Abstract P2-09-13: 21 Gene Recurrence Scores: Racial Differences in Testing, Scores, Treatment, and Outcome

BACKGROUND: African American (AA) women experience higher breast cancer mortality than white (W) women, partly attributable to their development of poor prognosis tumors and differences in access and treatment. However mortality differences persist among estrogen receptor positive (ER+) breast cancers, despite similar stage and treatment. The 21-gene recurrence score (RS) assay (Oncotype DX) is used to determine optimal individualized treatment in patients with ER+, node negative (N-) breast cancer. Results are reported on a continuum and also trichotomized into 3 RS groups: low(0-18), intermediate(19-31) and high(>31), the latter most likely benefitting from chemotherapy, achieving less benefit with hormonal therapy, and exhibiting lower ER levels (intrinsically categorized as luminal B cancers). We investigated differences between AA and W women in RS, treatment, and outcome.

METHODS: Tumor registry data from three Atlanta hospitals identified female invasive breast cancers of AA or W descent diagnosed during 2005-2009. Additional medical record abstraction obtained information on RS, treatment, and outcome. Statistical analyses employed chi-square, fisher exact, t-tests, and multivariate logistic regression. RESULTS: Of 1987 cases (AA=1110, W=877), 773 were identified as Stage I-II, ER+N-, thus eligible for RS testing [AA=350(45.3%), W=423 (54.7%), P<0.0001]; 170 (22.2%) of those received RS testing [AA=47(13.4%), W=123(29.1%), P<0.0001]. Patients distributed into the following risk groups: Low=91, Medium=63, High=16; mean(median) RS=19.0(17.0), range=0-69.

Neither mean RS (AA=20.4, W=18.5, p=0.287) nor risk groups (Low=51.1% vs 54.5%, Medium=34.0% vs 38.2%, and High=14.9% vs 7.3% for AA and W women respectively, p=0.333) significantly differed by race. However, AA women were more likely than W women to be diagnosed under age 50 (40.4% vs 23.5%, p=0.036) with higher prevalence of tumors of larger size (Mean = 2.0 cm vs 1.6cm, p=0.038) and Grade III (23.4% vs 8.1%, p=0.0.026), and stage II disease (38.3%% vs 23.6%, p=0.057). Only grade and tumor size were associated with RS in multivariate analyses.

After median follow-up of 20 months (range 1-55), 5 women recurred (2AA, 3W); 2 low, 2 intermediate, and 1 high risk. Chemotherapy was received by 40 women (Low=7, Medium=19, High=14) and did not differ by race (AA=31.9%, W=20.3%, p=0.156). Hormonal therapy was received by 80.5% of W and 63.8% AA women (p=0.027). DISCUSSION: AA women were less likely than W women to be diagnosed with ER+N-breast cancers and to receive RS testing if diagnosed. Of those tested, RS scores did not significantly differ by race. However, AA women tended to have poorer prognostic factors. Our data suggest that testing guidelines are not equivalently applied, that selection bias in testing could be attenuating any real racial differences in RS, and that disparate outcomes could partly be explained by treatment differences, treatment effectiveness e.g. endocrine agent metabolism, compliance, as well as differences in prognostic factors; all areas requiring future exploration.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-09-13.

Waiting Time for Breast Conserving Surgery Patients in a Public and a Private University Affiliated Hospital in Atlanta

Background: The time it takes for a patient to undergo the entire breast cancer pathway treatment varies for diverse patient populations in different health care settings. In this study we analyzed delay in breast cancer treatment (DBCT) for a defined population of breast cancer patients. All of the patients had identical cancer care trajectories of breast-conserving therapy (BCT) for infiltrating ductal carcinoma (IDC) or ductal carcinoma in situ (DCIS), followed by neo-adjuvant therapy in two different hospital settings; including a University-based inner-city hospital and a University-affiliated private practice hospital.Materials and Methods: A retrospective chart review of 214 patients treated from 2004 to 2008 was conducted. Five consecutive diagnostic and treatment events in a total of four time intervals (see Figure 1 below) were defined and correlated with demographic factors such as age, race, marital status, distance traveled to visit, insurance status type, and hospital type. Non-parametric Wilcoxon Rank-Sum test was used for statistical analysis.Results: The mean ages of the patients in both hospitals were similar (59.2 yrs public hospital vs. 61.9 yrs private hospital). Patients treated in the public hospital experienced greater DBCT compared to patients who were treated in the private institution (125 vs. 88 days, p < 0.001). Overall, the largest delay was the time period from diagnostic core biopsy to surgery (50 days). The only time interval that showed greater delay for African-American (AA) women compared to Caucasian women was time from final pathology diagnosis to medical oncology evaluations (26 vs. 33 days, p=0.036). Patients who were married or insured experienced less DBCT compared to patients who were not (80 vs. 117 days and 83.3 vs.167 days respectively, p < 0.001). Medicaid patients had shorter wait times in the public compared to in the private hospital (136 vs. 153 days, ns). Patients who experienced less than 90 days of delay to undergo the entire treatment traveled an average 27.3 miles (sd=76.6) for their hospital visit, while patients who experienced greater than 90 days of delay to undergo the same treatment traveled an average 14.2 miles (sd=19.9) for their hospital visit.Discussion: Differences in DBCT are multi-factorial and arise from system-based issues that vary among hospital settings along with demographic factors such as marital status and race that are independent of the hospital setting. More effective scheduling for surgical treatment and follow up appointments may reduce the wait time. In order to significantly shorten DBCT further, prospective studies are needed to evaluate the intricate connection of psychosocial and system barriers to breast cancer treatment.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3070.

Complications of isolated bilateral iliac artery aneurysms

Isolated iliac artery aneurysms occur infrequently. They comprise about 2 per cent of all abdominal aneurysms. Most patients are symptomatic at the time of presentation. The average diameter is 5.7 cm at diagnosis. We report the acutely symptomatic presentation of a 76-year-old African-American man with 7- and 9-cm bilateral common iliac and a right hypogastic artery aneurysms. Aneurysmorrhaphy was complicated by pelvic ischemia. Colonoscopy and arteriography were used postoperatively to evaluate the extent of his worsening gluteal ischemia. Restoration of pelvic blood flow corrected his gluteal ischemia.

Mycotic aortic aneurysm in a patient with Tolosa-Hunt syndrome

Mycotic aneurysms have been associated with many clinical conditions. A tender pulsatile abdominal mass in association with fever, chills, and unrelenting back pain is suggestive of a leaking mycotic aneurysm. However, the extracranial manifestations of Tolosa-Hunt syndrome (THS) may mimic several of these symptoms. We report the case of a woman who was successfully treated with high-dose steroids for THS. Two months later, she was admitted to another hospital with rigors and unremitting back and abdominal pain. CT-guided aspiration of an L5-S1 paravertebral mass was done. The aspirate and blood cultures grew Staphylococcus aureus. Intravenous antibiotics and analgesics were administered with good relief. A month after discharge from that hospital, she was admitted to our hospital with classic signs and symptoms of a leaking mycotic aneurysm. She was treated surgically and has remained asymptomatic for 21 months. Tolosa-Hunt syndrome associated with mycotic aortic aneurysms has not been previously reported.

The antiphospholipid symdrome in a teenage with miscarriages, thromboses, and diabetes mellitus

The antiphospholipid syndrome has been associated with many clinical conditions since its description by GRV Hughes in 1983. The linkage to Type 1 diabetes mellitus has not been established. There have been no reports of deep venous thrombosis in association with antiphospholipid syndrome and diabetes mellitus. We present the case of an African-American teenager with multiple miscarriages, diabetic ketoacidosis, deep venous thromboses, and elevated immunoglobulin M and G anticardiolipin antibodies. We urge that clinicians consider testing for antiphospholipid antibodies when diabetic patients present with multiple miscarriages or deep venous thrombosis.

Primary adenocarcinoma, signet-ring, and transitional cell carcinoma of the bladder with penile metastasis

This article reports a rare case of primary signet-ring cell carcinoma of the bladder with transitional cell and adenocarcinoma variants and metachronous metastases to the penis and lungs. This combination of lesions has not previously been reported. Together, they portend widespread dissemination and an early demise as is frequently the case with signet-ring cell carcinomas arising in other organs such as the breast and gastrointestinal tract. The optimal therapeutic intervention for this myriad of neoplasms with metastasis to the penis has yet to be ascertained because of the rarity of the lesions. Early diagnosis and an aggressive surgical approach appear to offer the best chance for quality survival and possible cure.

Morgagni hernias: an uncommon cause of chest masses in adults

Morgagni hernia is a congenital diaphragmatic hernia that occurs secondary to potential anterior medial defects in the diaphragm. Although the hernia usually is diagnosed incidentally, appearing as a mass on chest radiograph, symptoms of bowel obstruction may occur. Surgical repair is required in all cases and may be performed with either the abdominal or transthoracic approach.

The role of immunoscintigraphy in the staging and management of colorectal cancer

Colorectal cancer has continued to increase in incidence over the past 25 years. It now ranks as the second most common noncutaneous malignancy for men and women together. The projected 1995 statistics predict 153,000 new cases in the United States, with 109,000 of colonic origin and 44,000 cancers of the rectum. The shift to more proximal colonic involvement and a decrease in size of the presenting lesion is again noted. Unfortunately, the warning signals (rectal bleeding, change in bowel habits and, later, abdominal pain, distention, and weight loss), often become evident only after the tumor has progressed significantly in the patient. Despite improvements in endoscopic detection, anesthesia, pre- and postoperative care and more extensive en-bloc resections, the cure rate for all patients with colorectal cancer remains unchanged at 53 per cent at five years. Although radical resectional surgery is relied on for locoregional control of the disease, there has been an increased use of cross-sectional radiologic studies for staging of the cancer. This newer management of colorectal cancer is the result of a better understanding of the natural history and biologic behavior of the cancer. The main strategy presently is to diagnose the disease sooner, stage the cancer more accurately, select tumors that will respond to adjuvant therapy, and detect recurrences more efficiently. It is in the area of staging of the primary tumor and accurate localization of recurrences that this new modality, immunoscintigraphy, is felt to have an impact.

Growth and metastasis of surgical specimens of human breast carcinomas in SCID mice

PURPOSE

We have studied the growth and metastatic potential of surgical specimens of breast carcinomas engrafted into the large abdominal (gonadal) fat pad of severe combined immunodeficient (SCID) mice. We present results of this study, details of the implantation protocol and histologic characterization of several of the tumor xenografts.

MATERIALS AND METHODS

We evaluated the growth within SCID mice of 48 breast carcinoma specimens derived from 46 patients (45 primary breast cancers or local recurrences and 3 regional metastatic lymph nodes) obtained from resected tissues at this Institute over a 3-year period. The growth of each transplant was assessed by histologic examination of the xenografts at various times after implantation or upon passage into additional mice.

RESULTS

We observed that placement of human breast tumors within the gonadal fat pad could result in tumors that grew either rapidly, slowly, or not at all. Of 48 tumors studied, 12 (25%), including one of the three lymph node-derived tumors, grew rapidly enough within some or all of the implanted mice (i.e., the tumors reached a diameter of 2-3 cm within 2-6 months) to allow repeated passage. Metastatic spread to the SCID mouse lung, liver, and/or diaphragm and other sites was observed with the xenografts derived from 8 of these 12 rapidly growing tumors. Tumors in a second category often took from 6 months to over 1 year to only double or triple in size. This slow-growth group consisted of 25 patients' tumors (53%), including the remaining two metastatic lymph node-derived tumors. These xenografts would usually maintain a slow growth rate even upon later passage into new animals. A third category consisted ofpatients' tumors (23%) that failed to grow at all (i.e., no evidence of tumor growth in any of the mice implanted), as discerned by histologic evaluation at various times after implantation. Histologic examination of tumor xenografts and metastatic tumors revealed considerable variation in histopathology among the different patients' tumors.

DISCUSSION

Further examination of the heterogeneous properties of primary human breast carcinomas within SCID mice may provide a simple yet valuable new approach for the long-term study of human breast cancer biology. Importantly, use of the protocol described here can often permit the isolation of substantial quantities of human breast cancer cells for biochemical and molecular analyses. The ability to passage patients' breast tumors into large numbers of mice will permit the preclinical testing of new therapies for the treatment and prevention of this disease.

A complication of T-fasteners in percutaneous endoscopic gastrostomy (PEG) placement

Two patients with sinus tracts from retained T-fasteners following PEG tube placement are reported. Both patients had the PEG tubes subsequently removed and presented with purulent discharge and granulations near well-healed gastrostomy sites. The management of this complication and a possible method of prevention are discussed.

Etiology of diverticular disease with classic illustrations

Diverticulosis is a common colonic disorder and often is found incidentally on colonic endoscopy and contrast enema radiographs. Theories relating to the etiology of the pathologic processes are commonly quoted, although the actual anatomic features are rarely seen during colonoscopic examinations. Here we show classic illustrations that support the widely held theories regarding the etiologies of diverticular diseases.

Consistent hepatic metastasis of human colorectal cancer in severe combined immunodeficient mice

A major stumbling block in the study of human colorectal cancer metastasis has been the lack of an effective in vivo model producing liver metastasis on a consistent basis. In this study surgical specimens of colorectal carcinoma were implanted in scid mice and studied for engraftment, growth, and the capacity to produce hepatic metastases. Human colorectal cancers would engraft and propagate in the subcutis and intraperitoneally. Sporadic metastasis to the liver occurred in 3 of 54 (6%) animals with cancer implanted subcutaneously. Liver metastasis occurred in 24 of 25 (96%) mice with cancer implanted in the gonad fat pad. Tumor growth to extremely large volumes subcutaneously did not enhance metastatic potential, and neither did longer term growth in the subcutaneous space. Tumor placed in the gonad fat required no special manipulation and in most cases a single piece of solid tumor was implanted. In situ hybridization confirmed the persistence of the human tissue in these metastasizing tumors. Our model will allow for the study of the processes involved in metastasis of solid tumors, characterization of differences between the primary tumor and the metastatic one, and evaluation of possible therapeutic modalities.

Laparoscopic cholecystectomy in patients with ventriculoperitoneal (VP) shunts

Increased intracranial pressure is often relieved by a ventriculoperitoneal shunt. The shunt has a one-way valve which can withstand pressures of 300 mmHg and prevent reflux of intraabdominal fluid. We have utilized laparoscopy for cholecystectomy in four patients with VP shunts. In all patients the peritoneal cavity was free of adhesions. When CO2 insufflation pressure was as high as 10-15 mmHg cerebrospinal fluid was still noted to flow from the end of the shunts. In three patients the entire procedure was performed laparoscopically. In the fourth patient the procedure was converted to an open cholecystectomy because of extensive inflammation surrounding a gangrenous gallbladder. Postoperatively the shunts remained intact and functional. There were no central nervous system sequelae. None of the shunts became infected. Elective laparoscopic cholecystectomy in patients with VP shunts can be done safely without a need for clamping or other manipulation of the shunt.

Human villous adenomas engrafted into scid mice survive for prolonged period without malignant transformation

Human villous adenomas are thought to represent premalignancies that subsequently give rise to colorectal adenocarcinomas. Currently there is no in vivo model in which to study the dedifferentiation and malignant transformation of these tumors. We establish here that human villous adenomas can be successfully engrafted into severe combined immunodeficient (scid) mice. Furthermore, these xenografts remain viable for up to 18 mo after either a subcutaneous or intraperitoneal inoculation of the human tissue. Tumors grew slowly and secreted a clear mucinous fluid. Examination of the tumors histologically at 1, 4, and 12 mo after implantation revealed that the villous polypoid structure was maintained and islands of atypical cells were observed within pockets of mucin surrounding the adenomatous tissue. No gross or histologic evidence of malignancy was detected throughout the 20-mo observation period. The human identity of the cells in the graft was confirmed by DNA in situ hybridization with a human-specific probe. We conclude that the human-scid xenograft described here represents a viable animal model with which to study the potential malignant dedifferentiation of villous adenomas over a prolonged period of time and to evaluate the possible contribution of selected oncogenic vectors on the malignant transformation of these adenomas.

Multiple and distinct primary cancers: a case report

Multiple primary cancers in a single individual are rare when more than three distinct lesions are considered. This article reports a patient who developed four separate primary cancers: squamous cell carcinoma of the larynx, squamous carcinoma of the lung, adenocarcinoma of the breast, and adenocarcinoma of the colon. No specific hereditary syndrome could be identified from this patient's pedigree. Individuals with a history of multiple cancers should have a complete family history evaluation and follow-up for development of subsequent primaries.

Eccrine porocarcinoma

Eccrine porocarcinoma, a malignancy of the eccrine sweat glands, is extremely rare. Our report and a review of the literature (70 cases) emphasize the features of this tumor. Age at time of treatment ranged from 19 to 94 years (mean 67 years). Duration of the lesion ranged from two months to 50 years; 31 (44%) had the lesion present > or = 5 years. Forty-four patients (62%) had tumors located on the extremities, 13 (19%) on the head and neck region and 12 (17%) on the trunk. All patients whose race is known were white. Primary treatment should consist of wide local excision and regional lymphadenectomy, if clinically indicated. Although there is a significant risk of cutaneous, regional lymph node, or visceral metastases, the value of elective or therapeutic regional lymphadenectomy is unknown, as is the role of adjunctive therapy.

Colon cancer in blacks: age-related presentation and survival within a similar socioeconomic group

Young blacks with colon cancer continue to have a poor survival rate for reasons that remain undetermined. Medical records of blacks with colon cancer diagnosed at an inner-city hospital during a 10-year period were reviewed. The cohort consisted of 118 indigent, nonmigratory patients grouped by age. Group 1 consisted of 11 patients under age 50, and group 2 consisted of 107 patients age 50 and over. Admission symptoms were significantly different between groups. Patients in group 1 presented with abdominal pain more often than patients in group 2, and none of the patients in group 1 had anemia or obstruction, which comprised 14% and 11%, respectively, of the presenting symptoms in group 2 patients. Overall, survival difference was significant; the survival rate was 22.8 months for group 1 and 64.2 months for group 2 (P < .02). There was no difference in stage at presentation to account for the decreased survival in group 1. It is possible that the overwhelming majority (45%) of patients in group 1 with abdominal pain actually had more virulent disease, which accounts for the short survival. These individuals must be targeted for more aggressive patient education, surveillance, early detection and treatment, and follow-up.

A simple technique for insertion of PEJ via PEG

Percutaneous endoscopic jejunostomy provides good access for enteral nutrition in those patients at high risk for aspiration and poor tolerance of gastric feeding. Positioning the jejunostomy tube through the PEG tube and into the duodenum can be difficult and time consuming. We describe a simple method for gaining rapid control of the jejunal tube and its duodenal insertion.

Endocrine organ metastases in subjects with lobular carcinoma of the breast

OBJECTIVE

To define the frequency and pattern of endocrine organ metastases in patients dying of invasive lobular carcinoma.

DESIGN

Postmortem microscopic evaluation of the ovaries and adrenal, pituitary, thyroid, and parathyroid glands for breast cancer metastases.

SETTING

Roswell Park Cancer Institute, Buffalo, NY, between 1971 and 1990.

SUBJECTS

One hundred eighteen subjects who died of their cancer: 86 had infiltrating ductal carcinoma; 32, invasive lobular carcinoma.

MEAN OUTCOME MEASURE

Quantitative measurements to allow frequency determinations and statistical comparisons.

RESULTS

Endocrine organ metastases were found in 91% of the subjects with invasive lobular carcinoma vs 58% of subjects with infiltrating ductal carcinoma. The adrenal gland was most frequently involved. Multiple endocrine metastases were most common in the group with invasive lobular carcinoma.

CONCLUSIONS

A relationship exists between invasive lobular carcinoma and endocrine metastases. This indicates that antemortem endocrine evaluation may subsequently improve quality-of-life treatment.

Surgical management of advanced squamous cell skin cancers

Squamous cell cancer of the skin usually follows prolonged exposure to known carcinogens including ultraviolet light, ionizing radiation, chronic infection or irritation, chemicals, and immunologic suppression. The majority of squamous cell skin cancers metastasize infrequently and can be cured with aggressive wide local excision. However, on occasion they can be quite aggressive locally, with or without associated distant metastasis, and may require a radical surgical approach. We report a series of four male patients covering the spectrum of this disease with the following distribution: lower pole of the right ear, right posterior thigh below gluteal fold with positive inguinal nodes, lateral aspect of the foot with bone involvement, and as an incidental finding in a pilonidal cyst. We conclude that one should not hesitate to proceed with aggressive surgical resection as it may provide the only chance for cure. Finally, one should always look for lymph node metastasis, particularly with large (> 5 cm) lesions adjacent to a regional lymph node drainage basin.

Fiberoptic examination of the inferior vena cava during circulatory arrest for complete removal of renal cell carcinoma thrombus

Renal cell carcinoma is known to invade the inferior vena cava and may extend its entire length. Profound hypothermic circulatory arrest has been demonstrated to be a very effective technique to facilitate removal of tumor thrombus from the cava while limiting the amount of blood loss. We describe an innovative method of ensuring complete removal of tumor thrombus from the retrohepatic cava with a fiberoptic bronchoscope introduced through the right atrium during profound hypothermic circulatory arrest. Fiberoptic examination of the cava and hepatic vein orifices under these circumstances will prevent incomplete removal of tumor.

The effect of a novel C5 inhibitor (K-76 COONa) on tumor cell chemotaxis

Walker carcinosarcoma cells were cultured as an ascitic tumor in the rat. These cells were studied for their response to human chemotactic factors derived from complement. Complement activation for tumor chemotaxis was performed by reaction of serum with a tumor extract. An anticomplementary agent, K-76 sodium monocarboxylic acid (K-76 COONa), was tested in these systems. It was found to be effective in blocking the formation of a chemotactic factor for tumor cells from human complement at a concentration of 300 micrograms/ml. Addition of K-76 COONa after complement activation had no effect. No effect on random migration of tumor cells was found at concentrations of 500 micrograms/ml. No effect on tumor cell viability was found up to 500 micrograms/ml. At 1000 micrograms/ml there was a 15% decrease in viability (p less than 0.05). Since chemotactic mechanisms (probably from activated complement) may play a role in the movement of tumor cells, this apparently low toxic anticomplementary agent (K-76 COONa) may be of value in the prevention of tumor metastases.