A-Yong Cao

Mutation analysis of BRIP1/BACH1 in BRCA1/BRCA2 negative Chinese women with early onset breast cancer or affected relatives

The proper interaction between BRIP1/BACH1 and BRCA1 protein has been found to be crucial for BRCA1-mediated DNA double-strand break repair and BRIP1/BACH1 mutations were estimated to confer a relative risk for breast cancer of 2.0 in western populations. In Chinese population, BRCA1 mutations could explain a relatively large proportion of inherited breast cancer cases in comparison with BRCA2 mutations, which probably deduced a hypothesis that those genes involved in BRCA1-mediated DNA repair pathway might play a more significant role in the etiology of Chinese breast cancer. To investigate the contribution of BRIP1/BACH1 mutations to the predisposition of Chinese non-BRCA1/BRCA2 hereditary breast cancer, we screened all the coding exons and adjacent intronic splice junction regions of BRIP1/BACH1 in 357 Chinese women with early-onset breast cancer or affected relatives from five different breast disease clinical centers in China, using PCR-DHPLC and DNA sequencing analysis. Some genetic variants identified in the cases were then studied in 864 normal controls with no personal or family history of breast cancer. We found no protein-truncated mutations in our population, while a novel recurrent non-synonymous variant, Q944E, was detected in two independent families in contrast with none in the controls, interestingly, this alteration occurs in the BRCA1 binding domain of the BACH1 protein. Then a further study performed on the two mutation positive families revealed the partial co-segregation of this mutation allele with cancer. The novel alteration Q944E identified in our study possibly represents a rare disease-related allele, nevertheless functional analysis is still warranted to resolve the ability of this altered BACH1 protein to bind BRCA1. Altogether, the results of our study indicated that germline mutations in BRIP1/BACH were extremely rare in Chinese population and there was no evidence for the recommendation of BRIP1/BACH1 for genetic testing in Chinese.

Treatment outcomes and unfavorable prognostic factors in patients with occult breast cancer.

AIMS The purpose of this study was to evaluate the treatment outcomes and prognostic factors in patients with occult breast cancer (OBC). METHODS We retrospectively analyzed 95 patients with OBC who were treated at our facility between January 1998 and June 2010. Of the 95 patients, 64 underwent mastectomy plus axillary lymph node dissection (ALND) with or without post-mastectomy radiation (Mast + ALND group), 13 underwent ALND followed by ipsilateral breast radiotherapy (BR + ALND group) and the remaining 18 were treated with ALND (ALND group). RESULTS Patients who underwent Mast + ALND or BR + ALND had significantly improved rates of locoregional recurrence-free survival (LRFS) and recurrence/metastasis-free survival (RFS) than patients who only underwent ALND (p < 0.05). There were no significant differences in the LRFS (p = 0.718), RFS (p = 0.935) and breast cancer-specific survival (BCSS) (p = 0.991) rates between the patients who underwent Mast + ALND compared with those who received BR + ALND. Multivariate analysis revealed that patients with four or more involved lymph nodes had significantly worse outcomes (p = 0.042, HR = 4.63, 95% CI = 1.66-32.47 for BCSS and p = 0.038, HR = 3.62, 95% CI = 1.08-20.77 for RFS). CONCLUSIONS Patients with OBC who received ALND and subsequent breast radiotherapy had similar outcomes to patients who underwent mastectomy. The presence of four or more involved lymph nodes may independently predict poor outcomes of OBC.

Some common mutations of RAD50 and NBS1 in western populations do not contribute significantly to Chinese non-BRCA1/2 hereditary breast cancer

To the editor Breast cancer is one of the main causes of cancer-related deaths among women worldwide, with 5–10% of cases being attributed to germline mutations in major genes. Former genetic linkage analysis revealed that the etiology of a relatively large proportion of Chinese potential hereditary breast cancers could not be explained by BRCA1 or BRCA2 mutations [1]. RAD50 is one of the highly conserved DNA double-strand (DSB) break repair factors. Together with NBS1 and MRE11, it composes the Mre11 complex and functions in sensing and early processing of DSB, cell cycle checkpoints, DNA recombination, and maintenance of telomeres [2]. Heterozygosity for deleterious mutations in components of the RAD50-MRE11-NBS1 complex seems to influence risk of breast cancer. The initial finding of mutations in Rad50 and NBS1 associated with breast cancer risk is consistent with the involvement of DNA repair genes in carcinogenesis [3], and mutations in those genes seem to be moderately penetrant but infrequent. This study is a continuation of our efforts to determine the role of some known common mutations of RAD50 and NBS1 in western populations in the development of non-BRCA1/2 Chinese families with signs of hereditary susceptibility to breast cancer. High-risk breast cancer patients were recruited and collected through four different medical centers which were described in our previous study [4]. The index cases included should match the following criteria: (1) at least one firstor second-degree relatives with breast cancer and/or ovarian cancer, regardless of age; or (2) breast cancer diagnosed below 35 years of age. Written informed consent was obtained from all subjects in accordance with institutional guidelines. Previous testing had confirmed the included cases to be BRCA1/2 mutation negative. Altogether 192 cases came from independent families were identified, the average age at diagnosis of breast cancer was 42.2 years, ranging between 23 and 81. The family histories concerning four-generation pedigrees of all the eligible cases were retrieved from the medical records and standard questionnaires, ascertained by the families and/or the patients personally. Six of the families in our study were breast-ovarian cancer families. A total of 192 women with no personal or family history of cancer were enrolled as normal control from Cancer Hospital of Fudan University between 2003 and 2007. This project has been approved by the Scientific and Ethical Committee of the Cancer Hospital of Fudan University. Oligonucleotide primers and polymerase chain reaction (PCR) conditions as former publications were used to amplify the specific segments which spanned the three mutation spots (RAD50 687delT, NBS1 657del5 and NBS1 I171 V) [3, 5, 6]. The PCR and DNA sequencing analysis were performed as described previously [4]. Full sequencing of all the index cases did not revealed the Rad50 687delT mutation in any case, and we did not find any other deleterious mutations in exon 5 of RAD50. In addition, our analysis of sequence variations in the 5 and 6th exon of NBS1 indicated that 657del5 and I171 V were not present in our cohort of high-risk breast cancer cases and control individuals, and the common polymorphismQ185E identified in our study had a similar frequency in cases and controls, which implied that it was unlikely to be associated with an increased risk for breast cancer in Chinese population (Table 1). A.-Y. Cao Z. Hu W.-J. Yin W. Jin Z.-M. Shao (&) Breast Cancer Institute, Cancer Hospital/Cancer Institute, Department of Oncology, Shanghai Medical College, Institutes of Biomedical Science, Fudan University, 270 Dong’an Road, 200032 Shanghai, People’s Republic of China e-mail: zhimingshao@yahoo.com

Clinicopathologic characteristics at diagnosis and the survival of patients with medullary breast carcinoma in China: a comparison with infiltrating ductal carcinoma-not otherwise specified

BackgroundFew studies have addressed the biological features of medullary breast carcinoma (MBC) in the context of clinical outcomes. We sought to compare the baseline demographics, standard pathologic factors and long-term clinical outcomes between MBC and infiltrating ductal carcinoma-not otherwise specified (IDC-NOS) using a large database.MethodsA total of 2,202 cases with pure IDC-NOS and 188 cases with typical MBC meeting the inclusion criteria were identified. The clinical and biological features, the overall survival (OS) and recurrence/metastasis-free survival (RFS) were compared for both groups.ResultsThere were a higher proportion of patients diagnosed prior to 40 years of age in the MBC group compared to the IDC-NOS group. MBC cases demonstrated less aggressive tumor features such as lower tumor stage, smaller tumor size and a lower proportion of nodal involvement than IDC-NOS; however, immunohistochemical staining revealed that MBC displayed the triple-negative phenotype more often than IDC-NOS cases (40.4% versus 26.2%; P <0.001). Although the clinical behavior of MBC was not commensurate with its pathologic features, women diagnosed with MBC had a lower frequency of recurrence/metastasis (P = 0.032) and death (P = 0.042) than those with IDC-NOS, and the 10-year OS and RFS were significantly higher for MBC (91% and 74%) compared to IDC-NOS (81% and 64%). Moreover, multivariate analysis revealed that TNM stage was a statistically significant factor for survival.ConclusionsMBC in Chinese women demonstrated less aggressive behavior and better prognosis than IDC-NOS. This favorable outcome was maintained after 10 years.

Mutation screening of breast cancer susceptibility genes in Chinese high-risk families: The results will develop the genetic testing strategy in China

Inactivating mutations in 10 different genes in pathways critical to genomic integrity have been confirmed to be associated with inherited breast cancer in different ethnic groups [1]. We conducted a large-scale and systemic mutation analysis of BRCA1, BRCA2, p53, BRIP1, PALB2 and CHEK2 c.1100delC among 591 patients with early-onset (B35 years) breast cancer or affected relatives in China within 4 years, and the results contributed to the development of the genetic testing strategy in Chinese high-risk breast cancer families. All the included individuals were collected from six different medical centers located in southern and northern China, and were genetically independent ethnic Han Chinese. A total of 550 unrelated patients were analyzed for BRCA1 and BRCA2 mutations. The mutation frequency of BRCA1/2 in Chinese population was 9.45%, with 7.5% in early-onset and 13.4% in familial patients. When those patients with both early-onset breast cancer and affected relatives were concerned, the mutation frequency was up to 22.8%. We also observed that in patients with a family history of ovarian or gastric cancer, the incidence of BRCA1/2 mutation was about twice or more as that in patients without reporting the family history of these malignancies. The two recurrent BRCA1 mutations identified in our study, 1100delAT and 5589del8, accounted for 33.3% (8/24) of the deleterious mutations identified in BRCA1 gene, and haplotype analysis indicated that there might be some degree of shared ancestry for the two mutations in Chinese [2]. Among 240 non-BRCA1/2 patients without the phenotype of Li-Fraumeni syndrome (LFS) or Li-Fraumeni-like syndrome (LFL), we detected two novel germ line mutations (563T[C and 643_660del18) of p53, neither of which appeared in 768 normal controls. Functional assays revealed that they should be associated with the increasing risk of breast cancer [3]. PALB2 and BRIP1 have been recently identified as breast cancer susceptibility genes, which can colocalize with BRCA2 and BRCA1, respectively, at sites of DNA damage, and then contribute to their DNA repair function [1]. In our analysis, two truncating mutations of PALB2, 751C[T and 1050_1051delAAinsTCT, were identified in three independent patients with wild-type sequences at BRCA1 and BRCA2 (1% of the series), and that 751C[T was a recurrent mutation. We found that exon 4 accounted for 44.1% (15/34) of the person-times carrying any variant in PALB2 gene [4]. In BRIP1, we did not detect any protein-truncated mutation except a novel recurrent nonsynonymous variant (2971C[G, resulting in Q944E) [5]. Truncating allele 1100delC of CHEK2 has a frequency of 0.002-0.005 in northern Europe populations, but our results did not demonstrate the presence of CHEK2 c.1100delC among 114 studied patients [6]. At present, in view that much associated evidence in terms of the implications for breast cancer management in BRCA mutation carriers, current genetic testing still limits to BRCA genes, and there is growing evidence that BRCA mutation status may influence treatment recommendations [7]. Genetic testing for inherited breast cancer susceptibility has become a standard of care option for appropriately selected patients in the developed countries [8], while in China, little has been recognized. Recent trends show that A-Y. Cao Z. Hu Z.-M. Shao (&) Breast Cancer Institute, Cancer Hospital/Cancer Institute, Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong’an Road, 200032 Shanghai, People’s Republic of China e-mail: zhimingshao@yahoo.com

The spectrum of BRCA mutations and characteristics of BRCA-associated breast cancers in China: Screening of 2,991 patients and 1,043 controls by next-generation sequencing

To characterize the prevalence of BRCA mutations and characteristics of BRCA carriers in China and to update the clinical recommendations for BRCA testing, we conducted a wide screen for BRCA mutations using next‐generation sequencing (NGS). A total of 4,034 Chinese subjects were screened for germline BRCA1/2 mutations, including 2,991 breast cancer patients and 1,043 healthy individuals from the community enrolled as controls. We developed an NGS‐based approach to perform BRCA1/2 screening. BRCA mutations were identified in 9.1% (232/2,560) of cases with at least one risk factor, in 3.5% (15/431) of sporadic patients and in 0.38% (4/1,043) of healthy controls. The mutation frequency ranged from 8.9 to 15.2% in cohorts with a single risk factor to 16.6–100% in groups with multiple risk factors. We identified 70 novel BRCA mutations. A high frequency of BRCA1 c.5470_5477del was detected, accounting for 13.9% (16/115) of the BRCA1 mutations detected in our study. Clinical characteristics such as family history, invasive carcinoma, negative human epidermal growth factor receptor 2 (HER2), high Ki67 index, lymph node status, and high tumour grade were closely related to BRCA mutations. BRCA2 carriers had poorer disease‐free survival among HER2‐ or hormone receptor‐positive patients (hazard ratio = 1.892; 95% confidence interval: 1.132–3.161; p = 0.013). This study shows that BRCA mutation carriers could be frequently identified among breast cancer patients with multiple risk factors. Importantly, we established an NGS‐based pipeline for BRCA1/2 testing in clinical practice and strongly suggest that breast cancer patients of premier‐ and moderate‐grade risks receive BRCA1/2 mutations testing in China.

Tumor characteristics and the clinical outcome of invasive lobular carcinoma compared to infiltrating ductal carcinoma in a Chinese population

BackgroundWe sought to compare the baseline demographics, standard pathologic factors and long- term clinical outcomes between ILC and infiltrating ductal carcinoma (IDC) using a large database.MethodsClinicopathologic features, overall survival (OS), and recurrence/metastasis-free survival (RFS) were compared between 2,202 patients with IDC and 215 patients with ILC.ResultsILC was significantly more likely to be associated with a favorable phenotype, but the incidence of contralateral breast cancer was higher for ILC patients than for IDC patients (8.4% vs. 3.9%; P =0.001). The frequencies of recurrence/metastasis (P = 0.980) and death (P = 0.064) were similar among patients with IDC and patients with ILC after adjustment for tumor size and nodal status. The median follow-up was 42.8 months.ConclusionsChinese women with ILCs do not have better clinical outcomes than their counterparts with IDC. Management decisions should be based on individual patient and tumor biologic characteristics, and not on lobular histology.

Epidural Combined with General Anesthesia versus General Anesthesia Alone in Patients Undergoing Free Flap Breast Reconstruction.

Background: Addition of epidural anesthesia may have several benefits. The purpose of this study was to investigate the effectiveness and safety of epidural anesthesia combined with general anesthesia in patients undergoing free flap breast reconstruction. Methods: A retrospective chart review identified 99 patients who underwent free flap breast reconstruction under general anesthesia alone (46 patients) or general anesthesia plus epidural anesthesia (53 patients) between 2011 and 2014. Mean arterial blood pressure was measured before induction, after flap elevation but before flap transfer, 15 minutes after flap revascularization, and at the end of surgery. Postoperative pain was assessed using a visual analogue scale. Results: The incidence of flap thrombosis was 3.8 percent in the epidural anesthesia/general anesthesia group versus 4.3 percent in the general anesthesia group (p = 1). Flap failure was 0 percent in the epidural anesthesia/general anesthesia group versus 4.3 percent in the general anesthesia group (p = 0.213). Patients in the epidural anesthesia/general anesthesia group had lower visual analogue scale scores at 2 hours (0.76 ± 0.62 versus 2.58 ± 0.99; p < 0.001), 6 hours (1.94 ± 1.19 versus 4.04 ± 1.46; p < 0.001), and 24 hours (0.74 ± 0.69 versus 1.56 ± 1.01; p < 0.001) postoperatively. Mean arterial blood pressure was lower in the epidural anesthesia/general anesthesia group after flap elevation but before flap transfer, 15 minutes after flap revascularization, and at the end of surgery. Conclusion: Epidural anesthesia/general anesthesia combination improves postoperative pain and side effects without increasing the risk of flap thrombosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Preventive Intervention of Hereditary Breast Cancer

Approximately 5-10% of breast cancer is considered to be hereditary. Familial breast cancers exhibit a dominant hereditary pattern, which typically have an early age of onset and are accompanied by symptoms of ovarian cancer, bilateral breast cancer, or male breast cancer. BRCA gene mutation carriers should be regarded as high-risk groups for breast cancer, which necessitates early examination of breast cancer. Studies have built up kinds of predictive models and recommended that female BRCA mutation carriers should receive breast self-test training and take monthly breast self-examination. Familial or hereditary breast cancer family members are high-risk groups, and their risks of breast cancer can be reduced by chemoprevention, including dietary composition adjustment and application of endocrine drugs. In recent years, large-scale clinical trials have shown the important role of chemoprevention in reducing the occurrence of hereditary breast cancer. Prophylactic mastectomy is also suitable for healthy women with high breast cancer risk factors. It can reduce the incidence rate of breast cancer in high-risk women by 90% and decrease the breast cancer mortality rate in medium-risk and high-risk women by 100% and 81%, respectively.