Abstract P2-01-15: Inflammatory breast cancer cells are characterized by attenuated SMAD dependent TGFβ signaling leading to impaired cell motility responses

Introduction.Inflammatory breast cancer (IBC) is an aggressive form of locally advanced breast cancer with elevated metastatic potential, characterized by the frequent presence of tumor emboli in dermal and parenchymal lymph vessels. In the past, evidence was provided that TGFβ signaling is part of the molecular biology of this disease. In this study, this relation was further examined.

Materials and methods. TGFβ1 induced cell motility (i.e. XCELLigence, wound healing assays), gene expression (RNA-sequencing) and peptide phosphorylation (i.e. PAMGene technology) patterns were investigated in a panel of 3 IBC and 3 subtype-matched nIBC cell lines. In addition, a series of tissue samples from 75 and 135patients with and without IBC was investigated for nuclear expression of total SMAD2, SMAD3 and SMAD4 using immunohistochemistry. Finally, SMAD protein expression data were related to gene expression data from patients with available Affymetrix HGU133plus2 profiles.

Results. The cell motility inducing capacity of TGFβ1 was strongly abrogated in all IBC cells independent of their molecular subtype (P=0.003). Genes differentially expressed between IBC and nIBC cells post 4 hours of TGFβ1 revealed attenuated expression of SMAD3 transcriptional regulators with concomitant overexpression of MYC target genes in IBC. Assessment of SMAD expression in patient samples demonstrated a near absence of nuclear SMAD3 expression in the primary tumors from patients with IBC (P<0.001) and a further reduction of SMAD3 staining intensity was observed in tumor emboli (P=0.019). Integrated analysis of gene and protein expression data revealed that a substantial fraction of the IBC signature genes correlated with SMAD3 and these genes (i.e. 21/24; P<0.001) carry evidence in favor of attenuated SMAD3 signaling in IBC.

Discussion. It is demonstrated that IBC cells are characterized by attenuated SMAD3 protein expression and transcriptional activity that obliterates the cell motility inducing capacity of TGFβ1. Recent studies revealed that SMAD3 is essential for TGFβ1 induced cell motility through induction of epithelial to mesenchymal transition (EMT). In the absence of SMAD3 expression, a partial EMT is induced leading to collectively invading cancer cells that are gifted with a high metastatic potential and favor lymphatic dissemination, thereby providing an intriguing explanatory model of the biology of tumor emboli in IBC.

Citation Format: Rypens C, Van Berckelaer C, Billet C, Hauspy J, Bertucci F, Peter V, Dirix L, Van Laere S. Inflammatory breast cancer cells are characterized by attenuated SMAD dependent TGFβ signaling leading to impaired cell motility responses [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-01-15.

Radiation induced angiosarcoma of the breast: case series and review of the literature

Radiation therapy (RT) is an essential adjuvant treatment in early stage breast cancer decreasing the risk of local recurrence. One of the rare late complications of RT is the development of a second primary tumor in the form of radiation-induced angiosarcoma (RIAS). In this report, we present a series of cases of RIAS at a single center and discuss the presentation, management and outcome of this rare iatrogenic malignancy. We conducted a retrospective data analysis of all diagnosed RIAS at the GZA Sint Augustinus Hospital between 2008 and 2018 (n=10). Additionally, a literature search was done. The women were between 64 to 86 years old (mean 73 years). Median follow up was 13,0 months [range 6-96 months] The latency period till RIAS ranged from 4.1 to 14.9 years (average 7.3 years). All tumors, with various clinical presentations were located in the radiation field with sizes from 1 to 10 cm. Nine patients had surgery. Disease-free interval for first recurrence of RIAS was 2-51 months (median 4 months). Overall survival for 1, 2 and five years is respectively 80, 69 and 46%. Comparable numbers were found in the literature. In conclusion, RIAS can occur beyond the conventional 5-year oncological follow-up. Long-term follow-up is necessary with particular attention to post irradiation skin lesions to ensure early detection and prompt therapeutic intervention. Surgery is the golden standard, however the role of chemotherapy and/or RT remains ambiguous. Further investigation is needed.

Benchmarking and audit of breast units improves quality of care

Quality Indicators (QIs) are measures of health care quality that make use of readily available hospital inpatient administrative data. Assessment quality of care can be performed on different levels: national, regional, on a hospital basis or on an individual basis. It can be a mandatory or voluntary system. In all cases development of an adequate database for data extraction, and feedback of the findings is of paramount importance. In the present paper we performed a Medline search on "QIs and breast cancer" and "benchmarking and breast cancer care", and we have added some data from personal experience. The current data clearly show that the use of QIs for breast cancer care, regular internal and external audit of performance of breast units, and benchmarking are effective to improve quality of care. Adherence to guidelines improves markedly (particularly regarding adjuvant treatment) and there are data emerging showing that this results in a better outcome. As quality assurance benefits patients, it will be a challenge for the medical and hospital community to develop affordable quality control systems, which are not leading to excessive workload.

Abstract P2-01-08: Different numbers and prognostic significance of circulating tumour cells in patients with metastatic breast cancer according to immunohistochemical subtypes

Introduction: The enumeration of circulating tumour cells (CTCs) with the EPCAM-based CellSearch system has prognostic significance in patients with metastatic breast cancer (MBC). However, breast cancer has been shown to be a molecularly heterogeneous disease. The aim of this study was to assess potential differences in the detection and prognostic significance of CTCs according to the immunohistochemically defined molecular subtypes of breast cancer.

Methods: CellSearch CTC counts were obtained from 110 patients with MBC prior to first line systemic treatment, treated at GZA Hospitals Sint-Augustinus between november 2007 and december 2011. Clinicopathological variables were prospectively entered in a database. Based on the St-Gallen surrogate definitions of intrinsic breast cancer subtypes (Goldhirsch et al. Ann Oncol 2011), patients were divided in 5 groups: luminal A (ER/PR+, HER2−, Bloom-Richardson histological grade I-II), luminal B – HER2 negative (ER/PR+, Her2−, grade III), luminal B – HER2 positive (ER/PR+, HER2+, any grade), HER2 positive – non luminal (ER/PR−, HER2+), and triple negative (TN) (ER/PR−, HER2−). Differences in progression free survival (PFS) and overall survival (OS) according to the FDA approved prognostic cut-off of ≥5 CTC/7.5 ml blood were estimated using Kaplan Meier and Cox proportional hazard statistics.

Results: CTC were detected in 78 of 110 (71%) patients. Higher detection rates and numbers of CTC were observed in patients with luminal A and TN breast cancer as compared to patients with luminal B and HER2 positive disease. However, no differences in positivity rates were observed between molecular subtypes according to the 5 CTC prognostic cut-off point (table 1). After a median FU time of 3.1 years, 39 patients had died. In the total study population, the presence of ≥5 CTC was an independent predictor of PFS and OS in multivariate analysis (PFS: HRCTC≥5=2.236 (1.366–3.658), p = 0.001; OS: HRCTC≥5=3.180 (1.553–6.509), p = 0.002). When analyzing subgroups separately, a lower prognostic power was observed in the HER2 positive and luminal B subgroups.

P5-23-06: Monitoring of Quality Indicators Should Lead to Quality Measures. A Dynamic Clinical Pathway for the Treatment of Patients with Early Breast Cancer Is a Tool for Better Cancer Care: Implementation and Prospective Analysis between 2002–2010

Aim: To describe the effects of the development, implementation and prospective systematic evaluation and adaptation of a clinical care pathway for the management of patients with early breast cancer between 2002 and 2010) in a single breast unit.

Materials and methods: In 2002 a clinical pathway was developed by the multidisciplinary breast team of the Sint Augustinus Hospital for de diagnosis and treatment of patients with operable breast cancer. Performance measurements were documented systematically by care providers using an order communication, planning and result reporting system. Annual analysis of predefined clinical outcome measures and indicators was performed. Based on these data and evidence based guidelines the pathway was regularly adapted to improve patient care. Results: The annual number of patients included in the pathway (289 vs 390, p 0.01) ), proportion of patients with Tis-T1 tumors (42% vs 58 %, p 0.01), negative lymph nodes (44% vs 58%, p < 0.01)) and no metastases at diagnosis (91.5% vs 95.9%) has risen significantly between 2002 and 2010. Histological subtypes remained the same. The average length of hospital stay (7.0 days vs 4.1 days, p 0.01) nearly halved and the proportion of breast conserving surgery (BCS) (43% vs 57%), preoperative guide wire localization (14% vs 27%) for impalpable lesions and use of sentinel node biopsy (0% vs 49%) increased significantly (p 0.01). Evolution of quality indicators defined by Eusoma (www.eusomadb.org/indicators.htm) between 2002 and 2010 shows a significant improvement of cancer care: proportion of positive of preoperative histologic diagnosis (59.7% vs 88.4%, p 0.001), more then 9 lymph nodes removed when axillary clearance performed (85.6 vs 91.4%, p< 0.04), BCS for invasive carcinoma up to 3 cm (62.0% vs 82.6%, p 0.016), BCS for DCIS up to 20 mm (43.8% vs 78.6%, p 0.016), hormone therapy in endocrine sensitive tumor (84.8% vs 97.4%, p 0.002), adjuvant chemotherapy in ER negative (PT1c or N+) invasive carcinoma (72% vs 95.6% p 0.028), proportion of second surgery (25% vs 10%, p 0.001) and clear margins after last operation (95% vs 99%, p 0.02). All mandatory EUSOMA requirements were fulfilled in 2010. Patient satisfaction improved significantly over the years (13/19 measured parameters p <0.05 between 2002–2010). Progression free 4 year survival was significantly higher for all patients, for T1 tumors only and for T2-T4 tumors only, treated in 2006–2008 compared to 1999–2002 and 2003–2005 (respectively p 0.006, p 0.05, p 0.06). Overall 4 year survival of the entire M0 population treated in 2006–2008 was significantly better (p 0.05)

Conclusion: Although the patient characteristics changed over the years due to better screening, this clinical pathway for the treatment of patients operable breast cancer proved to be an important tool to improve the quality of patient care and patient satisfaction. Better adherence to guidelines and constant feedback of treatment data to the breast team contributes to a superior patient outcome. Measuring quality indicators proved useful to develop quality measures improving patient care.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-23-06.

Assessment of sentinel lymph node in cervical cancer: review of literature

Sentinel lymph node biopsy is a novel method for the surgical management of patients with cervical cancer. Sentinel nodes have a higher chance of harbouring metastases than non-sentinel nodes. Assessment of sentinel nodes provides an opportunity to stage patients intraoperatively and avoid complete pelvic lymph node dissection and hence its morbidities. The aim of this article is to review the diagnostic performance of sentinel node detection, to determine which technique (blue dye, Tc or both) has the highest detection rate and sensitivity, and also to illustrate different approaches of histological assessment of the sentinel lymph node biopsy.

Sentinel lymph nodes in early stage cervical cancer

OBJECTIVES

Lymph node status is the most important prognostic factor in cervical cancer. Sentinel lymph node (SLN) procedures have been purported to reduce peri- and postoperative morbidity and operative time.

METHODS

All patients with surgically managed clinical FIGO stage IA/B1 cervical cancer underwent SLN followed by pelvic lymphadenectomy with technetium+/-lymphazurin from April 2004 to April 2006. 0.1-0.2 mci of filtered sulfur colloid technetium was injected submucosally into 4 quadrants of the exocervix. Lymphazurin (4cc) was only used if technetium was unsuccessful in identifying bilateral sentinel lymph nodes. Serial microsections at 5 microm intervals were performed and stained intraoperatively. Complete pelvic node dissections were performed in all patients.

RESULTS

Forty-two patients underwent SLN, prior to full pelvic lymphadenectomy. Thirty-nine patients were included for the purposes of this study. The incidence in detecting at least one sentinel node was 98% per patient, and 85% per side. Identification of bilateral sentinel lymph nodes was successful in 28 cases (72%). The median number of SLN/side was 2. Three patients were found to have metastatic tumor to lymph nodes. No false negatives were identified. No adverse effects were noted.

CONCLUSIONS

SLN biopsy in cervical cancer is feasible to do, with a low false negative rate. We believe SLN should be evaluated per side and not per patient, that a pelvic lymphadenectomy is otherwise required. By following this protocol, the false negative rate can be minimized. The combined reported FN rate in the literature is 1.8%. If our definition is applied, the majority of reported false negative SLN is not actual false negatives.

Paraneoplastic syndrome in vaginal melanoma: a case report and review of the literature

The authors of this article present a case of a woman diagnosed with a vaginal melanoma who developed paraneoplastic syndrome (PNS) soon after diagnosis. A review of the literature regarding PNSs in gynecological malignancies is also described in this article. To our knowledge, this is the first reported case of paraneoplastic cerebellar degeneration with opsoclonus myoclonus secondary to a vaginal melanoma. In addition, our patient had an unusually acute progression to pancerebellar symptoms over the course of 3 weeks. Her paraneoplastic symptoms improved significantly after partial resection of the melanoma.

Small bowel obstruction during pregnancy

The authors report the case of a 28-year old pregnant woman with abdominal pain and contractions at 37 weeks of gestation. After labour and delivery, abdominal pain persisted and laparoscopy was performed. A bowel obstruction was diagnosed and surgically corrected. The authors discuss the clinical and therapeutic consequences of bowel obstruction during pregnancy.

Intraoperative sentinel node identification with Technetium-99m-labeled nanocolloid in patients with cancer of the uterine cervix: a feasibility study

The objective of this study is to determine the feasibility of intraoperative lymphatic mapping in patients with cervical carcinoma. Patients with early-stage cervical cancer, scheduled to undergo a Wertheims radical hysterectomy and pelvic lymphadenectomy, were eligible for the study. Technetium-99-m-labeled nanocolloid was injected intracervically at two locations around the tumor 3-6 hours before the operation. Images were recorded immediately and 2.5 hours later using a gamma camera. During the operation sentinel nodes (SLN) were identified using a handheld or laparoscopic gamma-detection probe (Navigator, Auto-Suture). After resection of the SLNs a standard pelvic (and para-aortic) lymphadenectomy was performed. The results of the histopathology of SLNs and non-SLNs were compared. The procedure was well tolerated by 24 of 25 patients. One or more SLN could be identified in 21 out of 25 patients. In one patient who was preoperatively irradiated, in two patients who had had a cone biopsy, and in one patient without previous interventions, no SLN could be detected. The mean time for identification was 5 minutes. In 16 patients, pathologic examination showed no metastatic disease in both SLNs and non-SLNs, whereas metastases were found in the SLN in five patients (in one case only SLN involved, four cases SLN and respectively 3, 11, 22 and 31 other positive nodes). This study shows that identification of SLNs in cancer of the uterine cervix is feasible with preoperatively administered 99mTc-labeled nanocolloid. To date, no false negative SLNs have been found, but expansion of the study is necessary to determine possible clinical application of this new technique.

Intraoperative sentinel node identification with Technetium-99m-labeled nanocolloid in patients with cancer of the uterine cervix: A feasibility study

The objective of this study is to determine the feasibility of intraoperative lymphatic mapping in patients with cervical carcinoma. Patients with early-stage cervical cancer, scheduled to undergo a Wertheims radical hysterectomy and pelvic lymphadenectomy, were eligible for the study. Technetium-99-m-labeled nanocolloid was injected intracervically at two locations around the tumor 3–6 hours before the operation. Images were recorded immediately and 2.5 hours later using a gamma camera. During the operation sentinel nodes (SLN) were identified using a handheld or laparoscopic gamma-detection probe (Navigator, Auto-Suture). After resection of the SLNs a standard pelvic (and para-aortic) lymphadenectomy was performed. The results of the histopathology of SLNs and non-SLNs were compared. The procedure was well tolerated by 24 of 25 patients. One or more SLN could be identified in 21 out of 25 patients. In one patient who was preoperatively irradiated, in two patients who had had a cone biopsy, and in one patient without previous interventions, no SLN could be detected. The mean time for identification was 5 minutes. In 16 patients, pathologic examination showed no metastatic disease in both SLNs and non-SLNs, whereas metastases were found in the SLN in five patients (in one case only SLN involved, four cases SLN and respectively 3, 11, 22 and 31 other positive nodes). This study shows that identification of SLNs in cancer of the uterine cervix is feasible with preoperatively administered 99mTc-labeled nanocolloid. To date, no false negative SLNs have been found, but expansion of the study is necessary to determine possible clinical application of this new technique.

Intrauterine versus postnatal transport of the preterm infant: a short-distance experience

AIM

The purpose of this study was to compare neonatal outcome (mortality, respiratory distress syndrome, intraventricular hemorrhage, necrotising enterocolitis, persisting ductus arteriosus, and septicaemia) after intrauterine transport versus neonatal transport in an area where short-distance transport is the rule.

METHODS

The study was retrospective in nature. The files of all neonates delivered between 24 and 34 weeks from 1994 to 1998 and transported intrauterine or postnatally to the Antwerp University Hospital were reviewed. Cases of intrauterine fetal death and mothers discharged before delivery were excluded, as were infants with lethal congenital anomalies.

RESULTS

A total of 328 deliveries after intrauterine transport, resulting in 416 neonates and 187 neonates transported postnatally were included. The maximum distance patients had to be transported was 40 km. Placental abruption was more frequent in the mothers of the neonatal transport group (13 vs. 5%, P=0.001). Corticosteroids were administered significantly less in the neonatal transport group (67 vs. 13%, P<0.0001). Preterm rupture of the membranes (36 vs. 20%, P<0.0001), preterm labour (73 vs. 36%, P<0.0001), and pre-eclampsia (10 vs. 7%, P<0.0001) were more frequent in the intrauterine transport group and this group had a lower mean birthweight and gestational age. There was no significant difference for overall neonatal mortality, respiratory distress syndrome, intraventricular hemorrhage, necrotising enterocolitis, persisting ductus arteriosus or septicaemia.