Identification and Validation of Radiographic Enhancement for Reliable Differentiation of CD117(+) Benign Renal Oncocytoma and Chromophobe Renal Cell Carcinoma

Purpose: The diagnostic differential for CD117/KIT(+) oncocytic renal tumor biopsies is limited to benign renal oncocytoma versus chromophobe renal cell carcinoma (ChRCC); however, further differentiation is often challenging and requires surgical resection. We investigated clinical variables that might improve preoperative differentiation of CD117(+) renal oncocytoma versus ChRCC to avoid the need for benign tumor resection.Experimental Design: A total of 124 nephrectomy patients from a single institute with 133 renal oncocytoma or ChRCC tumors were studied. Patients from 2003 to 2012 comprised a retrospective cohort to identify clinical/radiographic variables associated with renal oncocytoma versus ChRCC. Prospective validation was performed among consecutive renal oncocytoma/ChRCC tumors resected from 2013 to 2017.Results: Tumor size and younger age were associated with ChRCC, and multifocality with renal oncocytoma; however, the most reliable variable for ChRCC versus renal oncocytoma differentiation was the tumor:cortex peak early-phase enhancement ratio (PEER) using multiphase CT. Among 54 PEER-evaluable tumors in the retrospective cohort [19 CD117(+), 13 CD117(-), 22 CD117-untested], PEER classified each correctly as renal oncocytoma (PEER >0.50) or ChRCC (PEER ≤0.50), except for four misclassified CD117(-) ChRCC variants. Prospective study of PEER confirmed 100% accuracy of renal oncocytoma/ChRCC classification among 22/22 additional CD117(+) tumors. Prospective interobserver reproducibility was excellent for PEER scoring (intraclass correlation coefficient, ICC = 0.97) and perfect for renal oncocytoma/ChRCC assignment (ICC = 1.0).Conclusions: In the largest clinical comparison of renal oncocytoma versus ChRCC to our knowledge, we identified and prospectively validated a reproducible radiographic measure that differentiates CD117(+) renal oncocytoma from ChRCC with potentially 100% accuracy. PEER may allow reliable biopsy-based diagnosis of CD117(+) renal oncocytoma, avoiding the need for diagnostic nephrectomy. Clin Cancer Res; 24(16); 3898-907. ©2018 AACR.

Validation of the Kattan Nomogram for Prostate Cancer Recurrence After Radical Prostatectomy

BACKGROUND

The Kattan postoperative radical prostatectomy (RP) nomogram is used to predict biochemical recurrence-free progression (BCRFP) after RP. However, external validation among contemporary patients using modern outcome definitions is limited.

METHODS

A total of 1,931 patients who underwent RP at Roswell Park Cancer Institute (RPCI) between 1993 and 2014 (median follow-up, 47 months; range, 0-244 months) were assessed for NCCN-defined biochemical failure (BF) and RPCI-defined treatment failure (TF). Actual rates of biochemical failure-free survival (BFS; defined as 1 - BF) and treatment failure-free survival (TFS; defined as 1 - TF) were compared with Kattan BCRFP nomogram predictions.

RESULTS

The Kattan BCRFP nomogram predictions at 5 and 10 years were predictive of BFS (area under the receiver operating characteristic curve [AUC], 0.772) and TFS (AUC, 0.774). The Kattan BCRFP nomogram tended to underestimate BFS and TFS compared with actual outcomes. The Kattan 5-year BCRFP predictions consistently overestimated actual 5-year BFS outcomes among subgroups of high- and intermediate-risk patients with at least 5-year outcomes.

CONCLUSIONS

The Kattan BCRFP nomogram is a robust predictor of NCCN-defined BF in a large sample of patients with RP with substantial follow-up and modern, standardized failure definitions.

Blinded review of archival radical prostatectomy specimens supports that contemporary Gleason score 6 prostate cancer lacks metastatic potential

BACKGROUND

Retrospective identification of Gleason pattern 4 in metastatic Gleason score 3 + 3 = 6 (GS6) radical prostatectomy (RP) specimens has suggested true GS6 prostate cancer (CaP) lacks metastatic potential. However, pathologist awareness of study design and metastasis outcomes at the time of RP review might have introduced upgrading bias. We used pathologist-blinded methodology for unbiased characterization of metastasis rates for contemporarily defined pathologic GS6 (pGS6) CaP.

METHODS

An institutional RP database was queried to identify pGS6 patients with metastasis or concern for micrometastasis based on: 1) biochemical failure (BF) despite negative surgical margins or 2) incomplete biochemical response to salvage/adjuvant radiation. RP specimens were regraded independently by two genitourinary pathologists blinded to study aims or clinical outcomes. Additional blinding was performed by random inclusion of pGS6 control specimens from BF-free patients. Only upgrading identified independently by both pathologists was considered.

RESULTS

Among 451 pGS6 patients identified, none had synchronous lymph node metastases and 43/451 (10%) suffered BF. Two patients (0.4%) developed metachronous metastasis during a 110-month median follow-up for BF patients. Both metastatic cases had Gleason pattern 4 on blinded RP review, as did 88% of cases with concern for micrometastasis versus 38% of control cases (P = 0.02). All BF patients (29/29) undergoing postoperative radiation had a complete biochemical response or Gleason pattern 4 on blinded RP review.

CONCLUSIONS

Unbiased pathologist review of archival RP specimens supports absent metastatic potential for contemporarily defined GS6 CaP. Reduced postoperative monitoring is appropriate for pGS6, but may require pathology review to confirm absent Gleason pattern 4.

Tobacco use and outcome in radical prostatectomy patients

Cigarette smoking has been consistently associated with increased risk of overall mortality, but the importance of smoking for patients with prostate cancer (CaP) who are candidates for curative radical prostatectomy (RP) has received less attention. This retrospectively designed cohort study investigated the association of smoking history at RP with subsequent CaP treatment outcomes and overall mortality. A total of 1981 patients who underwent RP at Roswell Park Cancer Institute (RPCI) between 1993 and 2014 were studied. Smoking history was considered as a risk factor for overall mortality as well as for currently accepted CaP treatment outcomes (biochemical failure, treatment failure, distant metastasis, and disease‐specific mortality). The associations of smoking status with these outcomes were tested by Cox proportional hazard analyses. A total of 153 (8%) patients died during follow‐up. Current smoking at diagnosis was a statistically significant predictor of overall mortality after RP (current smokers vs. former and never smokers, hazards ratio 2.07, 95% confidence interval [CI]: 1.36–3.14). This association persisted for overall mortality at 3, 5, and 10 years (odds ratios 2.07 [95% CI: 1.36–3.15], 2.05 [95% CI: 1.35–3.12], and 1.8 [95% CI: 1.18–2.74], respectively). Smoking was not associated with biochemical failure, treatment failure, distant metastasis, or CaP‐specific mortality, and the association of smoking with overall mortality did not appear to be functionally related to treatment or biochemical failure, or to distant metastasis. Smoking is a non‐negligible risk factor for death among CaP patients who undergo RP; patients who smoke are far more likely to die of causes other than CaP.

Clinical significance of prospectively assigned Gleason tertiary pattern 4 in contemporary Gleason score 3+3=6 prostate cancer

OBJECTIVE

To determine the oncologic impact of prospectively assigned tertiary pattern 4 in contemporary Gleason score (GS) 3 + 3 = 6 radical prostatectomy (RP) specimens.

PATIENTS AND METHODS

Oncologic outcomes were retrospectively reviewed for 720 consecutive patients from a single National Comprehensive Cancer Network (NCCN) center with at least 6 months follow-up after RP for GS3 + 3 = 6 (GS6, N = 222), GS6 with tertiary pattern 4 (GS6t4, N = 62), or GS3 + 4 = 7 (N = 436) prostate cancer, as prospectively graded since 2006 using the 2005 International Society of Urologic Pathologists criteria. Preoperative NCCN risk category, RP pathology, progression-free survival (PFS) and metastasis-free survival (MFS) were compared among the GS6, GS6t4, and GS3 + 4 = 7 groups using χ(2) , Kaplan-Meier, and log-rank analyses.

RESULTS

The incidence of low NCCN preoperative risk classification for GS6t4 patients (63%) was less than that for GS6 patients (77%) while greater than that for GS3 + 4 = 7 patients (30%, P < 0.001). GS6t4 patients had RP pathologic features which were intermediate in risk between that of GS6 and GS3 + 4 = 7 based on extraprostatic extension (27% vs. 6% vs. 31%, respectively, P < 0.001) and mean percentage of prostate gland involvement (13% vs. 10% vs. 16%, respectively, P < 0.001). With a mean overall follow-up of 42 months, PFS for GS6t4 patients (5-year 85%) was intermediate between that of GS6 (5-year 93%) and GS3 + 4 = 7 (5-year 76%) patients (P < 0.001). The 5-year MFS rate was 100% for GS6 and GS6t4 patients compared to 97% for GS3 + 4 = 7 patients (P = 0.07).

CONCLUSIONS

This study provides the longest follow-up to date for RP patients with prospectively assigned GS6t4 and supports a risk for adverse RP pathology and postoperative disease progression that is intermediate between GS6 and GS3 + 4 = 7. Whether a tertiary pattern 4 in GS6 disease increases the risk of metastasis is uncertain and requires longer term study. Given favorable oncologic outcomes, less stringent postoperative surveillance for both GS6 and GS6t4 patients may be warranted.

Abstract P4-09-16: WAVE3 Over-Expression Is Associated with Adverse Tumor Characteristics and Mortality in Breast Cancer

Background: WAVE3 regulates actin polymerization and subsequent cell migration leading to enhanced metastatic potential. Based on pilot data that suggested WAVE3 expression was associated with high histologic grade and absence of estrogen receptor (ER) expression we hypothesized that WAVE3 expression would correlate with ER status and tumor grade in a matched group of breast cancer (BC) patients. WAVE3 expression was alsoanalyzed in relation to adverse tumor characteristics, distant recurrence (DR) and BC specific mortality. Methods: Our institutional BC database was reviewed for patients who presented with, invasive BC from 1999-2009. Matching by stage and treatment was achieved for 61 patients with Scarff-Bloom-Richardson (SBR) grade 1 and ER+ tumors (SBR1/ER+) to 61 patients with SBR grade 3 and ER-tumors (SBR3/ER-). Cytosolic WAVE3 tumor expression was determined by immunohistochemistry. The product of stain intensity (0-3) and percentage of cells staining (0-100) was used to derive a WAVE3 score (0-300). The log rank test was utilized to compare BC specific mortality or distant recurrence free survival at various WAVE3 scores. A score of ≥212 was found to have the strongest association with poor outcome. The association between WAVE3 score and clinicopatholigic features, DR and BC specific mortality was assessed. Results: Increased frequency of Her2-neu (+) status, DR and BC specific mortality was noted in the SBR3/ER-group but WAVE3 score was no different between the two groups(Table1). In all 122 patients median WAVE3 score increased with tumor size (0.234, p=0.009), (+) lymph node status 200 vs. (-), 145, p =0.03, and stage (I, 160 vs. II,180 vs III, 240, p=0.012). There was no association between WAVE3 score and Her2-neu status(+200 vs. -180, p=0.51). In the SBR1/ER+ group only (+) lymph node status remained associated with WAVE3 score(+) 200 vs. (-) 130 (p=0.02). In the SBR3/ER-group only lymph node status lost association with WAVE3 score (+)180 vs.(-)170, (p=0.50). DR and BC specific survival could only be assessed in the SBR3/ER-group. Median WAVE3 score was elevated with DR (240 vs. none, 160, p=0.03) and BC specific mortality (270 vs. none 170, p=0.004). A WAVE3 score ≥212 was associated with distant recurrence and BC specific mortality on Kaplan Meier analysis (p=0.01) and P&lt;0.001). On multivariate analysis a WAVE3 score ≥212 was associated with an increased risk for BC specific mortality (p=0.009). The association of DR and WAVE3 score ≥212 approached significance (p=0.068).

Table 1

Conclusion: WAVE3 expression is not associated with tumor grade, and ER or Her2 neu status. WAVE3 is associated with tumor size, stage, DR and BC specific mortality in the high risk SBR3/ER-group. A WAVE3 score of ≥212 is associated with distant recurrence and breast cancer specific mortality on univariate analysis and BC specific mortality on uni-and multivariate analysis. WAVE3 expression may contribute to adverse outcome in high risk breast cancer patients.

Genetic Susceptibility as a Possible Risk Factor for Breast Cancer

Background: Established risk factors for breast cancer (BC) only explain 25% to 47% of BC incidence. The Gail model is commonly used to assess BC risk and determine eligibility for prevention trials. Unfortunately, it has a discriminatory accuracy of 58% at the individual level. A greater understanding of BC risk factors is needed to offer improved risk stratification and prevention. It is plausible that BC risk may be related to deficiencies or abnormalities in DNA repair and cell cycle checkpoints because of their importance in maintaining genomic integrity. Recent epidemiologic studies support this hypothesis. In this pilot project, the bleomycin mutagen sensitivity assay (MSS), a measure of genetic susceptibility was performed on women of low, intermediate, and high risk based on commonly used risk models to determine if there was any correlation between MSS and established BC risk factors.Methods: Women in the Prevention Clinic at RPCI consented to donate blood for this study as part of the Data Bank and BioRepository (DBBR). Gail and Claus Models were calculated using CancerGene. Women were stratified into three groups low (&lt;20%), intermediate (20%-35%), and high (&gt; 35%) lifetime BC risk. For logistic regression analysis, women were grouped into low risk (&lt;20%) and high risk (≥20%). MSS in blood lymphocytes were performed at LCCC using fresh blood samples. The mean values of MSS were compared between low, intermediate, and high risk groups using Wilcoxon-Mann-Whitney tests. Multivariate logistic regression was used to analyze the relationship between BC risk groups and MSS.Results: A total of 78 women were enrolled in the study. MSS were performed on 70 blood samples and 67 had evaluable slides. There were 30, 26 and 11 women in the low, intermediate, and high risk groups respectively. The mean age was 49.1 years. There was no statistical difference between the three groups with respect to age, race, menopausal status, proportion of patients with a family history of BC or another cancer, and smoking status (never, former, or current). The mean MSS score was not significantly different among the three risk groups: mean ±SD = 0.86±0.37, 0.84±0.37 (p=0.565), and 0.76+0.44 (0.361) for low, intermediate and high risk groups respectively. Spearman correlation revealed that MSS score did not correlate with Gail lifetime BC risk score (r=-0.054, p=0.668) or Claus model-10 year risk score (r=-0.057, p=0.722). Using the median in low risk women as a cut point, when women who had higher MSS score were compared with women had lower MSS score, the adjusted OR was 1.16 (95% CI, 0.29 to 4.57), adjusted for age, race, smoking status, BMI and menopausal status. When the MSS score were categorized into quartiles, no significant dose-response relationship was observed.Conclusions: In this pilot study, there was no correlation between commonly used breast cancer risk assessment models based on hormonal, family and biopsy history and the MSS in our study population. Previous case-control studies have consistently shown that MSS is significantly associated with BC risk. The lack of correlation between mutagen sensitivity and Gail or Claus risk score suggests that mutagen sensitivity may measure the host susceptibility factors that are not considered by Gail or Claus risk models.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6067.

Reproducibility of random periareolar fine needle aspiration in a multi-institutional Cancer and Leukemia Group B (CALGB) cross-sectional study

BACKGROUND

Random periareolar fine needle aspiration (RPFNA) is a research technique developed to assess short-term breast cancer risk in women at increased risk of breast cancer. Although there is increasing acceptance of RPFNA, neither the reproducibility nor the inter-institutional compatibility of RPFNA has been established. To address these key limitations, the Cancer and Leukemia Group B (CALGB) Prevention Group tested the reproducibility of RPFNA in a multi-institutional cross-sectional study.

METHODS

Sixty-three high-risk women from five CALGB institutions (Duke, Ohio State, Roswell Park, Dana Farber, and Vermont) underwent RPFNA from July 1, 2007 to June 30, 2008. Duplicate bilateral RPFNA was performed on each woman by a single investigator on a single day. Masood Cytology Index score was assessed by a single blinded cytopathologist.

RESULTS

There was a high degree of statistical agreement in the Masood Cytology Index scores of duplicate RPFNA samples from the same breast, with a Spearman correlation coefficient of 0.8312 (P < 0.0001). Importantly, although there was agreement in duplicate samples from the same breast, there was lack of agreement between duplicate samples from the opposite breast.

CONCLUSIONS

This multi-institutional study shows that RPFNA is a highly reproducible measure of breast cytology in a cooperative group cross-sectional trial. RPFNA did not show a high degree of agreement between breasts, suggesting that breast cancer risk and progression may occur at different rates in individual breasts from a single woman. These studies provide proof-of-principle for future RPFNA-based cooperative group prevention studies.

TLE3 as a candidate biomarker of response to taxane therapy

Introduction

The addition of taxanes (Ts) to chemotherapeutic regimens has not demonstrated a consistent benefit in early-stage breast cancer. To date, no clinically relevant biomarkers that predict T response have been identified.

Methods

A dataset of immunohistochemistry stains in 411 patients was mined to identify potential markers of response. TLE3 emerged as a candidate marker for T response. To test the association with T sensitivity, an independent 'triple-negative' (TN) validation cohort was stained with anti-TLE3 antibody.

Results

TLE3 staining was associated with improved 5-year disease-free interval (DFI) in the overall cohort (n = 441, P < 0.004), in patients treated with cyclophosphamide (C), methotrexate, and 5-fluorouracil (n = 72, P < 0.02), and in those treated with regimens containing doxorubicin (A) and a T (n = 65, P < 0.04). However, no association was shown with outcome in untreated patients (n = 203, P = 0.49) or those treated with a regimen containing A only (n = 66, P = 0.97). In the TN cohort, TLE3 staining was significantly associated with improved 5-year DFI in all patients (n = 81, P < 0.015), in patients treated with AC + T (n = 45, P < 0.02), but not in patients treated with AC (n = 17, P = 0.81). TLE3 was independent of tumor size, nodal status, and grade by bivariable analysis in both cohorts.

Conclusions

TLE3 staining is associated with improved DFI in T-treated patients in two independent cohorts. Since the validation study was performed in a TN cohort, TLE3 is not serving as a surrogate for estrogen receptor or HER2 expression. TLE3 should be studied in large clinical trial cohorts to establish its role in T chemotherapy selection.

Multiple primary tumors in men with breast cancer diagnoses: a SEER database review

BACKGROUND

Male breast cancer (MBC) comprises 1% of all breast cancers and less than 1% of cancer cases in men. After a diagnosis of MBC, men are at risk of developing a second primary cancer, particularly a second primary breast cancer. The objective of this study is to analyze the characteristics of the population of men diagnosed with a second malignancy, specifically a second MBC.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, 4,873 male patients diagnosed with invasive or in situ breast cancer from 1973 to 2004 were identified and data from patients who developed a second MBC were reviewed. Additional non-breast primary cancer diagnoses were also recorded.

RESULTS

A review of 4,966 records corresponding to 4,873 patients revealed 4,462 invasive and 504 in situ breast cancer events. Of the 4,873 patients, 93 (1.9%) were identified with a second MBC. Among the 4,873 patients with MBC, 1,001 (21%) have other non-breast primary cancer diagnoses recorded in the SEER registry.

CONCLUSIONS

Although MBC is uncommon, these patients are at risk of a contralateral breast cancer and second primary non-breast cancers. Our findings support that men with breast cancer would benefit from continued long-term surveillance for breast cancer and appropriate screening for non-breast cancers.