Basilio Dueñas

Is it possible to increase pCR in the neoadjuvant treatment with a dose-dense/sequential combination?: results from a phase II Trial combining epirubicin and cyclophosphamide followed by paclitaxel and gemcitabine ± trastuzumab in stage II and III breast cancer patients.

Purpose:To evaluate the pathologic complete response (pCR) rate of a combination of epirubicin (E) and cyclophosphamide (C) followed by paclitaxel (P) and gemcitabine (G) (+ trastuzumab[T]) in Her2+ patients) in a sequential and dose-dense schedule as neoadjuvant chemotherapy for stages II and III patients with breast cancer. Secondary endpoints: clinical response rate, disease free survival, safety and correlation between pCR and biologic markers. Patients and Methods:Eligible patients were treated with E (90 mg/m2) and C (600 mg/m2) for 3 cycles (first sequence) followed by P (150 mg/m2) and G (2500 mg/m2) (second sequence) for 6 cycles. All drugs were administered on day 1, every 2 weeks, with prophylactic growth factor support. Weekly T (2 mg/kg [4 mg/kg first infusion]) was administered concomitantly with P and G in Her2+ patients. A core biopsy was performed before treatment for biologic markers assessment. Patients underwent surgery, radiotherapy, and adjuvant hormonal therapy according to institutional practice. Results:Seventy-three patients were treated. A pCR was achieved in 27 (37%) patients (32.1%, Her2− and 50%, Her2+). pCR was significantly higher in tumors that were hormonal receptor negative, poorly differentiated and positive for Ki67 and p53. Breast-conserving surgery was performed in 47 patients (64.4%). Most frequent grade 3/4 hematologic and nonhematological toxicities included neutropenia (12%), nausea/vomiting (17%), and transient liver enzymes elevation (7%). One patient suffered an asymptomatic and reversible decrease in left ventricular ejection fraction. Conclusions:These results show a highly effective regimen in terms of pCR with a good toxicity profile in the neoadjuvant treatment of patients with breast cancer. The addition of trastuzumab increased pCR rate in Her2+ tumors.

Renin angiotensin system-regulating aminopeptidase activities in serum of pre- and postmenopausal women with breast cancer.

Angiotensin peptides regulate vascular tone and natriohydric balance through the renin angiotensin system (RAS) and are related with the angiogenesis which plays an important role in the metastatic pathway. Estrogen influences the aminopeptidases (APs) involved in the metabolism of bioactive peptides of RAS through several pathways. We analyze RAS-regulating AP activities in serum of pre- and postmenopausal women with breast cancer to evaluate the putative value of these activities as biological markers of the development of breast cancer. We observed an increase in aminopeptidase N (APN) and aminopeptidase B (APB) activities in women with breast cancer; however, a decrease in aspartyl-aminopeptidase (AspAP) activity in premenopausal women. These results suggest a slow metabolism of angiotensin II (Ang II) to angiotensin III (Ang III) in premenopausal women and a rapid metabolism of Ang III to angiotensin IV (Ang IV) in pre- and postmenopausal women with breast cancer. An imbalance in the signals activated by Ang II may produce abnormal vascular growth with different response between pre- and postmenopausal women depending on the hormonal profile and the development of the disease.

Renin-Angiotensin System-Regulating Aminopeptidase Activities Are Modified in the Pineal Gland of Rats with Breast Cancer Induced by N-Methyl-Nitrosourea

Objective: Pineal function has been considered particularly as a neuroendocrine modulator in hormone responsive tumors, like the hormone-dependent mammary tumors. The complexity of the gland function, moreover, is denoted by the presence of a local renin-angiotensin-system (RAS) that regulates melatonin biosynthesis. Classically, angiotensin II (Ang II) has been considered as the effector peptide of the RAS, but Ang II is not the only active peptide. Several of its degradation products, including angiotensin III (Ang III) and angiotensin IV (Ang IV) also possess biological functions. These peptides are formed via the activity of several aminopeptidases. Our aim is to know their role in the regulation of pineal RAS and breast cancer. Design: Aminopeptidase N (APN), aminopeptidase B (APB) and aminopeptidase A (aspartyl- and glutamyl-aminopeptidase, APA) activities are measured in the pineal gland of rats with breast cancer induced by N-methyl nitrosourea (NMU). Methods: Aminopeptidase activities were measured fluorimetrically using their corresponding aminoacyl-ß-naphthylamides as substrates. Results: Specific APN and APB activities in pineal gland of controls and NMU-treated rats were not modified. Aspartyl aminopeptidase activity significantly decreased in NMU-treated rats when compared with control group. On the contrary, glutamyl aminopeptidase activity did not show significant differences between groups. Conclusions: We propose that the local RAS in pineal gland is modified in rats with breast cancer induced by NMU through the inhibition of AspAP activity, which may lead to increased levels of Ang II. Ang II could be responsible of the overproduction of melatonin, supporting a mechanism to restrain the promotion and/or progression of breast cancer.

Neoadjuvant chemotherapy modifies serum angiotensinase activities in women with breast cancer

PURPOSE The aim of this study was to investigate the putative changes in serum angiotensinase activities (aminopeptidase N, APN; aminopeptidase B, APB; aminopeptidase A, APA; aspartyl aminopeptidase, ASAP) involved in the renin-angiotensin system (RAS) in women with breast cancer treated or not with a neoadjuvant therapy of paclitaxel and anthracycline and in healthy women volunteers. METHODS We fluorometrically analysed serum APN, APB, APA and ASAP activities using their corresponding aminoacyl-β-naphthylamides as substrates in women with breast cancer treated with a neoadjuvant therapy of paclitaxel and anthracycline. RESULTS When compared with healthy controls, women with breast cancer not treated with neoadjuvant chemotherapy, showed a decrease in angiotensinase activity, which support the putative increase of angiotensin II (Ang II) levels, indicating that the tumour process would favour the development of the disease. Also, an increase in APN and APB activities was observed, which support a role for angiotensin IV (Ang IV). In women treated with a neoadjuvant therapy, we described an increase in ASAP and APA activities, supporting the idea that this treatment increases Ang II catabolism. The resulting decrease in Ang II level could lead to an inhibition of the tumour growth. CONCLUSION Present results show changes in serum angiotensinase activities in women with breast cancer and in women with breast cancer treated with a neoadjuvant therapy of paclitaxel and anthracycline. Therefore, considerable attention should be focused on the development of RAS blockade therapy as a new strategy for breast cancer treatment.

Circulating oxidative stress parameters in pre- and post-menopausal healthy women and in women suffering from breast cancer treated or not with neoadjuvant chemotherapy

We evaluate here the redox status in pre- and post-menopausal healthy women and in women with breast cancer in order to understand the consequences of the hormonal alterations of menopause for the oxidative stress status, its modifications with breast cancer and the influence of neoadjuvant chemotherapy (NC). To that, serum oxidative stress parameters (total antioxidant capacity, lipid peroxidation and protein oxidation), non-enzyme antioxidant defenses (total glutathione, uric acid and bilirubin) and enzyme antioxidant defenses (superoxide dismutase, catalase and glutathione peroxidase activities) were measured in healthy women and in women with breast cancer divided according to their menopausal status and that received or not NC. Circulating estradiol, progesterone, FSH and LH were also analyzed. We found that menopause itself modifies the redox status of healthy women, being most of these differences also reflected in women with breast cancer. However, several changes occur as a consequence of the disease. Furthermore, NC increases oxidative damage, decreases antioxidant defenses and eliminates the differences found in menopause. We conclude that the normal redox balance is disrupted by breast cancer but is also affected by the hormonal status promoted by menopause. In fact, NC nullifies the differences found between pre- and postmenopausal women in several antioxidant defense systems.

Putative relationship between hormonal status and serum pyrrolidone carboxypeptidase activity in pre- and post- menopausal women with breast cancer

In breast cancer, hormonal changes are rather constant in post-menopausal women since they tend to vary only over long time spans. However, in pre-menopausal women, the development of breast cancer is associated with hormonal physiological variations. The aim of the present work was to analyse the changes in circulating levels of gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in pre- and post-menopausal women that were healthy or with breast cancer, and their connection to serum pyrrolidone carboxypeptidase (Pcp) activity. We observed significant changes in the hormonal profile in post-menopausal women with breast cancer compared to the control group. In pre-menopausal women, we found significant changes in circulating GnRH levels with respect to the healthy group. Our present results support the existence of neuroendocrine misregulation that could be involved in tumour progression, with Pcp being a potentially new pharmacological target in breast cancer treatments.

Redox status in the sentinel lymph node of women with breast cancer

Abstract Background: Lymphatic metastasis is regulated in multiple steps including the transit of tumor cells via the lymphatic vessels and the successful seeding in draining lymph nodes. Thus, several molecular signals and cellular changes must be involved in this complex process to facilitate tumor cell entry, colonization, and survival in the lymph node. To our knowledge, the present work explores, for the first time in the literature, the redox status (oxidative stress parameters and enzymatic and non-enzymatic antioxidant defense systems) in the sentinel lymph node (SLN) of women with breast cancer. Patients and methods: SLNs from 75 women with breast cancer were identified using the one-step nucleic acid amplification (OSNA) method as negative (n = 43), with micrometastases (n = 13), or with macrometastases (n = 19). It will allow us to gain knowledge about the pro-oxidant/antioxidant mechanisms involved in the processes of distant metastases in breast cancer and also to assess whether these parameters may be alternative techniques for staging. Results: We found different levels of lipid peroxidation in SLNs with micrometastases (increased) and macrometastases (decreased), a decrease in carbonyl group content in SLNs with macrometastases only, and an increase in total antioxidant capacity (TAC) in SNLs with micrometastases and macrometastases. A decrease in the levels of reduced glutathione (GSH) also appears in the SLNs with macrometastases only. Finally, we show increased levels of superoxide dismutase (SOD) and catalase (CAT) activity in SLNs with micrometastases and macrometastases, and decreased levels of glutathione peroxidase (GPx) activity in SNLs with macrometastases but not with micrometastases. Conclusions: Redox status of lymph node microenvironment participates in the progression of metastatic breast cancer.

SERUM PYRROLIDONE CARBOXYPEPTIDASE ACTIVITY IS MODIFIED IN POSTMENOPAUSAL BUT NOT PREMENOPAUSAL WOMEN WITH BREAST CANCER

189 Citation: Maturitas Volume 63, Supplement 1, May 2009, Page S51 SERUM PYRROLIDONE CARBOXYPEPTIDASE ACTIVITY IS MODIFIED IN POSTMENOPAUSAL BUT NOT PREMENOPAUSAL WOMEN WITH BREAST CANCER M.J. Ramirez-Exposito, M.P. Carrera-Gonzalez, B. Duenas, J.M. Martinez-Martos 1 University of Jaen, Jaen, Spain; University of Jaen, Health Sciences, Jaen, Spain; Complejo Hospitalario de Jaen, Jaen, Spain Objectives: Pyrrolidone carboxypeptidase (Pcp) (E.C. 3.4.19.3), is an omega peptidase widely distributed in fluids and tissues and hydrolyses N-terminal pyroglutamic residues from biologically active peptides such as gonadotropin releasing hormone (GnRH). Previous results obtained by us showed a decrease in human breast cancer tissue Pcp activity, suggesting that this enzyme activity or its putative substrates may play a major role in breast cancer pathogenesis. The aim of the present work is to analyse serum Pcp activity in preand postmenopausal women with breast cancer and to compare it with their respective controls. Methods: We measured fluorometrically serum Pcp activity using pyroglutamyl-beta-naphthylamide as substrate in 57 women diagnosed with ductal infiltrating carcinomas. Results: Healthy postmenopausal women showed higher values of Pcp activity than premenopausal women (98.69±4.94.vs 79.06±4.37 pmol/min/mg protein). On the contrary, no differences were found in serum Pcp activity between preand postmenopausal women with breast cancer (75.62±4.42 vs 79.71±4.63 pmol/min/mg protein). Conclusions: The present results document changes in Pcp activity in serum of postmenopausal but not premenopausal women with breast cancer. These changes may reflect the functional status of the enzyme substrates, which can be selectively activated or inhibited as a result of specific conditions brought about by the tumor under different hormonal conditions. In this connection, GnRH receptors and GnRH mRNA have been found in breast tissue, raising the possibility of a local role for GnRH in the human mammary gland.

Safety and efficacy of neo-adjuvant sequential dose-dense chemotherapy doublets combined with trastuzumab in patients with HER-2-positive early stage breast cancer.

To the Editor: Neo-adjuvant chemotherapy is increasingly used in the management of early breast cancer. This strategy is indicated in patients with locally advanced breast cancer and has shown to increase the rate of breastconserving surgery. Neo-adjuvant chemotherapy is also an excellent in vivo chemosensitivity test that enables the rapid and direct assessment of tumor response, allowing the testing of new drug treatments for patients with early stages of the disease. Likewise, pathologic complete response (pCR) is a powerful predictor of both prolonged disease-free and overall survival (1–4). The aim of the present study was to evaluate the efficacy, measured as pCR rate and safety of dose-dense chemotherapy doublets (sequential treatment of cyclophosphamide and epirubicin followed by paclitaxel and gemcitabine) combined with the targeted agent trastuzumab as neo-adjuvant treatment in patients diagnosed with stage II and III breast cancer, including inflammatory disease, with HER-2 overexpression (3+ by immunohistochemistry or fluorescence in situ hybridization-positive). pCR was defined as the absence of invasive tumor in the breast. Patients with only carcinoma in situ were also considered to have pCR. Treatment consisted of a first sequence with epirubicin 90 mg ⁄ m (15-minute infusion) and cyclophosphamide 600 mg ⁄ m (30-minute infusion) for a total of three cycles and a second sequence with paclitaxel 150 mg ⁄ m (3-hour infusion) and gemcitabine 2,500 mg ⁄ m (60-minute infusion) to a total of six cycles. All drugs were administered intravenously on day one every 2 weeks with prophylactic growth factor support (5 days of subcutaneous injections per course). Weekly trastuzumab was administered at a dose of 2 mg ⁄ kg (infusion 60 minutes) (loading dose of 4 mg ⁄ kg, 90-minute infusion), concomitantly with paclitaxel and gemcitabine to a total of 12 doses. Subsequently, they underwent surgery and received radiotherapy and ⁄ or adjuvant hormonal therapy according to physician criteria. A tru-cut biopsy was performed before treatment for the assessment of biologic markers (hormone receptors, HER2 status, Ki-67 labeling index, and p53 levels). A total of 20 patients with early stage breast cancer were enrolled in the study. Baseline patient characteristics are summarized in Table 1. All patients achieved clinical response after treatment and 50% (95% CI: 28.1–71.8%) had a pCR that is in agreement with other reports of preoperative treatment in similar groups of patients with HER2-positive breast cancer (range of pCR rates: 47–65%) although none of the previous studies included patients with T4 lesions, including inflammatory disease (5,6). It should be noted, however, that three of these patients had in situ residual disease in the breast. After a median followup of 18.2 months, three patients had progressed. Patients with less differentiated tumors and high proliferative index were more likely to achieve a pathologically complete response (Table 2). Despite the high rate of pCR, a high proportion of patients underwent radical surgery (55%) because of the initial large tumor size. The regimen was very well tolerated with very few occurrences of grade III-IV toxicities (neutropenia [three patients], nausea [one patient], and vomiting [one patient]). Trastuzumab treatment was interrupted in one patient because of reduction of left ventricular ejection fraction (LVEF) to 43%. The patient remained asymptomatic and experienced a subsequent increase in LVEF up to 53%. Despite the small sample size, the regimen showed a good safety profile as well as promising anti-tumor activity in patients with HER2-positive early breast Address correspondence and reprint requests to: Alfonso SanchezMunoz, MD, Poeta Francisco Coronado y Delicado, 4,3 -C, 19011, Malaga, Spain, or e-mail: asmoncomed@yahoo.ex.