Pei-Fang Wu

Bevacizumab Preconditioning Followed by Etoposide and Cisplatin Is Highly Effective in Treating Brain Metastases of Breast Cancer Progressing from Whole-Brain Radiotherapy

Purpose: We hypothesized that a window period between bevacizumab and cytotoxic agents may enhance drug delivery into tumor tissue through bevacizumab-induced vascular normalization in patients with brain metastases of breast cancer (BMBC). Experimental Design: A single-arm phase II study was conducted in which BMBC patients refractory to whole-brain radiotherapy (WBRT) were enrolled. In a 21-day cycle, patients received bevacizumab (15 mg/kg) on day 1, which, with a 1-day window period, was followed by etoposide (70 mg/m2/day; days 2–4) and cisplatin (70 mg/m2; day 2; BEEP regimen). The BEEP regimen was administered for a maximum of 6 cycles. The primary endpoint was the central nervous system (CNS)–objective response rate according to volumetric response criteria. Results: A total of 35 patients were enrolled between January 2011 and January 2013. The median age was 54.3 years (range, 33–75); 19 patients (54.3%) had an Eastern Cooperative Oncology Group performance status of 2 or 3. Twenty-seven patients [77.1%; 95% confidence interval (CI), 59.9–89.6] achieved a CNS-objective response, including 13 patients (37.1%) with a ≥80% volumetric reduction of CNS lesions. With a median follow-up of 16.1 months, the median CNS progression-free survival and overall survival times were 7.3 months (95% CI, 6.5–8.1) and 10.5 months (95% CI, 7.8–13.2), respectively. Common grade 3 or 4 toxicities included neutropenia (30.8%) and infection (21.3%). Conclusions: By administering bevacizumab 1 day before etoposide and cisplatin, the BEEP regimen appeared highly effective in BMBC refractory to WBRT. Further study of vascular normalization window concept is warranted. Clin Cancer Res; 21(8); 1851–8. ©2015 AACR.

Clinical Relevance of Liver Kinase B1(LKB1) Protein and Gene Expression in Breast Cancer.

Liver kinase B1 (LKB1) is a tumor suppressor, and its loss might lead to activation of the mammalian target of rapamycin (mTOR) and tumorigenesis. This study aimed to determine the clinical relevance of LKB1 gene and protein expression in breast cancer patients. LKB1 protein expression was evaluated using immunohistochemistry in tumors from early breast cancer patients in two Taiwanese medical centers. Data on LKB1 gene expression were obtained from the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) data set. The correlations between LKB1 expression, clinicopathologic factors, and patient outcome were analyzed. LKB1 expression was significantly associated with estrogen receptor (ER) expression in 2 of the 4 cohorts, but not with other clinicopathologic factors. LKB1 expression was not a predictor for relapse-free survival, overall survival (OS), or breast cancer-specific survival. In a subgroup analysis of the two Taiwanese cohorts, high LKB1 protein expression was predictive of high OS in human epidermal growth factor receptor 2 (HER2)-positive breast cancer patients (P = 0.013). Our study results indicate that LKB1 expression is not prognostic in the whole population of breast cancer patients, but it is a potential predictor of OS in the subset of HER2-positive patients

High Prevalence of the BIM Deletion Polymorphism in Young Female Breast Cancer in an East Asian Country.

Background A rapid surge of female breast cancer has been observed in young women in several East Asian countries. The BIM deletion polymorphism, which confers cell resistance to apoptosis, was recently found exclusively in East Asian people with prevalence rate of 12%. We aimed to evaluate the possible role of this genetic alteration in carcinogenesis of breast cancer in East Asians. Method Female healthy volunteers (n = 307), patients in one consecutive stage I-III breast cancer cohort (n = 692) and one metastatic breast cancer cohort (n = 189) were evaluated. BIM wild-type and deletion alleles were separately genotyped in genomic DNAs. Results Both cancer cohorts consistently showed inverse associations between the BIM deletion polymorphism and patient age (≤35 y vs. 36-50 y vs. >50 y: 29% vs. 22% vs. 15%, P = 0.006 in the consecutive cohort, and 40% vs. 23% vs. 13%, P = 0.023 in the metastatic cohort). In healthy volunteers, the frequencies of the BIM deletion polymorphism were similar (13%-14%) in all age groups. Further analyses indicated that the BIM deletion polymorphism was not associated with specific clinicopathologic features, but it was associated with poor overall survival (adjusted hazard ratio 1.71) in the consecutive cohort. Conclusions BIM deletion polymorphism may be involved in the tumorigenesis of the early-onset breast cancer among East Asians.

Abstract 2984: Normalization of tumor vasculature by anti-angiogenesis therapy in metastatic tumor: A clinical study to determine the timing and effect

Proceedings: AACR Annual Meeting 2014; April 5-9, 2014; San Diego, CA Background: Clinically, combination of anti-angiogenic agents with chemotherapeutic agents demonstrated better antitumor efficacy. Instead of merely effect on vasculature regression, careful use of anti-angiogenic therapy may cause the grossly abnormal structure and function of tumor blood vessels to return to a more normal state. Treatment with anti-angiogenic agents can primarily improve chemotherapy efficacy by normalizing tumor vasculature, decrease the intra-tumor interstitial pressure, thereby leading to a more effective drug delivery. We planned to investigate the timing and effect of tumor vascular normalization in human after the administration of anti-angiogenic agent. It may help determine the appropriate timing of administration of chemotherapeutic agents after anti-angiogenic treatment. Materials and methods: This study enrolled the last 8 consecutive patients who participated in a phase II trial for treatment of refractory brain metastases from breast cancer (Eur J Can 49:2s, 2013 suppl; abstr 1878). The protocol treatment consists of bevacizumab 15mg/kg on day 1, chemotherapy of etoposide and cisplatin on day 2 (24 hours after administration of bevacizumab), in 21-day cycles. These 8 patients specifically received four dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) examinations. DCE-MRI was performed before treatment, 1 hour after the end of bevacizumab infusion (i.e., 2.5 hours after starting bevacizumab infusion), 24 hours and 21 days after bevacizumab infusion. This study was registered with ClinicalTrials.gov, identifier [NCT01281696][1], and was approved by the ethical review board. Results: Clinically, all the 8 patients achieved partial remission at central nervous system. All of the 4 DCE-MRI parameters decreased after bevacizumab infusion. Compared to baseline values, the mean reductions at 1 hour and 24 hours were -12.8% and -24.7% for Peak, -46.6% and -65.8% for Slope, -27.9% and -55.5% for iAUC60, -46.6% and -63.9% for Ktrans, respectively (all P values <0.05). The differences between 1 hour and 24 hours reached statistical significance (all P values <0.05) for all the parameters. However, the differences in the mean percentage change between 24 hours and 21 days did not reach significance in any of the four parameters Conclusion: Normalization of tumor vasculature induced by bevacizumab was clearly demonstrated in brain metastases in human at 1 hour after completion of bevacizumab infusion, but significantly became more obvious at 24 hours after bevacizumab administration. Citation Format: Yen-Shen Lu, Bang-Bin Chen, Ching-Hung Lin, Wei-Wu Chen, Pei-Fang Wu, Ann-Lii Cheng, Tiffany Ting-Fang Shih. Normalization of tumor vasculature by anti-angiogenesis therapy in metastatic tumor: A clinical study to determine the timing and effect. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2984. doi:10.1158/1538-7445.AM2014-2984 [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01281696&atom=%2Fcanres%2F74%2F19_Supplement%2F2984.atom

TP53 Mutational Analysis Enhances the Prognostic Accuracy of IHC4 and PAM50 Assays

IHC4 and PAM50 assays have been shown to provide additional prognostic information for patients with early breast cancer. We evaluated whether incorporating TP53 mutation analysis can further enhance their prognostic accuracy. We examined TP53 mutation and the IHC4 score in tumors of 605 patients diagnosed with stage I–III breast cancer at National Taiwan University Hospital (the NTUH cohort). We obtained information regarding TP53 mutation and PAM50 subtypes in 699 tumors from the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) cohort. We found that TP53 mutation was significantly associated with high-risk IHC4 group and with luminal B, HER2-enriched, and basal-like subtypes. Despite the strong associations, TP53 mutation independently predicted shorter relapse-free survival (hazard ratio [HR] = 1.63, P = 0.007) in the NTUH cohort and shorter breast cancer-specific survival (HR = 2.35, P = <0.001) in the METABRIC cohort. TP53 mutational analysis added significant prognostic information in addition to the IHC4 score (∆ LR-χ2 = 8.61, P = 0.002) in the NTUH cohort and the PAM50 subtypes (∆ LR-χ2 = 18.9, P = <0.001) in the METABRIC cohort. We conclude that incorporating TP53 mutation analysis can enhance the prognostic accuracy of the IHC4 and PAM50 assays.

Abstract 4490: Comparisons of genetic alterations of breast cancer between East and West: Special emphases on young patients with ER+/HER2- tumors

A rapid surge of female breast cancer has been observed in young East Asians. As a first step toward understanding this phenomenon, we compared the genetic alterations between breast cancer form Taiwan (East) and Western countries (West). Under the same array platforms, the differences in gene copy number alterations (n = 120 in East and 1,948 in West) and gene expressions (n = 327 in East and 423 in West) were analyzed as further stratified by age and estrogen receptor (ER)/ HER2 status. Gene-gene interaction networks were explored by analyzing the overlapping gene with ingenuity pathway analysis. The ingenuity pathway analysis revealed the common differences between East and West in NFkB, PI3K, Akt, MAPK, ERK, IFNα, and Jnk networks. Among the patients Citation Format: Ching-Hung Lin, Tzu-Pin Lu, Ruby Yun-Ju Huang, Yen-Shen Lu, Ko-Yun Lo, Kuan-Ting Kuo, Eric Y. Chuang, Pei-Fang Wu, I-Chun Chen, Jean Paul Thiery, Chiun-Sheng Huang, Ann-Lii Cheng. Comparisons of genetic alterations of breast cancer between East and West: Special emphases on young patients with ER+/HER2- tumors. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4490.

Abstract 3886: Activated insulin-like growth factor (IGF) signaling pathway is a potential therapeutic target for brain metastasis from lung cancer.

Background: Brain metastasis is a formidable challenge in lung cancer treatment. The incidence has been increasing recently because of the advances of treatment which leads to prolonged survival of many patients. Methods: We established xenograft model of brain metastasis. Repeated rounds of in vivo selection and ex vivo primary cultures of the brain metastases resulted in a cell line with a high propensity to metastasize to the brain. Brain-tropism was confirmed by bioluminescence study. Gene expression profiles between parental lung cancer cells (PC9) and brain-tropic cells (PC9-Br) was compared by Agilent Gene Expression Microarray followed by Ingenuity Pathway Analysis. The biologic effects and clinical implications of the candidate molecules were further investigated. Results: Significant activation of IGF and WNT signaling pathways was detected in PC9-Br, as compared with the parental cells. We selected IGF pathway as the first step to explore the potential therapeutic implication. Western blot and RT-PCR validated the results of IGF2 overexpression and activated IGF1R (pIGF1R) in PC9-Br cells. In vitro drug sensitivity tests showed that PC9-Br, in comparison to parental cells, was more resistant to erlotinib, an EGFR TKI (IC50: 30nM for PC9 and 189nM for PC9-Br). Knocking down IGF2 expression in PC9-Br reversed the drug resistance, while adding IGF2 to PC9 enhanced the resistance. In clinical samples, there was a significantly higher expression of pIGF1R in 26 brain metastases as compared to their paired primary lung tumors (mean of H score differences=40.96, 95% C.I.=10.96∼70.96, P=0.0094). Conclusions: IGF signaling pathway is activated in brain-tropic lung cancer cells and could potentially be a therapeutic target for brain metastasis. Acknowledgement: This study was supported by Research Grant 101-M2002 from the National Taiwan University Hospital. Citation Format: Pei-Fang Wu, Ching-Hung Lin, Wen-Chang Huang, Wen-Chi Feng, Yen-Shen Lu, Chih-Hsin Yang, Ann-Lii Cheng. Activated insulin-like growth factor (IGF) signaling pathway is a potential therapeutic target for brain metastasis from lung cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3886. doi:10.1158/1538-7445.AM2013-3886

Hashimoto's Encephalopathy As the Cause of Deteriorating Consciousness During Treatment of Leptomeningeal Carcinomatosis From Breast Cancer

Case Report A 53-year-old woman was diagnosed with breast cancer, and the pathologic results showed hormone-receptor–positive, HER2/neu– negative invasive lobular carcinoma in December 2007. The patient underwentamodifiedradicalmastectomyfollowedbyadjuvantchemotherapy, radiotherapy, and tamoxifen treatment immediately after the diagnosis. Unfortunately, a recurrence with a solitary brain metastasis developed in February 2009. Surgical excision of the brain tumor on February 27, 2009, confirmed the diagnosis of metastatic breast cancer. The patient received whole-brain radiotherapy (3,000 cGy per 10 fractions from March 18, 2009, to March 21, 2009) and salvage hormone therapy with letrozole for the next 2 years. The patient suffered from progressive slurred speech and an unsteady gait in early January 2011. One episode of brief unconsciousness resulted in a fall, and the patient came to our emergency department on January 7, 2011. The brain magnetic resonance imaging (MRI) showed multiple leptomeningeal lesions without brain parenchymal metastasis. The electroencephalography (EEG) later disclosed nonconvulsive status epilepticus. Anticonvulsive drugs were used. A CSF cytology study supported the diagnosis of leptomeningeal carcinomatosis. Intrathecal chemotherapy with methotrexate 12 mg was applied on January 18, 2011. An Ommaya reservoir implantation was done, and the patient was enrolled onto a clinical trial (NCT01281696) of systemic chemotherapy with bevacizumab, cisplatin plus etoposide (bevacizumab 15 mg/kg intravenous (IV) infusion for 90 minutes on day 1, cisplatin 70 mg/m IV infusion for 3 hours on day 2, etoposide 70 mg/m IV infusion for 60 minutes per day from days 2 to 4, repeated every 3 weeks on January 26, 2011, and February, 16, 2011, separately. The neurologic signs and symptoms of the patient improved gradually after two cycles of the chemotherapy. Follow-up CSF studies were all negative for malignant cells, and the neurologic deficit of the patient was much improved after treatment. She received the third course of systemic chemotherapy and concurrent intrathecal chemotherapy on March 8, 2011, the fourth course on March 28, 2011, and the fifth course on April 20, 2011. However, a new neurologic deficit developed approximately 10 days after the fifth course of systemic chemotherapy and concurrent intrathecal chemotherapy. The patient suffered from subacute onset, progressive right-limb weakness and, subsequently, tremors accompanied by a depressed level of consciousness. The patient came to our emergency department on May 1, 2011. Her laboratory tests revealed a hemoglobin level of 10.6 g/dL, WBC count of 6.2 K/ L, and platelet count of 81 K/ L. The biochemistry and electrolyte parameters were all within normal limits. A brain MRI study was performed but did not reveal any new lesions except for extensive white-matter changes. Repeated CSF cytology studies from both the Ommaya reservoir and the lumbar puncture indicated no malignant cells later. The CSF protein levels was 18 mg/dL (normal range, 15 to 45 mg/dL), and CSF glucose level was 60 mg/dL (normal range, 70 to 110 mg/dL). No WBCs were detected in CSF. Although the infectious process was on the list for a differential diagnosis, cultures for bacteria, virus, or fungus from all sites, including blood, CSF, sputum, and urine, were all negative. The clinical presentation of the patient, such as subacute cognitive dysfunction and possible complex partial seizure, also mimicked paraneoplastic limbic encephalitis, but the brain MRI did not demonstrate corresponding signal changes over the limbic system. Because the plasma level of valproate was within the therapeutic range, a second anticonvulsant (ie, levetiracetam) was added because of suspicion of uncontrolled complex partial seizure. Despite intensive studies for potential etiologies, none could be determined. The EEG on May 9, 2011, showed nearly continuous diffuse sharps and slow waves from 3 to 7 Hz and 20 to 100 V with some triphasic waves, which indicated the possibility of metabolic encephalopathy. Most of the metabolic factors, including renal function, electrolytes, hepatic function, serum adrenocorticotropic hormone, and cortisol level, were all within normal limits. Ultimately, thyroid-function tests exhibited a thyroid-stimulating hormone (TSH) level of 0.008 IU/mL (normal range, 0.1 to 4.5 IU/mL), free-T4 level of 1.26 ng/dL (normal range, 0.6 to 1.75 ng/dL), and T3 level of 190 ng/dL (normal range, 80 to 180 ng/dL). To figure out the cause of this unexplained encephalopathy, serum antithyroid antibodies were examined and were found to be markedly increased for both the antithyroglobulin (anti-TG) antibody (145.5 IU/mL [normal Conscious drowsy/unsteady gait MRI: Leptomeningeal carcinomatosis CSF: Positive for malignant cell cytology EEG: Nonconvulsive status epilepticus

Abstract 454: Glucocorticoids enhance metastatsis and tumorigenicity in a triple negative breast cancer cell line

Glucocorticoid (GC) is commonly co-administered with chemotherapy to prevent drug-induced allergic reaction, nausea, and vomiting. We have previously reported that GC may affect growth and chemosensitivity of carcinoma cells via diverse mechanisms (Lung Cancer 2006, 53:303-10; J Endocrinol 2006,188:311-9; World J Gastroenterol. 2005, 28:6373-80). Along this line, we further explored the effect of GC on breast cancer cells. Treatment of dexamethasone (DEX) resulted in early axillary lymph node metastases, and increased the number of lung and liver metastases in an orthotopic xenograft model of a triple negative breast cancer cell line (MDA-MB-231) in nude mice (BALB/cAnN.Cg-Foxn1 nu /CrlNarl). In tail vein injection assay of cancer metastasis, treatment of DEX dramatically enhanced the lung metastatic potential of a lung-seeking sub-clone, MDA-MB-231-Lu2 (derived from lung metastasis of MDA-MB-231 cells after two in vivo passages in nude mice using intracardiac injection). To explore the mechanism of GC-induced metastasis of breast cancer cells, we performed several in vitro studies. While DEX does not affect the proliferation rate of MDA-MB-231 cells according to MTT assay, treatment of DEX enhanced the tumorigenicity of the cells according to soft agar tumor sphere formation assay. On the other hand, treatment of DEX decreased tumorigenicity in two non-TNBC cell lines, MCF7 and T47D cells. Using quantitative polymerase chain reaction and Western blots assay, we found that treatment of DEX increased the expression of Slug, an epithelial-to-mesenchymal transition (EMT) related gene, and angiopoietin-like 4 (ANGPTL4), an important lung metastasis related gene, in MDA-MB-231 cells, but not in MCF7 and T47D cells. Using transwell migration/invasion assay (with or without matrigel above the membrane), we found that the conditioned medium of DEX-treated lung and liver tissues of mice attracted the MDA-MB-231 cells and promote migration/invasion. In conclusion, GC enhances metastasis and tumorigenicity in MDA-MB-231 cells, a triple negative breast cancer cell line. Whether GC may have a detrimental clinical effect on this subtype of breast cancer patients need to be verified. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 454. doi:1538-7445.AM2012-454