were combined (N = 321). The median follow-up period for IBTR was 94 months (4-192 months). Only three patients were treated with adjuvant chemotherapy. The 5- and 10-year IBTR-free rates were 97.0% and 90.5%, respectively. The age at operation and PR status affected IBTR rates independently. When we calculated IBTR-free rates of patients who were 65 years of age or older at the time of surgery and had PR-positive tumors, the 5- and 10-year IBTR rates were both 98.4%.

CONCLUSIONS

 Our "5-mm-thick slice and 5-mm free-margin" method may be effective to select patients who can be treated by breast-conserving surgery and hormone therapy without radiotherapy.

Diagnostic performance of dedicated breast positron emission tomography

Background

Dedicated breast positron emission tomography (dbPET) has been developed for detecting smaller breast cancer. We investigated the diagnostic performance of dbPET in patients with known breast cancer.

Methods

Eighty-two preoperative patients with breast cancer were included in the study (84 tumours: 11 ductal carcinomas in situ [DCIS], 73 invasive cancers). They underwent mammography (MMG), ultrasonography (US), and contrast-enhanced breast magnetic resonance imaging (MRI) before whole-body PET/MRI (WBPET/MRI) and dbPET. We evaluated the sensitivity of all modalities, and the association between the maximum standard uptake value (SUVmax) level and histopathological features.

Results

The sensitivities of MMG, US, MRI, WBPET/MRI and dbPET for all tumours were 81.2% (65/80), 98.8% (83/84), 98.6% (73/74), 86.9% (73/84), and 89.2% (75/84), respectively. For 11 DCIS and 22 small invasive cancers (≤ 2 cm), the sensitivity of dbPET (84.9%) tended to be higher than that of WBPET/MRI (69.7%) (p = 0.095). Seven tumours were detected by dbPET only, but not by WBPET/MRI. Five tumours were detected by only WBPET/MRI because of the blind area of dbPET detector, requiring a wider field of view. After making the mat of dbPET detector thinner, all 22 scanned tumours were depicted. The higher SUVmax of dbPET was significantly related to the negative oestrogen receptor status, higher nuclear grade, and higher Ki67 (p < 0.001).

Conclusions

The sensitivity of dbPET for early breast cancer was higher than that of WBPET/MRI. High SUVmax was related to aggressive features of tumours. Moreover, dbPET can be used for the diagnosis and oncological evaluation of breast cancer.

Abstract PS1-01: Combined analysis of the WORTH 1 and WORTH 2 studies of ipsilateral breast tumor recurrence after breast conservative surgery without radiotherapyusing the “5-mm thick slice and 5-mm free margin method”

Background: Breast conserving surgery with radiotherapy is one of the standard treatment methods for early breast cancer. However, it is regarded as an option to treat elderly patients with small hormone receptor positive breast cancer with breast conserving surgery and hormone therapy without radiotherapy. Two sequential prospective studies were conducted to examine the efficacy of breast conserving surgery without radiotherapy from 2002. Patients and Methods: Primary breast cancer patients were divided into the WORTH 1 (n=123) group (Oct. 2002 and Mar. 2005) and the WORTH 2 (n=198) group (Dec. 2006 and Nov. 2011) and the data was retrospectively combined and analyzed. The eligibility criteria of the two sequential studies were a tumor ≥3cm determined by palpation, pathologically node negative by axillary dissection or sentinel node biopsy and M0, no preoperative treatment, postmenopausal patients ≥50 years of age at surgery, no tumor cells within 5 mm from the margins, no lymphatic invasion around the primary tumor, and estrogen receptor positive. The surgical specimens were sliced at 5 mm intervals and all the slices were examined microscopically. Postoperative radiotherapy was not conducted and adjuvant chemotherapy was optional. The patients were treated with tamoxifen or anastrozole in WORTH 1 and anastrozole in WORTH 2 for 5 years. Ipsilateral breast tumor recurrence (IBTR)-free survival and distant relapse-free survival (DRFS) were recorded as the interval from initial surgery until IRTR or distant relapse. The factors related to IBTR were evaluated using the proportional hazard model. Patients who did not develop IBTR or distant relapse were statistically censored at the time of the last follow-up or death. Survival rates were calculated using the Kaplan-Mayer method. Statistical analyses were conducted using the log rank test. Values &lt; 0.05 were considered statistically significant. Results: The median age at surgery was 65 (range 50-84). The median tumor size was 1.5 cm (range 0-4.0 cm). The median follow-up period for IBTR was 95 months (range 4-192 months). Only 3 patients were treated with adjuvant chemotherapy. The 5- and 10-year overall survival rates were 98.7% and 95.1%, respectively and the 5- and 10-year distant DRFS rates were 99.3% and 96.3%, respectively. The 5- and 10-year IBTR free rates were 97.0% and 89.7%, respectively. Older patients had significantly less IBTR rates (5-year IBTR free rates: 95.8% for ≤64 vs. 98.1% for ≥65, p=0.019). There was no difference in IBTR rates between the large and small tumors (5-year IBTR free rates: 96.9% ≤1.4 cm vs. 96.8% for ≥1.5 cm, p=0.094). PR positivity had a significantly lower IBTR free rates (5-year IBTR free rates: 98.3% for PR positive vs. 91.5% for PR negative, p=0.009). The age at surgery (≤64, p=0.017, Hazard ratio 3.07, 95% CI 1.22-7.70) and the PR status (PR negative, p=0.024, Hazard ratio 2.54, 95% Cl 1.13-5.69) independently affected the IBTR rates. Both the 5- and 10-year IBTR free rates of the patients who were ≥65 at surgery and had PR positive tumors (n=136) were 98.4%. Conclusions: The findings suggest that the “5-mm thick slice and 5-mm free margin” method may be effective in selecting patients who can be treated with breast conserving surgery and hormone therapy without radiotherapy.

Citation Format: Norikazu Masuda, Shozo Ohsumi, Reiki Nishimura, Sadako Akashi-Tanaka, Kimito Suemasu, Hideko Yamauchi, Eriko Tokunaga, Tadashi Ikeda, Tsunehiro Nishi, Hiroto Hayashi, Yuichi Iino, Yuichi Takatsuka, Hideo Inaji. Combined analysis of the WORTH 1 and WORTH 2 studies of ipsilateral breast tumor recurrence after breast conservative surgery without radiotherapyusing the “5-mm thick slice and 5-mm free margin method” [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-01.

A Retrospective Analysis of the Relationship Between the Result of BRCA1/2 Genetic Testing and Surgical Method Selection in Japan

BACKGROUND

We studied the extent of BRCA1/2 genetic testing to help select the surgical approach for patients with breast cancer in Japan remains unclear.

PATIENTS AND METHODS

The study subjects were female patients with primary unilateral invasive breast cancer considered as candidates for breast-conserving surgery who underwent preoperative BRCA1/2 genetic testing. A retrospective analysis was performed on the results of BRCA1/2 genetic testing and surgical method selection using national registration data from the Japanese Hereditary Breast and Ovarian Cancer Syndrome Consortium.

RESULTS

Our study included 318 female patients. Among these patients, 23.7% of patients with BRCA1/2 mutations and 61.8% of patients without these variants underwent breast-conserving surgery (P < .01). Among the patients with BRCA1/2 mutations, those who chose breast-conserving surgery tended not to undergo risk-reducing salpingo-oophorectomy (P < .05). Among the patients with BRCA1/2 mutations who underwent mastectomy for the affected side, 31.8% received contralateral risk-reducing mastectomy. Patients diagnosed with breast cancer under the age of 50 years were more likely to have contralateral risk-reducing mastectomy than patients over the age 50 years (P < .05).

CONCLUSIONS

Patients with BRCA1/2 mutations tend to choose mastectomy. However, it is speculated that the final surgical method selection is made in consideration of not only the test results but also with careful consideration of the patient, taking into account other factors including individual values for risk-reducing surgeries and the age of breast cancer onset.

Prevalence of disease-causing genes in Japanese patients with BRCA1/2-wildtype hereditary breast and ovarian cancer syndrome

Panel sequencing of susceptibility genes for hereditary breast and ovarian cancer (HBOC) syndrome has uncovered numerous germline variants; however, their pathogenic relevance and ethnic diversity remain unclear. Here, we examined the prevalence of germline variants among 568 Japanese patients with BRCA1/2-wildtype HBOC syndrome and a strong family history. Pathogenic or likely pathogenic variants were identified on 12 causal genes for 37 cases (6.5%), with recurrence for 4 SNVs/indels and 1 CNV. Comparisons with non-cancer east-Asian populations and European familial breast cancer cohorts revealed significant enrichment of PALB2, BARD1, and BLM mutations. Younger onset was associated with but not predictive of these mutations. Significant somatic loss-of-function alterations were confirmed on the wildtype alleles of genes with germline mutations, including PALB2 additional somatic truncations. This study highlights Japanese-associated germline mutations among patients with BRCA1/2 wildtype HBOC syndrome and a strong family history, and provides evidence for the medical care of this high-risk population.

BRCAness as an Important Prognostic Marker in Patients with Triple-Negative Breast Cancer Treated with Neoadjuvant Chemotherapy: A Multicenter Retrospective Study

Triple-negative breast cancer (TNBC) has several subtypes. The identification of markers associated with recurrence and poor prognosis in patients with TNBC is urgently needed. BRCAness is a set of traits in which BRCA1 dysfunction, arising from gene mutation, methylation, or deletion, results in DNA repair deficiency. In the current study, we evaluated the clinical significance and prognosis of BRCAness in a multicenter retrospective study. Ninety-four patients with TNBC treated with neoadjuvant chemotherapy were enrolled from three university hospitals for this retrospective study. BRCAness was evaluated in 94 core needle biopsy (CNB) specimens prior to neoadjuvant chemotherapy and 49 surgical specimens without pathological complete response (pCR). The samples were assessed using multiplex ligation-dependent probe amplification, and the amplicons were scored. Of the 94 patients, 51 had BRCAness in CNB specimens. There were no significant differences in pCR rates or recurrence between the BRCAness and non-BRCAness groups. Among surgical specimens, the BRCAness group had a significantly shorter recurrence-free survival and overall survival compared with the non-BRCAness group. The BRCAness of surgical specimens was found to be an important marker to predict prognosis in patients with TNBC after neoadjuvant chemotherapy. A clinical trial to assess the clinical impact of carboplatin with BRCAness is planned.

Developing the structure of Japan's cancer survivorship guidelines using an expert panel and modified Delphi method

PURPOSE

To develop consensus-based components used in the first evidence-based cancer survivorship guidelines in Japan.

METHODS

Purposive sampling was used to recruit a panel of experts in oncology clinical practice, nursing, health science, epidemiology, and patient advocacy. The panel engaged in a modified Delphi process to (1) generate consensus related to the definition of survivorship, (2) determine the aim and target users of the guideline, and (3) identify clinical issues for inclusion. A Web-based survey and panel meeting were conducted to obtain the panelists' feedback on the initial draft proposed by the secretariat. Multiple online votes were then completed until all elements of the proposed guidelines reached an approval rate of 80% or higher. Following each round, iterative refinements were made based on all panelists' feedback.

RESULTS

Twenty-two experts were enrolled in the panel and participated in four rounds of online voting and two face-to-face meetings. Ultimately, the panel reached consensus on the definition of survivorship, the aim of the guidelines, and target users. Moreover, 11 of the original 17 clinical issues were retained. Finally, the panel selected two priority areas to implement immediately.

CONCLUSION

The panel's consensus on the definition of survivorship, aim and target users of the guideline, and 11 clinical issues will serve as a compass for the development of comprehensive cancer survivorship guidelines in Japan.

IMPLICATIONS FOR CANCER SURVIVORS

A culturally sensitive consensus approach was developed to improve the long term health and well- being of cancer survivors in Japan.

BRCA1/BRCA2 mutations in Japanese women with ductal carcinoma in situ

Background

Ductal carcinoma in situ (DCIS) is considered a component of the clinical spectrum of breast cancer even in those with BRCA1/2 mutation. The aim of this study was to report the feature of DCIS raised in Japanese women with BRCA1/2 mutations.

Methods

A total of 325 Japanese women with breast cancer (BC) (with or without invasive cancer) were referred for genetic counseling and underwent genetic testing for mutations in the BRCA1 and BRCA2 genes in Showa University Hospital between December 2011 and August 2016. And 49 of them who were pathologically diagnosed as DCIS were included in this study. Logistic regression models were fit to determine the associations between potential predictive factors and BRCA status. A Cox proportional hazards model is used to predictive value of parameters for Ipsilateral breast tumor recurrence (IBTR) and contralateral breast tumor recurrence (CBTR).

Results

(a) Of 325 patients (with or without invasive cancer), 19.1% (62/325) tested positive for BRCA1/BRCA2 mutations. And 18.4% (9/49) was positive for BRCA1/BRCA2 mutations in DCIS, compared with 19.2% (53/276) in IDC (p = 1.000). Among BRCA mutations, 14.5% (9/62) had DCIS compared with nonmutations (15.2%, 40/263). Incidence of DCIS was 3.0% (1/33) of BRCA1 mutations and 27.5% (8/29) of BRCA2 mutation (p = 0.009). (b) Median age of diagnosis in BRCA mutation carriers was 39 years, compared with 46 years in noncarriers. Age, Family history (FH) of BC, FH of first or second BC and total number of relatives with BC diagnosis (DX) has significant difference between BRCA mutation carriers and noncarriers in univariate analysis. In a multivariate logistic model, total relatives with BC DX ≥ 2 (odds ratio [OR], 5.128; 95% confidence interval [CI], 1.266–20.763; p = 0.022), age at diagnosis ≤35 years (OR 0.149, 95% CI 0.023–0.954, p = 0.045) and ER+/HER2+ status (OR 5.034, 95% CI 1.092–23.210, p = 0.038) remained as independent significant predictors for BRCA mutation. Ki67 index (cut off by 14% or 30%) did not differ between BRCA mutation carriers and noncarriers (p = 0.459 and p = 0.651). (c) There was a significant difference in ER‐positive tumors among BRCA2 carriers and noncarriers (p = 0.042). Subgroup analysis showed BRCA2 carriers tend to be of higher grade (Grade 2 and 3), more frequently ER+/PR+ (p = 0.041) and lower proliferation (Ki67 index) than noncarriers, whereas differences in nuclear grade and ki67 index were not found significantly in our study. (d) BRCA mutation was not associated with an increased risk of IBTR and CBTR.

Conclusion

DCIS is equally as prevalent in patients who were BRCA mutation carriers as in high familial‐risk women who were noncarriers, but occurs at earlier age. BRCA2 carriers have higher incidence in DCIS than that of BRCA1 carriers, and tend to be higher grade and more frequently ER positive and lower proliferation. Total relatives with BC DX ≥2, age at diagnosis ≤35 years and ER+/HER2+ might be independent predictors for BRCA mutation in Japanese women with DCIS and patients of these risk factors should be recommended to receive genetic counseling and BRCA testing.

Genetic variations in triple-negative breast cancers undergoing neo-adjuvant chemotherapy

Aim: Triple negative breast cancer (TNBC) is known as aggressive subtype and have no identified targeted therapies. We examined the relationship of neoadjuvant chemotherapy response to genetic variations of TNBC.

Methods: The tumors used in this study were collected from Showa University Hospital, Japan. Thirteen formalin-fixed paraffin-embedded tumors from Japanese TNBC patients who underwent neoadjuvant chemotherapy were used for analysis. Of these, eight surgically resected tumors showed progressive disease and/or recurrence after treatment (PD/REC), and biopsy tissues from five patients showing pathological complete response (pCR) were analyzed. DNA extracted from tissue sample were analyzed. The Miseq system and Trusight Tumor Sequence panel kit were used to sequence 174 amplicons over 82 exons of 26 cancer-related genes to identify genetic mutations.

Results: Seven somatic non-synonymous variants were detected in three genes (FOXL2, PIK3CA, and TP53) in all five pCR patients, and six somatic non-synonymous variants in two genes (PTEN and TP53) were detected in six of eight PD/REC patients. Eight of 13 TNBC tumors were found to have TP53 pathogenic variants, in both pCR and PD/REC cases.

Conclusion: Although TP53 variation was detected in both pCR and PD/REC cases, each location and type of the variant were different. We could not identify genetic mutations associated with chemotherapy response and recurrence.

QOL Evaluation of Nab-Paclitaxel and Docetaxel for Early Breast Cancer

Objective

A previous randomized phase II study showed that neoadjuvant nab-paclitaxel (nab-PTX) 100 mg/m²) was effective and well-tolerated in patients with HER2-negative early-stage breast cancer, compared with docetaxel (DTX). We evaluated patient outcomes in terms of the Functional Assessment of Cancer Therapy-Breast (FACT-B), as a measure of health-related quality of life (HRQoL).

Materials and Methods

Stage I-III HER2-negative breast cancer patients from the previous study were included. They received either four cycles of nab-PTX (100 mg/m² days 1/8/15) every 4 weeks, or DTX (75 mg/m² day 1) every 3 weeks, both followed by four cycles of 5-fluorouracil/epirubicin/cyclophosphamide (FEC). Patients completed a health-related quality-of-life questionnaire at baseline, after one and four cycles of taxanes, before administration of FEC, and after administration of one and four cycles of FEC.

Results

Thirty-six eligible patients were enrolled. The baseline characteristics of the two groups were well balanced. FACT-B scores at baseline and after four cycles of taxanes were 115/108 (DTX/nab-PTX) and 99/92, respectively. There were no significant differences between DTX and nab-PTX for FACT-B, FACT-B-Trial Outcome Index (FACT-B-TOI) and FACT-General. FACT-B and FACT-B TOI scores tended to decrease after one cycle and after four cycles of chemotherapy which did not recover to the baseline scores through the end of chemotherapy in each group.

Conclusion

There were no significant safety differences between nab-PTX and DTX. HRQoL tended to decrease during taxane-based anticancer treatment, with no significant differences between the treatments. We suggest that the HRQoL questionnaire has limited ability to evaluate different chemotherapy schedules. Trial registration UMIN000009855. Nov 20, 2012 registered.

A genome-wide association study identifies three novel genetic markers for response to tamoxifen: A prospective multicenter study

Purpose

Although association studies of genetic variations with the clinical outcomes of breast cancer patients treated with tamoxifen have been reported, genetic factors which could determine individual response to tamoxifen are not fully clarified. We performed a genome-wide association study (GWAS) to identify novel genetic markers for response to tamoxifen.

Experimental design

We prospectively collected 347 blood samples from patients with hormone receptor-positive and human epidermal growth factor receptor 2-negative, invasive breast cancer receiving preoperative tamoxifen monotherapy for 14 to 28 days. We used Ki-67 response in breast cancer tissues after preoperative short-term tamoxifen therapy as a surrogate marker for response to tamoxifen. We performed GWAS and genotype imputation using 275 patients, and an independent set of 72 patients was used for replication study.

Results

The combined result of GWAS and the replication study, and subsequent imputation analysis indicated possible association of three loci with Ki-67 response after tamoxifen therapy (rs17198973 on chromosome 4q34.3, rs4577773 on 6q12, and rs7087428 on 10p13, P_combined = 5.69 x 10⁻⁶, 1.64 x 10⁻⁵, and 9.77 x 10⁻⁶, respectively). When patients were classified into three groups by the scoring system based on the genotypes of the three SNPs, patients with higher scores showed significantly higher after/before ratio of Ki-67 compared to those with lower scores (P = 1.8 x 10⁻¹²), suggesting the cumulative effect of the three SNPs.

Conclusion

We identified three novel loci, which could be associated with clinical response to tamoxifen. These findings provide new insights into personalized hormonal therapy for the patients with breast cancer.

BRCAness and prognosis of triple-negative breast cancer patients treated with neoadjuvant chemotherapy

e12111

Background: Triple-negative breast cancers (TNBCs) consist of patients which are recalcitrant to chemotherapy. Dysfunction of BRCA, called “BRCAness” may be predictive of sensitivity to DNA repair inhibitors. However, adequate assay of “BRCAness” are still not confirmed. Multiplex ligation-dependent probe amplification (MLPA) with the Probemix P376-B2 BRCA1ness (MRC-Holland, The Netherlands) can be one method to determine BRCAness. We previously reported that “BRCAness” by MLPA predict resistance to taxane during neoadjuvant chemotherapy (NAC) and poor outcome. In the present study, we evaluated the clinical significance of BRCAness in a multicenter retrospective study. Methods: The data on 94 patients with TNBC treated with NAC were obtained from 3 hospitals in Japan. Most of them were treated by anthracyclines plus taxanes in 86 patients between 2005 and 2015. BRCAness was determined by core needle biopsy (CNB) specimens prior to NAC and surgical specimens. Genes from those specimens were amplified by MLPA, and the amplicons were scored. BRCA1-like type (BRCAness) was determined by tumors with greater than 0.5 Results: pCR (ypT0/Tis/N0) rate was 46%. Recurrence occurred in 22 patients, 11 of whom died from breast cancer. (1) BRCA1-like type accounted for 51 patients while the sporadic type in 43 patients in CNB specimens. No major differences in pCR rates and recurrence were observed between the BRCA1-like type and sporadic type (19/51 vs. 24/43), respectively. Patients with BRCA1-like tended to resist taxane than those with sporadic type when treated with taxane first. Among the 51 non-pCR patients, 19 were BRCA1-like type and 31 were sporadic type upon surgical specimens. Patients with a BRCA1-like tumors had more recurrences, than non-BRCA-1-like (13/19 vs. 9/31, respectively, P < 0.01). Conclusions: Tumors with BRCA-1 like tended to resist taxane than sporadic type when treated by taxane first. Anthracycline first might mask the progression during taxane regimen. Patients with BRCA1-like after NAC had more recurrences than those with sporadic type. Further study is needed to evaluate the significance of BRCAness.

[DEVELOPMENTS IN BREAST IMAGING]

Breast cancer is the most frequent cancer in Japanese women. As breast density increases, the detection rate of breast cancer by mammography (MMG) decreases. Breast density notification laws have been enacted in several states in the USA. Supplemental screening tools for women with dense breasts are needed. The results of a large randomized trial to compare the sensitivity, specificity, and cancer detection rate of MMG and adjunctive ultrasonography (US) to screen for breast cancer in Japan (J-START) were reported last year. More than 70,000 women aged 40 to 49 years were enrolled. The sensitivity and cancer detection rate were significantly higher in the MMG+US group than in the MMG-alone group. Automated breast ultrasonography is a tool to overcome the operator dependency of hand-held US and low reproducibility. Digital breast tomosynthesis, referred to as 3D MMG, offers higher sensitivity and specificity than MMG. Contrast-enhanced spectral MMG is an MMG scan using contrast medium to detect breast cancer more clearly even in dense breasts. It is often used for women at high risk for cancer and substituted for magnetic resonance imaging. A dedicated breast positron-emission tomography (PET) system has been available in Japan with insurance coverage since 2013. More cases of cancer were detected using breast PET than whole-body PET. Additional studies including mortality rates are needed.

Mentorship as Experienced by Women Surgeons in Japan

BACKGROUND

Women have accounted for over 30% of new medical students since 1995 in Japan. Establishing support systems for women surgeons to continue their work is a major issue in Japan. Mentorship can be one of the most effective means to help women surgeons to continue their work. The purpose of this study was to clarify the current status of mentorship among Japanese women surgeons and to discuss the role of mentors for women surgeons.

METHODS

Invitation letters were sent to all female members of the Japan Association of Women Surgeons in April 2011. An 84-item questionnaire survey was sent to those who agreed to participate in this study via the internet.

RESULTS

Fifty-five surgeons participated in this study, a response rate of 48.7%. Sixty-seven percent of respondents found it difficult to continue in their job; 85% thought mentorship was necessary for women surgeons to progress in their careers; and 84% reported that they already had a mentor. Respondents thought that a mentor helped them to advance their clinical career, to stay in their job, and to provide moral support. However, mentors appeared to be less useful in helping them to advance their research career, to network, to increase their status, and to achieve a work-life balance.

CONCLUSIONS

This study revealed areas where mentors appeared to be less helpful to women surgeons. The survey gave an indication of how to help improve and develop the career and personal life of women surgeons in Japan.

Abstract 2031: Association between CYP2D6 genotype and response to tamoxifen in a prospective multicenter study in Japan

Purpose:

CYP2D6 is key enzyme responsible for the generation of the potent active metabolite of tamoxifen, “endoxifen”. We previously reported that reduced- or null-function alleles of CYP2D6 were significantly associated with poor clinical outcome of breast cancer patients treated with tamoxifen. However, there are still discrepant reports questioning the association between CYP2D6 genotype and tamoxifen efficacy. Hence, we carried out prospective multicenter studies to evaluate the value of CYP2D6 genotyping in tamoxifen therapy.

Patients and Methods:

We studied 279 patients with hormone receptor-positive and Her-2 negative, invasive breast cancer receiving preoperative tamoxifen monotherapy for 14 - 28 days. Ki-67 response in breast cancer tissues after tamoxifen therapy was used as a surrogate marker of response to tamoxifen. We investigated the effects of allelic variants of CYP2D6 on Ki-67 change in breast cancer tissues, histological response, breast conservative operation and hot flash.

Results:

Ki-67 labeling index in breast cancer tissues significantly decreased after preoperative tamoxifen monotherapy for 14-28 days (P = 0.00000000024). Moreover, proportion of estrogen receptor positive cells in breast cancer tissues were significantly associated with Ki-67 change after tamoxifen therapy (P = 0.0099). CYP2D6 variants were not significantly associated with histological response, breast conservative operation and hot flash (P = 0.25, P = 0.28 and P = 0.34, respectively). However, CYP2D6 variants were significantly associated with Ki-67 decrease after the preoperative tamoxifen therapy (P = 0.000014; in patients with two variant alleles v patients carrying one or two wild-type alleles).

Conclusion:

Our result suggest that genetic variation in CYP2D6 is a key predictor for the prognosis of patients with breast cancer treated with tamoxifen.

Citation Format: Hitoshi Zembutsu, Seigo Nakamura, Sadako Akashi-Tanaka, Takashi Kuwayama, Chie Watanabe, Tomoko Takamaru, Hiroyuki Takei, Kana Miyahara, Hiroshi Matsumoto, Yoshie Hasegawa, Goro Kutomi, Hiroaki Shima, Fukino Satomi, Hideki Maeda, Minoru Okazaki, Hisamitsu Zaha, Mai Onomura, Ayami Matsukata, Yasuaki Sagara, Shinichi Baba, Akimitsu Yamada, Kazuhiro Shimada, Daisuke Shimizu, Koichiro Tsugawa, Arata Shimo, Tan Ern Yu, Mikael Hartman, Chan Ching Wang, Soo Chin Lee, Yusuke Nakamura. Association between CYP2D6 genotype and response to tamoxifen in a prospective multicenter study in Japan. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2031.

Analysis of clinical characteristics in breast cancer patients with the Japanese founder mutation of BRCA1 L63X

22

Background: Hereditary breast and ovarian cancer (HBOC) is a high-penetrance inherited disease, and founder mutation has been reported in the West. However, there are yet no reports of founder mutation of HBOC on breast cancer in the Japanese population. In this study, we report the breast cancer clinical characteristics of L63X, which is one of the founder mutations in BRCA1 in the Japanese population. Methods: Data on 223 affected breast cancer patients (28 BRCA1 carriers, 19 BRCA2 carriers, and 176 non-carriers) were collected at Showa University in Tokyo from September 2010 to June 2015. In 22 independent mutations of BRCA1, the L63X mutation was detected in 9 patients. Data regarding the age of breast cancer onset, pathological features, clinical features, and family history were collected. Results: The age of onset was no significant differences between the L63X mutation and other BRCA1 mutations (39.7 vs. 38.5years). The proportion of triple negative breast cancer patients was 87.5% in the L63X mutation carriers and 89.5% in other BRCA1 mutation carriers. No patients of the L63X affected bilateral breast cancers. On the other hand, 36.7% of other BRCA1mutations affected bilateral breast cancers. There was no significant difference in pathological features (intrinsic subtype, nuclear grade and ki-67 index). The L63X carriers tended to have a family history of breast cancers. All L63X mutations were detected in the Eastern part of Japan. Conclusions: The breast cancer clinical characteristics of L63X might be considered no different from other types of BRCA1 mutations. Recently, it has been reported that breast and ovarian cancer risks varied according to the type and location of BRCA1/2 mutations. L63X mutation is located in the breast cancer cluster region in BRCA1. Further investigation is necessary for appropriate validation and accumulation of data.

The expression and clinical significance of ribophorin II (RPN2) in human breast cancer

Ribophorin II (RPN2), part of the N-oligosaccharyltransferase complex, is highly expressed in breast cancer stem cells and is associated with tumor metastasis through interaction with mutant p53. The clinicopathological implication of RPN2 expression is undetermined. We examined immunohistochemically the expression levels of RPN2 and p53 in primary breast cancer tissues surgically resected from 218 patients. The correlations of RPN2 expression with the intrinsic subtype defined by hormone receptors (HRs) and HER2, clinicopathological parameters, p53 expression, and patients' clinical outcomes were examined. RPN2 was positive in 139 (64%), and the incidence of RPN2 expression was higher in the triple-negative breast cancer (TNBC) (HR-/HER2-) (65%) and HER2-enriched (HR-/HER2+) subtype (95%) than in the luminal A-like (HR+/HER2-) subtype (58%) (P = 0.0009). RPN2 expression was also correlated with p53 nuclear accumulation (P = 0.04). The RPN2-positive/p53-positive patient group showed significantly poorer prognosis than the RPN2-negative group for disease-free survival (P = 0.05) and for overall survival (P = 0.02). By multivariate analyses, the combination of RPN2 and p53 was not an independent prognostic factor. RPN2 expression was correlated with clinically aggressive features of breast cancer. These data support the further clinical application of anti-RPN2 therapy and the development of personalized medicine.

Clinicopathological predictive factors for ipsilateral and contralateral events following initial surgery to treat ductal carcinoma in situ

BACKGROUND

Ipsilateral breast tumor recurrence (IBTR) after partial breast resection and contralateral breast tumor recurrence (CBTR) have been shown to occur relatively frequently in patients with ductal carcinoma in situ (DCIS). However, there is only limited data from Japanese institutes to support this.

METHODS

Of 301 consecutive DCIS patients, 179 patients underwent a mastectomy, and the other 122 underwent partial resection in the National Cancer Center Hospital, Tokyo, with a median follow-up period of 2,106 days. We reviewed clinicopathological parameters including age, menopausal status, body mass index, family history (FH) of breast cancer, tumor size, histological subtype, nuclear grade (NG), hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status, treatment, and the surgical margin status of partially resected specimens. The risk associated with each of these parameters for IBTR in 122 patients who underwent partial resections, and for CBTR in a total of 301 patients were calculated using Cox proportional hazard general linear models.

RESULTS

Of the 122 patients who underwent partial breast resection, IBTR occurred in 7 (5.7%). The risk of IBTR was higher or tended to be higher in younger patients or those with lower NG tumors, but did not change significantly with respect to margin status or irradiation. Amongst the entire cohort of 301 patients, CBTR occurred in 18 cases (6.0%). CBTR occurred significantly more frequently in patients with a FH of breast cancer and with HR+/HER2- subtype tumors by univariate analyses, and tumor subtype was an independent risk factor for CBTR by multivariate analysis.

CONCLUSIONS

The local recurrence rate was low following partial resection of DCIS. Younger age was a risk factor for IBTR, whereas the HR+/HER2- tumor subtype and a FH of breast cancer were risk factors for CBTR.

p53 expression in pretreatment specimen predicts response to neoadjuvant chemotherapy including anthracycline and taxane in patients with primary breast cancer

While clinical and pathologic responses are important prognostic parameters, biological markers from core needle biopsy (CNB) are needed to predict neoadjuvant chemotherapy (NAC) response, to individualize treatment, and to achieve maximal efficacy. We retrospectively evaluated the cases of 183 patients with primary breast cancer who underwent surgery after NAC (anthracycline and taxane) at the National Cancer Center Hospital (NCCH). We analyzed EGFR, HER2, and p53 expression and common clinicopathological features from the CNB and surgical specimens of these patients. These biological markers were compared between sensitive patients (pathological complete response;pCR) and insensitive patients (clinical no change;cNC and clinical progressinve disease;cPD). In a comparison between the 9 (5%) sensitive patients and 30 (16%) insensitive patients, overexpression of p53 but not overexpression of either HER2 or EGFR was associated with a good response to NAC. p53 (p＝0.045) and histological grade 3 (p＝0.011) were important and significant predictors of the response to NAC. The correspondence rates for histological type, histological grade 3, ER, PgR, HER2, p53, and EGFR in insensitive patients between CNB and surgical specimens were 70%, 73%, 67%, 70%, 80%, 93%, and 73%. The pathologic response was significantly associated with p53 expression and histological grade 3. The correspondence rate of p53 expression between CNB and surgical specimens was higher than that of other factors. We conclude that the level of p53 expression in the CNB was an effective and reliable predictor of treatment response to NAC.

Comparative study of the value of dual tracer PET/CT in evaluating breast cancer

The present study was conducted to assess the relationship between tumor uptake and pathologic findings using dual-tracer PET/computed tomography (CT) in patients with breast cancer. Seventy-four patients with breast cancer (mean age 54 years) who underwent (11)C-choline and 2-[(18)F]fluoro-2-deoxy-d-glucose ((18)F-FDG) PET/CT prior to surgery on the same day were enrolled in the present study. Images were reviewed by a board-certified radiologist and two nuclear medicine specialists who were unaware of any clinical information and a consensus was reached. Uptake patterns and measurements of dual tracers were compared with the pathologic findings of resected specimens as the reference standard. Mean (±SD) tumor size was 5.9 ± 3.2 cm. All primary tumors were identified on (18)F-FDG PET/CT and (11)C-choline PET/CT. However, (18)F-FDG PET/CT demonstrated focal uptake of the primary tumor with (n = 38; 51%) or without (n = 36; 49%) diffuse background breast uptake. Of the pathologic findings, multiple logistic regression analysis revealed an independent association between fibrocystic change and diffuse background breast uptake (odds ratio [OR] 8.57; 95% confidence interval [CI] 2.86-25.66; P < 0.0001). Tumors with higher histologic grade, nuclear grade, structural grade, nuclear atypia, and mitosis had significantly higher maximum standardized uptake values (SUV(max)) and tumor-to-background ratios (TBR) for both tracers. Multiple logistic regression analysis revealed that only the degree of mitosis was independently associated with a high SUV(max) (OR 7.45; 95%CI 2.21-25.11; P = 0.001) and a high TBR (OR 5.41; 95%CI 1.13-25.96; P = 0.035) of (11)C-choline PET/CT. In conclusion, (11)C-choline may improve tumor delineation and reflect tumor aggressiveness on PET/CT in patients with breast cancer.

Abstract LB-378: The outlier approach discriminates drivers from passengers among genes methylated in cancers

A large number of genes are methylated in cancers, and most of them are methylated as passengers of carcinogenesis, and this fact hampers identification of drivers, tumor-suppressor genes (TSGs), silenced by aberrant methylation of promoter CpG islands (CGIs). To overcome this issue, we focused on the rule that the vast majority of genes methylated in cancers lack, in normal cells, RNA polymerase II (Pol II) and have trimethylation of histone H3 lysine 27 (H3K27me3) in their promoter CGIs. However, approximately 5% of the genes methylated in cancers are against this general rule, constituting a group of “outliers”. It is expected that TSGs belong to this group of outliers since they are expressed or ready to be expressed in normal cells. Here, we aimed to demonstrate that TSGs belong to the group of outliers, and that searching for outliers enables us to identify TSGs. First, we demonstrated that some of known TSGs in breast and colon cancers had Pol II and lacked H3K27me3 in normal cells, being outliers of the rule. We then made a genome-wide search for outlier genes in breast cancers. Based on Pol II binding and H3K27me3 statuses in normal cells and DNA methylation statuses in five breast cancer cell lines, 14 outlier genes were identified from 280 methylated genes. Among these genes, four genes were confirmed to be methylated in primary breast cancer samples, and two (HOXA5 and FBN2) of these were known TSGs. Among the remaining two genes, DZIP1 was shown to suppress growth of breast cancer cells, suggesting it to be a novel TSG. These results showed that some of known TSGs are the outlier genes and that TSGs can be efficiently identified by searching for outliers against the rule, the outlier approach.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-378. doi:1538-7445.AM2012-LB-378

Ipsilateral breast tumor recurrence (IBTR) in patients with operable breast cancer who undergo breast-conserving treatment after receiving neoadjuvant chemotherapy: risk factors of IBTR and validation of the MD Anderson Prognostic Index

BACKGROUND

There is limited information about the risk factors for ipsilateral breast tumor recurrence (IBTR) after patients undergo breast-conserving surgery plus radiotherapy (breast-conserving treatment [BCT]) subsequent to neoadjuvant chemotherapy (NAC). The objective of the current study was to analyze these risk factors.

METHODS

The authors collected data from 375 patients who underwent BCT and received NAC and analyzed the risk of IBTR associated with undergoing BCT after NAC. The usefulness of the MD Anderson Prognostic Index (MDAPI) for IBTR also was validated using the current data set.

RESULTS

The median follow-up was 47.8 months, and the 4-year IBTR-free survival rate was 95.6%. Multivariate analysis demonstrated that estrogen receptor (ER) status and multifocality of the residual tumor were associated significantly with IBTR-free survival. In addition, patients who had ER-positive and human epidermal growth factor 2 (HER2)-negative tumors did not develop IBTR during the observation period. Although prognostic stratification according to MDAPI was relatively good for the prediction of IBTR in the study patients, the IBTR rate in the high-risk group was not very high and was lower than that in the intermediate-risk group. Multivariate analyses demonstrated that IBTR was an independent predictive factor for overall survival.

CONCLUSIONS

ER status and multifocality of the residual tumor after NAC were independent predictors of IBTR after BCT. The MDAPI was barely adaptable to the study patients in terms of predicting IBTR. Patients with ER-positive and HER2-negative tumors had a favorable prognosis, whereas patients who developed IBTR after NAC had significantly worse overall survival. The authors propose a new IBTR prognostic index using the 2 factors that were identified as predictive of IBTR: ER status and multifocality of the residual tumor.

P3-12-03: A Prognostic Index of Ipsilateral Breast Tumor Recurrence in Patients Treated with Breast-Conserving Surgery after Preoperative Chemotherapy: Validation of M.D. Anderson Prognostic Index

Background: Preoperative chemotherapy (PCT) is widely used to increase the possibility of breast-conserving treatment (BCT). However, the appropriate indication for BCT after PCT is controversial, because the rates of ipsilateral breast tumor recurrence (IBTR) may be higher than those reported for BCT when surgery is used first. We performed a multicenter retrospective study to evaluate factors that were associated with IBTR in patients with BCT after PCT, and validated M. D. Anderson Prognostic Index (MDAPI) (Cancer 2005;103:689–95) using our data set.

Patients and Methods: From eight Japanese hospitals, data were extracted on a total of 381 patients with invasive breast cancer (BC) who were treated with ≥3 cycles of PCT followed by breast-conserving surgery and irradiation. The rates of IBTR were evaluated by MDAPI including clinical N2 or N3 disease, pathologic residual tumor &gt;2 cm, multifocal pattern of residual disease, and lymphovascular space invasion in the specimen. Kaplan-Meier method was used to estimate cumulative recurrence rates. Log-rank test and Cox's proportional hazard model were used for statistical analyses.

Results: Median age at diagnosis of the primary tumor was 48 years; median size of the primary tumor at diagnosis was 4.0 cm. One hundred and forty-six patients received postoperative chemotherapy and 211 received postoperative endocrine therapy. At a median follow-up period of 50 months, 18 of 381 patients developed IBTR, which resulted in 5-year IBTR-free rate of 94.1%. Univariate analyses revealed that estrogen receptor (ER) status both before and after PCT (positive vs. negative), pathological nodal status after PCT (≥4 vs. 0–3 positive nodes), and pathologically residual invasive tumor (≥1.8 vs. ≤1.7 cm) were significantly associated with IBTR (all P &lt; 0.05). Pathological margin status did not affect IBTR rate (P=0.88). Multivariate analysis revealed that significant independent predictors of IBTR included ER status after PCT (Hazard Ratio [HR], 0.10; P&lt;0.01), size of residual invasive tumor (HR, 5.29; P=0.03), and pathological nodal status after PCT (HR, 3.59; P=0.02). The rates of IBTR of patients with MDAPI 0–3 were 1.3%, 2.9%, 16.0%, and 3.6%, respectively. Based on the data of our multivariate analysis, ER status after PCT (ER positive;0 and ER negative; 1 was added to MDAPI. Total scores of the prognostic index including MDAPI and ER status after PCT ranged between 0 and 5. The rates of IBTR correlated well with this prognostic index. The 5-year IBTR-free survival rates were 0% for 23 patients in score 0, 3.4% for 89 in score 1, 3.9% for 51 in score 2, 21.2% for 33 in score 3, and 16.7% for 6 in score 4 (P &lt; 0.01).

Conclusion: Our prognostic index (MDAPI plus ER status) would be useful for clinical decision making according to surgical procedures after PCT. BCT is an appropriate treatment option for patients with the low prognostic index (0 to 2). The high risk population with the high prognostic index (3 to 5) may benefit from mastectomy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-12-03.

Preoperative CT evaluation of intraductal spread of breast cancer and surgical treatment

It is always a challenge to accurately determine the appropriate extent of resection in breast-conserving surgery (BCS), in order to reduce the need for re-excision, prevent local recurrence, and optimize cosmetic results. Detecting intraductal spread alone with high sensitivity may not be enough to realize safe BCS. Computed tomography carried out with the patient in the supine position accompanied by adequate marking is effective for preoperative determination of the optimum extent of BCS.

Modified primary tumour/vessel tumour/nodal tumour classification for patients with invasive ductal carcinoma of the breast

Background:

We previously reported that the primary tumour/vessel tumour/nodal tumour (PVN) classification is significantly superior to the UICC pTNM classification and the Nottingham Prognostic Index for accurately predicting the outcome of patients with invasive ductal carcinoma of the breast in a manner that is independent of the nodal status and the hormone receptor status.

Methods:

The purpose of the present study was to compare the outcome predictive power of a modified PVN classification to that of the newly devised pathological UICC pTNM classification and the reclassified Nottingham Prognostic Index in a different group of patients with invasive ductal carcinoma (n=1042) using multivariate analyses by the Cox proportional hazard regression model.

Results:

The modified PVN classification clearly exhibited a superior significant power, compared with the other classifications, for the accurate prediction of tumour recurrence and tumour-related death among patients with invasive ductal carcinoma in a manner that was independent of the nodal status, the hormone receptor status, and adjuvant therapy status.

Conclusion:

The modified PVN classification is a useful classification system for predicting the outcome of invasive ductal carcinoma of the breast.

Feasibility of breast conserving surgery for Paget's disease

INTRODUCTION

The standard treatment for Paget's disease of the breast is mastectomy. Since it is frequently associated with underlying carcinoma, many surgeons are reluctant to choose breast conserving surgery for Paget's disease.

PATIENTS AND METHODS

We retrospectively analyzed a series of 59 patients with Paget's disease who had undergone mastectomy at the National Cancer Center Hospital between 1963 and 2009.

RESULTS

In 55 of 59 cases (93%) there was underlying carcinoma in the ipsilateral breast. Clinically, 27 (46%) patients had no evidence of other tumors, but 23 (85%) had underlying histopathologically confirmed carcinoma. Based on the data from this subset, cone excision with a 3-cm radius and a 4-cm radius could completely resect any underlying malignancy in 74% and 85% of patients, respectively.

CONCLUSION

As Paget's disease is frequently accompanied by underlying intraductal and/or invasive carcinoma, patients should be carefully selected for breast conserving surgery.

Atypical tumor-stromal fibroblasts in invasive ductal carcinoma of the breast

Tumor-stromal fibroblasts have recently been reported to play important roles in the tumor progression of cancer in various organs. The purpose of this study was to investigate whether any characteristic histologic features of tumor-stromal fibroblasts could accurately predict the outcome of 1042 patients with invasive ductal carcinoma of the breast. We observed a small number of tumor-stromal fibroblasts with characteristic nuclear features existing inside and outside of fibrotic foci and named them atypical tumor-stromal fibroblasts. We then classified invasive ductal carcinomas into 4 types (1, 2, 3, and 4) according to the absence or presence of fibrotic foci and the absence or presence of atypical tumor-stromal fibroblasts. We then analyzed the outcome predictive powers of these types of invasive ductal carcinomas using multivariate analyses that included well-known clinicopathologic factors. The multivariate analyses showed that type 4 invasive ductal carcinomas with fibrotic foci and atypical tumor-stromal fibroblasts had significantly higher hazard ratios for tumor recurrence and tumor-related death, independent of the nodal status and histologic grade, and the type 2 invasive ductal carcinomas without fibrotic foci but with atypical tumor-stromal fibroblasts had a significant higher hazard ratio for tumor recurrence among patients with invasive ductal carcinoma with nodal metastasis and those with histologic grade 3 disease. The results of this study clearly indicated that the presence of atypical tumor-stromal fibroblasts, especially in fibrotic foci, is significantly associated with tumor recurrence and tumor-related death of patients with invasive ductal carcinoma of the breast.

Abstract P4-10-05: Factors Associated with Ipsilateral Breast Tumor Recurrence in Breast Cancer Patients Treated with Breast Conserving Surgery and Radiotherapy after Preoperative Chemotherapy

Background: Although preoperative chemotherapy (PCT) was originally used to make locally advanced breast cancers (BC) operable, it is now frequently utilized to make relatively large primary tumors small enough for breast conserving treatment (BCT). A large number of studies have been performed to identify risk factors of ipsilateral breast tumor recurrence (IBTR) after breast conserving treatment for originally small tumors. However, those studies for patients (Pts) who received BCT after PCT for relatively large tumors are limited. We have done a multicenter retrospective study to identify factors which were associated with IBTR in Pts treated with BCT after PCT.

Patients and methods: From 7 Japanese hospitals, data, which regard characteristics of tumors and Pts, and treatment, of Pts who fulfilled the following criteria; 1. Female BC Pts who started PCT before January 2007 2. Her tumor was invasive, clinically solitary, and 2 cm or largerby palpation at diagnosis 3. She received 3 or more cycles of PCT 4. She received breast conserving surgery as a definitive surgery after PCT including axillary dissection or sentinel node biopsy 5. She received radiotherapy at least to the conserved breast. Pts with inflammatory BC and BC Pts who received preoperative treatment(s) other than chemotherapy were excluded. Kaplan-Meier method was used to estimate cumulative recurrence rates. Log rank test and Cox's proportional hazard model were used for statistical analyses. Receiver Operating Characteristic (ROC) Curves and C statistics were used for evaluating the prediction ability of Cox's proportional hazard model about IBTR.

Results: A total of 324 Pts were registered. The median age at diagnosis of them was 48 years old. The median size of the primary tumors by palpation at diagnosis was 4 cm. For PCT anthracycline-based regimens were used for 83 Pts, taxane-based regimens were for 29, and anthracycline-taxane regimens were for 212. One hundred forty two Pts (43.8%) received postoperative chemotherapy, 180 (55.6%) had postoperative endocrine therapy, and only 7 had postoperative trastuzumab therapy. The median follow-up period was 45 months. Nineteen Pts (5.9%) developed IBTR. The cumulative 4-year IBTR rate was 5.5%. Univariate analyses revealed that estrogen receptor (ER) status both before and after PCT, pathological nodal status after PCT, and pathologically residual invasive tumor (solitary vs. multifocal, 1.7 cm or smaller vs. 1.8 cm or larger) were statistically significantly associated with IBTR (P &lt; 0.05 for all of them). Pathological margin status did not affect IBTR rate (P=0.73). ER status prior to PCT (positive vs. negative)(Hazard Ratio [HR], 6.76; P=0.012), size of the residual invasive tumor (1.7 cm or smaller vs. 1.8 cm or larger)(HR, 4.74; P=0.020), and pathological nodal status after PCT (0-3 positive nodes vs. 4 or more)(HR, 3.03; P=0.041) were associated with IBTR on multivariate analysis. C statistic was 78.3%.

Conclusion: Mastectomy may be a better choice for the Pts who have tumors with negative ER, pathologically large (1.8 cm or larger) residual invasive lesions after PCT, or 4 or more pathologically positive nodes after PCT in terms of local control.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-10-05.

Synchronous unilateral triple breast cancers composed of invasive ductal carcinoma, invasive lobular carcinoma, and Paget's disease

We report a case of synchronous unilateral triple breast cancers comprising invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), and Paget's disease. A 57-year-old woman with a left breast mass was referred to our hospital. Mammography revealed only an isodense area with foci of microcalcification in the lateral area of the left breast. Ultrasonography revealed 2 hypoechoic masses in the outer lower and inner upper areas, and these 2 lesions were diagnosed by core needle biopsy as ILC and IDC, respectively. Left total mastectomy with sentinel lymph node biopsies was performed. In addition to the ILC and IDC, histological examination also identified Paget's disease. Breast cancer often manifests as multiple unilateral lesions; however, it is sometimes difficult to determine whether these tumors have developed multicentrically or have multifocally invaded from an intraductal carcinoma. This case was clearly diagnosed to have occurred multicentrically because of the absence of continuity among the 3 tumors, the presence of a non-invasive component in all 3 tumors, and different histopathological findings. The synchronous unilateral development of ILCs is well known. Cases of synchronous unilateral triple or more breast cancers were reviewed, and their histopathological characteristics, including the incidence of Paget's disease, is discussed.

FcγR2A and 3A polymorphisms predict clinical outcome of trastuzumab in both neoadjuvant and metastatic settings in patients with HER2-positive breast cancer

BACKGROUND

Antibody-dependent-mediated cytotoxicity (ADCC) is one of the modes of action for trastuzumab. Recent data have suggested that fragment C γ receptor (FcγR) polymorphisms have an effect on ADCC. This prospective phase II trial aimed to evaluate whether these polymorphisms are associated with clinical efficacies in patients who received trastuzumab.

PATIENTS AND METHODS

Patients in a neoadjuvant (N) setting received Adriamycin and cyclophosphamide followed by weekly paclitaxel/trastuzumab. Patients in a metastatic (M) setting received single trastuzumab until progression. In total, 384 distinct single nucleotide polymorphisms of different FcγR, HER2, and fucosyltransferase loci were assessed.

RESULTS

Fifteen operable and 35 metastatic HER2-positive breast cancer patients were enrolled in each of the N and M settings, respectively. The FcγR2A-131 H/H genotype was significantly correlated with the pathologically documented response (pathological response) (P = 0.015) and the objective response (P = 0.043). The FcγR3A-158 V/V genotype was not correlated with the pathological response, but exhibited a tendency to be correlated with the objective response. Patients with the FcγR2A-131 H/H genotype had significantly longer progression-free survival in the M setting (P = 0.034).

CONCLUSION

The FcγR2A-131 H/H polymorphism predicted the pathological response to trastuzumab-based neoadjuvant chemotherapy in early-stage breast cancer, and the objective response to trastuzumab in metastatic breast cancer.

Prognostic factors in young Japanese women with breast cancer: prognostic value of age at diagnosis

OBJECTIVE

The primary objective of this study was to verify whether breast cancer patients aged <35 at diagnosis have poorer prognoses than those aged 35-39, in other words, to identify the prognostic value of age in younger premenopausal patients under 40 years old. The secondary objective was to assess prognostic factors specific for younger premenopausal patients.

METHODS

We identified 242 consecutive patients who were diagnosed with stage I-III breast cancer before the age of 40 and underwent surgery between 1990 and 2004. We compared disease-free survival and overall survival in patients aged <35 years and those aged 35-39 years, and evaluated clinicopathological factors associated with disease-free survival or overall survival in each age group and in all patients under the age of 40.

RESULTS

Ninety-nine (41%) patients were younger than 35 years and 143 (59%) were between 35 and 39 years. No significant difference in disease-free survival or overall survival was found between the two groups. In our cohort of patients under the age of 40, the independent factors associated with poor disease-free survival and overall survival included positive axillary lymph nodes and triple-negative status, but not age at diagnosis. Adverse prognostic factors also did not differ considerably between the two age groups.

CONCLUSIONS

Age at diagnosis was not an independent prognostic factor in our study. Our findings suggest that other clinicopathological features rather than age should be used to determine individualized treatment courses for breast cancer patients younger than 40 years.

Up-regulation of PSF1 promotes the growth of breast cancer cells

PSF1 is a subunit of the GINS complex that functions along with the MCM2-7 complex and Cdc45 in eukaryotic DNA replication. Although mammalian PSF1 is predominantly expressed in highly proliferating cells and organs, little is known about the roles of PSF1 in mature cells or cancer cells. We found that PSF1 was expressed at relatively high levels in breast tumor cells, but at low levels in normal breast cells. Knockdown of PSF1 expression using small interfering RNA (siRNA) slowed the growth of breast cancer cell lines by delaying DNA replication but did not affect proliferation of normal human mammary epithelial cells. Reduced PSF1 expression also inhibited anchorage-independent growth in breast cancer cell lines. These results suggest that PSF1 over-expression is specifically involved in breast cancer cell growth. Therefore, PSF1 inhibition might provide new therapeutic approaches for breast cancer.

Grading system for lymph vessel tumor emboli: significant outcome predictor for patients with invasive ductal carcinoma of the breast who received neoadjuvant therapy

The purpose of this study was to confirm that the grades of lymph vessel tumor emboli in biopsy specimens obtained before neoadjuvant therapy and in the surgical specimens obtained after neoadjuvant therapy according to the grading system we devised are significant histological outcome predictor for invasive ductal carcinoma (IDC) patients who received neoadjuvant therapy. The subjects of this study were the 318 consecutive IDC patients who had received neoadjuvant therapy in our institution. The lymph vessel tumor embolus grades in the biopsy specimens and in the surgical specimens were significantly associated with the increases in mean number of nodal metastases. Multivariate analyses with well-known prognostic factors and p53 expression in tumor-stromal fibroblasts clearly showed that the lymph vessel tumor embolus grade based on the biopsy specimens and based on the surgical specimens significantly increased the hazard rates for tumor recurrence and tumor-related death in all the IDC patients as a whole, in the IDC patients who did not have nodal metastasis, and in the IDC patients who had nodal metastasis, and the outcome-predictive power of the lymph vessel tumor embolus grades based on the surgical specimens was superior to that of the lymph vessel tumor embolus grades based on the biopsy specimens. The grades in the grading system for lymph vessel tumor emboli were significantly associated with nodal metastasis, and the histological grading system is an excellent system for accurately predicting the outcome of patients with IDC of the breast who have received neoadjuvant therapy.

Metaplastic carcinoma of the breast

The purposes of this study were to investigate whether the biological characteristics or outcomes of patients with metaplastic carcinoma, invasive ductal carcinoma, or invasive lobular carcinoma of the breast differ; to determine whether the metaplastic carcinoma subtypes have similar malignant potentials; and to identify accurate predictors of outcome in patients with metaplastic carcinoma. The subject comprised 6137 invasive ductal carcinoma patients, 301 invasive lobular carcinoma patients, and 46 metaplastic carcinoma patients of the breast. The metaplastic carcinomas were classified according to the World Health Organization classification. Multivariate analyses clearly demonstrated that the metaplastic carcinoma patients had a significantly poorer outcome than the invasive ductal carcinoma patients or the invasive lobular carcinoma patients independent of the nodal status or age not exceeding 39 years, whereas patients with triple-negative metaplastic carcinomas or triple-negative invasive lobular carcinomas had a poorer outcome than those with triple-negative invasive ductal carcinomas. Although no significant differences in clinical outcome were observed among the metaplastic carcinoma subtypes in multivariate analyses, an age not exceeding 39 years, the presence of skin invasion, and the presence of a squamous cell carcinoma component in nodal tumors were significant outcome predictors for metaplastic carcinoma patients. In conclusion, the results of this study clearly demonstrated that metaplastic carcinoma is more aggressive than invasive ductal carcinoma or invasive lobular carcinoma. Although the metaplastic carcinoma subtypes had no prognostic significance, an age not exceeding 39 years, the presence of skin invasion, and the presence of a squamous cell carcinoma component in nodal tumors were significant predictors of outcome among metaplastic carcinoma patients.

p53 expression in tumor-stromal fibroblasts is closely associated with the nodal metastasis and outcome of patients with invasive ductal carcinoma who received neoadjuvant therapy

The purpose of this study was to determine whether p53 immunoreactivity in tumor-stromal fibroblasts assessed by the Allred scoring system in biopsy specimens obtained before neoadjuvant therapy and assessed in surgical specimens obtained after neoadjuvant therapy is significantly associated with nodal metastasis by invasive ductal carcinoma and with the outcome of 318 patients with invasive ductal carcinoma who received neoadjuvant therapy, according to UICC pathologic TNM stage, in multivariate analyses with well-known clinicopathologic factors. The Allred scores for p53 in tumor-stromal fibroblasts in the surgical specimens were significantly associated with the presence of nodal metastasis. The Allred scores for p53 in the tumor-stromal fibroblasts of biopsy and surgical specimens were a very important outcome predictive factor for patients who received neoadjuvant therapy, independent of UICC pathologic TNM status, but the outcome predictive power of the Allred scores for p53 in tumor-stromal fibroblasts assessed in the surgical specimens was superior to that of the Allred scores for p53 in tumor-stromal fibroblasts in the biopsy specimens. The results indicated a close association between p53 protein expression in tumor-stromal fibroblasts, especially in surgical specimens, and both the presence of nodal metastasis and the outcome of invasive ductal carcinoma patients who received neoadjuvant therapy.

Grading system for lymph vessel tumor emboli: significant outcome predictor for invasive ductal carcinoma of the breast

The purpose of this study was to confirm that the grading system for lymph vessel tumor emboli is a significant histologic outcome predictor for patients with invasive ductal carcinoma. The subjects of this study were 1042 invasive ductal carcinoma patients who did not receive neoadjuvant therapy. We classified all invasive ductal carcinomas according to the grading system for lymph vessel tumor emboli we devised, and performed multivariate analyses with well-known prognostic factors. Of 1042 carcinomas, 666, 250, 97, and 29 were classified according to the grading system for lymph vessel tumor emboli as grade 0 (no lymph vessel invasion), grade 1, grade 2, and grade 3, respectively. The univariate analyses showed that the difference in outcome between the group with grade 0 and the group with grade 1 was not significant, but that survival time was significantly shorter in the group of patients with grade 2 carcinomas than in the group with grade 1 carcinomas and significantly shorter in the group of patients with grade 3 carcinomas than in the group with grade 2 carcinomas. Multivariate analyses demonstrated that having a grade 2 or grade 3 carcinoma significantly increased the hazard rates for tumor recurrence and tumor-related death in the patients as a whole as well as in both the group of patients with nodal metastasis and the group without nodal metastasis. The grading system for lymph vessel tumor emboli is an excellent histologic grading system for predicting the outcome of patients with invasive ductal carcinoma of the breast.

Utility of Intraoperative Frozen-Section Examinations of Surgical Margins: With Special Reference to the Implication of Features of Margin-Exposed Tumor Components on Further Surgical Treatment

Purpose: The assessment of surgical margins is important in breast conserving surgery (BCS). In BCS, we usually resect additional specimens after the diagnosis of positive margin by intraoperative frozen-section examinations (IFE). However, we often experience the patients who received additional resections after positive results by IFE but no tumors were detected in the permanent sections. If we can predict the absence of residual tumor components from IFE, it may be possible to avoid additional mastectomy. In the present study, we tried to identify histological characteristics of margin-exposed tumor components on IFE as predictive factors for the residual tumor components in the additionally resected specimens. Methods: 1,835 cases underwent BCS between October 1999 and July 2008 at the National Cancer Center Hospital, Tokyo, Japan. By the review of the pathological database, we chose patients who had positive surgical margins determined by IFE and had undergone immediate additional resection. Two observers (MK, HT) reviewed the slides of frozen sections and confirmed the presence of tumor components. Results: 220 cases (12%) were eligible for this study. Within the specimens of additional resection, residual tumors existed in 114 cases (51.8%) and no tumors existed in 106 cases (48.2%). As characteristics of the primary tumors, invasive lobular carcinoma, pT3, EIC(+) and lymphatic invasion were significantly associated with the residual tumor components. As characteristics of margin-exposed tumor components on IFE, the number of positive margins, their maximum diameter and histological type were correlated with the residual tumors. The rate of detection of the residual tumors was significantly higher in the group with multiple positive margins (50/72, 69%) than in the group with a single positive margin (64/148, 43%) (p=0.0003). The residual tumors were detected in 36.5% (38/104), 60.8% (62/102), and 100% (14/14) of the groups with &lt;6 mm, ≥6 to &lt;20 mm, and ≥20 mm of the maximum diameter of the exposed tumor components, respectively (p=0.0005). Although there was no significant relationship in the rate between the group with exposed noninvasive components and that with exposed invasive components, the residual tumor components were detected more frequently in the group with exposed lobular carcinoma components (20/29, 69%) than in the group with exposed ductal carcinoma components (94/191, 49%) (p=0.047). By a multivariate analysis, the number of positive margins and the maximum diameter were independent risk factors of the residual tumors. Conclusion: The diagnosis of positive margins by IFE was useful for the prediction of residual tumors, and three histological properties of margin-exposed tumor components were correlated with the absence of residual tumor components. It may be possible to consider stratification of additional surgical therapy according to the characteristics of margin-exposed tumor components on IFE.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4118.

Utility of Breast CT in the Management of Breast Cancer – Results from a Prospective Multi-Institutional Study

Background:In order to obtain negative margins after breast conserving surgery (BCS), even repeated surgery is widely accepted. Before surgery, it is important to conduct a precise assessment of the extent of the breast cancer so that each patient can receive individualized surgery. To evaluate the utility of breast computed tomography (CT) as a tool to manage BCS, a multi-institutional prospective study was conducted in Japan.Patients and Methods:Patients were eligible to participate in this study if they had histologically proven breast cancer and were determined to be BCS candidates based on palpation, mammography (MMG) and ultrasonography (US). Written informed consent was obtained from each patient. First, the surgeon marked the line of planned excision on the skin using information from the MMG and US. Next, an expired angiographic catheter was placed on the mark to show the original surgical margin on the CT image. Breast CT was scanned 60 seconds after the bolus injection of the contrast material in the supine surgical position. The surgeon determined the extent of surgery based on the breast CT results. Surgical specimens were serially sectioned in 5-mm slices.Results:Three hundred and two patients were enrolled in this study. The CT scanners used in this study varied from a single helical CT to a 64-row multidetector CT. The results of the breast CT changed the extent of resection in 14.7% of patients. Among the 5 patients who were recommended to undergo a mastectomy, 4 patients had multicentric tumors pathologically and 1 patient had a widely spread intraductal component. The other patients were recommended to have a quadrantectomy based on the extent of breast cancer that was visualized by CT. Three patients (1%) who required conversion from a lumpectomy to quadrantectomy resulted in overexcision. In short, breast CT correctly changed the extent of surgery in 13.7% of the examined patients.Conclusion:This prospective study suggested that breast CT is useful for hospitals equipped with any type of CT and can be used to provide patients with individualized surgery.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5021.

Tumor histology in lymph vessels and lymph nodes for the accurate prediction of outcome among breast cancer patients treated with neoadjuvant chemotherapy

The present study investigated fibrotic foci (FFs), the grading system for lymph vessel tumor emboli (LVTEs), and the histological characteristics of nodal metastatic tumors that were significantly associated with the outcomes of 115 patients with invasive ductal carcinoma (IDC) who had received neoadjuvant chemotherapy. We compared the outcome predictive power of FFs, the grading system for LVTEs, and the histological characteristics of metastatic tumors in lymph nodes with the well-known clinicopathological characteristics of tumor recurrence and tumor-related death in multivariate analyses. The presence of FFs, as assessed by a biopsy performed before neoadjuvant chemotherapy, significantly increased the hazard rates (HRs) for tumor-related death in all the cases and in cases with nodal metastasis. The grading system for LVTEs, which was assessed using surgical specimens obtained after neoadjuvant chemotherapy, was significantly associated with increasing hazard rates (HRs) for tumor recurrence and tumor-related death in all the cases and in cases with nodal metastasis. Moderate to severe stroma in nodal metastatic tumors and five or more mitotic figures in nodal metastatic tumors were significantly associated with elevated HRs for tumor recurrence and tumor-related death among all the cases. These results indicated that FFs, the grading system for LVTEs, and the histological characteristics of tumor cells in lymph nodes play important roles in predicting the tumor progression of IDCs of the breast in patients treated with neoadjuvant chemotherapy.