Bing Sun

Gene Expression Profiling for Breast Cancer Prognosis in Chinese Populations

Abstract:u2002 To investigate a quantitative reverse transcription polymerase chain reaction (QRT‐PCR) assay different from 21‐gene assay which can be used to prognosticate the risk of recurrence in patients with estrogen receptor (ER) positive, lymph node (LN) negative breast cancer. To accurately determine the relationship between the Recurrence Score (RS) derived from our assay and the risk of distant recurrence in Chinese patients with LN negative and positive breast cancer through the analysis of paraffin tissues. We obtained archival paraffin‐embedded tissues from patients with invasive breast cancer and varying axillary lymph node involvement. QRT‐PCR reaction was performed by using the method of SYBR Green I dye with primers. Expression of the 21‐genes was converted to RS by a prespecified algorithm. We then assessed the probability of the test to accurately predict distant recurrence‐free survival in this retrospective cohort. Ninety‐three patients were eligible based on gene expression profiles. In our population, most breast cancer patients were premenopausal (82.6%), at early stage (93.6%) and ER positive (91.4%). Median follow‐up was 65.9u2003months. The 5‐year recurrence‐free survival rate for the group was 58.8%. The concordance between the reverse transcription‐PCR and immunohistochemical (IHC) measurement for ER, progesterone receptor (PgR), and HER‐2 determinations was high and comparable. High RS was predictive of an elevated risk of relapse (pu2003<u20030.001). In subgroups of patients, RS had significantly predictive performance both in node‐negative (pu2003=u20030.009) and node‐positive patients (pu2003=u20030.038). Multivariable analysis showed that nodal status, adjuvant hormonal therapy and RS were significantly related to prognosis. RS category is a better predictor than the other risk assessment criteria or clinicopatholic features, with which we can determine more accurately the risks for recurrence of various patients. We have established an easy and economical QRT‐PCR assay and validated in concordance with IHC measurements for ER, PgR, and HER‐2. RS was associated with distant recurrence among Chinese patients with hormone receptor (HR) positive breast cancer. This study may promote the use of RS estimated from the expression of the 21‐gene set for prognostication and routine clinical diagnostic application in Chinese populations.

Incidence and relapse risk of intracranial metastases within the perihippocampal region in 314 patients with breast cancer

PURPOSEnThe safe prerequisite of hippocampal-sparing whole brain radiotherapy (HS-WBRT) for patients with breast cancer is unclear. This study investigated the risk and relapse of perihippocampal (PH) metastases in breast cancer.nnnMETHODSnConsecutive breast cancer patients with brain metastasis (BM) were reviewed. Metastases and hippocampi were contoured in cranial magnetic resonance imaging (MRI). The closest distance from metastasis to hippocampus was calculated. Clinical and radiographic variables were correlated with PH (in or within 5mm around the hippocampus) metastasis. The risk of post-treatment PH recurrence was estimated.nnnRESULTSnThree hundred and fourteen patients with 1678 metastases exhibited a median breast cancer-specific overall survival (OS) and OS after BM (BMOS) of 75.4 and 14.3 months, respectively. Hippocampal metastases were identified in 1.2% of metastases and 4.1% of patients. PH lesions comprised 3.5% of lesions in 11.1% of patients. The number and aggregated volume of BM were associated with PH disease probability (univariate). Only the number of BM significantly correlated with PH disease in the multivariate analysis. The patients with PH lesions exhibited more non-oligometastatic disease, increased tumor volume, and poor BMOS. One hundred and eleven patients without original PH lesions developed intracranial progression post-treatment. The risks of PH metastasis recurrence were 4.6% for WBRT and 6.8% for sub-therapeutic irradiation in the PH region. The increase in the absolute risk of PH recurrence with hippocampal-sparing irradiation was approximately 2%.nnnCONCLUSIONSnThese novel findings indicate that BM from breast cancer exhibits low risks of metastases and relapse within the hippocampal avoidance region. Non-oligometastatic disease is associated with PH metastasis. Thus, HS-WBRT is considered safe and suitable for breast cancer.

Usefulness of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in hormone-receptor-negative breast cancer

Purpose We aimed to investigate the relationship between pretreatment neutrophil-to-lymphocyte ratio (NLR)/platelet-to-lymphocyte ratio (PLR) and the estimation of hormone-receptor-negative (HR−) breast cancer patients’ survival in a Chinese cohort. Patients and methods Of 434 consecutive HR− nonmetastatic breast cancer patients treated between 2004 and 2010 in the Affiliated Hospital of Academy of Military Medical Sciences, 318 eligible cases with complete data were included in the present study. Kaplan–Meier analysis was performed to determine the overall survival (OS) and disease-free survival (DFS). Univariate and multivariate Cox proportional hazards models were used to test the usefulness of NLR and PLR. Results Univariate analysis indicated that both elevated NLR and PLR (both P<0.001) were associated with poor OS. The utility of NLR remained in the multivariate analysis (P<0.001), but not PLR (P=0.104). The analysis results for DFS were almost the same as OS. Subgroup analysis revealed a significant association between increased NLR and PLR (P<0.001 and P=0.011) and poor survival in triple-negative breast cancer. However, for human epidermal growth factor receptor 2-positive breast cancer, only NLR was significantly associated with OS in the multivariate analysis (P=0.001). Conclusion The present study indicates that both increased NLR and PLR are associated with poor survival in HR−breast cancer patients. Meanwhile, NLR is independently correlated with OS and DFS, but PLR is not.

Combined treatment with everolimus and fulvestrant reversed anti-HER2 resistance in a patient with refractory advanced breast cancer: a case report.

Background Everolimus, an inhibitor of the mammalian target of rapamycin, shows promising antitumor activity when combined with trastuzumab and chemotherapy for human epidermal growth factor receptor-2 (HER2)-positive breast cancer or when combined with endocrine agents for hormone receptor (HR)-positive tumors. However, data are limited regarding the effect of everolimus in combination with endocrine drugs in HER2-positive advanced breast cancer regardless of the HR status. Case presentation A 44-year-old female was diagnosed with recurrent HER2-positive breast cancer. The primary tumor was HR positive; however, the metastatic tumor was HR negative. The patient was resistant to classical chemotherapeutic agents and anti-HER2 treatment. Thus, the combination of everolimus and fulvestrant, a selective estrogen receptor downregulator, was chosen to reverse the resistance to anti-HER2 therapy. Indeed, the patient experienced long-term disease stabilization. Adverse events associated with the treatment were manageable by dose adjustments. We performed genetic testing of the metastatic tumor, which harbored a PIK3CA gene mutation but was positive for phosphatase and tensin homologue expression, which might result in resistance to the mammalian target of rapamycin inhibitor. Conclusion This case study indicates that combined treatment with everolimus and fulvestrant might be a viable option for the treatment of metastatic breast cancer patients who are HER2 positive and carry a PIK3CA gene mutation but are resistant to anti-HER2 therapy and classical chemotherapeutic agents. Further prospective randomized trials are needed to confirm this finding.

A panel containing PD-1, IL-2Rα, IL-10, and CA15-3 as a biomarker to discriminate breast cancer from benign breast disease

Introduction Programmed cell death protein 1 (PD-1), an immune checkpoint molecule, has recently been recognized as a predictive and prognostic biomarker in several malignant tumors, but its diagnostic value remains largely unknown. We aimed to investigate the differential diagnostic efficiency of PD-1 and other immune molecules and propose a panel of immune molecules combined with cancer antigen 15-3 (CA15-3) to distinguish breast cancer (BC) from benign breast disease (BBD). Patients and methods Ninety-one eligible BC patients and 31 BBD patients were enrolled. Pretreatment peripheral blood was collected and tested for mRNA expression of PD-1, cytotoxic T lymphocyte antigen 4, forkhead box P3, transforming growth factor beta, interleukin-10 (IL-10), IL-2 receptor alpha (IL-2Rα), and cluster of differentiation 28 by quantitative reverse transcription PCR. Results The diagnostic areas under curve (AUCs) of PD-1, IL-2Rα, and IL-10 for BC–BBD discrimination were 0.764, 0.758, and 0.743, respectively. The diagnostic efficiencies of these three parameters in distinguishing early-stage or advanced BC from BBD were consistent with a role in BC–BBD discrimination. A panel of PD-1 + IL-10 + IL-2Rα + CA15-3 showed the highest AUC (0.862), with a sensitivity of 0.933 and a specificity of 0.724, for BC–BBD discrimination. In addition, for early-stage BC discrimination, this panel also had the highest AUC (0.811), with a sensitivity of 0.933 and a specificity of 0.614, while for advanced BC discrimination, a panel of PD-1 + IL-10 + CA15-3 exhibited the highest AUC (0.896), with a sensitivity of 0.933 and a specificity of 0.783. Conclusion These data indicate that the panel containing PD-1, IL-2Rα, IL-10, and CA15-3 can effectively discriminate BC from BBD with a high efficiency. After further confirmation, it could be used to complement conventional imaging modalities, especially in discriminating early-stage BC from BBD.

Low BMI is correlated with increased TGF‐β and IL‐10 mRNA levels in the peripheral blood of breast cancer patients

Transforming growth factor‐β (TGF‐β), interleukin‐10 (IL‐10), and forkhead box P3 (Foxp3) have important roles in breast cancer development. Previous studies confirmed a correlation between these immune molecules and tumor characteristics, but their association with nutritional status in breast cancer is largely unknown. We aimed to investigate the association between body mass index (BMI), hemoglobin, total protein, albumin, globulin (GLB), albumin/GLB ratio (AGR), pre‐albumin, prognostic nutritional index, and TGF‐β, IL‐10, and Foxp3 mRNA expression in patients with breast cancer. Quantitative real‐time PCR was used to detect the mRNA expression of TGF‐β, IL‐10, and Foxp3 in the peripheral blood of 107 patients with breast cancer and 21 healthy controls. We found that TGF‐β mRNA levels were 2.6‐fold, 3.2‐fold, and 2.3‐fold higher in patients with low BMI (<23), low AGR, and high GLB, respectively, than in their counterparts (Pu2009<u20090.05). In addition, IL‐10 mRNA expression levels in patients with normal BMI (<23) were 2.8‐fold and 3.5‐fold higher than in those who were overweight (23≤ BMI <25) and obese (BMIu2009≥u200925), respectively (Pu2009<u20090.05). In addition, TGF‐β, IL‐10, and Foxp3 mRNA levels were significantly higher in patients with breast cancer than in healthy controls (Pu2009<u20090.05). In summary, our results suggest that nutritional status, especially BMI, may strongly affect systematic immune function in patients with breast cancer.

Predictive value of peripheral regulatory T cells in non-small cell lung cancer patients undergoing radiotherapy

Background Studies increasingly focus on the impact of radiotherapy on immunity; however, the role of peripheral cellular immunity prior to radiotherapy in cancer patients remains largely unknown. In this study, we investigated the predictive roles of lymphocyte subsets on tumor progression in non-small cell lung cancer (NSCLC) patients undergoing radiotherapy, and their expression in NSCLC patients at first relapse. Methods We enrolled 70 NSCLC patients and 14 age- and sex-matched healthy donors and tested the lymphocyte subsets in their peripheral blood by flow cytometry. Among them, 40 newly diagnosed patients received radiotherapy and were enrolled to investigate the predictive value of lymphocyte subsets on tumor progression after radiotherapy by uni- and multivariate analyses; 30 patients at first relapse were included to evaluate the differences of lymphocyte subsets between them and first diagnosed patients and healthy volunteers. Results Increased proportions of regulatory T cells, CD8+ T cells, and CD8+CD28- T cells and decreased CD4+ T cells and CD4/CD8 ratios were observed in NSCLC patients at first relapse compared to newly diagnosed patients. In the 40 first diagnosed patients undergoing radiotherapy, uni- and multivariate analyses showed that increased level of regulatory T cells correlated with poor progression-free survival (hazard ratio = 2.55 and 3.76, P = 0.022 and 0.010, respectively). Conclusions Peripheral regulatory T cells were increased and independently predict tumor progression in NSCLC patients undergoing radiotherapy, suggesting the promising combination of radiotherapy and immunotherapy.

Receptor conversion in metastatic breast cancer: a prognosticator of survival.

Objective This retrospective study investigated the association between hormone receptor (HR) conversion and survival in breast cancer patients. Methods Estrogen receptor (ER) and progesterone receptor (PR) status (positive or negative) of primary tumors and of paired metastatic sites in 627 breast cancer patients were analyzed by McNemars test for rates of receptor conversion. A survival analysis was performed using the Kaplan-Meier method, and prognostic factors were assessed using Coxs proportional hazards regression model. Results Conversion of ER occurred in 165 (26.31%) patients, and conversion of PR in 213 (33.97%; P < 0.001, both). For 82 patients whose ER and PR were reassessed 2-4 times during metastatic progression, ER and PR re-conversion occurred in 22 (26.83%) and 29 (35.36%), respectively. The change of ER or PR from positive to negative was associated with worse overall survival and post-recurrent survival (log-rank; P < 0.001, both). A subgroup analysis of HR-positive patients (i.e., positive ER, PR, or both) in primary tumor and HR-negative in metastatic sites showed that patients who accepted both salvage endocrine therapy and chemotherapy had better post-recurrent survival than did those who accepted salvage chemotherapy only (log-rank; P = 0.003). Conclusion ER and PR status may change several times during metastatic tumor progression. A change of HR from positive to negative was associated with worse survival compared with consistent positivity. Repeated evaluations of HR status are necessary in metastatic breast cancer. Salvage hormonal therapy is still worth trying for patients whose HR status changes from positive to negative.

Bilateral breast adenocarcinomas with EML4 — ALK fusion in a patient with multiple metastases successfully treated with crizotinib: is lung the primary site?

Breast metastases from non-mammary cancers are rare, especially when they appear synchronously. Clinically, it is vitally important to accurately diagnose these patients, as this will directly influence their treatment and survival. We present a very rare and complex case of bilateral breast adenocarcinomas with an EML4–ALK fusion, which was diagnosed as bilateral breast metastases of non-small-cell lung cancer by immunohistochemistry and comprehensive genomic investigation. The patient was successfully treated with an ALK inhibitor (crizotinib); symptoms improved quickly after initiation of crizotinib therapy, and a partial response was observed after 3 months. The experience of diagnosis and treatment of this case indicates the importance and necessity of genomic investigations in such patients, and suggests that we need to consider the rare possibility of this kind of metastasis in order to provide optimal treatment.

A nomogram for predicting survival in patients with breast cancer brain metastasis

Brain metastasis (BM) is common in patients with breast cancer. Predicting patient survival is critical for the clinical management of breast cancer brain metastasis (BCBM). The present study was designed to develop and evaluate a prognostic model for patients with newly diagnosed BCBM. Based on the clinical data of patients with BCBM treated in the Affiliated Hospital of Academy of Military Medical Sciences (Beijing, China) between 2002 and 2014, a nomogram was developed to predict survival using proportional hazards regression analysis. The model was validated internally by bootstrapping, and the concordance index (c-index) was calculated. A calibration curve and c-index were used to evaluate discriminatory and predictive ability, in order to compare the nomogram with widely used models, including recursive partitioning analysis (RPA), graded prognostic assessment (GPA) and breast-graded prognostic assessment (Breast-GPA). A total of 411 patients with BCBM were included in the development of this predictive model. The median overall survival time was 14.1 months. Statistically significant predictors for patient survival included biological subtype, Karnofsky performance score, leptomeningeal metastasis, extracranial metastasis, the number of brain metastases and disease-free survival. A nomogram for predicting 1- and 2-year overall survival rates was constructed, which exhibited good accuracy in predicting overall survival with a concordance index of 0.735. This model outperformed RPA, GPA and Breast-GPA, based on the comparisons of the c-indexes. The nomogram constructed based on a multiple factor analysis was able to more accurately predict the individual survival probability of patients with BCBM, compared with existing models.