Julie E. Lang

Adaptive Randomization of Veliparib–Carboplatin Treatment in Breast Cancer

BACKGROUND The genetic and clinical heterogeneity of breast cancer makes the identification of effective therapies challenging. We designed I-SPY 2, a phase 2, multicenter, adaptively randomized trial to screen multiple experimental regimens in combination with standard neoadjuvant chemotherapy for breast cancer. The goal is to match experimental regimens with responding cancer subtypes. We report results for veliparib, a poly(ADP-ribose) polymerase (PARP) inhibitor, combined with carboplatin. METHODS In this ongoing trial, women are eligible for participation if they have stage II or III breast cancer with a tumor 2.5 cm or larger in diameter; cancers are categorized into eight biomarker subtypes on the basis of status with regard to human epidermal growth factor receptor 2 (HER2), hormone receptors, and a 70-gene assay. Patients undergo adaptive randomization within each biomarker subtype to receive regimens that have better performance than the standard therapy. Regimens are evaluated within 10 biomarker signatures (i.e., prospectively defined combinations of biomarker subtypes). Veliparib-carboplatin plus standard therapy was considered for HER2-negative tumors and was therefore evaluated in 3 signatures. The primary end point is pathological complete response. Tumor volume changes measured by magnetic resonance imaging during treatment are used to predict whether a patient will have a pathological complete response. Regimens move on from phase 2 if and when they have a high Bayesian predictive probability of success in a subsequent phase 3 neoadjuvant trial within the biomarker signature in which they performed well. RESULTS With regard to triple-negative breast cancer, veliparib-carboplatin had an 88% predicted probability of success in a phase 3 trial. A total of 72 patients were randomly assigned to receive veliparib-carboplatin, and 44 patients were concurrently assigned to receive control therapy; at the completion of chemotherapy, the estimated rates of pathological complete response in the triple-negative population were 51% (95% Bayesian probability interval [PI], 36 to 66%) in the veliparib-carboplatin group versus 26% (95% PI, 9 to 43%) in the control group. The toxicity of veliparib-carboplatin was greater than that of the control. CONCLUSIONS The process used in our trial showed that veliparib-carboplatin added to standard therapy resulted in higher rates of pathological complete response than standard therapy alone specifically in triple-negative breast cancer. (Funded by the QuantumLeap Healthcare Collaborative and others; I-SPY 2 TRIAL ClinicalTrials.gov number, NCT01042379.).

Intraoperative frozen section analysis of sentinel lymph nodes in breast cancer patients

Accurate intraoperative pathologic examination of sentinel lymph nodes (SLNs) has been an important tool that can reduce the need for reoperations in patients with SLN‐positive breast cancer. The objective of the current study was to determine the accuracy of intraoperative frozen section (IFS) of SLNs during breast cancer surgery.

Radiation-Induced Sarcoma of the Breast: A Systematic Review

INTRODUCTION Radiation-induced sarcoma (RIS) is a rare, aggressive malignancy. Breast cancer survivors treated with radiotherapy constitute a large fraction of RIS patients. To evaluate evidenced-based practices for RIS treatment, we performed a systematic review of the published English-language literature. METHODS We performed a systematic keyword search of PubMed for original research articles pertaining to RIS of the breast. We classified and evaluated the articles based on hierarchical levels of scientific evidence. RESULTS We identified 124 original articles available for analysis, which included 1,831 patients. No randomized controlled trials involving RIS patients were found. We present the best available evidence for the etiology, comparative biology to primary sarcoma, prognostic factors, and treatment options for RIS of the breast. CONCLUSION Although the evidence to guide clinical practice is limited to single institutional cohort studies, registry studies, case-control studies, and case reports, we applied the available evidence to address clinically relevant questions related to best practice in patient management. Surgery with widely negative margins remains the primary treatment of RIS. Unfortunately, the role of adjuvant and neoadjuvant chemotherapy remains uncertain. This systematic review highlights the need for additional well-designed studies to inform the management of RIS.

Aminolevulinic acid (ALA): photodynamic detection and potential therapeutic applications.

Aminolevulinic acid (ALA) is a heme precursor that may have potential applications for photodynamic detection and photodynamic therapy-based treatment of solid tumors in a variety of malignancies. ALA may have a role in other applications in surgical oncology based on its ability to discriminate neoplastic tissue from adjacent normal tissue. In this review, we provide a comprehensive summary of the published studies of ALA in noncutaneous solid malignancies.

Oxidative stress, mammospheres and Nrf2-new implication for breast cancer therapy?

Mammosphere culture of breast cancer cell lines is an important approach used for enrichment of cancer stem cells (CSCs), which exhibit high tumorigenicity and chemoresistance features. Evidence shows that CSCs maintain lower ROS levels due to elevated expression of ROS‐scavenging molecules and antioxidative enzymes, which favors the survival of the CSCs and their chemoresistance. The transcription factor NF‐E2‐related factor 2 (Nrf2) has emerged as the master regulator of cellular redox homeostasis, by up‐regulating antioxidant response element (ARE)‐bearing genes products. Although Nrf2 has long‐term been regarded as a beneficial defense mechanism, accumulating studies have revealed the “dark side” of Nrf2. High constitutive levels of Nrf2 was observed in many types of tumors and cancer cell lines promoting their resistance to chemotherapeutics. In this study, we report a high expression of Nrf2 and its target genes in mammospheres compared to corresponding adherent cells. In MCF‐7 and MDA‐MB‐231 mammmosphere cells, the Nrf2‐mediated cellular protective response is significantly elevated which is associated with increased resistance to taxol and anchorage‐independent growth. Brusatol, an inhibitor of the Nrf2 pathway, suppressed the protein level of Nrf2 and its target genes, enhanced intracellular ROS and sensitized mammospheres to taxol, and reduced the anchorage‐independent growth. These results suggest that mammospheres rely on abnormal up‐regulation of Nrf2 to maintain low intracellular ROS levels. Nrf2 inhibitors, such as brusatol, have the potential to be developed into novel adjuvant chemotherapeutic drug combinations in order to combat refractory tumor initiating CSCs.

Human breast tissue disposition and bioactivity of limonene in women with early stage breast cancer

Limonene is a bioactive food component found in citrus peel oil that has shown chemopreventive and chemotherapeutic activities in preclinical studies. We conducted an open-label pilot clinical study to determine the human breast tissue disposition of limonene and its associated bioactivity. We recruited 43 women with newly diagnosed operable breast cancer electing to undergo surgical excision to take 2 grams of limonene daily for two to six weeks before surgery. Blood and breast tissue were collected to determine drug/metabolite concentrations and limonene-induced changes in systemic and tissue biomarkers of breast cancer risk or carcinogenesis. Limonene was found to preferentially concentrate in the breast tissue, reaching high tissue concentration (mean = 41.3 μg/g tissue), whereas the major active circulating metabolite, perillic acid, did not concentrate in the breast tissue. Limonene intervention resulted in a 22% reduction in cyclin D1 expression (P = 0.002) in tumor tissue but minimal changes in tissue Ki67 and cleaved caspase-3 expression. No significant changes in serum leptin, adiponectin, TGF-β1, insulin-like growth factor binding protein-3 (IGFBP-3), and interleukin-6 (IL-6) levels were observed following limonene intervention. There was a small but statistically significant postintervention increase in insulin-like growth factor I (IGF-I) levels. We conclude that limonene distributed extensively to human breast tissue and reduced breast tumor cyclin D1 expression that may lead to cell-cycle arrest and reduced cell proliferation. Furthermore, placebo-controlled clinical trials and translational research are warranted to establish limonenes role for breast cancer prevention or treatment. Cancer Prev Res; 6(6); 577–84. ©2013 AACR.

Breast ductal secretions : Clinical features, potential uses, and possible applications

BACKGROUND Nipple discharge accounts for approximately 5% of visits to a breast specialist surgical practice and may be encountered as the chief complaint by many other types of physicians. The vast majority of breast cancers originate in the ductal system, which prompted interest in the evaluation of the intraductal approach to breast cancer. Ductoscopy, nipple aspiration, and ductal lavage have emerged as innovative fields of study that may have clinical applications. METHODS We performed a literature search of published manuscripts using the keywords nipple discharge, breast ductal secretions, and intraductal approach. We also report our single-institution experience in managing nipple discharge. RESULTS We present our institutional algorithm for the management of nipple discharge. The possible etiologies of nipple discharge and the appropriate workup are reviewed. Three evolving minimally invasive techniques for the evaluation of high-risk patients include ductoscopy, nipple aspiration, and ductal lavage. Nipple aspiration and ductal lavage fluid may be assayed for cytology, genomic, gene expression, and proteomic studies. Several different translational approaches are being undertaken to investigate the local microenvironment associated with the development and progression of breast carcinoma. CONCLUSIONS Nipple aspiration fluid and ductal lavage offer the opportunity to study the local microenvironment of the ductal system, which is where most breast cancers originate. These powerful approaches to biomarker analysis could be applied to the prevention and treatment of breast cancer.

Trends in post-mastectomy reconstruction: A SEER database analysis

This study was performed to investigate recent trends and factors associated with immediate breast reconstruction (IBR) using a large population‐based registry. We hypothesized that rates of IBR have increased since passage of the Womens Health and Cancer Rights Act of 1998.

A comparison of RNA amplification techniques at sub-nanogram input concentration

BackgroundGene expression profiling of small numbers of cells requires high-fidelity amplification of sub-nanogram amounts of RNA. Several methods for RNA amplification are available; however, there has been little consideration of the accuracy of these methods when working with very low-input quantities of RNA as is often required with rare clinical samples. Starting with 250 picograms-3.3 nanograms of total RNA, we compared two linear amplification methods 1) modified T7 and 2) Arcturus RiboAmp HS and a logarithmic amplification, 3) Balanced PCR. Microarray data from each amplification method were validated against quantitative real-time PCR (QPCR) for 37 genes.ResultsFor high intensity spots, mean Pearson correlations were quite acceptable for both total RNA and low-input quantities amplified with each of the 3 methods. Microarray filtering and data processing has an important effect on the correlation coefficient results generated by each method. Arrays derived from total RNA had higher Pearsons correlations than did arrays derived from amplified RNA when considering the entire unprocessed dataset, however, when considering a gene set of high signal intensity, the amplified arrays had superior correlation coefficients than did the total RNA arrays.ConclusionGene expression arrays can be obtained with sub-nanogram input of total RNA. High intensity spots showed better correlation on array-array analysis than did unfiltered data, however, QPCR validated the accuracy of gene expression array profiling from low-input quantities of RNA with all 3 amplification techniques. RNA amplification and expression analysis at the sub-nanogram input level is both feasible and accurate if data processing is used to focus attention to high intensity genes for microarrays or if QPCR is used as a gold standard for validation.

Molecular markers for breast cancer diagnosis, prognosis and targeted therapy.

Precision medicine involves understanding the molecular drivers unique to an individual patients cancer so that specific factors may be targeted with the goal of improved patient outcomes. The purpose of this article is to review standard of care and research grade (non‐standard of care) biomarkers in breast cancer that may be useful for diagnosis, prognosis and targeted therapy. J. Surg. Oncol. 2015 111:81–90.