W. Bradford Carter

Randomized Trial Using Gonadotropin-Releasing Hormone Agonist Triptorelin for the Preservation of Ovarian Function During (Neo)Adjuvant Chemotherapy for Breast Cancer

PURPOSE Chemotherapy-induced amenorrhea is a serious concern for women undergoing cancer therapy. This prospective randomized trial evaluated the use of gonadotropin-releasing hormone (GnRH) analog triptorelin to preserve ovarian function in women treated with chemotherapy for early-stage breast cancer. PATIENTS AND METHODS Premenopausal women age 44 years or younger were randomly assigned to receive either triptorelin or no triptorelin during (neo)adjuvant chemotherapy and were further stratified by age (< 35, 35 to 39, > 39 years), estrogen receptor status, and chemotherapy regimen. Objectives included the resumption of menses and serial monitoring of follicle-stimulating hormone (FSH) and inhibin A and B levels. RESULTS Targeted for 124 patients with a planned 5-year follow-up, the trial was stopped for futility after 49 patients were enrolled (median age, 39 years; range, 21 to 43 years); 47 patients were treated according to assigned groups with four cycles of adriamycin plus cyclophosphamide alone or followed by four cycles of paclitaxel or six cycles of fluorouracil, epirubicin, and cyclophosphamide. Menstruation resumed in 19 (90%) of 21 patients in the control group and in 23 (88%) of 26 in the triptorelin group (P= .36). Menses returned after a median of 5.8 months (range, 1 to 19 months) after completion of chemotherapy in the triptorelin versus 5.0 months (range, 0 to 28 months) in the control arm (P= .58). Two patients (age 26 and 35 years at random assignment) in the control group had spontaneous pregnancies with term deliveries. FSH and inhibin B levels correlated with menstrual status. CONCLUSION When stratified for age, estrogen receptor status, and treatment regimen, amenorrhea rates on triptorelin were comparable to those seen in the control group.

Institutional Variation in the Surgical Treatment of Breast Cancer: A Study of the NCCN

Objective: To investigate the relationship between supply of subspecialty care and type of procedure preferentially performed for early stage breast cancer. Background: Three surgical options exist for early stage breast cancer: (1) breast conserving surgery (BCS), (2) mastectomy with reconstruction (RECON), and (3) mastectomy alone. Current guidelines recommend that surgical treatment decisions should be based on patient preference if a patient is eligible for all 3. However, studies demonstrate persistent variation in the use of BCS and RECON. Methods: Patients undergoing an operation for DCIS or stage I or II breast cancer at NCCN institutions between 2000 and 2006 were identified. Institutional procedure rates were determined. Spearman correlations measured the association between procedure types. Patient-level logistic regression models investigated predictors of procedure type and association with institutional supply of subspecialty care. Results: Among 10,607 patients, 19% had mastectomy alone, 60% BCS, and 21% RECON. The institutional rate of BCS and RECON were strongly correlated (r = −0.80, P = 0.02). Institution was more important than all patient factors except age in predicting receipt of RECON or BCS. RECON was more likely for patients treated at an institution with a greater supply of reconstructive surgeons or where patients live further from radiation facilities. RECON was less likely at institutions with longer waiting times for surgery with reconstruction. Conclusions: Even within the NCCN, a consortium of multidisciplinary cancer centers, the use of BCS and mastectomy with reconstruction substantially varies by institution and correlates with the supply of subspecialty care.

Human Epidermal Growth Factor Receptor 2 Regulates Angiopoietin-2 Expression in Breast Cancer via AKT and Mitogen-Activated Protein Kinase Pathways

Abnormal activation of human epidermal growth factor receptor 2 (HER2; ErbB-2) in breast tumors results in increased metastasis and angiogenesis, as well as reduced survival. Here, we show that angiopoietin-2 (Ang-2) expression correlates with HER2 activity in human breast cancer cell lines. Inhibiting HER2 activity with anti-HER2 monoclonal antibody trastuzumab (Herceptin) or HER2 short interfering RNA in tumor cells down-regulates Ang-2 expression. Consistent with the important roles of AKT and mitogen-activated protein kinase in the HER2 signaling pathway, AKT and ERK mitogen-activated protein kinase (MAPK) kinase activity is necessary for Ang-2 up-regulation by HER2. Moreover, overexpression of HER2 protein up-regulates Ang-2 expression. Heregulin-beta1-induced Ang-2 up-regulation is abrogated when AKT and ERK kinase activity are blocked. Immunohistochemical analysis of HER2 and Ang-2 proteins in human breast carcinomas shows that Ang-2 expression in breast cancer correlates with HER2 expression. These studies provide evidence that the Ang-2 gene is regulated by HER2 activity in breast cancer, and propose an additional mechanism for HER2 contributing to tumor angiogenesis and metastasis.

A Mammaglobin-A Targeting Agent for Noninvasive Detection of Breast Cancer Metastasis in Lymph Nodes

Pathologic axillary lymph node (ALN) status is an important prognostic factor for staging breast cancer. Currently, status is determined by histopathology following surgical excision of sentinel lymph node(s), which is an invasive, time consuming, and costly procedure with potential morbidity to the patient. Here, we describe an imaging platform for noninvasive assessment of ALN status, eliminating the need for surgical examination of patients to rule out nodal involvement. A targeted imaging probe (MamAb-680) was developed by conjugation of a mammaglobin-A-specific monoclonal antibody to a near-infrared fluorescent dye. Using DNA and tissue microarray, mammaglobin-A was validated as a cell-surface target that is expressed in ALN-positive patient samples but is not expressed in normal lymph nodes. In vivo selectivity was determined by i.v. injection of MamAb-680 into mice with mammaglobin-A-positive and -negative mammary fat pad (MFP) tumors; and by peritumoral MFP injection of the targeted imaging probe in mice with spontaneous ALN metastases. Fluorescence imaging showed that probe was only retained in positive tumors and metastases. As few as 1,000 cells that endogenously express mammaglobin-A were detected in ALN, indicating high sensitivity of this method. Translation of this approach offers considerable potential as a noninvasive clinical strategy to stage breast cancer.

Chemotherapy Use for Hormone Receptor–Positive, Lymph Node–Negative Breast Cancer

PURPOSE To describe the frequency of chemotherapy use for hormone receptor (HR)-positive, lymph node (LN)-negative breast cancer from 1997 to 2004 at eight National Comprehensive Cancer Network institutions, to explore whether chemotherapy use varied over time and between institutions, and to identify factors associated with the decision to forego chemotherapy. PATIENTS AND METHODS Among women younger than age 70 years with HR-positive, LN-negative breast cancer measuring more than 1 cm, we analyzed the frequency of chemotherapy use on a yearly basis. A multivariable logistic regression model assessed the relationship between receipt of chemotherapy and year of diagnosis, institution, tumor features, and patient characteristics. Interaction terms were added to the model, and stratified analyses were conducted to further explore the determinants of chemotherapy use. RESULTS Fifty-five percent of 3,190 women received chemotherapy. Chemotherapy use was less common for patients with 1.1- to 2-cm tumors than for patients tumors greater 2 cm (47% v 87%, respectively; P < .01) and for women age 60 to 69 years versus women younger than age 50 years (24% v 76%, respectively; P < .01). On multivariable analysis, predictors independently associated with receiving chemotherapy included larger tumor size, higher grade, human epidermal growth factor receptor 2 overexpression, younger age, and institution (P < .01 for all). Institutions exhibited dramatically different rates of chemotherapy use (from 46% to 65%) and patterns of change in chemotherapy use over time (from a 79% relative increase to a 22% relative decrease). CONCLUSION Although institutions seemed to agree that not all women with HR-positive, LN-negative breast cancer need chemotherapy, there did not seem to be consensus regarding which women should get chemotherapy. Only prospective randomized controlled trials will conclusively establish which subtypes of HR-positive, LN-negative breast cancer benefit from chemotherapy.

Role of Axillary Staging in Women Diagnosed With Ductal Carcinoma In Situ With Microinvasion

BACKGROUND Axillary staging via sentinel node biopsy (SLNB) in patients with ductal carcinoma in situ with microinvasion (DCISM) is routinely performed but remains controversial with regard to the risk-benefit ratio. METHODS Retrospective single-institution review of patients with diagnosis of DCISM (invasive tumor ≤ 0.1 cm). Age, clinicopathologic data, and follow-up were recorded. RESULTS Of 90 patients, 33% were diagnosed by core needle biopsy (CNB), 37% by excisional biopsy, and 29% were upstaged from DCIS on CNB to DCISM at final operation. Three (10%) of 30 patients with DCISM on CNB were upstaged to invasive cancer on final pathology. Median age at diagnosis was 58.9 years (range: 30-89). Lumpectomy was performed in 45% of patients and mastectomy in 55%. Mean number of sentinel nodes was 2.59 (SE 0.17). Six (6.9%) of 87 patients with DCISM as final diagnosis had a positive SLNB (four lumpectomies, two mastectomies). There was no correlation with any clinicopathologic features, including palpable DCIS, DCIS grade/necrosis, or age at diagnosis. All six SLNB-positive patients had a complete axillary dissection; two had additional disease. Median follow-up time was 74.2 months (range: 2-169). In-breast recurrence was seen in three patients (5%), regardless of SLN status, DCIS grade, or necrosis. Two patients developed distant metastasis. Overall survival was 94.19% at 5 years for DCISM and 100% for DCISM with nodal disease. CONCLUSION DCISM comprises 0.6% of breast cancer diagnoses at our institution. There is a low likelihood of nodal spread; however, a lack of identifiable clinicopathologic features associated with a positive SLNB limits selective SLNB use.

Mechanisms of HER2-induced endothelial cell retraction.

BackgroundHER2 overexpression imparts a metastatic advantage in breast cancer. We have shown that HER2 signaling in breast cancer cells induces adjacent endothelial cell (EC) retraction, disrupting endothelial integrity. Because endothelial integrity is dependent on the adherens junctions, we postulated that the mechanism of tumor cell-induced EC retraction involves dissociation of catenin proteins from vascular endothelial (VE) cadherin. In this study, we report a loss of VE-cadherin in tumor-associated EC. We also tested for a change of catenin dissociation from VE-cadherin by manipulating HER2 signaling in tumor cells.MethodsWe tested confluent monolayers of human EC for downregulation of VE cadherin and dissociation of catenins from VE cadherin after exposure to breast cancer cells or conditioned media. Using immunoprecipitation, we quantitated the remaining complexed catenins to VE-cadherin in tumor-associated EC after different treatments to manipulate HER2 signaling.ResultsTreatment of EC with conditioned media from MCF-7 cells expressing HER2 induced a loss of VE-cadherin expression, and time-dependent dissociation of catenins from VE cadherin. Catenin dissociation from VE-cadherin was enhanced by Heregulin β1 (P < .05) stimulation and decreased by trastuzumab (P < .05) blockade of HER2 signaling in cancer cells. An increase in EC phosphoSrc (Tyr 416) was seen by 8 hours.ConclusionsOur data suggest that HER2 induction of EC retraction involves both down-regulation of VE-cadherin and dissociation of catenins. HER2 signaling appears to regulate this potential metastatic mechanism. Further, Src phosphorylation suggests that this pathway may be involved in this mechanism.

Adenoid Cystic Carcinoma of the Breast: A Review of a Single Institution’s Experience

To the Editor: Adenoid cystic carcinoma of the breast (ACCB) is rare, comprising less than 0.1% of breast cancers, and may be under-reported due to misclassification (1). Such misclassification has negative impact, as this tumor requires different clinical management when compared to breast adenocarcinoma. We reviewed our institutional experience by searching a prospectively accrued database of 17,703 patients from 1989–2006 for ‘‘cylindroma,’’ ‘‘cribriform,’’ ‘‘papillary,’’ or ‘‘adeno’’ to minimize misclassification. After histological confirmation, records were reviewed for presentation, staging, therapy, and outcome. Eighty-eight potential patients with ACCB were identified, but after slide review, only seven true ACCB cases were identified (Table 1). Six patients presented with either breast pain or palpable mass. Median age was 49 years (range 37–82 years) and median tumor size was 1.8 cm (range 1.3–5 cm). Imaging studies included mammography in all seven patients that revealed spiculated masses, and ultrasonography in six patients that revealed hypoechoic, well-circumscribed masses. Diagnosis of ACCB was made by core biopsy in one patient and excisional biopsy in six patients performed prior to referral to our institution. Definitive surgery included partial mastectomy in four and total mastectomy in three patients. While at operative resection all lesions appeared grossly wellcircumscribed, histological analysis revealed microscopic tumor extending away from the gross margin, requiring re-excision in all who underwent partial mastectomy. While acceptable margin width has not been definitively established, a minimum of one millimeter seems advisable due to the high rate of margin positivity in this study, and the local recurrence rates of 30–40% reported previously (2). Histologically, ACCB appeared different from the common forms of breast cancer and similar to adenoid cystic carcinomas seen in the head and neck (Fig. 1). The tumor is characterized by a mixture of proliferating epithelial cells forming ductule-like structures and glands (true lumina), and modified myoepithelial elements forming cribriform spaces (‘‘pseudolumens’’). In our series, all but one of our patients underwent sentinel node biopsy, with one patient having isolated tumor cell clusters in the sentinel node detected on IHC only. For this patient, on complete node dissection, the remaining 21 nodes were all negative. In review of the literature, axillary involvement appears in approximately 15% (3). While routine complete node dissection in modern practice is unwarranted, consideration for the low morbidity procedure of a sentinel lymph node biopsy should be given. Omission of sentinel node biopsy in the absence of palpable axillary disease can be weighed on an individual basis. As in our series, this includes small, medial tumors in patients with significant co-morbidity. The follow-up of patients included a clinical examination every 6 months for 5 years, and mammography every 6 months for 2 years and annually thereafter. The three patients treated with partial mastectomy received adjuvant whole breast radiation (range 50– 65 Gy). None of the seven patients received adjuvant hormonal or chemotherapy. All seven tumors were estrogen receptor, progesterone receptor, and HER2 ⁄ neu negative. Despite the ‘‘triple negative’’ hormone receptor status and histological similarity to the clinically aggressive adenoid cystic carcinomas of the head and neck, ACCB had an indolent clinical course. At a median follow-up of 49 months after resection, only one patient had a local recurrence. This patient initially presented to an outside institution and Address correspondence and reprint requests to: Christine Laronga, MD, Comprehensive Breast Program, 12902 Magnolia Drive, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, or e-mail: Christine. Laronga@moffitt.org

Abstract 1289: Cooperation between beta-catenin, Snail, Slug, and Twist is required for maximum repression of the human vascular endothelial-cadherin promoter

Vascular endothelial (VE)-cadherin is a key protein in the adherens junctions. This protein forms homophilic intercellular interactions and is required for the integrity of the endothelial monolayer, endothelial permeability, and control of cell growth. We have previously demonstrated that exposure of endothelial cells to breast cancer cell-conditioned media results in upregulation of Twist, Slug, and Snail expression, which in turn downregulate the activity of the human VE-cadherin promoter through at least two E-box motifs. Since these repressors have been linked to the β-catenin signaling pathway, we chose to determine whether β-catenin could regulate the activity of the human VE-cadherin promoter. Herein, we demonstrate that β-catenin represses the VE-cadherin promoter either alone or in coordination with the repressors Twist, Slug, and Snail. Electrophoretic mobility shift assays showed that the VE-cadherin promoter contains four β-catenin/LEF-1 binding motifs (designated Site-1-4) that appear to be involved in this regulatory process. In addition, we identified TGFβ as one of the factors released by breast cancer cells that could be involved in the regulation of the VE-cadherin gene when HDMEC are exposed to breast cancer cell conditioned medium. 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 1289. doi:1538-7445.AM2012-1289