Aldo-keto reductase family 1 member B10 is regulated by nucleos(t)ide analogues for chronic hepatitis B

The number of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients persists even under nucleos(t)ide analogues (NAs) treatment. Aldo-keto reductase family 1 member B10 (AKR1B10) expression has been reported in advanced chronic liver diseases as well as cancer tissues. We observed an association between related to HCC incidence and serum AKR1B10 by analyzing patients under treatment with NAs. Serum AKR1B10 levels measured by ELISA were higher in HCC cases under NA treatment compared with non-HCC cases and were associated with lamivudine- and adefovir pivoxil-, but not entecavir- or tenofovir alafenamide-treated cases. The latter drugs did not increase AKR1B10 values even in HCC cases, suggesting that they influence the reduction of AKR1B10 in any cases. This analysis was supported by in-vitro examination, which showed reduced AKR1B10 expression by entecavir and tenofovir via immunofluorescence staining. In conclusion there was a relationship between HBV-related HCC incidence and AKR1B10 under nucleos(t)ide analogues, especially in the use of lamivudine and adefovir pivoxil, but entecavir and tenofovir had suppressive effects of AKR1B10.

Serum Laminin γ2 Monomer as a Diagnostic and Predictive Biomarker for Hepatocellular Carcinoma

BACKGROUNDS AND AIMS

Structural dynamics of basement membrane components are still to be elucidated in the process of hepatocarcinogenesis. We evaluated the characteristics of HCC expressing laminin γ2 monomer (LG2m), a basement membrane component not detected in normal tissues, for HCC diagnosis. We further determined whether elevated serum LG2m is a risk factor for HCC development in patients with chronic hepatitis C (CHC).

APPROACH AND RESULTS

In HCC cell lines, LG2m was expressed in alpha-fetoprotein (AFP)-negative, CD90-positive cells characterized by highly metastatic natures. Using 14 cell lines and 258 HCC microarray data, we identified that LG2m gene signature was associated with Hoshida's S1/Boyault's G3 molecular subclasses with poor prognosis, which could not be recognized by AFP. Serum LG2m was assessed in 24 healthy donors, 133 chronic liver disease patients, and 142 HCC patients, and sensitivity and specificity of LG2m testing for HCC diagnosis were 62.9% and 70.5%, respectively (cutoff, 30 pg/mL). We evaluated the consequence of LG2m elevation in two independent HCC cohorts (n = 47 and n = 81), and LG2m-high HCC showed poor prognosis with later development of distant organ metastasis (cutoff, 60 pg/mL). LG2m was slightly elevated in a subset of CHC patients, and Kaplan-Meier analysis indicated a high incidence of HCC (n = 70). For validation, we enrolled 399 CHC patients with sustained virological response (SVR) as a multicenter, prospective study, and serum LG2m elevation correlated with a high incidence of HCC in the CHC patients with SVR (P < 0.0001).

CONCLUSIONS

LG2m is a predictive biomarker for the development of metastatic HCC. Elevated serum LG2m is an HCC risk in CHC patients who have achieved SVR.

Neck Location on the Outer Convexity is a Predictor of Incomplete Occlusion in Treatment with the Pipeline Embolization Device: Clinical and Angiographic Outcomes

BACKGROUND AND PURPOSE

With the increasing use of the Pipeline Embolization Device for the treatment of aneurysms, predictors of clinical and angiographic outcomes are needed. This study aimed to identify predictors of incomplete occlusion at last angiographic follow-up.

MATERIALS AND METHODS

In our retrospective, single-center cohort study, 105 ICA aneurysms in 89 subjects were treated with Pipeline Embolization Devices. Patients were followed per standardized protocol. Clinical and angiographic outcomes were analyzed. We introduced a new morphologic classification based on the included angle of the parent artery against the neck location: outer convexity type (included angle,  <160°), inner convexity type (included angle,  >200°), and lateral wall type (160° ≤ included angle  ≤200°). This classification reflects the metal coverage rate and flow dynamics.

RESULTS

Imaging data were acquired in 95.3% of aneurysms persistent at 6 months. Complete occlusion was achieved in 70.5%, and incomplete occlusion, in 29.5% at last follow-up. Multivariable regression analysis revealed that 60 years of age or older (OR, 5.70; P = .001), aneurysms with the branching artery from the dome (OR, 10.56; P = .002), fusiform aneurysms (OR, 10.2; P = .009), and outer convexity-type saccular aneurysms (versus inner convexity type: OR, 30.3; P < .001; versus lateral wall type: OR, 9.71; P = .001) were independently associated with a higher rate of incomplete occlusion at the last follow-up. No permanent neurologic deficits or rupture were observed in the follow-up period.

CONCLUSIONS

The aneurysm neck located on the outer convexity is a new, incomplete occlusion predictor, joining older age, fusiform aneurysms, and aneurysms with the branching artery from the dome. No permanent neurologic deficits or rupture was observed in the follow-up, even with incomplete occlusion.

Danaparoid sodium-based anticoagulation therapy for portal vein thrombosis in cirrhosis patients

Background

Portal vein thrombosis (PVT) is a common complication of cirrhosis. However, in patients with PVT and cirrhosis, there is no clear evidence supporting effective treatment modalities. In this study, we examined the effectiveness and safety of anticoagulation therapy using danaparoid sodium for PVT in patients with cirrhosis.

Methods

This retrospective study assessed 52 cirrhotic patients with PVT treated with danaparoid sodium for 2 weeks between November 2008 and September 2018. The primary outcome measure was the post-treatment status of PVT assessed by reduction in thrombus volume and safety of the therapeutic intervention. PVT status was evaluated with contrast-enhanced computed tomography (CECT). All patients received 1250 units of danaparoid sodium twice daily by intravenous injection for 14 days. Patients on antithrombin III (AT-III) combination therapy were additionally administered 1500 units of AT-III on days 1–5 and days 8–12. Effectiveness was evaluated by CECT from between days 13 and 18. The secondary outcome measure was the prognosis of PVT.

Results

All patients showed reduction in PVT volume without complications. Return of plasma AT-III level to > 70% during the treatment period contributes to ≥75% reduction of PVT volume. The prognosis in PVT patients depends on hepatic reserve capacity. When limited to Child-Pugh B and C liver cirrhosis patients, a ≥ 75% reduction of PVT volume improved the prognosis.

Conclusions

Danaparoid sodium-based anticoagulation therapy was effective and safe for PVT in patients with cirrhosis. Return of plasma AT-III level to the normal range during the treatment period contributes to reduction of PVT volume. A reduction of ≥75% in PVT volume may improve the prognosis of Child-Pugh B and C decompensated cirrhosis patients with PVT.

Serum C16:1n7/C16:0 ratio as a diagnostic marker for non-alcoholic steatohepatitis

BACKGROUND AND AIMS

Accurate diagnosis of non-alcoholic steatohepatitis (NASH) from non-alcoholic fatty liver disease (NAFLD) is clinically important. Therefore, there is a need for easier ways of diagnosing NASH. In this study, we investigated the serum fatty acid composition and evaluated the possibility of using the serum fatty acid composition as a diagnostic marker of NASH.

METHODS

The subjects were 78 NAFLD patients (non-alcoholic fatty liver [NAFL]: 30, NASH: 48) and 24 healthy individuals. Fatty acids extracted from the liver tissue and serum were identified and quantified by gas chromatography. In addition, we evaluated the relationship between serum and liver tissue fatty acid composition, patient background, and liver histology. The diagnostic performance of NASH was evaluated by calculating the area under the receiver operating characteristic (AUROC).

RESULTS

The results of the fatty acid analysis showed the C16:1n7/C16:0 ratio to have the strongest correlation between serum and liver tissue (r = 0.865, P < 0.0001). The serum C16:1n7/C16:0 ratio in the NASH group was higher compared with that in the NAFL group (P = 0.0007). Evaluation of the association of the serum C16:1n7/C16:0 ratio with liver histology revealed significant correlation with lobular inflammation score, ballooning score, and fibrosis score. The AUROC for predicting NASH in all NAFLD patients was 0.7097. The AUROC was nearly equivalent even when the study subjects were restricted to patients with a fibrosis score ≤ 2 only (AUROC 0.6917).

CONCLUSION

Measuring the serum C16:1n7/C16:0 ratio may be an effective non-invasive method for diagnosing NASH, particularly in its early stages.

MicroRNA-10a Impairs Liver Metabolism in Hepatitis C Virus-Related Cirrhosis Through Deregulation of the Circadian Clock Gene Brain and Muscle Aryl Hydrocarbon Receptor Nuclear Translocator-Like 1

The circadian rhythm of the liver plays an important role in maintaining its metabolic homeostasis. We performed comprehensive expression analysis of microRNAs (miRNAs) using TaqMan polymerase chain reaction of liver biopsy tissues to identify the miRNAs that are significantly up‐regulated in advanced chronic hepatitis C (CHC). We found miR‐10a regulated various liver metabolism genes and was markedly up‐regulated by hepatitis C virus infection and poor nutritional conditions. The expression of miR‐10a was rhythmic and down‐regulated the expression of the circadian rhythm gene brain and muscle aryl hydrocarbon receptor nuclear translocator‐like 1 (Bmal1) by directly suppressing the expression of RA receptor‐related orphan receptor alpha (RORA). Overexpression of miR‐10a in hepatocytes blunted circadian rhythm of Bmal1 and inhibited the expression of lipid synthesis genes (sterol regulatory element binding protein [SREBP]1, fatty acid synthase [FASN], and SREBP2), gluconeogenesis (peroxisome proliferator‐activated receptor gamma coactivator 1 alpha [PGC1α]), protein synthesis (mammalian target of rapamycin [mTOR] and ribosomal protein S6 kinase [S6K]) and bile acid synthesis (liver receptor homolog 1 [LRH1]). The expression of Bmal1 was significantly correlated with the expression of mitochondrial biogenesis‐related genes and reduced Bmal1 was associated with increased serum alanine aminotransferase levels and progression of liver fibrosis in CHC. Thus, impaired circadian rhythm expression of Bmal1 by miR‐10a disturbs metabolic adaptations, leading to liver damage, and is closely associated with the exacerbation of abnormal liver metabolism in patients with advanced CHC. In patients with hepatitis C‐related liver cirrhosis, liver tissue miR‐10a levels were significantly associated with hepatic reserve, fibrosis markers, esophageal varix complications, and hepatitis C‐related hepatocellular carcinoma recurrence. Conclusion: MiRNA‐10a is involved in abnormal liver metabolism in cirrhotic liver through down‐regulation of the expression of the circadian rhythm gene Bmal1. Therefore, miR‐10a is a possible useful biomarker for estimating the prognosis of liver cirrhosis.

Serum aldo-keto reductase family 1 member B10 predicts advanced liver fibrosis and fatal complications of nonalcoholic steatohepatitis

BACKGROUND

Nonalcoholic steatohepatitis (NASH) is associated with liver inflammation in patients with nonalcoholic fatty liver disease, and it can progress to liver fibrosis at an advanced stage, as well as hepatocellular carcinoma (HCC) and portal hypertension. Although liver fibrosis is accurately diagnosed via biopsy, noninvasive methods are preferable. Aldo-keto reductase family 1 member B10 (AKR1B10) is associated with HCC and is secreted into the blood by liver cells via a lysosome-mediated nonclassical pathway. Accordingly, we analyzed whether secretion of AKR1B10 protein is associated with advanced NASH.

METHODS

We performed histological staging in 85 Matteoni classification type III and IV NASH patients and evaluated the incidence of HCC, formation of gastroesophageal varices, and prognosis according to serum AKR1B10 and Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA(+)-M2BP)(M2BPGi) and by comparison with conventional markers of fibrosis.

RESULTS

 A positive correlation was found between the Brunt classification and serum AKR1B10 level. In Brunt stage 4 patients, AKR1B10 levels were higher than those of other liver fibrosis markers, with higher specificity. The cutoff values for AKR1B10 and WFA(+)-M2BP for stage 4 fibrosis were 1.03 and 3.11, respectively. The rates of stage 4 fibrosis, HCC incidence, and gastroesophageal varix formation were significantly different between the two groups subdivided according to these cutoff levels. Moreover, the patients in the higher value group had significantly worse prognosis after NASH diagnosis CONCLUSION: AKR1B10 is a useful serum biomarker for advanced liver fibrosis in NASH and, combined with serum WFA(+)-M2BP, can predict HCC development, gastroesophageal varix formation, and poor prognosis.

Development of novel diagnostic system for pancreatic cancer, including early stages, measuring mRNA of whole blood cells

Pancreatic ductal adenocarcinoma (PDAC) is the most life-threating disease among all digestive system malignancies. We developed a blood mRNA PDAC screening system using real-time detection PCR to detect the expression of 56 genes, to discriminate PDAC from noncancer subjects. We undertook a clinical study to assess the performance of the developed system. We collected whole blood RNA from 53 PDAC patients, 102 noncancer subjects, 22 patients with chronic pancreatitis, and 23 patients with intraductal papillary mucinous neoplasms in a per protocol analysis. The sensitivity of the system for PDAC diagnosis was 73.6% (95% confidence interval, 59.7%-84.7%). The specificity for noncancer volunteers, chronic pancreatitis, and patients with intraductal papillary mucinous neoplasms was 64.7% (54.6%-73.9%), 63.6% (40.7%-82.8%), and 47.8% (26.8%-69.4%), respectively. Importantly, the sensitivity of this system for both stage I and stage II PDAC was 78.6% (57.1%-100%), suggesting that detection of PDAC by the system is not dependent on the stage of PDAC. These results indicated that the screening system, relying on assessment of changes in mRNA expression in blood cells, is a viable alternative screening strategy for PDAC.

Abstract P4-08-29: Lymphatic invasion is an independent risk factor in patients with small node-negative luminal breast cancer

[Background]

In patients with node-negative (N0), hormone receptor-positive, human epidermal growth factor receptor (HER2) -negative (luminal) breast cancer, the impact of lymphatic invasion (ly) on the prognosis remains to be clarified.

[Methods]

Among 3,158 patients with primary breast cancers who underwent surgery in our institute from January 2007 to December 2009, we analyzed 1027 N0 luminal invasive breast cancers without preoperative systemic therapy. The luminal breast cancer was defined as hormone receptor-positive (ER of ≥ 10% or PgR of ≥ 10%) and HER2-negative (immunohistochemistry: 0, 1+ or FISH: ratio &lt; 2.0) cancer in the postoperative pathological specimen. ly was defined as positive when cancer cell nests were detected within the lymph duct in the whole specimen. N0 was confirmed pathologically by the sentinel lymph node biopsy in all the patients. The Fisher's exact test was used for comparison between different categories. The distant recurrence rate (DRR) was analyzed using the Kaplan-Meier method and the log-rank test. For multivariate analysis, Cox's regression analysis was performed.

[Results]

The median follow-up period was 103.8 months (range: 5.6-128.8). Recurrence with distant metastasis occurred in 26 patients (2.5%). There were 5 (0.7%) deaths related to breast cancer. ly was detected in 240 patients (23.4%). In the ly-positive group, the tumor size was larger (p = 0.007), and the nuclear grade (NG) was higher (p &lt; 0.001) than in the ly-negative group. Postoperative endocrine therapy (p &lt; 0.001) and postoperative chemotherapy (p &lt; 0.001) were more frequently employed for patients with ly-positive tumor. The univariate analysis showed that ly positivity (p &lt; 0.001), large tumor size (p &lt; 0.001), high NG (p &lt; 0.001), PgR negativity (p = 0.002) and the history of adjuvant chemotherapy (p &lt; 0.001) were associated with high DRR. In the multivariate analysis, large tumor size (p = 0.007) and PgR negativity (p = 0.015) remained significant. Although positive ly had a risk ratio of 2.2, it was not an independent risk factor.When restricted to T1 tumor (n = 899), the aforementioned factors still showed prognostic value in the univariate analysis, among which ly positivity (p = 0.004)remained significant together with PgR negativity (p = 0.047)in themultivariate analysis.The 8-year DRR was very favorable (0.8%) in patients with ly-negative T1N0 tumor while it was modest (6.6%) in patients with ly-positive T1N0 tumor (p &lt; 0.001). Only 1.3% of the patients had received adjuvant chemotherapy in the ly-negative group while 27% of the patients had in the ly-positive group.

[Conclusion]

Lymphatic invasion was associated with higher DRR although it was not independent in the multivariate analysis among patients with N0 luminal breast cancer. When restricted to patients with T1N0 luminal breast cancer, the presence of ly was independently associated with higher risk of distant recurrence. It suggests that the assessment of ly is clinically more relevant when considering treatment options for small luminal breast cancer.

Citation Format: Abe T, Ito Y, Fukada I, Shibayama T, Ono M, Kobayashi T, Kobayashi K, Takahashi S, Horii R, Akiyama F, Iwase T, Ueno T, Ohno S. Lymphatic invasion is an independent risk factor in patients with small node-negative luminal breast cancer [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 P4-08-29.

Three renal failure cases successfully treated with ombitasvir/paritaprevir/ritonavir for genotype 1b hepatitis C virus reinfection after liver transplantation

We report three cases of genotype 1b hepatitis C virus (HCV) reinfection after liver transplantation. When antiviral treatment was considered, all three patients had renal dysfunction and had been treated with immunosuppressive agents for a long time; one with tacrolimus (TAC) and the others with cyclosporine A (CyA). Therefore, the possible antiviral regimens among direct-acting antivirals (DAA) were limited and so we treated all three patients with ombitasvir/paritaprevir/ritonavir (OBV/PTV/r). Because ritonavir is known to markedly increase the blood concentration of TAC and CyA through drug-drug interactions, close monitoring of blood concentrations of TAC or CyA and dose adjustments of immunosuppressive agents were needed. Sustained virus response was achieved in all the patients treated, and there were no adverse effects or transplant rejection. OBV/PTV/r might be a useful DAA regimen for patients with genotype 1 HCV reinfection in the setting of renal dysfunction.

Abstract P2-06-02: Breast cancer HER2 epigenetic intratumoral heterogeneity results from lack of HER2 protein translation

Research objective

Previously, we reported the negative correlation between pathological complete response (pCR) and HER2 positive breast cancer exhibiting amplified HER2 gene tumor cells without HER2 protein overexpression (HER2 epigenetic intratumoral heterogeneity) among trastuzumab-based neoadjuvant chemotherapy treated patients. Our objective in this study was to elucidate if tumor cells with HER2 epigenetic intratumoral heterogeneity express HER2 RNA using a HER2 RNA in situ hybridization (ISH) method.

Materials and methods

Formalin-fixed, paraffin-embedded (FFPE) sections of breast cancer biopsy samples were investigated for HER2 RNA expression at the individual cell level using a HER2 RNA ISH assay. RNA preservation in tissue sections was examined using a peptidylprolyl isomerase B (PPIB) RNA ISH assay.

Three groups of cases were examined:

1) HER2 negative breast cancer cases (HER2 RNA ISH negative control group).

2) HER2 positive breast cancer cases with homogeneous HER2 positive tumor cells (HER2 RNA ISH positive control; pCR group)

3) HER2 positive breast cancer cases with HER2 epigenetic intratumoral heterogeneity (a mixture of HER2 gene and protein positive tumor cells and HER2 gene positive tumor cells without HER2 protein expression; incomplete response group)

Consecutive sections of HER2 RNA ISH slides were stained for HER2 gene and protein concurrently on the same tissue section using HER2 gene-protein assay (GPA) which is a combination of FDA-approved HER2 immunohistochemical (HER2 protein) and HER2 dual ISH (HER2 gene and chromosome 17 centromere) assays. Analyses of HER2 RNA expression in individual cells was microscopically evaluated and matched to HER2 GPA slides.

Results

RNA preservation was confirmed in tissue sections of all three groups by a PPIB RNA ISH assay. Tumor cells of HER2 negative breast cancer cases (negative control group) lacked HER2 RNA ISH signal while HER2 gene and protein positive tumor cells of homogeneous breast cancer cases (positive control group) demonstrated high HER2 RNA expression levels. HER2 gene and protein positive tumor cells of HER2 positive intratumoral heterogeneity cases showed high HER2 RNA expression. However, amplified HER2 gene breast cancer cells without HER2 protein overexpression of HER2 positive intratumoral heterogeneity cases also showed high levels of HER2 RNA expression. Thus, revealing in cases with intratumoral heterogeneity, transcription of HER2 RNA occurs, but translation of HER2 protein is altered by some mechanism(s) in tumor cells.

Conclusions

Transcription of HER2 RNA was observed in breast tumor cells with amplified HER2 gene but absence of HER2 protein overexpression (HER2 epigenetic intratumoral heterogeneity) of patients who showed incomplete response to neoadjuvant trastuzumab therapy. Our study suggests that inconsistent HER2 protein translation in breast cancer with HER2 epigenetic heterogeneity might be the primary resistance mechanism to trastuzumab-based neoadjuvant chemotherapy.

Citation Format: Nitta H, Horii R, Murillo A, Portier B, Akiyama F. Breast cancer HER2 epigenetic intratumoral heterogeneity results from lack of HER2 protein translation [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-06-02.

Light alcohol consumption has the potential to suppress hepatocellular injury and liver fibrosis in non-alcoholic fatty liver disease

Background & aims

The modest consumption of alcohol has been reported to decrease the incidence of fatty liver or prevalence of steatohepatitis. In this study, we investigated the effect of light alcohol consumption on liver function and gene expression in patients with non-alcoholic fatty liver disease (NAFLD).

Methods

The study group was formed of 178 patients diagnosed with non-alcoholic fatty liver disease, subclassified into two groups for analysis based on the daily alcohol consumption: non-alcohol group and light alcohol consumer group (≤20 g of ethanol/day). Clinical characteristics, liver histological features, gene expression, comprehensively analyzed using microarrays (BRB-Array tools), and molecular network were evaluated and compared between the two groups.

Results

No significant differences in steatosis or inflammation score were noted among the groups. However, the ballooning and fibrosis scores were significantly lower in the light alcohol consumer group than in the non-alcohol group. Gene expression analysis revealed a marked inhibition of the pathways involved in the immune response in the light alcohol group compared to that in the non-alcohol group.

Conclusions

Light alcohol consumption might suppress activity of non-alcoholic steatohepatitis by reducing gene expression levels involved in the immune response. This inhibition in gene expression was associated with a lowering of liver fibrosis and hepatocellular injury.

Potential efficacy of therapies targeting intrahepatic lesions after sorafenib treatment of patients with hepatocellular carcinoma

Background

We investigated the contribution of subsequent therapy for advanced hepatocellular carcinoma refractory or intolerant to sorafenib. Further, we investigated the impact of sorafenib on overall survival using individual data.

Methods

We reviewed the medical records of patients with advanced hepatocellular carcinoma treated with sorafenib. Survival after sorafenib treatment and overall survival were defined as the time when we discovered that patients were either refractory or intolerant to sorafenib and the period from the start of sorafenib treatment, respectively, until death during the study. We compared patients’ prognoses according to their subsequent treatment as follows: group A, therapies targeting intrahepatic lesions; group B, systemic therapies alone; group C, no subsequent therapy. We used linear regression analysis to determine whether there was an association with survival after sorafenib treatment and with overall survival.

Results

Of 79 patients, 63 (79.7 %) received one or more subsequent therapies (44 and 19 patients in groups A and B, respectively). The five patients who survived more than two years after sorafenib treatment was discontinued responded to therapies targeting intrahepatic lesions. The median survival times of groups A, B, and C were 11.9 months, 5.8 months, and 3.6 months, respectively. Multivariate analysis revealed that group A, Child-Pugh score, serum α-fetoprotein level, and cause of failure of sorafenib treatment were independent prognostic factors for survival after sorafenib treatment. Individual survival after sorafenib treatment correlated highly with overall survival.

Conclusions

Targeting intrahepatic lesions may be useful for treating patients with advanced hepatocellular carcinoma patients after sorafenib treatment is discontinued.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2380-4) contains supplementary material, which is available to authorized users.

Abstract P4-02-13: The pattern of tumor shrinkage is associated with prognosis in low grade luminal early breast cancer during neoadjuvant chemotherapy

BACKGROUND: In neoadjuvant chemotherapy (NAC) for early breast cancer, the pathological response rate in estrogen receptor (ER)-positive tumors has been low in comparison with those of ER-negative tumors. Therefore, surrogate makers other than the pCR rate are needed during NAC for luminal breast cancer. Using MRI, we analyzed the patterns of tumor shrinkage after NAC as a surrogate prognostic factor in low grade luminal breast cancer. METHODS: Of 854 patients who had received NAC in a single institute from Jan. 2000 to Dec. 2009, 183 patients with low grade luminal breast cancer were retrospectively evaluated for this study. They were defined as ER and/or PgR positive in more than 10% of cancer cells and HER2 negative (IHC 0, 1+ or FISH &lt;2.0) with nuclear grade 1 and 2. RESULTS: The median observation period was 67.9 months following surgery, and recurrence was observed in 31 patients (16.9%). The median age was 49 (22-76) years. One hundred eighty patients received anthracycline-containing chemotherapy, and 158 received taxane. There were 16 deaths (8.7%) related to breast cancer. We categorized the patterns of tumor shrinkage by MRI into 6 types: concentric shrinkage (CS), diffuse decrease (DD), reduction to small foci (RSF), decrease of intensity only (DIO), no change (NC), and enlargement (EL). According to our categorization, CS occurred in 97 (53.0%), RSF in 7 (3.8%), DD in 62 (33.9%), DIO in 7 (3.8%), NC in 5 (2.7%), and EL in 5 (2.7%). As expected, there were statistically significant differences in both the median DFS and OS in each pattern of tumor shrinkage (p &lt;0.001 and p=0.001, respectively); in particular, the CS pattern had excellent prognosis. Multivariate analysis demonstrated that concentric shrinkage was the only significant good prognostic factor for OS (p=0.015). CONCLUSIONS: Tumor shrinkage patterns as revealed by MRI could be important surrogate prognostic factors for NAC in early low grade luminal breast cancer.

Citation Format: Fukada I, Araki K, Kobayashi K, Gomi N, Horii R, Akiyama F, Takahashi S, Iiwase T, Ohno S, Ito Y. The pattern of tumor shrinkage is associated with prognosis in low grade luminal early breast cancer during neoadjuvant chemotherapy. [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 P4-02-13.

Abstract P5-08-15: Prognostic value of aldehyde dehydrogenase 1 (ALDH1) and tumor infiltrating lymphocytes (TIL) to predict the late recurrence in ER positive, HER2 negative breast cancer

Introduction: Aldehyde dehydrogenase 1(ALDH1) is known to be cancer stem cell marker. Also, tumor infiltrating lymphocytes (TILs) are known to be prognostic factor for triple negative breast cancer. It is reported that these factors have the correlation with chemosensitivity. Meanwhile, the late recurrence (LRec; 5 years after primary surgery) of ER positive breast cancer is the major problem. Significance of expressions of ALDH1 and TILs in primary tumor as predictive factors for late recurrence in ER positive, HER2 negative breast cancer is still unknown.

Methods: ER-positive, and HER2-negative breast cancer patients who underwent surgery or received neoadjuvant chemotherapy between January 2000 and December 2004 were registered from nine institutes belonging the Collaborative Study Group of Scientific Research of the Japanese Breast Cancer Society. For each LRec patient, approximately two matched control patients without relapse for more than ten years were selected. Expression of ALDH1 was assessed by immunohistochemistry. Positive ALDH1 was defined as tumor including more than 1% cancer cells with ALDH1 expression. TIL was assessed by single whole section according to Denkert's definition. A tumor showing high ki67 and/or low PgR expressions was categorized into Luminal B-like group.

Results: 639 patients (184 with early recurrence (ERec), 134 with LRec and 321 with no recurrence (NoRec)) were analyzed. The rates of positive ALDH1 in ERec, LRec and NoRec groups were 18%, 13% and 8%, respectively. ALDH1 positivity was significantly higher in ERec compared with NoRec group (p&lt;0.01). There was no significant difference between LRec and NoRec group (p=0.12). Positive ALDH1 showed significantly shorter DFS and OS in multivariate analyses (DFS: p=0.03, OS: p&lt;0.01). Especially, that was the significantly prognostic factor in the Luminal B like tumor with adjuvant or neoadjuvant chemotherapy (p=0.01), but not in those without any chemotherapy (p=0.53). High TILs in ERec, LRec and NoRec was 1.1%, 1.5% and 3.7%, respectively. There was no significant difference among three recurrent groups (p=0.13). High TILs was not significantly associated with DFS (p=0.09) and OS (p=0.72). However, there was significant correlation between High TILs and DFS in Luminal B like group (p=0.04) and ALDH1-negative group (p=0.02).

Conclusion: In ER-positive, and HER2-negative breast cancer, ALDH1 was an independent prognostic factor (a predictor of ERec, but not LRec). ALDH1 might be a predictor of benefit from chemotherapy in Luminal B like subtype. TILs was neither a predictor of ERec nor LRec. However, significance of TILs as prognostic factor might differ depending on subtypes and cancer stemness.

Citation Format: Miyoshi Y, Shien T, Ogiya A, Ishida N, Yamazaki K, Horii R, Horimoto Y, Masuda N, Yasojima H, Inao T, Osako T, Takahashi M, Tomioka N, Hagio K, Endo Y, Hosoda M, Yamashita H. Prognostic value of aldehyde dehydrogenase 1 (ALDH1) and tumor infiltrating lymphocytes (TIL) to predict the late recurrence in ER positive, HER2 negative breast 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 P5-08-15.

[Diagnostic benefits of adrenocortical scintigraphy in hepatic adrenal rest tumor]

An 81-year-old female was referred to our hospital for the examination of an S7 liver tumor. The tumor was suspected to be a hepatic adrenal rest tumor (HART) based on ultrasonography, dynamic CT, Gd-EOB-DTPA-enhanced MRI, and CT during abdominal angiography. After various hormonal tests, the tumor was confirmed as hormonally non-functional. The diagnosis of HART was confirmed based on (131)I-adosterol accumulation in the tumor by adrenocortical scintigraphy. The resected tumor was histologically compatible with HART, and it may have been able to produce cortisol based on the immunohistochemical findings of various adrenocortical hormone metabolic enzymes. Adrenocortical scintigraphy may thus be useful in diagnosing HART.

Hepatic interferon-stimulated genes are differentially regulated in the liver of chronic hepatitis C patients with different interleukin-28B genotypes

Pretreatment up-regulation of hepatic interferon (IFN)-stimulated genes (ISGs) has a stronger association with the treatment-resistant interleukin (IL)28B minor genotype (MI; TG/GG at rs8099917) than with the treatment-sensitive IL28B major genotype (MA; TT at rs8099917). We compared the expression of ISGs in the liver and blood of 146 patients with chronic hepatitis C who received pegylated IFN and ribavirin combination therapy. Gene expression profiles in the liver and blood of 85 patients were analyzed using an Affymetrix GeneChip (Affymetrix, Santa Clara, CA). ISG expression was correlated between the liver and blood of the MA patients, whereas no correlation was observed in the MI patients. This loss of correlation was the result of the impaired infiltration of immune cells into the liver lobules of MI patients, as demonstrated by regional gene expression analysis in liver lobules and portal areas using laser capture microdissection and immunohistochemical staining. Despite having lower levels of immune cells, hepatic ISGs were up-regulated in the liver of MI patients and they were found to be regulated by multiple factors, namely, IL28A/B, IFN-λ4, and wingless-related MMTV integration site 5A (WNT5A). Interestingly, WNT5A induced the expression of ISGs, but also increased hepatitis C virus replication by inducing the expression of the stress granule protein, GTPase-activating protein (SH3 domain)-binding protein 1 (G3BP1), in the Huh-7 cell line. In the liver, the expression of WNT5A and its receptor, frizzled family receptor 5, was significantly correlated with G3BP1.

CONCLUSIONS

Immune cells were lost and induced the expression of other inflammatory mediators, such as WNT5A, in the liver of IL28B minor genotype patients. This might be related to the high level of hepatic ISG expression in these patients and the treatment-resistant phenotype of the IL28B minor genotype.

Ink4a/Arf(-/-) and HRAS(G12V) transform mouse mammary cells into triple-negative breast cancer containing tumorigenic CD49f(-) quiescent cells

Intratumoral heterogeneity within individual breast tumors is a well-known phenomenon that may contribute to drug resistance. This heterogeneity is dependent on several factors, such as types of oncogenic drivers and tumor precursor cells. The purpose of our study was to engineer a mouse mammary tumor model with intratumoral heterogeneity by using defined genetic perturbations. To achieve this, we used mice with knockout (−/−) of Ink4a/Arf, a tumor suppressor locus; these mice are known to be susceptible to non-mammary tumors such as fibrosarcoma. To induce mammary tumors, we retrovirally introduced an oncogene, HRAS(G12V), into Ink4a/Arf^−/− mammary cells in vitro, and those cells were inoculated into syngeneic mice mammary fat pads. We observed 100% tumorigenesis. The tumors formed were negative for estrogen receptor, progesterone receptor, and HER2. Further, they had pathological features similar to those of human triple-negative breast cancer (e.g. pushing borders, central necrosis). The tumors were found to be heterogeneous and included two subpopulations: CD49f⁻ quiescent cells and CD49f⁺ cells. Contrary to our expectation, CD49f⁻ quiescent cells had high tumor-initiating potential and CD49f⁺ cells had relatively low tumor-initiating potential. Gene expression analysis revealed that CD49f⁻ quiescent cells overexpressed epithelial-to-mesenchymal transition-driving genes, reminiscent of tumor-initiating cells and claudin-low breast cancer. Our animal model with intratumoral heterogeneity, derived from defined genetic perturbations, allows us to test novel molecular targeted drugs in a setting that mimics the intratumoral heterogeneity of human triple-negative breast cancer.

Abstract P1-01-12: The Performance of the One Step Nucleic acid Amplification (OSNA) Assay in Breast Cancer Patients with Receiving Preoperative Systemic Therapy

Background: The OSNA (One Step Nucleic acid Amplification) assay is a semi-automated lymph node examination method using molecular biological technique. The OSNA assay has been validated for breast cancer patients without receiving preoperative systemic therapy (PST) by several clinical studies and has currently become more popular as sentinel lymph node (SLN) examination method with the following two main advantages; 1) to allow examination of the whole portion of a node, 2) to allow intraoperative judgment of metastasis positive or negative. However, the feasibility of the OSNA assay in breast cancer patients treated by PST has never been confirmed. In this multi-central clinical study, we compared the judgments of the OSNA assay and of pathological examination on lymph nodes dissected after receiving PST to evaluate the performance of the OSNA assay.

Material & Methods: Three hundred two nodes dissected from the 80 breast cancer patients who received PST were examined. Each lymph node was divided at 2mm intervals and the slices were alternately applied to the OSNA assay and pathological examination with H&E staining and CK19 immunohistochemical staining of permanent-section. In pathological examination, judgments of metastasis positive or negative were determined by one central-review pathologist according to the criteria of AJCC 7th edition (“positive” if &gt;0.2mm metastases were detected).

Result: The overall concordance rate between the OSNA assay and pathological examination was 91.1% (275/302) with sensitivity of 88.3% (53/60) and specificity of 91.7% (222/242) (Table). These results are very similar to those of the Japanese clinical validation study in breast cancer patients without receiving PST which was conducted by the almost same protocol (Tamaki Y, et al. Clin Cancer Res, 2009, 15: 2879–2884).

Conclusion & Discussion: These results indicate the OSNA assay can be applicable for breast cancer patients after receiving PST as well as breast cancer patients without receiving PST. The OSNA assay will enable to examine the whole portion of nodes, leading to more detection of metastases (especially micrometastases) and more exact nodal staging for breast cancer patients treated by PST. Also, for the patients who receive sentinel lymph node biopsy after PST, the OSNA assay will be useful as intraoperative examination method of SLNs because it is expected to provide more correct judgments than current intraoperative methods such as frozen-section or touch-print cytology.

Abstract P5-01-02: Inter-observer concordance of Ki-67 labeling index in breast cancer: Japan Breast Cancer Research Group (JBCRG) Ki-67 Ring Study

Background: The standardized assessment of Ki-67 labeling index (LI) plays pivotal roles in identifying the patients (pts) with primary breast cancer who could benefit from systemic chemotherapy, in particular among pts with estrogen receptor(ER)-positive cancers. Therefore, in this study, we evaluated the inter-observer concordance of the assessment of Ki-67 LI in archival materials.

Methods: Six surgical pathologists specializing in breast pathology from different Japanese institutions participated in this study. All slides were prepared from archival tissues of breast cancer fixed in 10% buffered formalin for 24 hours in a single institution (KU). Three independent studies were conducted. Study 1) Six consecutive slides were prepared from 5 cases. A slide from each case was stained with MIB-1 (DAKO, Denmark) in each institution according to their routine methods. Total of 30 stained slides were assessed for Ki-67 LI by each pathologist using two different modes of assessment. One is the scoring system in which the rate of positive cells was scored from 1 (0–9 %) to 10 (90–100%) without counting the cell number. The second one is the counting system in which approximately 1000 cells in total were counted in the hot spots and the positive rate was calculated. Study 2) Twenty tumors with Ki-67 LI ranging from 5 to 25 (15 ± 10) %, stained in a single institution (KU) were assessed by each pathologist by the counting system. Study 3) In order to avoid variations by assessment in varied microscopic fields and to further evaluate the variation of threshold of immunointensity interpreted as positive by different pathologists, fifteen printed photographs of Ki-67-stained slides were sent and assessed for Ki-67 LI by each participating breast pathologist.

Results: Study 1) The counting system demonstrated a better correlation of Ki-67 LI among six pathologists than the scoring system {the intraclass correlation coefficient (ICC), 0.66 (95% confidence interval 0.52–0.78) for the counting system, 0.57 (0.42–0.72) for the scoring system}. The two assessment systems showed a moderate correlation {ICC, 0.68 (0.60–0.75)}. Study 2) The assessment of Ki-67 LI in 20 slides with Ki-67 LI of 5 to 25 % demonstrated a correlation similar to that in the specimens with an unrestricted range of Ki-67 LI in the study 1 {ICC, 0.68 (0.50–0.81) for the study 2, 0.66 (0.52–0.78) for the study 1}. Study 3) The assessment of Ki-67 LI in the same photographs yielded a considerably significant concordance among six pathologists {ICC, 0.94 (0.88–0.97)}.

Conclusion: The counting system turned out better than the scoring system in terms of the inter-observer agreement of the Ki-67 LI assessment. The degree of concordance was by no means influenced by the range of Ki-67 LI. The concordance of the Ki-67 LI assessment among six participating pathologists was significantly high when the assessed field was fixed using the same photographs for evaluation, suggesting that the selection of the fields for evaluation is critical. These results suggest that identification of hot spots for evaluation is pivotal for obtaining the accurate Ki-67 LI of breast cancer and still images of these hot spots could provide reproducible results.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-01-02.

Incidence and possible pathogenesis of sentinel node micrometastases in ductal carcinoma in situ of the breast detected using molecular whole lymph node assay

Background:

The pathogenesis of lymph node metastases in preinvasive breast cancer – ductal carcinoma in situ (DCIS) – remains controversial. The one-step nucleic acid amplification (OSNA) assay is a novel molecular method that can assess a whole node and detect clinically relevant metastases. In this retrospective cohort study, we determined the performance of the OSNA assay in DCIS and the pathogenesis of node-positive DCIS.

Methods:

The subjects consisted of 623 patients with DCIS who underwent sentinel lymph node (SN) biopsy. Of these, 2-mm-sectioned nodes were examined using frozen-section (FS) histology in 338 patients between 2007 and 2009, while 285 underwent OSNA whole node assays between 2009 and 2011. The SN-positivity rate was compared between cohorts, and the characteristics of OSNA-positive DCIS were investigated.

Results:

The OSNA detected more cases of SN metastases than FS histology (12 out of 285, 4.2% vs 1 out of 338, 0.3%). Most of the metastases were micrometastases. The characteristics of high-risk DCIS (i.e., mass formation, size, grade, and comedo) and preoperative breast biopsy (i.e., methods or time to surgery) were not valid for OSNA assay–positive DCIS.

Conclusion:

The OSNA detects more SN metastases in DCIS than FS histology. Further examination of the primary tumours and follow-up of node-positive DCIS are needed to elucidate the pathogenesis.

P3-07-08: Accurate Staging of Axillary Lymph Nodes from Breast Cancer Patients Using a Novel Molecular Method

Background: In breast cancer, the number of axillary lymph node metastases is the powerful prognostic factor. However, it is obvious that conventional histopathological examinations are non-standardized and limited in their ability to detect metastases accurately due to the partial evaluation of a node. This may lead to underestimation of nodal staging. The one-step nucleic acid amplification (OSNA) assay was developed to overcome this limitation of the histopathological examination. This assay can assess the whole lymph node and yields semi-quantitative results for the detection of clinically relevant nodal metastases by detection and amplification of cytokeratin 19 mRNA. This assay can classify the nodes into 4 categories, (++), (+I), (+), and negative. (++) and (+I) are theoretically regarded as macrometastasis and (+) as micrometastasis according to the American Joint Committee on Cancer (AJCC) staging system. We have shown the OSNA whole node assay detects more sentinel node (SN) metastases, particularly micrometastases than 2-mm-section frozen-section histology. Thus, we had hypothesized that the OSNA assay for non-sentinel nodes (nonSNs) in addition to SNs enables the classification of accurate nodal staging for breast cancer patients. In the present retrospective cohort study, we compared the performance of the OSNA assay with that of routine permanent histology for the detection of nonSN metastases among patients with positive SN biopsy who have undergone axillary dissection.

Patients and methods: Subjects comprised of consecutive 183 patients with clinically and ultrasonographically node-negative pT1-2 breast cancer who had undergone axillary dissection after positive SN biopsy with the OSNA assay between April 2009 and September 2010. Of these, for nonSN evaluation, 64 had single-section permanent histology while 119 patients underwent the OSNA whole node assay. We compared 1) detection rates of nonSN metastasis, including macro- and micrometastases and 2) upstaging rates from SN stage after the nonSN assessment according to the 7th AJCC staging system between both cohorts. We performed the two-population z test.

Results: 1) NonSNs were found to be positive for metastasis more frequently in the OSNA cohort than in the histology cohort (histology 13/64, 20.3%, 95% CI 11.7−32.6% vs. OSNA 66/119, 55.5%, 95% CI 46.1−64.5%; P&lt;0.001). We found no significant difference in the frequency of macrometastasis in nonSNs (12/64, 18.8%, 95% CI 10.5−30.8% vs. 30/119, 25.2%, 95% CI 17.9−34.2%; P=0.42). However, we found significant difference in the frequency of micrometastasis in nonSNs (1/64, 1.6%, 95% CI; 0.1−9.5% vs. 36/119, 30.3%, 95% CI; 22.3−39.5%; P&lt;0.001).

2) Total upstaging rates were similar in both cohorts (histology 9/64, 14.1%, 95% CI 7.0−25.5% vs. OSNA 20/119, 16.8%, 95% CI 10.8−25.0%; P=0.79).

Conclusion: The OSNA whole node assay detects a far greater proportion of nonSN metastases than single-section histology in patients with positive SN biopsy. However, in terms of the AJCC staging system, upstaging rates from the SN stage were similar in both cohorts. Follow-up of the OSNA cohort is required to clarify the prognostic implications of this technique; this may lead to the establishment of a new breast cancer staging.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-08.

Accurate staging of axillary lymph nodes from breast cancer patients using a novel molecular method

Background:

The one-step nucleic acid amplification (OSNA) assay is a molecular-based lymph-node metastasis detection procedure that can assess a whole node and yields semi-quantitative results for the detection of clinically relevant nodal metastases. We aimed to determine the performance of the OSNA assay as an accurate nodal staging tool in comparison with routine histological examination.

Methods:

Subjects comprised 183 consecutive patients with pT1-2 breast cancer who underwent axillary dissection after positive sentinel-node (SN) biopsy with the OSNA assay. Of these, for non-SN evaluation, 119 patients underwent OSNA assay evaluation, whereas 64 had single-section histology. We compared the detection rates of non-SN metastasis and upstaging rates from the SN stage according to the American Joint Committee on Cancer staging between the OSNA and histology cohorts.

Results:

OSNA detected more cases of non-SN metastases than histology (OSNA 66/119, 55.5% vs histology 13/64, 20.3% P<0.001), particularly micrometastases (36/119, 30.3% vs 1/64, 1.6% P<0.001). Total upstaging rates were similar in both cohorts (20/119, 16.8% vs 9/64, 14.1%, P=0.79).

Conclusion:

OSNA detects a far greater proportion of non-SN micrometastases than routine histological examination. However, upstaging rates after axillary dissection were not significantly different between both cohorts. Follow-up of the OSNA cohort is required to determine its clinical relevance.

Abstract P1-11-13: Triple Negative or HER2 Positive Subtypes of Breast Cancer Groups Are Chemo-Sensitive, but Higher Rate of Brain Metastasis Contributes Poorer Prognosis

Background: The purpose of this study was to determine the primary chemosensitivity and prognosis among women with four common breast subtypes, Luminal A, Luminal B, HER2 and Triple negative (TN). In this study, we evaluated the response to primary chemotherapy of each subtype, reported the outcome of each subgroup after primary chemotherapy.

Method: We analyzed the outcome and characteristics of patients treated with primary chemotherapy using anthracycline and/or taxanes. Before initiation of chemotherapy, invasive carcinoma was confirmed on initial biopsy specimen obtained and hormone receptor status and HER2/neu status was also determined on this specimen. ER and PgR positivity was recognized at a cut-off of &gt; 10% positive nuclei by immunohistochemistory (IHC). HER2/neu-positive status was defined as either 3+ by IHC or presence of gene amplification by fluorescence in situ hybridization testing. Breast cancer subtypes were defied as follow, TN (ER-, PgR-, HER2-), Luminal A (ER+ and/or PgR+, HER2-), Luminal B (ER+ and/or PgR+, HER2+), HER2 (ER-, PgR-, HER2+).

Result: Between 2000 and 2007, 639 breast cancer patients were treated with primary chemotherapy at Cancer Institute Hospital. Clinical and immunohistochemical data was available on 503 patients. Median observation period was 49.9 months (2.8-122.4). In these cases, 105 cases (20.9%) were defined as TN, 276 cases (54.9%) were defined as Luminal A, 49 cases (9.7%) were defined as Luminal B, 73 cases (14.5%) were defined as HER2, respectively. 138 patients (27.4%) received anthracycline-based regimen, 139 patients (27.6%) received taxane, 227 patients (45.1%) received taxane-anthracycline combination regimen. The pathologic complete response (pCR) rate of each group was 15.2%, 2.0%, 8.2%, 16.4%, in TN, Luminal A, Luminal B, HER2, respectively (P&lt;0.001). The 5-yr disease free survival estimated 69.1%, 74.4%, 62.8%, 70.6% (p=0.140), and the 5-yr overall survival estimated 69.1%, 75.6%, 88.6%, 69.4% in TN, Luminal A, Luminal B, HER2, respectively (p=0.007). Mean survival time from the first recurrence was 21.1 months (95%CI 11.5-30.7), 40.6 months (95%CI 31.6-49.6), 81.8 months (95%CI 59.1-104.5), 30.0 months (95%CI 21.1-38.9), respectively (P&lt;0.001). According to the first recurrence, most frequent visceral metastatic site of TN and HER2 patients was brain (P&lt;0.001), and median time to brain metastasis was

13.2 months (95%CI 8.5-17.9). Surprisingly, three (21.4%) of the patients who had brain metastasis resulted in pCR by primary chemotherapy. Of note, Luminal A patients were more likely to have bone metastasis than other groups at first (p=0.003), and median time to bone metastasis was

16.3 months (95%CI 14.1-18.6).

Conclusions: With primary chemotherapy, pCR rate of TN and HER2 were higher than Luminal groups, but they developed brain metastasis early irrespective of pCR, this might contribute to their worse prognosis. In contrast, Luminal A developed bone metastasis at first, this might result in good prognosis instead of their low pCR rate.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-11-13.

Abstract P3-03-02: Molecular Detection of Micrometastasis in Sentinel Lymph Nodes Using One-Step Nucleic Acid Amplification Assay for Breast Cancer Patients — Comparison with Routine Pathological Examination

Background:

In AJCC 7th edition, Stage I breast tumors have been subdivided into Stage IA and Stage IB; Stage IB includes small tumors (T1) with exclusively micrometastases in lymph nodes (N1mi), in order to facilitate further investigation. However, it is obvious that the current routine pathological examination has the limitation to detect micrometastasis, because it can examine only a part of lymph node.

One-Step Nucleic acid Amplification (OSNA) assay was developed to overcome this limitation of the routine pathological examination. This assay can classify the patients into 4 categories, (++), (+), (+I), and negative. (++) and (+I) are theoretically regarded as high-volume metastasis corresponding to macrometastasis, and (+) as low-volume metastasis corresponding to micrometastasis. Since OSNA has the potential for standardization and semi-quantitative assay for evaluating the amount of tumor cells in a lymph node, we decided to apply a whole node into OSNA assay to maximize the semi-quantitative advantage in clinical settings. In the present study, we report the results of sentinel node (SN) examination with whole node OSNA assay. And we compare the results with the pathological examination to reveal the characteristics of OSNA assay. Patients and Methods:

Data of 961 patients from January 2008 to March 2010 with clinically node-negative and pT1 breast cancer and having received SN biopsy with the radioactive tracer were evaluated. SNs were examined by whole node OSNA assay with Gene Amplification Detector RD-100i and Lynoamp®BC or 2mm-thick intraoperative frozen section with H&E staining for 442 and 519 patients respectively.

We compared the performance of whole node OSNA assay and the pathological examination. And we performed two-population-z-test. Results:

1) SN positive rates of whole node OSNA assay and the pathological examination in T1 patients were 88/442 (19.9%, 95% CI; 16.3-24.0%) and 77/519 (14.8%, 95% CI; 11.9-18.3%), respectively. The difference was 5.1% (95% CI; 0.1-9.6%, p=0.046).

2) The populations of OSNA (++) or (+I) and macrometastasis were 51/442 (11.5%, 95% CI; 8.8-15.0%) and 55/519 (10.6%, 95% CI; 8.1-13.6%), respectively. There was no significant difference. On the other hand, the populations of OSNA (+) and micrometastasis were 37/442 (8.4%, 95% CI; 6.0-11.5%) and 22/519 (4.2%, 95% CI; 2.7-6.4%), respectively. The difference was 4.1% (95% CI; 0.9-7.0%, p=0.012).

Conclusions:

OSNA assay could detect more low-volume metastases corresponding to micrometastasis than the routine pathological examination. Therefore, it is suggested that OSNA can select accurate SN/micrometastasis cohort. Follow up of the patients is required to clarify the prognosis of OSNA (+) patients, and as the result, it may be possible to establish the new breast cancer staging system using OSNA results.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-03-02.

The feasibility of sentinel node biopsy in the previously treated breast

PURPOSE

Sentinel lymph node biopsy (SNB) has been a standard technique in early breast cancer. However, it is not clear that the SNB procedure can be applied to second breast cancer or recurrence occurring in the previously treated breast. The purpose of this study was to clarify the feasibility of the SNB procedure in breast cancer occurring in the previously treated breast, and to investigate the factors related to altered lymphatic flow.

PATIENTS AND METHODS

Between April 2004 and December 2006, 1490 patients underwent the breast SNB procedure. Among them, 31 patients had a history of previous treatments in the same breast. Recent excision biopsy cases were not included in this group. All patients had previous breast-conserving surgery in the same breast. Sixteen patients had axillary dissection, 3 had SNB, and 12 had no axillary treatment. Ten patients had received radiation therapy to the breast and axilla. Visualization of axillary nodes, internal mammary nodes and contralateral axillary nodes was evaluated and compared with pathological results.

RESULTS

Axillary nodes were visualized in 23 patients, internal mammary nodes in 7 patients, and contralateral axillary nodes in 7 patients. The patients with previous axillary dissection exhibited altered lymph node distribution, but did not show involvement of contralateral axillary nodes. Visualization of contralateral axillary nodes occurred in 7 of the 10 patients with previous irradiation to breast irrespective of axillary dissection. Twenty-eight patients underwent SNB, 4 of whom showed cancer-positive nodes. Three patients were cancer-positive in non-ipsilateral axillary nodes (one patient showed positive opposite axillary node and two patients showed positive internal mammary nodes).

CONCLUSION

Previous axillary dissection or irradiation to the breast greatly influences lymphatic flow. Irradiation to the breast may be a strong factor for the visualization of contralateral axillary nodes. Despite the frequent alteration of lymphatic flow, SNB seems to be feasible in secondary or recurrent breast cancer patients.

Optimal indications of endocrine therapy alone as adjuvant systemic treatment of breast cancer

We examined the validity of the St Gallen algorithm for Japanese breast cancer patients and sought the optimal indications of endocrine monotherapy as adjuvant systemic treatment. According to the 2005 St Gallen algorithm, endocrine responsiveness (responsive, uncertain, or non-responsive) and recurrence risk (low, intermediate, or high) were assessed in 436 invasive breast cancer patients, who underwent surgery and adjuvant therapy of tamoxifen alone in 1982–1993. Furthermore, intermediate-risk patients were divided into three groups based on lymph node metastasis and number of risk factors as follows: Group A, negative lymph node metastasis and one risk factor; Group B, negative lymph node metastasis and two to five risk factors; and Group C, positive lymph node metastasis. Cumulative 10-year recurrence-free survival (RFS) rates of each type were calculated. Recurrence-free survival was as follows: endocrine responsiveness; responsive: 86.0%, uncertain: 79.5%, non-responsive: 72.4%, risk category; low: 93.3%, intermediate: 84.0%, high: 59.6%, intermediate-risk patients; Group A: 93.5%, Group B: 88.2%, and Group C: 75.0%. In conclusion, patient classification based on St Gallen algorithm appears valid in Japanese breast cancer patients. Endocrine monotherapy may be sufficient as adjuvant treatment in the intermediate-risk patients, in which only one risk factor was present without any metastatic involvement in lymph node.

A case of malignant fibrous histiocytoma after breast conserving therapy for breast cancer

A 45-year-old woman with malignant fibrous histiocytoma (MFH) of the breast following breast conserving therapy (BCT) is described. She noticed a lump in her left breast 52 months after BCT for breast cancer. The lump was excised and nodular fasciitis was initially diagnosed. However, the tumor recurred locally 4 times in the next 18 months. MFH was finally diagnosed. This case is considered to be radiation-induced sarcoma. The risk of radiation-induced sarcoma after BCT seems to be very low, however careful follow-up is necessary.