Angiographically Occult Subarachnoid Hemorrhage: Yield of Repeat Angiography, Influence of Initial CT Bleed Pattern, and Sources of Diagnostic Error in 242 Consecutive Patients

BACKGROUND AND PURPOSE

Nearly 20% of patients with spontaneous SAH have no definitive source on initial DSA. The purpose of this study was to investigate the timing and yield of repeat DSA, to clarify the influence of initial CT bleed pattern, and to characterize sources of diagnostic error in this scenario.

MATERIALS AND METHODS

We evaluated the yield of repeat DSA and clinical outcomes stratified by hemorrhage pattern on CT in consecutive patients with nontraumatic SAH with negative initial DSA findings at a referral center. Cases in which the culprit lesion was subsequently diagnosed were classified as physiologically occult (ie, undetectable) on the initial DSA, despite adequate technique and interpretation or misdiagnosed due to operator-dependent error.

RESULTS

Two hundred forty-two of 1163 (20.8%) patients with spontaneous SAH had negative initial DSA findings between 2009 and 2018. The SAH CT pattern was nonperimesencephalic (41%), perimesencephalic (36%), sulcal (18%), and CT-negative (5%). Repeat DSA in 135/242 patients (55.8%) revealed a source in 10 patients (7.4%): 4 saccular aneurysms, 4 atypical aneurysms, and 2 arteriovenous shunts. The overall yield of repeat DSA was 11.3% with nonperimesencephalic and 2.2% for perimesencephalic patterns. The yield of the second and third DSAs with a nonperimesencephalic pattern was 7.7% and 12%, respectively. Physiologically occult lesions accounted for 6/242 (2.5%) and operator-dependent errors accounted for 7/242 (2.9%) of all angiographically occult lesions on the first DSA.

CONCLUSIONS

Atypical aneurysms and small arteriovenous shunts are important causes of SAH negative on angiography. Improving DSAs technique can modestly reduce the need for repeat DSA; however, a small fraction of SAH sources remain occult despite adequate technique. These findings support the practice of repeating DSA in patients with a nonperimesencephalic SAH pattern.

Emergent Premedication for Contrast Allergy Prior to Endovascular Treatment of Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Management of contrast media allergies may lead to treatment delays in patients with acute ischemic stroke undergoing endovascular therapy. The optimal premedication strategy remains unclear. The aim of this report was to analyze our experience with emergent administration of premedication regimens before endovascular therapy.

MATERIALS AND METHODS

We retrospectively reviewed prospective data for all patients undergoing endovascular therapy from 2012 to 2019 at an academic comprehensive stroke center. Records of patients with documented contrast allergy were reviewed and analyzed. Data collected included stroke risk factors and characteristics, historical contrast reaction details, premedication regimens administered, and signs or symptoms of allergic reaction developing post-endovascular therapy. Hospital arrival time to endovascular therapy was compared with that in those who did not have a history of contrast allergy.

RESULTS

We analyzed 1521 patients undergoing endovascular therapy; 60 (4%) had documented contrast allergies and constituted the study cohort. The median age was 73 years (interquartile range, 66-81 years), and 65% were women. The median time from premedication to contrast was 24 minutes (interquartile range, 0-36 minutes). Forty-three patients (72%) proceeded directly to endovascular therapy; in 17 patients, the first contrast exposure was CTA. Time from hospital arrival to endovascular therapy was not slower for patients with documented allergies (96 versus 134 minutes, P = .32). No patients experienced a contrast media reaction.

CONCLUSIONS

In a single-institution cohort study of 60 consecutive patients with documented contrast allergies undergoing endovascular therapy with emergent premedication en route to (or in) the neuroangiography suite, no patients experienced allergic symptoms. This pragmatic approach may be safe for patients who have documented contrast media allergies.

Abstract P3-04-23: Combination therapy of targeted anticancer pathways and estrogen receptor ligands and their responses in de novo andtamoxifen resistant cell models

Approximately 75% of breast cancers are classified as Estrogen Receptor positive (ER+). Tamoxifen, a selective estrogen receptor modulator (SERM), is the standard of care for many of these ER+ breast cancer patients. Unfortunately, tamoxifen resistance occurs in almost 50% of patients within 5 years of treatment, and endocrine-independence accompanying resistance also negates the effects of aromatase inhibitors. Combination therapy is increasingly used in non-cytotoxic therapeutic approaches in many types of cancer. The potential exists that endocrine resistance can be lessened, eliminated, or overcome through targeted therapy in combination with endocrine therapy. Inhibition of kinase signaling (e.g. via CDK4/6 or PI3K) and other pathways (e.g. HSP90) are expected to be effective in combination with endocrine therapy. We have discovered a variety of ER ligands with potential as endocrine therapeutic agents, based upon a single chemical scaffold with a diverse set of pharmacological responses: including SERMs, selective ER downregulators (SERDs), selective estrogen mimics (SEMs), and selective human ER partial agonists (ShERPAs). To predict which agents in combination with these endocrine-targeted ligands would be of potential therapeutic benefit it was necessary to develop 3D spheroidal cultures of ER+ breast cancer cell lines: including endocrine-dependent lines; and cell lines made endocrine-independent either by extended exposure to tamoxifen or extended deprivation of estradiol. In contrast to 2D cultures, drug response in 3D spheroidal cell cultures was predictive of response to treatment in mouse xenograft studies. Growth of endocrine-dependent cell lines was, as expected, inhibited by SERDs; and endocrine-independent, tamoxifen-resistant cell lines were also sensitive to SERD treatment, although one cell line was largely resistant. Growth of all three tamoxifen-resistant cell lines was inhibited by SEMs/ShERPAs. Importantly, regardless of the type of endocrine therapeutic agent studied, concentrations leading to saturation of the target (ER) did not cause cell death. Equally, all endocrine therapies studied benefited from combination treatment with other agents, leading to enhanced cell death.

Citation Format: Gutgesell LM, Xiong R, Thatcher GRJ, Tonetti DA. Combination therapy of targeted anticancer pathways and estrogen receptor ligands and their responses in de novo andtamoxifen resistant cell models [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-04-23.

Dynamic transcription factor activity and networks during ErbB2 breast oncogenesis and targeted therapy

Tissue development and disease progression are multi-stage processes controlled by an evolving set of key regulatory factors, and identifying these factors necessitates a dynamic analysis spanning relevant time scales. Current omics approaches depend on incomplete biological databases to identify critical cellular processes. Herein, we present TRACER (TRanscriptional Activity CEll aRrays), which was employed to quantify the dynamic activity of numerous transcription factor (TFs) simultaneously in 3D and networks for TRACER (NTRACER), a computational algorithm that allows for cellular rewiring to establish dynamic regulatory networks based on activity of TF reporter constructs. We identified major hubs at various stages of culture associated with normal and abnormal tissue growth (i.e., ELK-1 and E2F1, respectively) and the mechanism of action for a targeted therapeutic, lapatinib, through GATA-1, which were confirmed in human ErbB2 positive breast cancer patients and human ErbB2 positive breast cancer cell lines that were either sensitive or resistant to lapatinib.

Crosstalk between PKCα and Notch-4 in endocrine-resistant breast cancer cells

The Notch pathway is functionally important in breast cancer. Notch-1 has been reported to maintain an estrogen-independent phenotype in estrogen receptor α (ERα)+ breast cancer cells. Notch-4 expression correlates with Ki67. Notch-4 also plays a key role in breast cancer stem-like cells. Estrogen-independent breast cancer cell lines have higher Notch activity than estrogen-dependent lines. Protein kinase Cα (PKCα) overexpression is common in endocrine-resistant breast cancers and promotes tamoxifen (TAM)-resistant growth in breast cancer cell lines. We tested whether PKCα overexpression affects Notch activity and whether Notch signaling contributes to endocrine resistance in PKCα-overexpressing breast cancer cells.Analysis of published microarray data from ERα+ breast carcinomas shows that PKCα expression correlates strongly with Notch-4. Real-time reverse transcription PCR and immunohistochemistry on archival specimens confirmed this finding. In a PKCα-overexpressing, TAM-resistant T47D model, PKCα selectively increases Notch-4, but not Notch-1, expression in vitro and in vivo. This effect is mediated by activator protein-1 (AP-1) occupancy of the Notch-4 promoter. Notch-4 knockdown inhibits estrogen-independent growth of PKCα-overexpressing T47D cells, whereas Notch-4IC expression stimulates it. Gene expression profiling shows that multiple genes and pathways associated with endocrine resistance are induced in Notch-4IC- and PKCα-expressing T47D cells. In PKCα-overexpressing T47D xenografts, an orally active γ-secretase inhibitor at clinically relevant doses significantly decreased estrogen-independent tumor growth, alone and in combination with TAM. In conclusion, PKCα overexpression induces Notch-4 through AP-1. Notch-4 promotes estrogen-independent, TAM-resistant growth and activates multiple pathways connected with endocrine resistance and chemoresistance. Notch inhibitors should be clinically evaluated in PKCα- and Notch-4-overexpressing, endocrine-resistant breast cancers.

Abstract P6-04-24: Overexpression of protein kinase C alpha differentially activates transcription factors in T47D breast cancer cells in the presence of 17β-estradiol both in the 2D and 3D environments

Background: Our lab has previously shown that overexpression of protein kinase C alpha (PKCα) results in a hormone independent, tamoxifen resistant phenotype in the T47D:A18 breast cancer cell line. Moreover, 17β-estradiol (E2) inhibits colony formation of T47D/PKCα in 3D Matrigel and tumor growth in vivo but not in the 2D environment (Zhang et al, Mol. Cancer Res, 2009). Differential transcriptional activation may account for the phenotypic changes observed in T47D/PKCα cells. In this study, we sought to identify transcription factors (TF) differentially activated in T47D:A18/neo versus T47D:A18/PKCα grown in 3D Matrigel in the presence and absence of E2, and compare these TFs with those activated in the 2D environment using a high-throughput screening (HTS) technology.

Methods: A system for rapid, non-invasive, large scale, dynamic quantification of TF activity was developed (Weiss et al, PLoS ONE, 2010). Reporter constructs were created containing a TF binding site that preceeds a basal promoter to produce firefly luciferase (Fluc) using a lentiviral backbone. The control construct contained only the basal promoter and was used for normalization. T47D/PKCα and T47D/neo cells were infected with lentiviral reporter constructs. Cells were seeded either on top of Matrigel or without Matrigel in 384 well plates in E2-free media. After 3 days, cells were treated with either E2 (10–9M) or vehicle (0.1% ethanol). Fluc activity was assessed by bioluminescence imaging at 24, 48 and 72 hours following treatment using Xenogen IVIS Spectrum imaging system.

Results: Initial findings showed differential transcriptional activities between the parental T47D/neo and T47D/PKCα cell lines at the basal level (without E2 treatment) in the 3D environment. Specifically, TFs involved in tumorigenesis (such as ETS1, STAT5) or the EMT process (such as SNAI1) were more highly activated in T47D/PKCα cells. Furthermore, E2 has a modulating effect on the activities of TFs in the two cell lines over time; observed both in the 2D and 3D environments. In particular, some TFs, such as Oct4, ETS1, and Stat5; were modulated (either induced or suppressed) by E2 only in T47D/PKCα cells.

Conclusion: These findings suggest that overexpression of PKCα alters TF activity in T47D breast cancer cells both basally and in response to E2. This HTS technology allowed us to reveal the dynamic regulation of TF activation in PKCα overexpressing T47D breast cancer cells. We are now beginning to understand the mechanism whereby PKCα may mediate differential response to E2 dependent on the microenvironment. This HTS approach is likely to lead to the identification of new therapeutic targets.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-04-24.

Increased Expression of Inflammatory Genes in Pregnancy-Associated Breast Cancers

Introduction: Epidemiological studies have shown that women of all ages experience a transient increase in the risk of developing breast cancer following pregnancy. Furthermore, breast cancers detected soon after a completed pregnancy (pregnancy-associated breast cancers, or PABCs) have a worse prognosis than those detected at more distant intervals (Schedin 2006). We previously found evidence for increased expression of inflammatory genes in the human breast following pregnancy. (Asztalos et al. 2008). In this study we analyzed the same gene set in human breast cancer tissue, to investigate the role of inflammation in pregnancy associated breast cancers.Patients and Methods: Women ≤ 45 years of age with breast cancer were eligible for the study, and were categorized as either nulliparous, recently pregnant or distantly pregnant. Thirteen nulliparous, 14 recently pregnant (<2 years since pregnancy) and 15 distantly pregnant (5-10 years) patients were identified. Tumor regions were isolated from formalin-fixed paraffin embedded tissues using Laser Capture Microdissection, followed by RNA extraction and cDNA synthesis. Genes of interest were preamplified linearly, followed by real time PCR. We chose 59 genes involved in the processes of inflammation, ECM remodeling and angiogenesis. A small number of breast cancer prognostic genes were also included. Gene expression between groups was compared using either t-test, ANOVA or unsupervised hierarchical clustering.Results: When recent and distant PABCs were combined and compared to the nulliparous group, we observed a number of significantly differentially regulated genes, such as CXCL1, THBS1, ELN, IL11 and MMP3. Upregulation of CXCL1 in the post-pregnant samples is interesting since CXCL1 is an important inflammatory chemokine, with implications in cancer. THBS1, a natural inhibitor of neovascularization and tumorigenesis, was downregulated in the post-pregnancy group. In this early analysis, we did not observe a difference in gene expression between recent and distant pregnancies, possibly due to the limited number of samples. However, immunoglobulin A showed a trend towards upregulation in the recent pregnancy group, suggesting an enhanced state of immune activity in the cancers occurring in the recently pregnant breast. When concerted gene expression was compared by non-supervised hierarchical clustering, we found that PABCs (both recent and distant) had more frequent associations with inflammation associated gene-expression patterns than those of nulliparous patients.Conclusions: This is the first study to address the hypothesis suggesting the role of post-pregnancy events, such as inflammation, ECM remodeling and angiogenesis in the etiology and aggressiveness of PABCs by looking at a set of human breast cancers with known pregnancy history. We show that the cancers of patients detected post-pregnancy are more frequently associated with an inflammation-associated gene expression pattern, than those of nulliparous women. The exact role of inflammation in the aggressiveness of PABCs remains to be further elucidated.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5158.

T47D/PKCα Cells Are Nonmigratory and Noninvasive In Vitro Despite Tamoxifen Resistance In Vivo

Background: We have previously reported that overexpression of PKCα in T47D (T47D/PKCα) breast cancer cells results in hormone independence, growth inhibition by estradiol, and tamoxifen resistance (Chisamore, 2001). This has clinical relevance because we have shown that PKCα overexpression may predict disease recurrence and tamoxifen treatment failure suggesting consideration of other treatments (Tonetti, 2003). Further characterization reveals that T47D/PKCα cells are noninvasive in vitro compared to T47D/neo control cells in Matrigel invasion assays and that knockdown of PKCα reverses the phenotype (Perez White, AACR 2009). We have further characterized the in vitro phenotype of T47D/PKCα cells using migration assay and profiling of proteins associated with epithelial-mesenchymal transition (EMT). Adherens junctions are made of a complex of proteins including E-cadherin whose dissolution is thought to play a role in EMT. E-cadherin can be transcriptionally repressed by the embryonic transcription factor Snail1. Generally, cells that lose expression of E-cadherin gain expression of N-cadherin and/or vimentin which is correlated to increased migration, invasion, and metastasis.Methods: To determine migration, cells were plated in serum-free media into Boyden chambers for 24 h with media containing 10% fetal bovine serum as chemoattractant. Protein expression levels were determined by western blot of whole cell extracts and transcript levels by RT-qPCR. Statistical analyses were performed by t-test with GraphPad Prism 5.Results: Migration assay results show that T47D/PKCα cells are nonmigratory compared to T47D/neo cells (P < 0.0001). Western blots show that there is significantly lower expression of E-cadherin in T47D/PKCα cells compared to T47D/neo cells (P < 0.005). However, transcripts of E-cadherin are expressed at 3-fold higher levels in T47D/PKCα cells compared to T47D/neo cells. Neither cell line expresses vimentin, N-cadherin, or Snail1 proteins.Conclusions: T47D/PKCα cells have reduced invasive and migratory potential even though they have decreased expression of E-cadherin. Results indicate that regulation of E-cadherin may be due to translational repression or increased degradation due to increased transcripts and absence of a transcriptional repressor. In summary, despite the fact that PKCα overexpression correlates with tamoxifen resistance, these tumors may have a better prognosis due to the less invasive and migratory nature of these cells. Future mechanistic and clinical studies are needed to determine the full prognostic impact of PKCα tumor overexpression in patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6173.

Estradiol Induced Regression of T47D:A18/PKCα Tumor Involves Translocation of Estrogen Receptor alpha from the Nucleus to the Cytoplasm

Background: Resistance to tamoxifen (TAM) is one of the most challenging problems in the treatment of breast cancer. In our laboratory we have developed a PKCα overexpressing T47D:A18 cell line which is TAMresistant and 17β estradiol (E2) independent compared to the E2 dependent T47D:A18/neo cell line (Chisamore et al, 2001). PKCα overexpression is known to be associated with TAM treatment failure in breast cancer (Tonetti et al, 2003). This T47D:A18/PKCα model exhibits E2-induced tumor regression in in vivo or when grown in matrigel (3D matrix) but not on 2D plastic. Recently we have demonstrated that tumor regression involves participation of estrogen receptor alpha (ERα), Fas/FasL and the extracellular matrix (Zhang et al, 2009). Interestingly membrane impermeable E2-BSA conjugate mediates growth inhibition of T47D:A18/PKCα colonies in matrigel similar to E2 suggesting a potential role of extranuclear ERα. On the basis of our preliminary data we investigated whether extranuclear ERα may play a critical role in E2-induced tumor regression.Materials and methods: T47D:A18/PKCα cells were injected into mammary fat pads of 20 ovariectomized athymic mice. Mice were left untreated and tumors were allowed to grow until the mean tumor size reached 0.5 cm2, then 10 mice were implanted with a 1.0 cm E2 capsule and the other 10 continued with no treatment (control). T47D:A18/neo tumors were also established in 10 athymic mice in the presence of E2. Four micrometer thick sections were prepared from the paraffin embedded T47D:A18/PKCα tumor tissues of control and E2-treated mice and T47D:A18/neo tumors. For immunofluorescence staining, alexa fluor 488 and Cy3 fluorescence tagged secondary antibodies were used against ERα and β-actin primary antibodies respectively.Results: Immunofluorescence images of T47D:A18/PKCα tumor sections from untreated control mice showed that the ERα was mainly localized in the nucleus. Interestingly, treatment with E2 resulted in significant translocation of ERα from the nucleus to the cytoplasm and the plasma membrane of tumor cells. Immunofluorescence analysis of tumor sections obtained from E2 treated mice indicated that approximately 5-10% of cells contained ERα localized to the plasma membrane whereas the majority of ERα was localized to the cytosol. However in T47D:A18/neo tumors the majority of ERα was found in the nucleus suggesting the involvement of the ERE mediated classical pathway in tumor growth.Discussion: This is the first time we are reporting that E2-induced T47D:A18/PKCα tumor regression is accompanied by translocation of ERα to extranuclear sites. E2-induced tumor regression observed in our pre-clinical model suggests E2 or an E2-like compound may be a potential treatment option for patients harboring PKCα overexpressing tumors. Furthermore the extranuclear ERα signaling pathway may be an attractive therapeutic target to treat PKCα overexpressing tumors that are refractory to current endocrine therapies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4140.

2-(4-Hydroxyphenyl)-Benzo[b]thiophen-6-ol, an Estrogen-Like Compound, Induces Apoptosis in T47D/PKCα Breast Cancer Cells

Background: Tamoxifen (TAM) treatment failure is a major obstacle encountered in the clinical setting. Our lab has previously shown that constitutive overexpression of PKCα imparts a TAM resistant/ hormone independent phenotype in the T47D:A18 breast cancer cell line. Furthermore 17β-estradiol (E2) inhibits tumor growth in vivo as well as inhibits colony formation when cells are grown in 3D Matrigel (Zhang, 2009). Before TAM treatment was introduced, breast cancer patients received high-dose E2 and diesthystilbesterol (DES) treatment. DES treated patients may have a survival advantage over TAM treated patients in the long term (Peethambaram,1999). Others have shown that E2 can have inhibitory effects on MCF-7 cells both in vitro and in vivo (Lewis-Wambi, 2009). Taken together, this suggests an estrogenic compound may be efficacious for TAM-resistant breast cancer. The present study was designed to evaluate the effect of an estrogenic compound, 2-(4-hydroxyphenyl)-benzo[b]thiophen-6-ol (BTC), related to the SERMs raloxifene and arzoxifene, on the T47D:A18/PKCα breast cancer cell line.Methods: To determine if BTC can activate estrogen regulated genes we preformed an ERE-luciferase reporter assay 24 hours after BTC treatment. 3D Matrigel colony formation assay was performed to determine if BTC could inhibit colony formation. Colonies were stained and counted on day 10. To determine if apoptosis was occurring, cells were grown in Matrigel and the TUNEL Assay was performed on Day 6.Results: T47D:A18/PKCα cells showed a 31-fold induction in ERE-luciferase reporter activity when treated with BTC (10-7M) compared to 7-fold induction when treated with E2. In the T47D:A18/Neo parental cell line, BTC induced a 40-fold induction whereas estradiol induced a 96-fold induction. In the Matrigel colony formation assay T47D:A18/PKCα cells formed significantly fewer colonies when treated with BTC. Conversely, in the T47D:A18/Neo parental cell line BTC enhanced colony formation similar to E2 treatment. Our results indicate that BTC was able to induce significant apoptosis on day 6 (P= 0.038) as determined by the TUNEL Assay. Therefore BTC acts similarly to estradiol by inhibiting T47D:A18/PKCα colony formation and inducing apoptosis when cells are grown in Matrigel.Conclusion: These findings suggest that BTC is a potential lead compound in the treatment of PKCα overexpressing breast cancer. Furthermore, BTC was shown to be a potent inducer of the cytoprotective enzyme NQO1 in the Hepa 1c1c7 cell system as well as a strong activator of antioxidant responsive elements (Yu, 2007) indicating it may have the added benefit of chemoprotective effects which are absent in estradiol treatment. Further understanding of the mechanism in which BTC induces apoptosis in the T47D:A18/PKCα cell line may result in a clinical advantage to estradiol treatment including fewer side effects.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5140.

Role of lobular involution in pregnancy-associated breast cancer

Abstract #5038

Introduction: Epidemiological studies have shown that women of all ages experience a transient increase in the risk of developing breast cancer following pregnancy. Furthermore, breast cancers detected soon after a completed pregnancy have a worse prognosis than those detected at more distant intervals. One explanatory hypothesis supported by animal studies suggests that molecular events associated with mammary gland involution, namely inflammation, extracellular matrix (ECM) remodeling and angiogenesis stimulate growth and metastasis (Schedin, P., Nat Rev Cancer 2006). Since no equivalent research has been done on human tissues, the present study compares the expression of a panel of genes in non-malignant human breast tissue obtained from nulliparous and recently pregnant women.
 Patients and Methods: Women ≤ 45 years of age who had undergone reduction mammoplasty or a negative excision biopsy were eligible for the study, and were categorized as either nulliparous or pregnant within 2 years. Twenty nulliparous and 13 patients with recent pregnancy (<2 years) were identified. Lobular structures were isolated from formalin-fixed paraffin embedded tissues using LCM, followed by RNA extraction and cDNA synthesis. Genes of interest were preamplified linearly, followed by real time PCR. We chose 59 genes involved in the processes of inflammation, ECM remodeling or angiogenesis. A small number of breast cancer prognostic genes were also included. We compared gene expression between patient groups using 2-way ANOVA controlling for sample type and the average linkage method for unsupervised clustering.
 Results: Clustering analysis failed to show evidence for coordinated upregulation of these genes in the recent pregnancy group. However, 11 genes were differentially regulated between the two groups at the P< 0.05 level. Notably, two immunoglobulin genes, IGKC and IGHA1, were overexpressed and the collagen gene COL1A1 was repressed in the recent pregnancy group, in agreement with published animal studies. Interestingly, expression of ERα, PR and Her2/neu was relatively repressed in recently pregnant subjects, whereas ERβ was upregulated.
 Conclusions: This is the first report to address a novel potential mechanism for pregnancy-associated breast cancer (PABC) by examining gene expression in human breast tissues. Evidence for differential expression of a number of genes involved in inflammation/ECM in recently pregnant vs. nulliparous women is consistent with the hypothesis that these processes might contribute to the etiology or progression of PABC. However, repression of ERα, PR, and Her2/neu and upregulation of ERβ following pregnancy supports the reported protective effect of pregnancy against breast cancer. We are expanding the number of patients, including a group with a longer interval after pregnancy and also comparing gene expression in breast cancers from nulliparous vs. recently pregnant patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5038.

Elevated protein kinase C alpha expression may be predictive of tamoxifen treatment failure

We previously reported that stable transfection of protein kinase C alpha (PKCalpha) into T47D human breast cancer cells results in tamoxifen (TAM)-resistant tumour growth. Relevance of PKCalpha expression in clinical specimens was determined by comparing PKCalpha expression in tumours from patients exhibiting disease recurrence with patients remaining disease-free following TAM treatment. Our results suggest that PKCalpha expression may predict TAM treatment failure.

Novel antitumor effect of estradiol in athymic mice injected with a T47D breast cancer cell line overexpressing protein kinase Calpha

PURPOSE

Resistance to tamoxifen (TAM) represents a significant challenge to the management of breast cancer. We previously reported that the estrogen receptor (ER)-negative hormone-independent T47D:C42 cell line has both elevated protein kinase Calpha (PKCalpha) protein expression and basal activator protein-1 activity compared with the parental ER+ (hormone-dependent) T47D:A18 cell line. Stable transfection of PKCalpha to the T47D:A18 breast cancer cell line results in increased basal activator protein-1 activity, reduced ER function, increased proliferation rate, and hormone-independent growth (Tonetti et al., Br. J. Cancer, 83: 782-791, 2000). In this report, we further characterize the role of PKCalpha overexpression in vivo to elucidate a possible molecular mechanism of tamoxifen resistance.

EXPERIMENTAL DESIGN

To determine whether the T47D:A18/PKCalpha cell line would produce hormone-independent tumors in athymic mice, we injected T47D:A18, T47D:A18/neo, or the T47D:A18/PKCalpha20 cell clones bilaterally into the mammary fat pads of athymic mice. Tumor growth was evaluated following treatment with estradiol (E2), TAM, and the pure antiestrogen, ICI 182,780.

RESULTS

Mice receiving either T47D:A18 or T47D:A18/neo cells produced tumors that grew in response to E2 treatment, whereas the untreated control and TAM-treated groups showed no tumor growth. Interestingly, mice receiving the T47D:A18/PKCalpha20 clone produced tumors in both the control and TAM groups, whereas tumor growth was inhibited in mice treated with E2. PKCalpha was also overexpressed in an MCF-7 tumor model that also exhibited TAM-stimulated and E2-induced regression.

CONCLUSIONS

These results suggest that overexpression of PKCalpha in breast tumors results in hormone-independent tumor growth that cannot be inhibited by TAM treatment. Furthermore, the finding that E2 has an antitumor effect on breast tumors overexpressing PKCalpha is a novel observation that may have important therapeutic implications.

Protein Kinase C Alpha Expression Is Inversely Related to ER Status in Endometrial Carcinoma: Possible Role in AP-1-Mediated Proliferation of ER-Negative Endometrial Cancer

OBJECTIVE

Tamoxifen is the most widely used antiestrogen to treat all stages of estrogen-receptor (ER)-positive breast cancers. However, tamoxifen acts as a partial estrogen in the uterus and is known to increase the risk of endometrial cancer by two- to threefold. Recent evidence indicates that there is a connection between tamoxifen resistance and activation of the activator protein-1 (AP-1) pathway. We have previously reported a possible role for overexpression of protein kinase C alpha (PKCalpha), an upstream activator of the AP-1 pathway, in hormone-independent breast cancer and antiestrogen-stimulated endometrial tumors. We hypothesize that alterations of the PKC isozyme profile of endometrial carcinomas are similar to that of hormone-independent breast cancer and determine whether specific PKC isozyme alterations correlated with known clinicopathological features of endometrial cancer.

METHODS

The PKC isozyme profile of endometrial carcinomas from 42 patients who were not previously exposed to antiestrogens was examined by Western blot. The relationship between PKC isozyme expression and key prognostic factors for endometrial carcinoma including hormone receptor status, tumor grade, stage, size, and depth of myometrial invasion was examined using the Spearman's rho correlation coefficient.

RESULTS

As previously found in breast cancers, PKCalpha and estrogen receptor alpha (ERalpha) expression are inversely related (r(s) = -0.35, P = 0.046). We report significant inverse correlations among ER/progesterone receptor (PR) expression and tumor grade (r(s) = -0.49, P = 0.001 and r(s) = -0.44, P = 0.004, respectively), ER, and depth of myometrial invasion (r(s) = -0.40, P = 0.009). There were no other significant correlations between PKC isozyme expression and other key prognostic factors examined.

CONCLUSION

This study indicates that, similar to what was previously observed in breast cancer, PKCalpha and ER expression is inversely related in endometrial cancer. PKCalpha expression may be a useful prognostic indicator in endometrial cancers. A model is offered which describes the putative role of PKCalpha overexpression in activation of the AP-1 pathway and increased proliferation of ER negative endometrial cancers.

Stable transfection of protein kinase C alpha cDNA in hormone-dependent breast cancer cell lines

An inverse relationship between protein kinase C (PKC) activity and oestrogen receptor (ER) expression in human breast cell lines and tumours has been firmly established over the past 10 years. To determine whether specific alterations in PKC expression accompany hormone-independence, we examined the expression of PKC isozymes in the hormone-independent human breast cancer cell clones MCF-7 5C and T47D:C42 compared with their hormone-dependent counterparts, MCF-7 A4, MCF-7 WS8 and T47D:A18 respectively. Both hormone-independent cell clones exhibit elevated PKC alpha expression and increased basal AP-1 activity compared with the hormone-dependent cell clones. To determine whether PKC alpha overexpression is sufficient to mediate the hormone-independent phenotype, we stably transfected an expression plasmid containing PKC alpha cDNA to the T47D:A18 and MCF-7 A4 cell lines. This is the first report of PKC alpha transfection in T47D cells. In contrast to MCF-7 cells, T47D has the propensity to lose the ER and more readily forms tamoxifen-stimulated tumours in athymic mice. We find that in T47D:A18/PKC alpha clones, there is concomitant up-regulation of PKC beta I and delta, whereas in the MCF-7 A4/PKC alpha transfectants PKC epsilon is up-regulated. In T47D:A18, but not in MCF-7 A4, PKC alpha stable transfection is accompanied by down-regulation of ER function whilst basal AP-1 activity is elevated. Our results suggest PKC alpha overexpression may play a role in growth signalling during the shift from hormone dependent to hormone-independent breast cancers.

The estrogen receptor: a logical target for the prevention of breast cancer with antiestrogens

A strategy for the prevention of breast cancer has been refined over the last century beginning with the first observation that oophorectomy caused disease regression in some patients, to the identification of the estrogen receptor some 60 years later, and finally to the synthesis of the first nonsteroidal antiestrogen. Tamoxifen was the first clinically useful antiestrogen and has been used for the treatment of breast cancer for the last twenty-one years in the United States. It is therefore a logical progression that antiestrogens are now recognized as useful agents for the prevention of breast cancer. We will discuss the estrogen receptor as a target for the treatment and now the prevention of breast cancer. Data from the National Surgical and Bowel Project (NSABP)4 tamoxifen prevention trial will be discussed with the preliminary results of two other European studies. The status of breast cancer prevention to date involves the comparison of the current standard of prevention, tamoxifen, with the osteoporosis prevention drug, raloxifene in an ongoing trial called Study of Tamoxifen and Raloxifene (STAR).

The interaction of raloxifene and the active metabolite of the antiestrogen EM-800 (SC 5705) with the human estrogen receptor

A naturally occurring mutation at amino acid 351 (D351Y) in the human estrogen receptor (ER) can change the pharmacology of antiestrogens. Raloxifene is converted from an antiestrogen to an estrogen, whereas the biological properties of the steroidal pure antiestrogen ICI 182,780 are not affected by the D351Y ER (Levenson, A. S., and Jordan, V. C. Cancer Res., 58: 1872-1875, 1998). We propose an assay system that can be used to classify antiestrogens by determining their ability to up-regulate transforming growth factor alpha (TGF-alpha) mRNA in MDA-MB-231 cells stably transfected with either wild-type or D351Y ER. The novel compound EM-800 and its active metabolite, EM-652, have been reported to be p.o. active nonsteroidal pure antiestrogens. Using the D351Y cell line, EM-652 is able to up-regulate TGF-alpha mRNA in a dose-dependent manner and to a similar extent as estradiol, whereas in the wild-type cell line, it acts as an antiestrogen. In addition, the pure antiestrogen ICI 182,780 is capable of inhibiting EM-652-induced TGF-alpha mRNA expression at the D351Y ER. In MCF-7 cells expressing wild-type ER, it has previously been shown that ICI 182,780 decreases ER only at the protein level. EM-652 treatment does not decrease ER protein levels to a similar extent as ICI 182,780 treatment, and, in addition, EM-652 has no effect on ER mRNA levels. In proliferation assays, EM-652 is as effective as raloxifene in inhibiting cell growth. From these studies, we conclude that the reason the pharmacology of EM-652 is similar to that of raloxifene is because they both fit the ER in the same manner, and their biology depends on an interaction of the antiestrogenic side chain with amino acid 351.

The oestrogen-like effect of 4-hydroxytamoxifen on induction of transforming growth factor alpha mRNA in MDA-MB-231 breast cancer cells stably expressing the oestrogen receptor

Oestrogens and antioestrogens modulate the synthesis of transforming growth factor alpha (TGF-alpha) in breast cancer cells. The purpose of the present report was to examine regulation of TGF-alpha gene expression by oestradiol (E2) and antioestrogens in MDA-MB-231 breast cancer cells transfected with either the wild-type or mutant oestrogen receptor (ER). We recently reported the concentration-dependent E2 stimulation of TGF-alpha mRNA in MDA-MB-231 ER transfectants (Levenson et al, 1997). We now report that 4-hydroxytamoxifen (4-OHT) shows oestrogen-like effects on the induction of TGF-alpha gene expression in our transfectants. Accumulation of TGF-alpha mRNA in response to both E2 and 4-OHT but not in response to the pure antioestrogen ICI 182,780 suggests that E2-ER and 4-OHT-ER complexes can bind to an oestrogen response element (ERE), located in the promoter region of the TGF-alpha gene and can activate transcription of the gene. Surprisingly, no activation of luciferase expression was observed after transient transfection of the TGF-alpha ERE/luciferase reporter constructs. Possible activation of an alternative ER-mediated pathway responsible for the regulation of TGF-alpha gene expression in the ER transfectants is discussed.

Antiestrogen stimulated human endometrial cancer growth: laboratory and clinical considerations

The new antiestrogen toremifene (TOR) is currently on the market for the treatment of advanced breast cancer in postmenopausal women. TOR is known to exhibit a similar efficacy profile as tamoxifen (TAM) in the treatment of advanced breast cancer and there are studies to suggest that the beneficial side effects of TAM on bone and blood lipids are also achieved with TOR. However, the data concerning the action of TOR on the endometrium is sorely lacking. In light of the estrogenic effect of TAM on the uterus and the 2-3-fold increased incidence in endometrial carcinoma detected in patients receiving TAM therapy, it is imperative to investigate the effect of TOR on endometrial carcinoma. We compared the actions of TAM and TOR on the EnCa101 human endometrial tumor model and find that both antiestrogens have similar growth stimulatory effects. To investigate a potential mechanism of antiestrogen-stimulated endometrial tumor growth, we have examined known activators of the AP-1 signal transduction pathway, the protein kinase C (PKC) family of isozymes, in the EnCa101 human endometrial tumor model. We find that increased PKC isozyme expression correlates with hormone-independent breast cancer as well as antiestrogen-stimulated endometrial cancer.

The role of estrogen receptor mutations in tamoxifen-stimulated breast cancer

During the past 20 years, the hormonal therapy of choice for the treatment of breast cancer has been the antiestrogen, tamoxifen. The use of tamoxifen has been proved to produce a favorable response and survival advantage in patients whose tumors are classified as estrogen receptor-positive (ER+)/progesterone receptor-positive (PR+). Additionally, tamoxifen is the only drug known to reduce the incidence of contralateral disease. This drug produces relatively few harmful side effects, while exhibiting several beneficial effects such as maintaining bone density and reducing the incidence of myocardial infarction in the postmenopausal woman. However, tumors eventually acquire a tamoxifen-resistant or tamoxifen-stimulated phenotype, resulting in disease recurrence. Several mechanisms have been proposed to account for tamoxifen-resistant breast cancer, in the hope of developing a more effective first-line or perhaps second-line treatment strategy. One popular theory is the occurrence of a mutation in the estrogen receptor, the drug target. A plethora of studies have reported the detection of estrogen receptor mRNA splice variants, and it has been suggested that the accumulation of these variant mRNAs are responsible for the development of tamoxifen-resistant breast cancer. In this review, several questions will be posed to address the suitability of both laboratory and clinical evidence to support this hypothesis. Although there is adequate data generated in the laboratory, there is, as yet, no compelling evidence to suggest that mutation of the estrogen receptor is the molecular mechanism producing tamoxifen-stimulated growth in human breast and endometrial cancer.

Targeted anti-estrogens to treat and prevent diseases in women

The estrogen receptor has been successfully targeted with the anti-estrogen tamoxifen to treat all stages of breast cancer. Because tamoxifen is a partial agonist, it exhibits target-site specificity: it acts as an anti-estrogen in the breast to inhibit tumor growth, while exhibiting estrogenic effects on bones and lipid metabolism. Therefore, tamoxifen has the added benefit of maintaining bone density and reducing the risk of myocardial infarction in postmenopausal women. However, undesirable side effects of tamoxifen preclude its use as a hormone replacement therapy for otherwise healthy women. New anti-estrogens are currently being developed that may prevent osteoporosis, breast and endometrial cancer, and reduce the risk of myocardial infarction.

Possible mechanisms in the emergence of tamoxifen-resistant breast cancer

Tamoxifen (TAM), a non-steroidal antiestrogen, is the endocrine treatment of choice for all stages of breast cancer. However, despite a favorable initial response to therapy, most tumors will eventually exhibit TAM resistance resulting in disease recurrence. Several mechanisms of TAM resistance have been proposed, yet a single distinct mechanism has not been identified. We will systematically consider the following steps of the estrogen receptor (ER)-mediated signal transduction pathway to identify possible sites of alteration leading to tamoxifen-resistance: (1) ligand metabolism and availability, (2) loss or mutation of the ER, (3) defects in ER post-translational modification, and (4) alteration of the estrogen response element (ERE). In particular, the ERE will be discussed as a position in the signal transduction pathway with considerable potential, if altered, to confer TAM resistance.

Protein kinase C-beta is required for macrophage differentiation of human HL-60 leukemia cells

The requirement for protein kinase C (PKC)-beta in phorbol 12-myristate 13-acetate (PMA)-induced macrophage differentiation of human HL-60 promyelocytic leukemia cells was studied by using the variant HL-525, which is deficient in PKC-beta and is resistant to PMA-induced differentiation. Transfecting these resistant HL-525 cells with expression vectors containing either PKC-beta I or PKC-beta II cDNA resulted in clones that displayed PKC-beta transcript levels similar to or higher than those of the parental HL-60 cells or cells from a PMA-susceptible HL-60 clone, HL-205. These productive transfectants also exhibited PMA-induced cell attachment and spreading, inhibition of cell replication, reactivity to the OKM1 monoclonal antibody, and the ability to phagocytize opsonized beads, which are all characteristic macrophage markers. No PMA-induced differentiation markers were observed in any of the PKC-beta I or PKC-beta II transfectants that did not exhibit an increased PKC-beta RNA level or in cells transfected with control plasmids. These results indicate that restoration of the PKC-beta isozyme deficiency by productive gene transfection causes HL-525 cells to revert to a phenotype like that of the parental HL-60 cells, which is characterized by susceptibility to PMA-induced macrophage differentiation. Therefore, we can conclude that PKC-beta is one of the essential elements in the PMA-induced signal transduction pathway which leads to macrophage differentiation in HL-60 cells and perhaps in other related cell types.

Protein kinase C beta gene expression is associated with susceptibility of human promyelocytic leukemia cells to phorbol ester-induced differentiation

To study the signal transduction pathway leading to phorbol 12-myristate 13-acetate (PMA)-induced differentiation in human promyelocytic HL-60 leukemia cells, we examined the expression of protein kinase C (PKC) isozyme genes in HL-60 cells that are susceptible or resistant to PMA-induced differentiation. The PKC-alpha, -beta, -gamma, -delta, epsilon, and -zeta transcript levels were assessed by Northern blotting, and the PKC-alpha, -beta, and -gamma protein levels were examined by immunoblotting. The PMA-resistant cell variants HL-525 and HL-534 were found to be deficient in the PKC-beta isozyme RNA and protein as compared with the PMA-susceptible HL-60 and HL-205 cell lines. In addition, a "delta-like" PKC RNA species identified in these cells demonstrated a reduced abundance in the HL-525 and HL-534 cells. Southern blot analysis indicated that the observed reduction in PKC-beta gene expression does not appear to be due to a gross deletion or rearrangement of the gene. The expression of the early response genes junB, c-fos, and c-jun was attenuated in PMA-treated HL-525 and HL-534 cells as compared to the PMA-treated HL-60 and HL-205 cells. These results suggest that the signal transduction pathway that leads to PMA-induced differentiation in the HL-60 cell system requires PKC-beta and/or delta-like PKC for the proper expression of the early response genes, and ultimately the expression of genes that define the mature state.

Maternal ethanol consumption: binding of L-glutamate to synaptic membranes from whole brain, cortices, and cerebella of offspring

We examined the influence of chronic maternal ethanol consumption on the Na+- and Ca2+-independent binding of L-glutamate to synaptic plasma membranes from whole brain as well as from cortices and cerebella of developing offspring. The maximum specific binding (Bmax) of L-glutamate to the Na+- and Ca2+-independent binding sites in synaptic plasma membranes of brain peaked at 17 days of age in the offspring of both control and ethanol-fed rats, although at that age there were significantly fewer binding sites in the brains of the offspring of ethanol-fed rats. The regional localization of this deficit is not now known. However, it appears that one major glutamatergic region (the cortex) does not reflect the transient deficiency of L-glutamate sites in brain. In fact, the concentration of L-glutamate binding sites in cortical synaptic plasma membranes was significantly increased in the 20-day-old offspring of ethanol-fed rats. In contrast to the cortex, binding to cerebellar synaptic plasma membranes was comparable in 20-day-old offspring of control and ethanol-fed rats. Despite transient alterations in the concentrations of L-glutamate binding sites in brain and synaptic plasma membranes, the affinity of the sites for L-glutamate (Kd) was consistently normal in the 14- to 26-day-old offspring of ethanol-fed rats.

Preferential maternal derivation in inv dup(15): analysis of eight new cases

Eight patients are reported with a de novo extra inverted duplicated chromosome 15. The abnormal chromosome was considered to be the same in all cases, but its precise delineation remained uncertain and was defined as either 15pter leads to 15q12::15q12 leads to 15pter or 15pter leads to 15q11::15q13 leads to 15pter. Analysis with various techniques of the satellite regions of the bisatellited chromosomes demonstrated maternal derivation in six and paternal derivation in one of the seven families. A non-sister chromatid exchange between the two homologous chromosomes 15 is considered a likely origin of the inv dup(15) in the cases with maternal derivation; in the only case of paternal derivation, however, the abnormal chromosome originated from one single chromosome 15. The clinical findings confirm that patients with inv dup(15) have mental and developmental retardation and are frequently affected by seizures, while severe physical malformations are absent.