Abstract P2-12-14: Therapeutic mammoplasty reduces high incomplete excision rate in lobular cancer

Introduction: Incomplete excision rate for lobular cancer is much higher compared to other types of breast cancer, since lobular cancer is frequently occult on imaging. This, and the inability to downstage lobular cancer with neoadjuvant therapy lead to the highest mastectomy rate of all subtypes. Here, we investigated the association between histopathological characteristics and incomplete excision as well as mastectomy rates.

Further, we investigated whether the application of level 2 therapeutic mammoplasty (TM) would extend the indication for conservation with lobular cancers.

Methods: Data of 1389 consecutive patients underwent surgery for (non)invasive breast cancer between January 2008 and June 2012 was analysed. Pathological and preoperative radiological results were analysed in the context of final surgery and tumour excision margins. Statistical significance was calculated using Chi-square, Mann-Whitney and Z-tests with a significance<0.05.

Results: Overall incomplete excision rate was 13.74% (131/953), and mastectomy rate was 35.35% (491/1389). Higher incomplete excision and mastectomy rates were strongly associated with lobular subtype (IE: 26.03% (19/73)); M: 51.22% (63/123); p<0.01 vs. other subtypes), node positivity (IE: 25% (36/144) vs. 10.43% (68/652); p=0 and M: 60.69% (193/318) vs. 25.65% (216/842); p=0) and tumour size (IE:T3 80% (4/5) vs. T2 22.51% (43/191) vs. T1 9.23% (55/596); all p<0.01; and M: T3 95.35% (41/43) vs. 59.46% (242/407) vs. 16.16% (112/693); all p=0). Incomplete excision rates were independent of hormonal and HER-2 expressions (ER+: 12.55% (89/709) vs. ER-: 16.67% (15/90); p=0.27 and HER2 neg.: 12.67% (91/718) vs. HER2 pos.: 16.67% (13/78); p=0.32) and it was just higher in grade 2 and 3 cancers (14.6% (60/411); p=0.037 and 16.22% (36/222); p=0.021 vs. G1:6.86% (7/102). However, hormonal and HER-2 expressions as well as tumour grade were in strong association with mastectomy rate (ER pos.: 33.28% (335/1007) vs. ER neg.: 48.75% (78/160); p<0.01; HER2 neg.: 33.43% (341/1020) vs. HER2 pos.: 49.65% (71/143); p<0.01; G3: 50.49% (205/406) vs. G2: 30.77%(172/559) vs. G1: 14.28% (17/119); all p=0).

135 patients underwent surgery for lobular cancer (simple wide excision: 66; TM:19; mastectomy: 50). TM was offered for significantly larger tumours than lumpectomy (28.29mm (10-62) vs. 19.96mm(5-57);p<0.01; vs. mastectomy: 37.56 mm(5-110);p=0.096). Incomplete margins were found with significantly smaller tumours when lumpectomy was applied compared to TM(25.94 mm(6-56) vs. 38.6 mm(30-45);p=0.031). Conservation was achieved with significantly bigger tumours when TM was used (25.46mm (10-62) vs. 17.66mm (5-57); p=0.032). Multifocality, however, significantly increased the chance for incomplete excision even after TM (4/7; p=0.019).

Conclusion: Higher incomplete excision rate is strongly associated with lobular subtype, node positivity and tumour size, but independent of hormonal end HER-2 expression, while tumour grade is not a strong predictor. All histopathological characteristics are strong predictors of final mastectomy rate. Using TM, breast conservation can be achieved for significantly larger lobular cancers, and incomplete excision rate decreased in smaller cancers, which are routinely treated with wide excision.

Citation Format: Romics L, Kabir SA, Mansell J, Mallon EA, Stallard S, Doughty JC. Therapeutic mammoplasty reduces high incomplete excision rate in lobular cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-14.

Abstract S4-06: HER2 status as predictive marker for AI vs Tam benefit: A TRANS-AIOG meta-analysis of 12129 patients from ATAC, BIG 1-98 and TEAM with centrally determined HER2

There is now significant evidence emerging from the pivotal trials of AIs versus Tamoxifen (AIOG) demonstrating the value of meta-analysis of key clinical questions. The "Trans-AIOG" group has been tasked with the exploration of key molecular/biomarker questions that are pertinent to meta-analyses of biomarkers (past/present/future) in AIOG trials. HER2 has been long proposed as a marker of endocrine "resistance". Data from three trials, before the era of HER-directed therapy, suggest a potential role for HER2 to select patients for treatment with upfront AIs. However the individual trials lack power to test treatment-by-HER2 interaction due to sample size and low HER2+ve rates. A meta-analysis of the predictive value of HER2 status, specifically within the first 3 years of endocrine therapy, has the potential to inform patient selection for upfront or sequential strategies with AIs. The pre-existing standardization of methodology for HER2 (IHC/FISH) facilitates analysis of existing data from BIG-1-98, TEAM and ATAC for this key marker.

Analysis plan: Following a prospectively-designed analysis plan, patient-level data from 3 randomized phase III trials (ATAC, BIG 1-98, TEAM) comparing AIs to tamoxifen during the first 2-3 years of adjuvant treatment were collected at the CRCTU (Birmingham UK), accounting for both the established time-dependency of relapse in HER2+ve, anti-endocrine treated patients and to address the clinical question of "upfront" vs "sequential" strategies for AIs. For each trial, covariate-adjusted Cox models estimated HER2-by-treatment (AI vs Tam) interaction on distant recurrence-free interval-censored at 2-2.75 years follow-up. A meta-analysis of the HER2-by-treatment interaction terms and of treatment effects according to HER2 status was performed.

Results: 12129 patients with centrally-confirmed ER and HER2 status, 1092 (9%) HER2+ve, with 473 (4%; 111 among HER2+ve) distant recurrences were analyzed. The meta-analysis estimated a pooled HER2-by-treatment interaction of 1.61 (95% CI 1.01,2.57), reflecting treatment effect hazard ratio(AI/Tam) of HR=1.13 (0.75,1.71) among HER2+ve and HR=0.70 (0.56,0.87) among HER2-ve. There was heterogeneity among interaction terms (I-squared=59%, p=.09) that resulted from treatment effect heterogeneity among HER2+ve subgroup (I2=71%, p=.03), not the HER2-ve subgroup (I2=0%). The results for disease-free survival were similar.

Conclusion: An individual patient data meta-analysis across 3 trials (ATAC, BIG 1-98, TEAM) conducted prior to standard use of HER2-directed adjuvant therapy demonstrated a marginally-significant interaction between HER2 status and treatment with AIs vs Tamoxifen in the 2-2.75 years prior to potential "switching" between Tamoxifen and AIs. Patients with HER2-ve cancers experienced improved outcomes when treated with AIs vs Tamoxifen whilst patients with HER+ve cancers fared no better, or slightly worse, during AI treatment. However, the small number of HER2+ve cancers and events even in this meta-analysis may explain a large degree of heterogeneity in the treatment effects within the HER2+ve subgroups across the 3 trials. Other causes, perhaps related to subtle differences between AIs, cannot be excluded.

Citation Format: Bartlett JMS, Ahmed I, Regan MM, Sestak I, Mallon EA, Dell'Orto P, Thürlimann BJK, Seynaeve C, Putter H, Brookes CL, Forbes JF, Colleoni MA, Bayani J, van de Velde CJH, Viale G, Cuzick J, Dowsett M, Rea DW, On Behalf of the Translational Aromatase Inhibitor Overview Group (Trans-AIOG). HER2 status as predictive marker for AI vs Tam benefit: A TRANS-AIOG meta-analysis of 12129 patients from ATAC, BIG 1-98 and TEAM with centrally determined HER2. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S4-06.

An International Multicenter Review of the Malignancy Rate of Excised Papillomatous Breast Lesions

BACKGROUND

Papillary lesions of the breast are a relatively rare, but heterogeneous group ranging from benign to atypical and malignant. Debate exists regarding the optimal management of these lesions. In the absence of more accurate risk-stratification models, traditional management guidelines recommend surgical excision, despite the majority of lesions proving benign. This study sought to determine the rate of malignancy in excised breast papillomas and to elucidate whether there exists a population in which surgical excision may be unnecessary.

METHODS

A multicenter international retrospective review of core biopsy diagnosed breast papillomas and papillary lesions was performed between 2009 and 2013, following institutional ethical approval. Patient demographics, histopathological, and radiological findings were recorded. All data was tabulated, and statistical analysis performed using Stata.

RESULTS

A total of 238 patients were included in the final analysis. The age profile of those with benign pathology was significantly younger than those with malignant pathology (p < 0.001). Atypia on core needle biopsy was significantly associated with a final pathological diagnosis of malignancy (OR = 2.73). The upgrade rate from benign core needle biopsy to malignancy on the final pathological sample was 14.4 %; however, only 3.7 % had invasive cancer.

CONCLUSIONS

This international dataset is one of the largest in the published literature relating to breast papillomas. The overall risk of malignancy is significantly associated with older age and the presence of atypia on core needle biopsy. It may be possible to stratify higher-risk patients according to age and core needle biopsy findings, thereby avoiding surgery on low-risk patients.

Do type 1 receptor tyrosine kinases inform treatment choice? A prospectively planned analysis of the TEAM trial

BACKGROUND

Epidermal growth factor receptors contribute to breast cancer relapse during endocrine therapy. Substitution of aromatase inhibitors (AIs) may improve outcomes in HER-positive cancers.

METHODS

Tissue microarrays were constructed. Quantitative analysis of HER1, HER2, and HER3 was performed. Data were analysed relative to disease-free survival and treatment using outcomes at 2.75 and 6.5 years.

RESULTS

Among 4541 eligible samples, 4225 (93%) had complete HER1-3 data. Overall, 5% were HER1-positive, 13% HER2-positive, and 21% HER3-positive; 32% (n=1351) overexpressed at least one HER receptor. In the HER1-3-negative subgroup, the hazard ratio (HR) for upfront exemestane vs tamoxifen at 2.75 years was 0.67 (95% confidence interval (CI), 0.52-0.87), in the HER1-3-positive subgroup, the HR was 1.15 (95% CI, 0.85-1.56). A prospectively planned treatment-by-marker analysis demonstrated a significant interaction between HER1-3 and treatment at 2.75 years (HR=0.58; 95% CI, 0.39-0.87; P=0.008), as confirmed by multivariate regression analysis adjusting for prognostic factors (HR=0.55; 95% CI, 0.36-0.85; P=0.005). This effect was time dependent.

CONCLUSION

In the 2.75 years prior to switching patients initially treated with tamoxifen to exemestane, a significant treatment-by-marker effect exists between AI/tamoxifen treatment and HER1-3 expression, suggesting HER expression could be used to select appropriate endocrine treatment at diagnosis to prevent or delay early relapses.

Ten-year follow-up of skin-sparing mastectomy followed by immediate breast reconstruction

BACKGROUND

The oncological safety of skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is debated owing to a presumed compromise in the completeness of mastectomy. Current evidence is poor as it is based mostly on short-term follow-up data from highly selected patients.

METHODS

A prospectively maintained institutional database was searched to identify patients who underwent SSM and IBR between 1995 and 2000. A retrospective review of medical records was carried out, including only patients with ductal carcinoma in situ and invasive breast cancer. During this time all patients treated with mastectomy were offered IBR regardless of tumour stage.

RESULTS

Follow-up data from 253 consecutive patients with IBR were reviewed. Patients with incomplete follow-up data and those undergoing SSM for recurrent disease following previous lumpectomy were disregarded, leaving 207 for analysis. Offering IBR to all women requiring mastectomy resulted in a large proportion of patients with advanced disease. During a median follow-up of 119 months, 17 (8·2 per cent) locoregional, six (2·9 per cent) local and 22 (10·6 per cent) distant recurrences were detected; the overall recurrence rate was 39 (18·8 per cent). Overall recurrence rate was associated with axillary lymph node metastasis (P = 0·009), higher stage (P < 0·001) and higher tumour grade (P = 0·031). The breast cancer-specific survival rate was 90·8 per cent (19 of 207 women died from recurrence).

CONCLUSION

Based on these long-term follow-up data, SSM combined with IBR is an oncologically safe treatment option regardless of tumour stage.

P1-12-05: Complete Pathological Response of Ductal Carcinoma In Situ after Treatment with Neoadjuvant Herceptin

Introduction: The introduction of neo-adjuvant herceptin has led to pathological complete response rates of up to 60% in patients with breast cancer. The traditional (NSABP) definition of pathological complete response includes cases demonstrating residual DCIS and little is known about the effects of neo-adjuvant herceptin in this situation. Current evidence suggests that DCIS is chemo-resistant, but it has also been shown that DCIS is more likely to be HER-2 positive than primary cancer.

Results: We describe six patients who received neo-adjuvant chemotherapy and herceptin for biopsy-proven, node-positive, large breast cancers either with an extensive component of concomitant DCIS or a separate DCIS focus. Neo-adjuvant treatment did not result in any changes in the pattern of mammographic calcification seen pre-operatively (Figure 1 a-c), however histopathology of all six specimens showed ductal spaces containing macrophages and calcification but no residual lining epithelium, features consistent with pathological complete response of the DCIS component (Figure 1d). Figure 1: Pathologically complete response of DCIS after neo-adjuvant treatment with herceptin. (a) Pre-treatment mammogram (b) Post neo-adjuvant chemotherapy and herceptin mammogram showing resolution of the mass effect of the primary cancer and unchanged residual mammographic calcification associated with the extensive DCIS component (c) Wire-localised specimen demonstrating excision of calcification (d) Histopathology of the same specimen showing calcium-filled ducts and no residual lining epithelium. Discussion: In conclusion, neo-adjuvant herceptin is associated with complete pathological response of both breast cancer and DCIS. The presence of unchanged persistent mammographic calcification in known regions of DCIS after treatment complicates any role of mammographic surveillance in this group and raises the question of optimal surgical management in the future management of these individuals.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-12-05.

Abstract P6-08-10: Disease Specific Survival of Breast Cancer Patients Is Not Associated with Expression of Inactive or Even Partially Activated Src Kinase

Background: c-Src is implicated as a regulator of cell proliferation and survival (1). Recent work has demonstrated that c-Src and fully activated Y419Src expression in breast cancer specimens was associated with poor clinical outcome of breast cancer patients (2). c-Src is activated by a number of pathways. Known as the classical activation pathway, dephosphorylation of Y530 is needed to initiate a configuration change of the protein allowing full activation by autophosphorylation of tyrosine site 419. Phosphorylation of the tyrosine residual 530 on the c-terminal tail by Csk tyrosine kinase acts as a negative regulatory protein binding site, keeping Src kinase in a closed confirmation (3).

The aim of this translational study was to assess associations between inactivate and partially activated Src expression to clinic-pathological features of the cohort and if different stages of c-Src activation equally influences breast cancer patients’ disease specific survival. Methods: Tissue microarray technology was used to analyse tissue taken from 165 breast cancer patients taken at time of surgical resection. Immunohistochemistry was performed using anti-Clone 28 and Clone 28 antibody. To investigate those different stages of Src kinase activation, Clone 28 antibody was employed to recognise the semi-active form of Src. To evaluate protein expression of inactive Src kinase, anti-Src family negative regulatory [pY] site (anti-Clone 28= AC28) antibody was utilised for detecting phosphorylated tyrosine site 530. Expression was assessed using the weighted histoscore method by two independent scorers. Results: Using those antibodies, 50% of AC28 and Clone28 expression was observed in the nucleus and 44% AC28 and 46% Clone28 expression in the cytoplasm. Only 3.6% of AC28 was detected in the membrane, compared to Clone28 with 53% in the membrane and 55 % perinuclear. Nuclear expression of AC28 correlated negatively with ER status (chi square P&lt;0.001), whereas cytoplasmic AC28 and Clone28 correlated negatively with membrane c-Src expression (chi square p=0.008, chi square P&lt;0.001). On univariate and multivariate analysis there was no significant association noticed between AC28 and Clone28 expression and disease specific survival at any cellular location.

Conclusions: ER negative breast cancers patients were more likely to express inactive Src in the nucleus. Breast cancer patients with higher cytoplasmic expression of inactive or partially activated Src were more likely not to express c-Src at the membrane (site of activation). Inactive and partially activated Src are not associated with patients’ survival. References:

1) Frame MC. Biochim Biophys Acta 2002; 1602: 114-130.

2) Elsberger B, et. al: Am J Path (2009);175(4):1389-97.

3) Roskoski R Jr. Biochem Biophys Res Commun. 2005 May 27;331(1):1- 14.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-08-10.

Abstract P3-10-04: An Integration of Biological and Pathological Marker Panel in the TEAM Pathology Sub-Study: The Impact of Different Parameters on Risk Estimation of Relapse at Both 2.75 and 5 Years

Background: Recent evidence confirms the importance of both biological and pathological risk markers in predicting early relapse for breast cancer patients treated with endocrine therapy. Most studies use a two step process integrating biological markers into a “biological predictor (e.g. Oncotype Dx, “IHC4” etc) followed by assessment of the predictive value of such tests in the context of pathological markers (grade, nodal status etc). We have taken a one step process integrating both biological and pathological markers into a single model to assess key factors for predicting outcome at 2.75 years and 5 years of endocrine therapy; to inform choices between switching, upfront and extended adjuvant treatment with AIs. Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative analysis ER, PgR, Ki67, HER1, HER2, and HER3 was performed centrally. A prognostic model, integrating data from biological and pathological markers was created to assess risk (disease-free survival) after 2.75 and 5 years of follow up in the TEAM trial.

Results: Of 4595 eligible cases samples received, 16 were excluded, and 3993 had complete biomarker data for all markers for the final biomarker analysis. In univariate analysis nodal status, grade, size, age at diagnosis, HER1, HER2, PgR, ER and Ki67 were all prognostic. At 2.75 years nodal status, age, PgR histoscore, size, grade, HER2, ER histoscore and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), Ki67 and HER3 were not included in this model. At 5 years median follow up; age, nodal status, size, PgR histoscore, grade, Ki67, HER2, and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), ER and HER3 were not included in this model. Conclusion: Combined biological and pathological marker panels are of significant value in predicting early relapse in breast cancer patients treated with endocrine therapy, however duration of follow-up may impact on the inclusion of variables in the model. This provides significant information relevant to the choice of different adjuvant endocrine therapies.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-04.

Abstract P6-08-06: C-Reactive Protein Expression and Its Association with Disease Specific Survival and Disease Recurrence in ER Negative Breast Cancer Patients

Background: The systemic inflammatory response, as evidenced by elevated serum C-reactive protein (CRP) has been reported to be predictive of poor survival, independent of tumour stage, in a variety of solid tumours (1). Previous studies suggest that systemic elevated serum CRP did not predict relapse-free, cancer-specific (DSS) nor overall survival (2). Aim of this study was to examine the relationship between expression of CRP within ER negative breast cancers and patients’ clinical outcome. Methods: Tissue microarray technology was employed to analyse tissue taken from 171 ER negative breast cancer patients at time of surgery. Immunohistochemistry was performed using an antibody to CRP. Expression was assessed using the weighted histoscore method by two independent scorers.

Results: Cohort's median age was 56 years and tumour size was 20mm, 22% were pathologically graded G2 and 74% G3 and 46% were lymph node positive. 60% underwent a mastectomy, 56% received radiotherapy and 67% chemotherapy. 33% had recurrence after a median time of 5.6 years. 47/171 patient were deceased at time of analysis. There was a definitive trend noticed between high nuclear and cytoplasmic CRP expression and DSS (p=0.078 and p=0.173, figure 1a and 1b) and recurrence (p=0.133, p=0.253, figure 2a and 2b). There was a significant association seen with high CRP expression in the surrounding tumoural stroma and DSS (p=0.007) as well as recurrence (p=0.016). Conclusion: Due to small patient numbers only trends indicating that high CRP expression within and surrounding the tumour play an important role in ER negative patients regards poorer survival and earlier recurrence. We are currently expanding our cohort further. References:

(1) Roxburgh CSD (2009). Future Oncol. 2010 Jan;6(1):149-63

(2) Al Murri AM (2007) British Journal of Cancer, 96, 891-895 Figure available in online version.

Is the biology of breast cancer changing? A study of hormone receptor status 1984-1986 and 1996-1997

Using archived tumours, those from 1984–1986 and 1996–1997 underwent immunohistochemistry for hormone receptors and grade analysis. A significant shift towards more ER-positive and low-grade disease was found; this appears to reflect screening practices, but could still influence survival.

Determination of HER2 amplification by in situ hybridization: when should chromosome 17 also be determined?

Abstract #3002

Introduction: Aberrations of chromosome 17 (aneusomy) are common in breast cancer and therefore have a critical impact on the assessment and reporting of HER2 gene amplification in a significant sub-set of cases. There is an ongoing debate as to the proportion of cases for which assessment of chromosome 17 copy number may be important. According to current guidelines1,2, amplification of HER2 is considered to be a HER2/chromosome 17 ratio ≥2.0 and a ratio &lt;2.0 is regarded as non-amplified. For HER2 gene copy number assays, it has been assumed that copy numbers of &gt;6.0 reflect amplification and a result of &lt;4.0 HER2 gene copies per nucleus is always associated with lack of amplification; cases with 4-6 copies per cell are thought to require validation by testing of a parallel section for chromosome 171,2. To our knowledge, this assumption has not been verified experimentally.&#x2028; Methods: HER2 and chromosome 17 were measured by dual color FISH in 1711 breast cancer samples referred to the authors laboratories between 2000-2008. Using HER2 copy number and chromosome 17 data the impact of chromosome 17 testing upon accuracy of diagnosis of gene amplification was assessed.&#x2028; Results: At a HER2 copy number of 2 to &lt;3, 16 of 488 cases (3.3%) had HER2 amplification; and at a copy number of 3 to &lt;4, 32 of 195 cases (16.4%) were amplified. The proportion of cases with HER2 amplification increased considerably at HER2 copy numbers of 4 to &lt;7: 50.0% at 4 to &lt;5; 67.5% at 5 to &lt;6, and 77.3% at 6 to &lt;7. Virtually all cases were amplified at HER2 copy numbers of ≥7.&#x2028; Conclusion: Werecommend that all cases with observed HER2 copy numbers of 2 to 7 should also be analyzed for chromosome 17 in order to accurately determine HER2 gene amplification. This would require analysis of chromosome 17 in 48.3% of all breast cancer cases based upon the study population. Current guidelines1,2 recommend chromosome 17 measurement only in cases with a HER2 copy number of 4 to &lt;6, which represents only 6.6% of all breast cancer cases in the current study. Although single color ISH is becoming more widely used with the availability of CISH, the importance of chromosome 17 measurement cannot be ignored. It is essential that HER2 testing is of high quality, so that optimal patient management can be provided.&#x2028; 1. Ellis IO, Bartlett J, Dowsett M et al: Updated recommendations for HER2 testing in the UK. J.Clin.Path. 57(3), 233-237 (2004).&#x2028; 2. Wolff AC, Hammond ME, Schwartz JN et al: American Society of Clinical Oncology/College of American Pathologists Guideline Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer. Journal of Clinical Oncology 25(1), 118-145 (2007).

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3002.

Is the biology of breast cancer changing? A study of hormone receptor status and grade of breast cancers 1984-1986 and 1996-97

Abstract #3088

Introduction: There has been a significant improvement in breast cancer survival in the UK in recent decades. Changes in the molecular epidemiology of breast cancers may have contributed to this, but the existing evidence may be confounded by heterogeneity of laboratory protocols. This study aimed to re-analyse the molecular profile of breast cancers from two different time periods using archived tissue. Methods: Archived tumour samples from all breast cancer patients at two Glasgow hospitals between 1984-86 and 1996-97 were sought, and linked to clinicopathologic, screening, demographic and survival data. Patients in the 1984-6 cohort would not have been offered mammographic screening but those in 1996-97 would have. Samples were placed in tissue microarrays and underwent immunohistochemistry for ER, PR and Her-2 status with strict standardisation. H&E sections were constructed to assess tumour grade. Statistical analysis included Kaplan-Meier survival analysis and Cox's regression. Results: 900 tumour samples underwent staining. In 1984-86, 8% of tumours were grade 1 and 42.9% grade 3 but in 1996-97 14.9% were grade 1 and 36.8% grade 3 (p=0.009). This effect appeared to be exerted by the presence of screen detected tumours in 1996-97 (p for difference in grade distribution between symptomatic patients between 1984-86 and 1996-97 = 2). In 1984-86 64.2% of tumours were ER positive and in 1996-97 71.5% were ER positive (p=0.042). This did not appear to be a function of the screening programme as there was a significant rise in ER positivity in symptomatic patients between the two cohorts (p=0.024). 44.9% of tumours in 1984-86 and 49.9% of tumours in 1996-97 were PR positive (p=0.181). 21.5% of tumours in 1984-86 and 20.6% of tumours in 1996-97 were Her-2 positive (p=0.772). 5-year survival in 1984-1986 patients was significantly lower than in 1996-1997 patients (p&lt;0.001). When the effect of cohort on survival was adjusted for these changes in ER status and grade, cohort remained a significant independent factor. Conclusions: This study suggests a small but significant rise has occurred in the incidence of ER positive tumours in women in Glasgow. There has also been a shift in grade distribution of tumours, which is likely to be an effect of the NHS screening programme. The changes do not fully explain improvements in breast cancer survival but should be borne in mind when applying the results of clinical trials performed in the past to the women of today.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3088.

Role of Src family members in breast cancer-dependent on site of phosphorylation

Abstract #2074

Background: In vitro work implicates c-Src in breast cancer. However there is little evidence to support this in clinical specimens. Activation of Src family members are associated with phosphorylation at two different tyrosine sites Y419: the classical activation site and Y215, known to induce a 50-fold increase in activation.&#x2028; We have analysed a cohort of human breast cancers to establish if expression levels of 2 Src family members (c-Src and Lyn) are associated with survival and whether this is dependent on site of activation.&#x2028; Methods: Tissue microarrays were constructed from 895 breast cancer tumors. Median follow up was 6 years with 229 breast cancer specific deaths. Immunohistochemistry was performed using antibodies to c-Src, Lyn, pSrc419 and pSrc215 (antibodies to Y419 and Y215 will detect phosphorylation of either c-Src and Lyn). Expression was assessed by two independent scorers. All statistical calculations were performed using SPSS 15.&#x2028; Results: Membrane expression of c-Src and Lyn was rarely observed. However, cytoplasmic expression of c-Src and Lyn was frequently observed and further results presented relate to this site. High expression levels of c-Src but not Lyn were associated with HER2 positivity (p=0.001) and ER negativity (p&lt;0.001).&#x2028; High c-Src expression was associated with a poor outcome. In direct contrast pSrc215 was associated with improved outcome on univariate and multivariate analysis.&#x2028; Antibodies to phosphorylation sites will detect both activated c-Src and Lyn (and other family members). The individual impact of phosphorylation on clinical outcome was determined by categorising expression based on overexpression of c-Src or Lyn in combination with activation at each site.&#x2028; &#x2028; Discussion: Our findings demonstrate that phosphorylation of c-Src at Y419 is associated with poor prognosis in breast cancer. In contrast phosphorylation at Y215 was independently associated with better outcome.&#x2028; Further work is ongoing to explore our hypothesis that:&#x2028; 1. phosphorylation at 215 'deactivates' c-Src or desensitizes downstream pathways or,&#x2028; 2. that activation of Lyn or other Src family members at 215 is responsible for good outcome.&#x2028; If confirmed, these results strongly suggest that commercial development of highly specific Src inhibitors is necessary and that these will require appropriate patient selection.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2074.

IHC for Her2 with CBE356 antibody is a more accurate predictor of Her2 gene amplification by FISH than HercepTest in breast carcinoma

BACKGROUND

Her2 (c-erbB-2/neu) overexpression in breast carcinoma predicts response to the anti-Her2 monoclonal antibody, trastuzumab, and is associated with a poor prognosis. When considering patients for trastuzumab treatment, Her2 protein expression is measured by imunohistochemistry (IHC) and, where staining is equivocal, by fluorescence in situ hybridisation (FISH) detection of Her2 gene amplification.

AIMS

To compare IHC using CBE356 with IHC using the Food and Drug Administration approved HercepTesttrade mark.

METHODS

CBE356 and HercepTest were analysed using 167 FISH characterised breast carcinomas. Immunohistochemical expression of Her2 was measured semiquantitatively. Sensitivity, specificity, predictive values, and overall accuracy were calculated for both IHC methods using gene amplification by FISH as the end point, and IHC and FISH assays were tested in Kaplan-Meier survival analysis.

RESULTS

The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CBE356 positive (2+ and 3+) cases were 94%, 89%, 95%, 84%, and 97%, respectively, and of HercepTest positive (2+ and 3+) cases were 91%, 66%, 98%, 92%, and 91%, respectively. A positive result with CBE356, HercepTest, or FISH was associated with significantly decreased overall survival (log rank p = 0.005, p = 0.0017, and p = 0.0005, respectively).

CONCLUSIONS

Positive IHC staining for Her2 using CBE356 is 3% more accurate and 23% more sensitive at predicting Her2 gene amplification by FISH than positive staining with HercepTest. Negative IHC using CBE356 antibody is 6% more likely to represent a truly negative result than negative staining with HercepTest. Overall, CBE356 was a more accurate predictor of Her2 gene amplification by FISH than HercepTest.

Adjuvant ovarian ablation vs CMF chemotherapy in premenopausal breast cancer patients: trial update and impact of immunohistochemical assessment of ER status

This trial, initiated in 1980, examined the relative values of adjuvant ovarian ablation and chemotherapy comprising cyclophosphamide, methotrexate and 5-fluorouracil (CMF) in premenopausal women with pathological stage II breast cancer. With median follow-up for patients still alive of 13.9 years, there is no difference in survival between women receiving ovarian ablation and CMF (hazard ratio 1.01; 95% CI: 0.74, 1.37). Tumour oestrogen receptor (ER) status was assessed at the time using biochemical ligand-binding assay and retrospectively by immunohistochemistry (IHC). Agreement between these two methods was only fair, but both confirmed the importance of ER status in determining appropriate adjuvant systemic therapy. A statistically significant interaction between IHC quick score and treatment (P=0.001) showed ovarian ablation was more beneficial for patients with a positive quick score, whereas women with a quick score of 0 had a significantly higher risk of death with ovarian ablation (2.33; 95% CI: 1.30, 4.20). We have shown that IHC identifies women with ER 'poor' tumours for whom endocrine manipulation is not appropriate.

Evaluating HER2 amplification and overexpression in breast cancer

The development of Herceptin (Trazumatab) makes testing for HER2 status important for choosing optimal therapy in breast cancer. This study addresses the precision, accuracy, and reproducibility of HER2 assays. HER2 was assessed retrospectively by immunohistochemistry (IHC) with Dako 'Herceptest', by IHC with the monoclonal antibody CB11, and by fluorescence in situ hybridization (FISH, PathVysion), in a series of 216 formalin-fixed breast carcinomas including 191 for which quantitative HER2 data from radioimmunohistochemistry (Q-IHC) were available. All tests were scored independently by two observers. Positivity rates varied between Herceptest (12.6%), FISH (19.4%), and CB11 IHC (28.5%). Kappa values showed that IHC-based tests were more susceptible to inter-observer variation (kappa=0.67 and 0.74 for Herceptest and CB11, respectively) than FISH (kappa=0.973). Overall test accuracy (see the Materials and methods section) for CB11 IHC (83.8%) was lower than Herceptest (87.4%) or FISH (93.2%). FISH predicted p185 HER2 overexpression (determined by Q-IHC) better (concordance index C.Ind. 0.90) than CB11 IHC (C.Ind.=0.85) or Herceptest (C.Ind.=0.81). Of 42 cases with gene amplification by FISH, 67% were positive in the Herceptest (2+ or 3+) vs. 83% with CB11. Of 174 cases negative by FISH, 96% were negative in the Herceptest and 68% with CB11. In conclusion, FISH is the most accurate, reproducible, and precise predictor of HER2 overexpression in routine diagnostic laboratories.

What the clinician needs from the pathologist: evidence-based reporting in breast cancer

Histopathology has a vital role in determining breast cancer management and pathologists must be part of the clinical team. Carcinoma size, grade, and especially lymph node status remain the best available prognostic factors. Metastatic carcinoma in axillary nodes is more important than any other prognostic factor presently available. ER status is an important predictor of response to endocrine manipulation, but its independent prognostic significance, and that of micrometastatic disease, circulating carcinoma cells and other molecular factors, even well-studied ones such as HER2 status, are less clear. Pathology is the first clinical speciality to subject its practice to rigorous scientific analysis, and it has stood up well. However, workers without appropriate experience in Pathology or scientific design have created difficulties by undertaking poorly planned studies with ill-defined end-points, lacking appropriate quality control. New analytical techniques and therapeutic targets make it essential that we learn from past mistakes and integrate pathologists into the research teams pursing clinical trials and the assessment of new bio-markers. Without this, input resource will be wasted on false leads that could have been curtailed. Morphology alone will not be enough to select patients likely to benefit in trials of new therapies, but selection 'tests' must be appropriate. The confusion of tests for selection of patients to receive Herceptin shows what happens when this process fails. Much of the microarray data being put into data-bases has no quality control, and meta-analysis of this data will produce even more conflict than the clinical trials. This can be avoided, as the ability to standardise is available.

Ductal carcinoma in situ of the breast -- among factors predicting for recurrence, distance from the nipple is important

AIMS

To assess local and systemic recurrence rates and factors predicting for recurrence in patients treated for ductal carcinoma of the breast (DCIS).

METHODS

Patients with DCIS treated between January 1986 and January 1997 were identified. All pathology specimens were reviewed. DCIS type, lesion size, nuclear grade and margin clearance were assessed. Mammograms were reviewed and mammographic patterns, size, type of lesion and distance from the nipple were measured. Treatments and subsequent outcomes were established by case note review. Factors predicting for recurrence were analysed by both univariant and multivariant analysis.

RESULTS

Of the 220 patients, 153 (70%) had breast-conserving surgery. Sixty-seven (30%) had a mastectomy. Ninety-seven patients had adjuvant therapy of which 22 had radiotherapy alone, 54 had tamoxifen alone and 21 had radiotherapy and tamoxifen. Following mastectomy, two patients developed axillary recurrences. Following breast-conserving surgery 20 (13%) patients developed local recurrences, of which one developed systemic disease and died from breast cancer.

CONCLUSIONS

Mammographic nipple to lesion distance of <40 mm and high/intermediate nuclear grade were the only factors found to increase the likelihood of recurrence.

Margin assessment by cavity shaving after breast-conserving surgery: analysis and follow-up of 543 patients

AIMS

To analyse cavity shaving as a method of assessing completeness of surgical excision after breast-conserving surgery.

METHODS

Shavings were taken from the wall of the cavity remaining in the breast after breast-conserving surgery in 543 women. Each shaving was extensively sectioned and the presence and type of microscopic disease recorded. Disease in cavity shavings (tumour bed positivity) was correlated with clinicopathological factors as well as overall survival.

RESULTS

Tumour bed positivity (TBP) was found in 37% of patients (16% with invasive disease). Patients were selected for further surgery according to the extent of positivity, which varied widely. A total of 15% of patients underwent re-excision or mastectomy. TBP was significantly associated with high tumour grade, presence of an extensive intraduct component, young age and large tumour diameter. It was also associated with a significantly shorter overall survival when compared to patients who were tumour bed negative.

CONCLUSIONS

Cavity shaving is a practical and sensitive method of assessing completeness of excision after breast-conserving surgery. In addition it may provide useful prognostic information.

Influence of tumour bed assessment on local recurrence following breast-conserving surgery for breast cancer

AIMS

To assess the impact of adopting a policy of tumour bed assessment with selective re-excision in patients undergoing breast-conserving surgery for breast cancer.

METHODS

Tumour bed assessment was introduced in our institution in 1988. Patients treated prior to 1988 (125 patients) were compared with patients treated post-1988 (239 patients) for clinico-pathological factors, surgical and adjuvant therapy. Outcome measures were examined at a fixed 5-year follow-up period for each patient.

RESULTS

There were a greater number of small, node-negative, oestrogen receptor tumours post-1988, probably due to the influence of the National Breast Screening Programme. There was also a difference in the prescription of adjuvant systemic therapy between the two cohorts. The incidence of tumour bed positivity was 30.5%. The re-excision rate was 16.4%. There was a significant fall in the incidence of local recurrence from pre-1988 (15.7%) to post-1988 (2.5%).

CONCLUSION

By adopting a policy of tumour bed assessment with selective re-excision, a low local recurrence rate has been achieved. The improvement in systemic recurrence and breast cancer-related death rate are mainly secondary to other factors.

Interphase cytogenetic analysis of erbB2 and topoII alpha co-amplification in invasive breast cancer and polysomy of chromosome 17 in ductal carcinoma in situ

Breast cancer is a genetically complex disease. Fluorescence in situ hybridisation can be used to analyse the genetics of breast-cancer progression in interphase cytogenetics. We have analysed the histological distribution of erbB2 and topoll alpha co-amplification in paraffin sections of invasive breast cancer and show that the co-amplified loci share the same histological distribution in the tumour and have a similar nuclear distribution within individual nuclei. Regions of the tumours without amplification are easily recognized and tumours with erbB2 and topoll alpha co-amplification can be distinguished from those with erbB2 amplification alone. In addition, FISH was used to show polysomy of chromosome 17 in non-invasive ductal carcinoma in situ of the breast and erbB2 amplification in both the invasive and non-invasive components of a breast cancer biopsy. This report of an interphase cytogenetic analysis of non-invasive breast carcinoma in situ demonstrates the usefulness of FISH for the genetic study of breast cancer progression.

Relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer

OBJECTIVE

To investigate the relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer as a possible explanation for socioeconomic differences in survival.

DESIGN

Retrospective analysis of data from cancer registry and from pathology and biochemistry records.

SETTING

Catchment areas of two large teaching hospitals in Glasgow.

SUBJECTS

1361 women aged under 75 who had breast cancer diagnosed between 1980 and 1987.

MAIN OUTCOME MEASURES

Tumour size, axillary lymph node status, histological grade, and oestrogen receptor concentration in relation to deprivation category of area of residence.

RESULTS

There was no significant relation between socioeconomic deprivation and four pathological prognostic factors: 93 (32%) women in the most affluent group presented with tumours less than 20 mm in size compared with 91 (31%) women in the most deprived group; 152 (48%) of the most affluent group presented with negative nodes compared with 129 (46%) of the most deprived group; 23 (22%) of the most affluent group presented with grade I tumours compared with 12 (17%) of the most deprived group; and 142 (51%) of the most affluent group had a low oestrogen receptor concentration at presentation compared with 148 (52%) of the most deprived group. None of these differences was statistically significant.

CONCLUSIONS

Differences in survival from breast cancer by socioeconomic deprivation category could not be accounted for by differences in tumour stage or biology. Other possible explanations, such as differences in treatment or in host response, should be investigated.

Nasal leishmaniasis

Leishmaniasis is an uncommon condition in Western Europe, except around the Mediterranean coast. However, it may occasionally be seen in the United Kingdom, in patients who acquired the infection in foreign lands. An unusual case of localized cutaneous leishmaniasis recidiva affecting the nose after septal surgery is presented.

Flow cytometric analysis of tumour infiltrating lymphocytes in breast cancer

In 31 patients with carcinoma of the breast the phenotype and activation status of tumour infiltrating lymphocytes (TILs) was analysed by flow cytometry. The predominant cells, in all patients, were T lymphocytes and in the majority of cases CD8+ (cytotoxic/suppressor) T lymphocytes were present in greater numbers than CD4+ (helper) T lymphocytes. There was no relationship between the degree of lymphocytic infiltration and either tumour stage or grade but there appeared to be an inverse correlation with the levels of oestrogen receptor (ER) in the tumour (P less than 0.01). Both populations of T cells had significantly higher numbers of cells carrying HLA DR (class II major histocompatibility antigen) than the equivalent populations in peripheral blood from the same patient group (P less than 0.001). The transferrin receptor was found on similar numbers of CD8+ T cells in peripheral blood and among the tumour infiltrating lymphocytes while more of the CD4+ T cells infiltrating the tumour were found to carry this receptor (P = 0.034). The Tac (CD 25) antigen was also on similar numbers of CD8+ T cells from both peripheral blood and the tumour but was on fewer of the CD4+ T cells in the tumour with respect to peripheral blood (P = 0.029). In both TILs and blood lymphocytes, the Tac antigen was consistently present on greater numbers of CD4+ T lymphocytes than on the CD8+ T lymphocytes (P less than 0.001) and as this is a component of the interleukin 2 (IL-2) receptor this may be of relevance to the use of IL-2 in TIL cancer therapy.

Semiquantitative analyses of fine needle aspirates from benign and malignant breast lesions

A scoring system for the assessment of fine needle aspirates of benign and malignant breast lesions was devised which showed a positive correlation (r = 0.67) between the scores obtained from the fine needle aspirates from ductal carcinomas and the Bloom and Richardson-type scores for their paired excision biopsy specimens. This system permitted grades II and III ductal breast carcinoma to be distinguished reliably from grade I tumours but no correlation with the lymph node state of patients with breast carcinoma was shown. Some overlap between the scores for grade I ductal carcinomas and some benign lesions was found, and this underlines a need for caution in the reporting of such equivocal aspirates. No cytological features that distinguished reliably ductal from lobular carcinoma were identified but the same spectrum of severity of cytological abnormality in the ductal and lobular carcinoma aspirates was seen. This system may be of prognostic value in the assessment of lobular carcinoma which has hitherto defied histological grading.

ANF (99-126) and its propeptide, ANF (1-16) are secreted simultaneously from the human atrial myocyte

We have raised antisera to two synthetic peptides representing different portions of the human pro-atrial natriuretic factor (ANF) molecule; one antiserum identifies active human ANF, the 28-amino-acid sequence on the C-terminal end of the prohormone [ANF (99-126)], and the other detects ANF (1-16), the first 16-amino-acid sequence at the N-terminal end of the prohormone. With ultrastructural immunocytochemistry we have studied the distribution staining for both peptides within the myocytes in surgically excised human auricular appendages. Most of the endocrine granules stained with equal density for both ANF (1-16) and ANF (99-126). Also, double immuno-staining techniques on the same tissue section showed that both the C-terminal peptide and the N-terminal peptide co-existed within the same endocrine granules. It has been shown that, like other endocrine cells, atrial myocytes secrete their stored peptides by exocytosis of their granules. Therefore, our observations suggest that both the main active hormone, ANF (99-126), and the N-terminal propeptide ANF (1-16) are secreted simultaneously from the cell.

Atrial natriuretic peptide in the heart and pancreas

We used antisera to pure atrial natriuretic peptide to localise this peptide by immunocytochemistry in rat and human tissue. We showed that both rat and human atrial cardiocytes gave a positive reaction while ventricular cardiocytes were consistently negative. Peripheral islet cells in rat but not in human pancreas also showed positive staining for ANP. We showed by double labelling techniques that the ANP was present in the glucagon containing cells.