Marc Inciardi

Assessing Improvement in Detection of Breast Cancer with Three-dimensional Automated Breast US in Women with Dense Breast Tissue : The Somoinsight Study

PURPOSE To determine improvement in breast cancer detection by using supplemental three-dimensional (3D) automated breast (AB) ultrasonography (US) with screening mammography versus screening mammography alone in asymptomatic women with dense breasts. MATERIALS AND METHODS Institutional review board approval and written informed consent were obtained for this HIPAA-compliant study. The SomoInsight Study was an observational, multicenter study conducted between 2009 and 2011. A total of 15 318 women (mean age, 53.3 years ± 10 [standard deviation]; range, 25-94 years) presenting for screening mammography alone with heterogeneously (50%-75%) or extremely (>75%) dense breasts were included, regardless of further risk characterization, and were followed up for 1 year. Participants underwent screening mammography alone followed by an AB US examination; results were interpreted sequentially. McNemar test was used to assess differences in cancer detection. RESULTS Breast cancer was diagnosed at screening in 112 women: 82 with screening mammography and an additional 30 with AB US. Addition of AB US to screening mammography yielded an additional 1.9 detected cancers per 1000 women screened (95% confidence interval [CI]: 1.2, 2.7; P < .001). Of cancers detected with screening mammography, 62.2% (51 of 82) were invasive versus 93.3% (28 of 30) of additional cancers detected with AB US (P = .001). Of the 82 cancers detected with either screening mammography alone or the combined read, 17 were detected with screening mammography alone. Of these, 64.7% (11 of 17) were ductal carcinoma in situ versus 6.7% (two of 30) of cancers detected with AB US alone. Sensitivity for the combined read increased by 26.7% (95% CI: 18.3%, 35.1%); the increase in the recall rate per 1000 women screened was 284.9 (95% CI: 278.0, 292.2; P < .001). CONCLUSION Addition of AB US to screening mammography in a generalizable cohort of women with dense breasts increased the cancer detection yield of clinically important cancers, but it also increased the number of false-positive results.

Expression profiling of in vivo ductal carcinoma in situ progression models identified B cell lymphoma-9 as a molecular driver of breast cancer invasion

IntroductionThere are an estimated 60,000 new cases of ductal carcinoma in situ (DCIS) each year. A lack of understanding in DCIS pathobiology has led to overtreatment of more than half of patients. We profiled the temporal molecular changes during DCIS transition to invasive ductal carcinoma (IDC) using in vivo DCIS progression models. These studies identified B cell lymphoma-9 (BCL9) as a potential molecular driver of early invasion. BCL9 is a newly found co-activator of Wnt-stimulated β-catenin-mediated transcription. BCL9 has been shown to promote progression of multiple myeloma and colon carcinoma. However BCL9 role in breast cancer had not been previously recognized.MethodsMicroarray and RNA sequencing were utilized to characterize the sequential changes in mRNA expression during DCIS invasive transition. BCL9-shRNA knockdown was performed to assess the role of BCL9 in in vivo invasion, epithelial-mesenchymal transition (EMT) and canonical Wnt-signaling. Immunofluorescence of 28 patient samples was used to assess a correlation between the expression of BCL9 and biomarkers of high risk DCIS. The cancer genome atlas data were analyzed to assess the status of BCL9 gene alterations in breast cancers.ResultsAnalysis of BCL9, by RNA and protein showed BCL9 up-regulation to be associated with DCIS transition to IDC. Analysis of patient DCIS revealed a significant correlation between high nuclear BCL9 and pathologic characteristics associated with DCIS recurrence: Estrogen receptor (ER) and progesterone receptor (PR) negative, high nuclear grade, and high human epidermal growth factor receptor2 (HER2). In vivo silencing of BCL9 resulted in the inhibition of DCIS invasion and reversal of EMT. Analysis of the TCGA data showed BCL9 to be altered in 26 % of breast cancers. This is a significant alteration when compared to HER2 (ERBB2) gene (19 %) and estrogen receptor (ESR1) gene (8 %). A significantly higher proportion of basal like invasive breast cancers compared to luminal breast cancers showed BCL9 amplification.ConclusionBCL9 is a molecular driver of DCIS invasive progression and may predispose to the development of basal like invasive breast cancers. As such, BCL9 has the potential to serve as a biomarker of high risk DCIS and as a therapeutic target for prevention of IDC.

NEMO, a transcriptional target of estrogen and progesterone, is linked to tumor suppressor PML in breast cancer

The beneficial versus detrimental roles of estrogen plus progesterone (E+P) in breast cancer remains controversial. Here we report a beneficial mechanism of E+P treatment in breast cancer cells driven by transcriptional upregulation of the NFκB modulator NEMO, which in turn promotes expression of the tumor suppressor protein promyelocytic leukemia (PML). E+P treatment of patient-derived epithelial cells derived from ductal carcinoma in situ (DCIS) increased secretion of the proinflammatory cytokine IL6. Mechanistic investigations indicated that IL6 upregulation occurred as a result of transcriptional upregulation of NEMO, the gene that harbored estrogen receptor (ER) binding sites within its promoter. Accordingly, E+P treatment of breast cancer cells increased ER binding to the NEMO promoter, thereby increasing NEMO expression, NFκB activation, and IL6 secretion. In two mouse xenograft models of DCIS, we found that RNAi-mediated silencing of NEMO increased tumor invasion and progression. This seemingly paradoxical result was linked to NEMO-mediated regulation of NFκB and IL6 secretion, increased phosphorylation of STAT3 on Ser727, and increased expression of PML, a STAT3 transcriptional target. In identifying NEMO as a pivotal transcriptional target of E+P signaling in breast cancer cells, our work offers a mechanistic explanation for the paradoxical antitumorigenic roles of E+P in breast cancer by showing how it upregulates the tumor suppressor protein PML. Cancer Res; 77(14); 3802-13. ©2017 AACR.

Mammography Positioning Standards in the Digital Era: Is the Status Quo Acceptable?

OBJECTIVE The objective of our study was to evaluate positioning of full-field digital mammography (FFDM) and digital breast tomosynthesis (DBT) compared with film-screen (FS) mammography positioning standards. MATERIALS AND METHODS A retrospective study was conducted of consecutive patients who underwent screening FFDM in 2010-2012 and DBT in 2012-2013 at an academic institution. Examinations were performed by five experienced technologists who underwent updated standardized positioning training. Positioning criteria were assessed by consensus reads among three breast radiologists and compared with FS mammography data from a 1993 study by Bassett and colleagues. RESULTS One hundred seventy patients (n = 340 examinations) were analyzed, showing significant differences between FFDM and DBT examinations (p < 0.05) for medial or inferior skin folds (FFDM vs DBT: craniocaudal [CC] view, 16% [n = 56] vs 23% [n = 77]; mediolateral oblique [MLO] view, 35% [n = 118] vs 45% [n = 154]), inclusion of lateral glandular tissue on CC view (FFDM vs DBT, 73% [n = 247] vs 81% [n = 274]), and concave pectoralis muscle shape (FFDM vs DBT, 36% [n = 121] vs 28% [n = 95]). In comparison with Bassett et al. data, all positioning criteria for both FFDM and DBT examinations were significantly different (p < 0.05). The largest differences were found in visualization of the pectoralis muscle on CC views and the inframammary fold on MLO views, inclusion of posterior or lateral glandular tissue, and inclusion of skin folds, with DBT and FFDM more frequently exhibiting all criteria than originally reported Bassett et al. FINDINGS CONCLUSION DBT and FFDM mammograms more frequently include posterior or lateral tissue, the inframammary fold on MLO views, the pectoralis muscle on CC views, and skin folds than FS mammograms. Inclusion of more breast tissue with newer technologies suggests traditional positioning standards, in conjunction with updated standardized positioning training, are still applicable at the expense of including more skin folds.

Interpretation Time Using a Concurrent-Read Computer-Aided Detection System for Automated Breast Ultrasound in Breast Cancer Screening of Women With Dense Breast Tissue.

OBJECTIVE The purpose of this study was to compare diagnostic accuracy and interpretation time of screening automated breast ultrasound (ABUS) for women with dense breast tissue without and with use of a recently U.S. Food and Drug Administration-approved computer-aided detection (CAD) system for concurrent read. MATERIALS AND METHODS In a retrospective observer performance study, 18 radiologists interpreted a cancer-enriched set (i.e., cancer prevalence higher than in the original screening cohort) of 185 screening ABUS studies (52 with and 133 without breast cancer). These studies were from a large cohort of ABUS-screened patients interpreted as BI-RADS density C or D. Each reader interpreted each case twice in a counterbalanced study, once without the CAD system and once with it, separated by 4 weeks. For each case, each reader identified abnormal findings and reported BI-RADS assessment category and level of suspicion for breast cancer. Interpretation time was recorded. Level of suspicion data were compared to evaluate diagnostic accuracy by means of the Dorfman-Berbaum-Metz method of jackknife with ANOVA ROC analysis. Interpretation times were compared by ANOVA. RESULTS The ROC AUC was 0.848 with the CAD system, compared with 0.828 without it, for a difference of 0.020 (95% CI, -0.011 to 0.051) and was statistically noninferior to the AUC without the CAD system with respect to a margin of -0.05 (p = 0.000086). The mean interpretation time was 3 minutes 33 seconds per case without the CAD system and 2 minutes 24 seconds with it, for a difference of 1 minute 9 seconds saved (95% CI, 44-93 seconds; p = 0.000014), or a reduction in interpretation time to 67% of the time without the CAD system. CONCLUSION Use of the concurrent-read CAD system for interpretation of screening ABUS studies of women with dense breast tissue who do not have symptoms is expected to make interpretation significantly faster and produce noninferior diagnostic accuracy compared with interpretation without the CAD system.

Radiologic and Pathologic Features Associated With Upgrade of Atypical Ductal Hyperplasia at Surgical Excision

RATIONALE AND OBJECTIVES To evaluate radiologic and pathologic features associated with upgrade of atypical ductal hyperplasia (ADH) to ductal carcinoma in situ or invasive breast cancer at surgical excision, in order to identify patients who may consider alternatives to excision. MATERIALS AND METHODS This retrospective analysis examined patients who underwent surgical excision of biopsy-proven ADH at our institution. Imaging and pathology from biopsy were reviewed to determine radiologic (lesion size, radiologic abnormality, biopsy type, needle gauge, number of cores, percent of lesion removed) and pathologic features (histologic calcifications, presence of necrosis, micropapillary features, extent of ADH) associated with ADH upgrade. RESULTS One hundred twenty four cases of percutaneous biopsy-proven ADH with subsequent excision were included. The overall upgrade rate was 17.7% (n = 22), with 17 cases to ductal carcinoma in situ and five to invasive cancer. Radiologic features associated with a lower upgrade rate were smaller lesion size (p = 0.032) and larger percent of lesion removed at biopsy (p = 0.047). Larger needle gauge at biopsy (p = 0.070), absence of necrosis (p = 0.051) and focal ADH (<3 foci, p = 0.12) were nearly associated with a lower rate of upgrade and were included for the purpose of multi parameter analyses. CONCLUSION For women with ADH identified on percutaneous biopsy, the risk of upgrade may in part be determined by lesion size, percent of lesion removed at biopsy, presence of necrosis, and extent of ADH. Using a combination of these radiographic and pathologic features to stratify patients with biopsy-proven ADH may help identify women who could be considered for alternative treatment options.

Abstract 1853: Ovarian steroid hormones promote progression of DCIS by increasing cancer stem cell self-renewal through IL-6 signaling

Introduction: The ability of the ovarian steroid hormones estradiol (E) and progesterone (P) to influence cancer stem cell (CSC) self-renewal and progression of human ductal carcinoma in situ (DCIS) is a critical but understudied area or research. The objective of this study is to characterize steroid hormone signaling involved in CSC self-renewal and invasion in ER+PR+ DCIS. We have found that these hormones can increase CSC self-renewal in a subset of DCIS patients, and that this may be facilitated by activation of the IL-6 pathway. Methods: Mammosphere (MS) assays (an in vitro assessment of CSC self-renewal) and the mouse intraductal (MIND) xenograft model were used to characterize hormonal regulation of the CSC population and invasion potential of primary human ER+PR+ DCIS cells. Additionally, ovarectomized mice were used to create MIND xenografts of ER+PR+ DCIS, treated with E+P or vehicle for 8 weeks, and used for RNA sequencing and immunofluorescent staining. Results: Only a subset of cases responded to E+P in vitro by increasing MS efficiency, indicating increased CSC self-renewal. RNA sequencing of MSs identified genes that differed between vehicle and E+P treatment only in DCIS cases that respond to E+P by increasing MS efficiency. Many of these changes were associated with epithelial mesenchymal transition (EMT), including Twist1, Snai1, MMP9. In E+P-treated MIND xenografts, DCIS cases that respond to E+P by increasing MS efficiency also had higher IL-8 and vimentin (markers of EMT) compared to non-responders (P Conclusions: Our results indicate that steroid hormone treatment can enrich the CSC population by increasing MS efficiency in some but not all DCIS cases, and that IL-6 may be involved in this selective ability. Therefore, DCIS cases with higher MS efficiency in response to E+P treatment may also show higher invasion potential in vivo. Our current model is that steroid hormones induce increased secretion of IL-6, leading to increased self-renewal and invasion potential. Further characterization of the signaling pathway(s) associated with this selective effect may allow us to predict which DCIS lesions have the ability to progress to invasive ductal carcinoma and allow development of novel therapeutic targets. Citation Format: Kelli E. Valdez, Yan Hong, Fang Fan, Lisa May, Therese Cusick, Marc Inciardi, Mark Redick, Jason Gatewood, Fariba Behbod. Ovarian steroid hormones promote progression of DCIS by increasing cancer stem cell self-renewal through IL-6 signaling. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1853. doi:10.1158/1538-7445.AM2015-1853