Ductal Carcinoma Of Breast Research Articles

Abstract P1-05-25: Clinical and biological features of 158 consecutive and unselected oligometastatic breast cancers

Abstract Background: In order to determine the optimal treatment strategy for oligometastatic breast cancer (OMBC), effective and safe treatments for metastatic sites and sensitive and specific imaging techniques are needed. But it is also essential to know the incidence of oligometastatic breast cancer and its clinical and biological characteristics [1]. Efficient imaging techniques and therapeutic tools exist, but knowledge of incidence, clinical and biological characteristics of OMBC is scarce. This is partly due to the lack of publications describing these data on recent, consecutive, and unselected series of OMBC. Methods: we retrospectively collected data from 998 patients diagnosed with synchronous or metachronous metastatic breast cancer (MBC) between January 2014 and December 2018 at our institution. The only criterion used to define OMBC was the presence of one to five metastases at diagnosis. Hormone receptor (HR) and HER2 receptor status, histology, SBR grade, number of metastases and organs affected were collected. Results: Of 998 MBC, 15.8% were OMBC (158/998). Among the series, 88% (139/158) of OMBC had 1 to 3 metastases and 86.7% (137/158) had only one organ involved. Among 158 patients, 52.5% (n=83) had bone metastases, 20.9% (n=33) had lymph node metastases, 14.6% (n=23) had liver metastases, 13.3% (n=21) had brain metastases, 8.2% (n=13) had lung metastases, and 3.8% (n=6) had others (skin, pancreas, adrenal). Among these 158 patients, 83.4% (n=131) had ductal breast carcinoma, 55.7% (n=88) had HR+/HER2- OMBC, 25.3% (n=40) had HER2+ OMBC and 19% (n=30) had HR-/HER2- OMBC. HR+/HER2- subtype was statistically associated with bone and bone only metastases (p=0.001), HER2+ subtype with brain metastases (p=0.001) and HR-/HER2- subtype with lymph node metastases (p=0.008). Visceral metastases (lung or liver) are not statistically associated with any biological subtypes. The proportion of OMBC with SBR grade III was statistically higher than in a series of 22,109 patients with MBC [2] (49.4% vs 35.2%; p< 0.001). Conclusion: OMBC is a heterogeneous entity. OMBC incidence is certainly much higher than the commonly used values. OMBC is not an indolent disease, and each subgroup, according to its biological and anatomical characteristics, may deserve a specific management. [1] Hellman S, Weichselbaum RR. Oligometastases. J Clin Oncol Off J Am Soc Clin Oncol 1995;13:8–10. https://doi.org/10.1200/JCO.1995.13.1.8. [2] Deluche E, Antoine A, Bachelot T, Lardy-Cleaud A, Dieras V, Brain E, et al. Contemporary outcomes of metastatic breast cancer among 22,000 women from the multicentre ESME cohort 2008–2016. Eur J Cancer 2020;129:60–70. https://doi.org/10.1016/j.ejca.2020.01.016. Citation Format: Jean Louis LACAZE, Clémence Brac de la Perrière, Mony Ung, Florence Dalenc, Vincent Nicolai, Eleonore De Maio, Marion Montastruc, Bastien Cabarrou, Nils Monselet, Ciprian Chira, Gauthier Glemarec, Thibaut Cassou-Mounat. Clinical and biological features of 158 consecutive and unselected oligometastatic breast cancers [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-05-25.

Abstract P2-21-11: A high content imaging and analysis approach to screen compounds for novel drug targets in 3D breast cancer co-culture model

Abstract The desired effect of cancer therapeutics can only be conceived when applied to complex multicellular structures with different cell types and extracellular matrix (ECM) in three-dimensional (3D) space. Therefore, 3D cell culture systems have become very popular in drug screening and discovery. There is an immense demand for highly efficient and easy methods to produce 3D spheroids in any cell format. However, heterogeneity in size, extended cultivation times, and reproducibility for high throughput assays are limiting factors in the generation of spheroids. Recently we have established a naturally transformed breast cancer cell line, KAIMRC1 (1), from ductal breast carcinoma. We have developed a novel and easy method to produce spheroids (2) from KAIMRC1 cells in vitro, which can be used as a 3D model to study proliferation, differentiation, metabolism, cell death, and drug response of cells in the tumor microenvironment. We developed an in-vitro high content imaging (HCI) based cellular assay using commercially available compound panels to perform initial drug screening in the KAIMRC1 spheroids model. Our approach allows rapid screening of a panel of drugs to assess inhibitory effects on the growth of tumor cells in 3D cultures. To mimic the actual in-vivo tumor microenvironment, we are now developing an HCI-based assay utilizing 3D KAIMRC1 spheroids co-cultured with patient-derived fibroblast cells. 1. Ali, Rizwan, et al. “Isolation and Characterization of a New Naturally Immortalized Human Breast Carcinoma Cell Line, KAIMRC1.” BMC Cancer 17 (2017) 2. Rizwan Ali et al., (2021) New Born Calf Serum (NBCS) can induce spheroid formation in breast cancer KAIMRC1 cell line. Front. Mol. Biosci. DOI: 10.3389/fmolb.2021.769030 Citation Format: Rizwan Ali, Sarah Huwaizi, Arwa Alsubait, Mohamed Boudjelal. A high content imaging and analysis approach to screen compounds for novel drug targets in 3D breast cancer co-culture model [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-21-11.

Radiation-Induced Localized Bullous Pemphigoid.

Radiation-Induced Localized Bullous Pemphigoid.

Abstract GS4-08: 10-year results of a phase 3 trial of low-dose tamoxifen in non-invasive breast cancer

Abstract We have previously shown in a phase 3 trial that tamoxifen 5 mg/day for 3 years decreased by 52% the incidence of recurrence of invasive breast cancer or DCIS after a median follow-up of 5.1 years in women with excised non invasive breast disease, including atypical ductal hyperplasia, DCIS or LCIS (DeCensi et al. JCO 2019; 37:1629). Toxicity was negligible with only an extra hot flash per day in the tamoxifen arm compared with the placebo arm. These findings were incorporated into the ASCO clinical practice guidelines for breast cancer risk reduction as an alternative option to standard doses and duration of tamoxifen or aromatase inhibitors in women with non-invasive disease (Visvanathan et al. JCO 2019; 37:3152). In the present study we update the findings on breast cancer recurrence after a median of 9.14 years (interquartile range, IQR, 7.16-10.73) and a total of 10.57 person years of follow up to see if the treatment effect is retained with more events and after a median of approximately 6 years from treatment cessation. We conducted a national multicenter randomized trial of tamoxifen, 5 mg/d or placebo administered for 3 years after surgery in women with hormone-sensitive or unknown breast intraepithelial neoplasia, including atypical ductal hyperplasia and lobular or ductal carcinoma in situ. The primary end point was the incidence of invasive breast cancer or ductal carcinoma in situ. Between November 1, 2008, and March 31, 2015, 1,160 women were screened and 500 aged 75 years of age or younger were included in the study. Women with high-grade or comedo/necrotic DCIS received adjuvant radiotherapy of 50 Gy in 25 courses. The mean age was 54 years (standard deviation, 9 years), and 55% of participants were postmenopausal. The mean (SD) body mass index, kg/m2, was 25.7 (4.8) on tamoxifen and 25.3 (4.2) on placebo. Twenty percent had ADH, 11% had LCIS, and the remaining 69% had DCIS. After a median follow-up of 9.14 years, there were 22 neoplastic events (invasive breast cancer or DCIS) with tamoxifen and 37 with placebo (annual rate 11.09, 95% CI, 7-30-16.84 on T vs 19.71, 95% CI, 14.28-27.21 on P per 1,000 person-years; hazard ratio, 0.56; 95% CI, 0.33 to 0.95; P = .03), which resulted in a 5-year number needed to treat of 18. Overall, 71% of the recurrences were invasive breast cancer. The follow-up was updated with the most recent visit within 12 months in two thirds of the participants, so an update of all participants will be performed by Sept 30th with full analysis of neoplastic events, annual risk rate ratio, serious adverse events and deaths. Moreover, an updated analysis of potential effect modifiers will be conducted, including menopausal status, baseline estradiol levels, menopausal symptoms, BMI, smoking status and Ki-67 of the primary lesion. In conclusion, our findings indicate that low dose tamoxifen given for 3 years still significantly prevents recurrences from non-invasive breast cancer after a median of 6 years from treatment cessation, providing a valid prevention/interception option in this disease group. Supported by Ente Ospedaliero Ospedali Galliera, Genova, Italy, the Italian Ministry of Health (RFPS-2006-1-339898), the Italian Association for Cancer Research (IG 2008 Grant No. 5611), and the Italian League against Cancer (LILT 7-08). Citation Format: Andrea De Censi, Matteo Lazzeroni, Matteo Puntoni, Luca Boni, Aliana Guerrieri Gonzaga, Tania Buttiron Webber, Marianna Fava, Irene Maria Briata, Livia Giordano, Maria Digennaro, Laura Cortesi, Fabio Falcini, Franca Avino, Francesco Millo, Katia Cagossi, Elisa Gallerani, Alessia De Simone, Anna Cariello, Giuseppe Aprile, Maria Renne, Bernardo Bonanni. 10-year results of a phase 3 trial of low-dose tamoxifen in non-invasive breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr GS4-08.

Abstract P5-07-02: Embryo utilization in young breast cancer patients who have undergone egg harvesting for fertility preservation

Abstract INTRODUCTION: Much progress has been made related to fertility preservation in women diagnosed with breast cancer. This includes heightened awareness of impaired fertility due to breast cancer treatment, increased referrals to fertility specialists and development of safe and expeditious means of egg harvesting. Nevertheless, there has been limited investigation of the ultimate issue in fertility preservation, namely the frequency with which women who have undergone egg harvesting actually pursue childbearing. We have retrospectively reviewed a single institution’s experience with egg and embryo utilization among patients who expressly desired childbearing and underwent egg harvesting after a diagnosis of breast cancer. These issues have also been analyzed relative to race and insurance coverage. METHODS: In an IRB approved study, breast cancer patients treated in our institution between 2010 and 2020 were identified and their post-diagnosis fertility and childbearing history was reviewed. Inclusion criteria were age at presentation ≤ 45 years and diagnosis of either invasive breast cancer or ductal carcinoma in situ. Race (self-reported on clinic intake form) and insurance coverage data were analyzed. In cases of incomplete medical record data, we interviewed patients by telephone. RESULTS: 316 breast cancer patients of reproductive age were identified (average age at diagnosis = 39 years, range: 23 - 45). Of these, 168 patients (53%) were offered fertility referral and 118 (38%) saw a fertility specialist. 91 patients (29%) pursued egg harvesting followed by cryopreservation of eggs in 49 cases and embryos in 41 with 1 case unknown. Over an average of 5 years of follow-up (range: 2 - 12 years), 28 women (31% of those who pursued egg harvesting) utilized the egg or embryo to pursue childbearing. 17 underwent embryo transfer to themselves and 11 used surrogate carriers. To date, this has resulted in 20 childbirths from 24 pregnancies. Four pregnancies are currently ongoing and 1 woman is awaiting embryo transfer. Four patients who had undergone egg harvesting conceived without fertility intervention. Of the 55 Medicaid patients of reproductive age diagnosed with breast cancer, only 8 (15%) met with a fertility specialist, 4 harvested eggs, and none pursued childbearing. HMO/PPO insured patients were significantly more likely than Medicaid patients to pursue egg harvesting and embryo utilization (X2 = 7.320, df = 2, p = 0.026). Of 260 HMO/PPO insured patients, 110 (42%) met with a fertility expert, 87 harvested eggs and 28 pursued embryo transfer. Due to the small sample size of patients who utilized embryos in each racial subgroup, analysis did not yield statistically significant differences across groups (p=0.067). Nevertheless, apparent racial disparities exist. Our data reveal that 5 of 17 (29%) Asian patients and 22 of 62 (36%) White patients utilized embryos as opposed to Black patients (1/4 or 25%), Hispanic patients (0/4 or 0%) and those who identified their race as “other” (1/4 or 25%). CONCLUSIONS: These data demonstrate a low overall rate of cryopreserved egg and embryo utilization among women treated for breast cancer whose earlier pursuit of egg harvesting was evidence of a desire for childbearing. Furthermore, racial and insurance data demonstrate disparities in the pursuit of fertility treatment and utilization of preserved eggs and embryos. Further research will utilize interviews to analyze individual women’s decision-making process relevant to such issues as hormone therapy utilization, concerns about breast cancer recurrence, progression of disease and restraints imposed by relationship status and finances. Given the disparity findings reported here, finances will likely emerge as a significant barrier to childbearing in future qualitative research. Citation Format: Christina Weltz, Daniella Nevid, Alison Pruzan, Elisa Port, Ronald Couri. Embryo utilization in young breast cancer patients who have undergone egg harvesting for fertility preservation [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-07-02.

Abstract PD15-10: PD15-10 Impact of procedure type on long-term revisional surgery and secondary reconstruction following immediate breast reconstruction: The UK Brighter national population-based cohort study

Abstract Introduction: Women considering immediate breast reconstruction (IBR) after mastectomy for breast cancer require high-quality information about the short and long-term clinical outcomes of different procedure types, including the need for further surgery, to allow them to make fully informed decisions about their breast reconstruction options. Long-term outcome data is currently lacking. The UK Brighter population-based cohort study aimed to compare the need for revisional surgery and secondary reconstruction by type of IBR at a minimum of 12 years following the index procedure to support informed decision-making. Methods: Women who underwent unilateral mastectomy and IBR for invasive breast cancer or ductal carcinoma in situ (DCIS) in England between 1 April 2008 and 31 March 2009 were identified using National Health Service (NHS) Hospital Episode Statistics (HES). Lists of procedure codes indicating revisional surgery, defined as operations performed to the same site as the index reconstruction and/or the donor site (if appropriate), excluding a single planned implant exchange in the expander group, or secondary reconstruction, defined as the replacement of one reconstruction with another, with or without a period of being flat, were iteratively developed and refined. Numbers of revision procedures and secondary reconstructions were compared by type of index reconstruction. Multivariable regression was used to control for potential confounders. Results: 2,260 women underwent IBR during the study period including 742 (32.8%) expander/implant (EI), 1,146 (50.7%) latissimus dorsi (LD) flap reconstructions with (n=649) and without (n=497) an implant and 372 (16.5%) abdominal free-flap (AFF) procedures. Women receiving reconstructions involving implants were significantly more likely to require more revisions over time, with 201/742 (27.1%) patients undergoing EI reconstruction and 154/649 (23.7%) those receiving an implant-assisted LD reconstruction requiring two or more post-reconstruction revision procedures compared with 77/497 (15.5%) patients undergoing autologous LD and 59/372 (15.9%) patients receiving AFF procedures (p< 0.001). Undergoing primary reconstructive surgery before the age of 50, and region of residence at the time of the mastectomy were factors influencing revisional surgery in the multivariable regression analysis. By 12 years, 128/742 (17.3%) of women who initially underwent an expander/implant reconstruction had received a secondary reconstruction compared with 34/1146 (3.0%) patients who had initially received an LD +/- implant procedure and 11/372 (3.0%) patients initially undergoing an AFF reconstruction (p< 0.001). Conclusions: The need for revisional surgery in women electing to undergo IBR involving implants is significantly greater than that for women electing to receive autologous reconstructions and almost 1 in 5 women undergoing primary EI reconstruction required a secondary reconstruction by 12 years. These findings should be shared with women considering IBR to support informed decision making and with healthcare providers and commissioners to support the provision of high-quality, evidence-based reconstructive care. Citation Format: Leigh Johnson, Paul White, Ranjeet Jeevan, John Browne, Carmel Gulliver-Clarke, Joe O’Donoghue, Syed Mohiuddin, William Hollingworth, Patricia Fairbrother, Mairead MacKenzie, Chris Holcombe, Shelley Potter. PD15-10 Impact of procedure type on long-term revisional surgery and secondary reconstruction following immediate breast reconstruction: The UK Brighter national population-based cohort study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD15-10.

Abstract PD15-09: PD15-09 Impact of procedure type on the long-term patient-reported outcomes of immediate breast reconstruction: The UK Brighter Study

Abstract Introduction: Women considering immediate breast reconstruction (IBR) after mastectomy for breast cancer require high-quality information about the short and long-term outcomes of different procedure types to allow them to make informed decisions about their surgical options. Long-term multicentre patient-reported outcomes (PROs) comparing the patients’ perspectives of different techniques is currently lacking. The UK Brighter study aimed to compare the long-term patient-reported outcomes of different types of IBR to support informed decision-making. Methods: Women who underwent unilateral mastectomy and/or breast reconstruction for invasive breast cancer or ductal carcinoma in situ (DCIS) in England between 1 April 2008 and 31 March 2009 were identified from National Health Service (NHS) Hospital Episode Statistics (HES), and current contact information for the surviving cohort were provided by the NHS Personal Demographic Service. Women were sent a letter inviting them to complete three validated patient report questionnaires, the BREAST Q, EQ-5D5L and ICECAP-A, electronically or by post at a minimum of 12 years following their index surgery. Questionnaires were scored according to developers’ instructions and results compared by type of IBR procedure performed. Results: 11,977 women were invited to participate of whom 4,207 (35.1%) completed the questionnaires. Of these, 1,236 (29.4%) received IBR with 343 (27.8%) expander/implant (EI) reconstructions, 629 (50.9%) latissimus dorsi (LD) procedures with or without an implant, and 264 (21.4%) abdominal flap (AF) reconstructions. The mean age at index surgery was 52.1 years, standard deviation (SD) 9.5. The majority of respondents were white (n=1,179, 97.4%) and predominantly from areas of the lowest socioeconomic deprivation. The mean body mass index (BMI) was 24.6 (SD 3.9). 141 (11.6%) women actively smoked at the time of surgery and 227 (19.0%) had a complication requiring further surgery. Women undergoing AFs reported significantly higher ‘Satisfaction with Breasts’ (mean 67.7, SD 20.4) than those undergoing LD (mean 58.9, SD 21.1), or EI reconstructions (mean 54.7, SD 19.2), (p< 0.001). ‘Satisfaction with Breasts’ was also greater in women undergoing index surgery over 50 years of age (p=0.02) and in those who did not smoke (p=0.03) whereas experiencing post-operative complications was strongly associated with poorer ‘Satisfaction with Breasts’ in the multivariable analysis (p=0.001). Women receiving AF also reported better ‘Physical Well-being’ (mean 87.8, SD 16.04) than women undergoing LD flap (mean 79.5, SD 20.5) or EI procedures (mean 82.1, SD 18.2), (p< 0.001). Overall, women undergoing AFs were more likely to rate the outcome of their surgery as ‘excellent’ or ‘very good’ (189/256, 73.8%) compared with those receiving other reconstruction types (LD - 386/610, 63.3%; EI - 175/331, 52.9%, p< 0.001). Conclusion: Women undergoing abdominal flap reconstruction report significantly better outcomes 12 years following IBR than women receiving other reconstruction types. These findings should be shared with women considering breast reconstruction to help them make informed decisions about their surgical options. Citation Format: Leigh Johnson, Paul White, Ranjeet Jeevan, John Browne, Carmel Gulliver-Clarke, Joe O’Donoghue, Syed Mohiuddin, William Hollingworth, Patricia Fairbrother, Mairead MacKenzie, Chris Holcombe, Shelley Potter. PD15-09 Impact of procedure type on the long-term patient-reported outcomes of immediate breast reconstruction: The UK Brighter Study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD15-09.

Abstract P2-15-03: Impact of radiotherapy on the long-term patient-reported outcomes of immediate breast reconstruction: The UK Brighter

Abstract Introduction: Post-mastectomy radiotherapy (PMRT) is an important component of breast cancer treatment and has been shown to improve overall survival for women with large cancers or node positive disease. The long-term effects of radiotherapy on the outcomes of immediate breast reconstruction (IBR) and how these are perceived from the patients’ perspective, however, are largely unknown. The UK Brighter study aimed to evaluate the long-term impact of PMRT on the patient-reported outcomes of IBR to support informed decision-making. Methods: Women who underwent unilateral mastectomy and/or breast reconstruction for invasive breast cancer or ductal carcinoma in situ (DCIS) in England between 1/4/2008 and 31/3/2009 were identified from National Health Service (NHS) Hospital Episode Statistics (HES), and current contact information for the surviving cohort provided by the NHS Personal Demographic Service. Women were sent a letter inviting them to complete three validated patient-reported outcome questionnaires, the BREAST Q, EQ-5D-5L and ICECAP-A, electronically or by post at a minimum of 12 years following their index surgery. Questionnaires were scored according to developers’ instructions and scores for women who had received PMRT following IBR compared with those who underwent IBR without radiotherapy, in the cohort as a whole and by reconstruction type. Results: 11,977 women were invited to participate of whom 4,207 (35.1%) completed the questionnaires. Some 1,236 (29.4%) underwent IBR with 343 (27.8%) expander/implant (EI) reconstructions, 629 (50.9%) latissimus dorsi (LD) flaps with or without (+/-) an implant, and 264 (21.4%) abdominal flap (AF) reconstructions. Of these, 388 (31.4%) (EI n=79 (20.4%); LD+/-implant n=222 (57.2%); AF n=87 (22.4%) received PMRT. In the cohort overall, women who received PMRT following IBR reported significantly lower ‘Satisfaction with Breasts’ scores at 12 years compared with those who did not receive radiotherapy (PMRT mean 56.4. standard deviation (SD) 21.5 vs. no PMRT mean 61.3, SD 20.5), p< 0.001). However, this difference varied across procedure types. Specifically, the ‘Satisfaction with Breasts’ scores of women receiving PMRT following AF reconstruction were 10.5 points lower than those not receiving PMRT (PMRT mean 60.9, SD 20.2; no PMRT mean 71.4, SD 19.6, p< 0.001). This difference was lower in in women undergoing LD reconstruction (mean with PMRT 54.3, SD 21.1; mean without PMRT 61.6, SD 20.7; p< 0.001). There were no significant differences in women undergoing EI reconstruction (PMRT mean 57.5, SD 23.6, no PMRT mean 53.9, SD 17.7). ‘Physical Well-being’ (chest) scores were also significantly lower in women receiving PMRT following IBR in the cohort overall (PMRT mean 78.7, SD 20.1, no PMRT 83.6, SD 18.6, p< 0.001) but women undergoing AF reconstruction showed the greatest difference in scores (PMRT mean 83.2, SD 17.0 vs No PMRT mean 90.1, SD 15.0, p< 0.001). There were no significant differences in ‘Physical Well-being’ scores for women who underwent EI reconstruction with or without PMRT. ‘Psychosocial Well-being’ scores were lower in women receiving PMRT after IBR (PMRT mean 70.8, SD 22.0, No PMRT 75.4, SD 21.0), but again, differential effects were seen by procedure type with no significant differences seen in the EI group but significant differences in scores seen in women receiving PMRT after flap-based procedures. Conclusions: Women undergoing PMRT report significantly lower long-term patient-reported outcomes of flap-based reconstruction, in particular ‘Satisfaction with Breasts’ and ‘Physical Well-being’ scores. This difference was not apparent in women undergoing EI procedures. This information should be shared with patients to help them make fully informed decisions about the type and timing of their reconstructive surgery. Citation Format: Leigh Johnson, Paul White, Ranjeet Jeevan, John Browne, Carmel Gulliver-Clarke, Joe O’Donoghue, Syed Mohiuddin, William Hollingworth, Patricia Fairbrother, Mairead MacKenzie, Chris Holcombe, Shelley Potter. Impact of radiotherapy on the long-term patient-reported outcomes of immediate breast reconstruction: The UK Brighter [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-15-03.

Abstract PD15-07: PD15-07 7-gene predictive biosignature improves risk stratification for breast ductal carcinoma in situ patients compared to clinicopathologic criteria, identifying a low risk group not clinically benefiting from adjuvant radiotherapy

Abstract Background: Prognostic and predictive tools are needed to optimize treatment for women diagnosed with ductal carcinoma in situ (DCIS). While radiotherapy (RT) is standard of care for DCIS after breast conserving surgery (BCS), those at low-risk for ipsilateral breast recurrence (IBR) risk may be treated without RT. Low-risk has been defined as the absence of high risk clinicopathologic (CP) factors, including larger (>2 cm), palpable, or high nuclear grade (NG) tumors, and younger age (< 50 yrs). However, prospective trials have failed to identify low risk patients (pts) who do not clinically benefit from RT after BCS (RTOG 9804). DCISionRT® (PreludeDxTM, CA) is a 7-gene predictive biosignature providing a validated score (DS) to assess the 10-yr IBR risk and RT benefit, using individual tumor biology and CP factors. This study assessed total 10-yr IBR rates, RT benefit, and number needed to treat (NNT) for risk groups defined by biosignature and CP criteria. Methods: DCIS patients (n=926) from four international cohorts (median follow up 8.5 yrs, 1-3rd quartile 5.8 – 10.2 yrs) treated with BCS (negative margins), with (n=641) and without RT (n=335), had formalin-fixed paraffin-embedded tissues analyzed at a CLIA lab (PreludeDx, Laguna Hills, CA) for DCISionRT with a Residual Risk subtype (RRt). A biosignature Low Risk group (DS≤2.8 without RRt) was contrasted to a High Risk group comprising Elevated Risk (DS>2.8 without RRt) and Residual Risk (DS>2.8 with RRt) groups. Low-risk CP groups were RTOG 9804-like (NG1-2, non-palpable, negative margins, screening detected) or (age >50 and NG 1-2). Total 10-yr IBR rates were evaluated using Cox Proportional Hazards and Kaplan Meier analysis by treatment, biosignature and CP risk groups. NNT was determined with 10-yr IBR rate differences with RT. Results: The biosignature classified 37% (n=338) of women as Low Risk and 63% (n=588) as High Risk. Among women who did not receive RT, biosignature Low Risk pts had lower IBR than biosignature High Risk pts (5.6% vs. 25.7%, p<.001). About half of pts defined as CP low-risk by 9804-like (51%) or favorable Age/NG (58%) criteria were reclassified by the biosignature to High Risk. These pts had significant RT benefit: 9804-like group - HR 0.3, p=.007, absolute 10-yr IBR reduction of 12.7%, and for favorable Age/NG group - HR .34, p=0.012, absolute 10-yr IBR reduction of 11.2%. The corresponding NNTs were ~8-9. Overall, RT significantly reduced IBR for biosignature High Risk patients (p<.001, n=588), with an absolute 17.7% reduction and a NNT of ~6. For patients in CP high risk groups, 23% of not-9804-like and 31% of (age< 50 or NG 3) pts were reclassified as biosignature Low Risk. RT did not significantly reduce IBR in any Low Risk Biosignature group, including those in CP high-risk groups. IBR for not-9804-like group was 5.9% vs 3.0% without and with RT, p=.52, and for (age< 50 or NG 3) pts was 4.4% vs 3% without and with RT, p=.70. For CP low-risk and biosignature Low Risk groups, RT reduced IBR by 0%. Overall, RT did not significantly reduce IBR rate for biosignature Low Risk patients (p=.71, n=338), with a 0.8% absolute 10-yr IBR rate difference and a NNT of ~100. Conclusion: In a large multicenter population, DCISionRT was a better predictor of 10-yr prognosis and RT benefit than CP criteria alone. Pts with biosignature Low Risk disease, comprising about 1/3 of CP high-risk pts, had no significant RT benefit. Whereas pts with biosignature High Risk disease, comprising about 1/2 of CP low-risk pts, significantly benefited from RT, highlighting the lack of accuracy of these CP factors in assessing RT benefit. Table 1. Ten-Year Risk of Ipsilateral Breast Recurrence (IBR) Citation Format: Rachel Rabinovitch, Frank Vicini, Chirag Shah, Julie A. Margenthaler, Brian J. Czerniecki, Pat Whitworth, DAVID J. DABBS, G Bruce Mann, Fredrik Wärnberg, Sheila Weinmann, Michael Leo, Jess Savala, Steven C. Shivers, Karuna Mittal, Troy Bremer. PD15-07 7-gene predictive biosignature improves risk stratification for breast ductal carcinoma in situ patients compared to clinicopathologic criteria, identifying a low risk group not clinically benefiting from adjuvant radiotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD15-07.

Abstract P3-05-18: Unravelling the clinicopathological and functional significance of Replication Protein A (RPA) heterotrimeric complex in sporadic breast cancers

Abstract Unravelling the clinicopathological and functional significance of Replication Protein A (RPA) heterotrimeric complex in sporadic breast cancers Mashael Algethami1, Michael S Toss 1,4, Juliette Brownlie 1, Corinne L Woodcock 1,2, Chandar Jaipal1, Ahmed Shoqafi 1, Katia A Mesquita1, Adel Alblihy1,3, Andrew R Green1, Nigel P Mongan 1,5, Emad A Rakha 1,4, Jennie N Jeyapalan 1,2 and Srinivasan Madhusudan1,6 1 Nottingham Biodiscovery Institute, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, University Park, Nottingham NG7 2RD, UK. 2 Faculty of Medicine and Health Sciences, Centre for Cancer Sciences, University of Nottingham, Sutton Bonington Campus, Sutton Bonington, Leicestershire LE12 5RD, UK 3 Medical Center, King Fahad Security College (KFSC), Riyadh 11461, Saudi Arabia. 4 Department of Pathology, Nottingham University Hospital, City Campus, Hucknall Road, Nottingham NG5 1PB, UK. 5 Department of Pharmacology, Weill Cornell Medicine, New York, NY, 10065, USA 6 Department of Oncology, Nottingham University Hospitals, Nottingham NG5 1PB, UK. Introduction: Replication Protein A (RPA) is a critical single-stranded DNA (ssDNA)-binding protein that coats and protects exposed ssDNA from endogenous nucleases. RPA is a heterotrimeric complex consisting of RPA1 (70kDa), RPA2 (32kDa), and RPA3 (14kDa) subunits. RPA provides a platform for recruitment of factors required during replication, checkpoint regulation, DNA repair [including homologous recombination (HR), nucleotide excision repair (NER), base excision repair (BER) and mismatch repair (MMR)], telomere maintenance and retro-transposition. To understand the role of RPA in breast cancer pathogenesis we conducted a comprehensive genomic, transcriptomic, bioinformatic, proteomic and preclinical study. Patients and methods: RPA1, RPA2 and RPA3 protein expression was evaluated in 4221 primary invasive breast carcinomas and 776 breast ductal carcinoma in situ (DCIS). Transcriptomic investigation was completed in the METABRIC cohort (n=1980). Detailed bioinformatics was conducted in the TCGA cohort (n=1090). RPA deficient breast cancer cell lines were tested for Cisplatin, Palbociclib and Olaparib sensitivity. Results: RPA1, RPA2 and RPA3 loss is frequent in DCIS and linked to aggressive phenotype (including high grade, ER and PR negativity) (all p values < 0.01). DCIS with low RPA1 was also associated with poor local recurrence-free interval (p< 0.00001). In invasive breast cancers, low RPA1, low RPA2 and low RPA3 were all associated with larger size, lympho-vascular invasion, higher histological grade, high stage, ER negativity and poor breast cancer specific survival. Transcriptomic alterations in low RPA tumors included those genes involved in steroid hormone biosynthesis, chemical carcinogenesis, and drug metabolism. Pre-clinically, RPA deficient breast cancer cells were sensitive to Cisplatin and Palbociclib (CDK4/6 inhibitor) therapy compared to controls. Additionally, the PARP1 inhibitor Olaparib was synthetically lethal in RPA1 and RPA2 deficient cells compared to controls. Increased Olaparib sensitivity was associated with double strand breaks, S-phase cell cycle arrest and increased apoptosis. Conclusions: We provide the first comprehensive evidence that RPA loss is an early event during breast cancer pathogenesis and promotes aggressive phenotypes. Pre-clinically RPA deficient breast cancer cells were selectively toxic to Cisplatin, Palbociclib and Olaparib. Citation Format: Mashael A. Algethami, Michael Toss, Juliette Brownlie, Corinne L. Woodcock, Chandar Jaipal, AHMED SHOQAFI, Katia Mesquita, Adel Alblihy, Nigel Mongan, Emad Rakha, Jennie N. Jeyapalan, Srinivasan Madhusudan, Andrew R. Green. Unravelling the clinicopathological and functional significance of Replication Protein A (RPA) heterotrimeric complex in sporadic breast cancers [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-05-18.

Expression analysis of novel long non-coding RNAs for invasive ductal and invasive lobular breast carcinoma cases

AimLong non-coding RNAs (LncRNAs) serve as important regulatory molecules of gene expression and protein functionality at multiple biological levels, and their deregulation plays a key role in tumorigenesis including in breast cancer metastasis. Therefore, in this study, we aim to compare the expression of novel lncRNAs in the landscape of invasive ductal carcinoma (IDC) and invasive lobular (ILC) carcinoma of breast. Main MethodsWe have designed an in-silico approach to find the lncRNAs that regulate the breast cancer. Then, we used the clinical samples to carry out the verification of our in silico finding. In the present study, the tissues of breast cancer were deparaffinized. RNA was extracted by the TRIzole method. After synthesizing cDNA from the extracted RNA, expression levels of lncRNAs were analyzed by qPCR using primers specifically designed and validated for the targeted lncRNAs. In this study, breast biopsy materials from 41 female patients with IDC and 10 female patients with ILC were examined histopathological and expression changes of candidate lncRNAs were investigated in line with the findings. The results were analyzed using IBM SPSS Statistics 25 version. ResultsThe mean age of the cases was 53.78 ± 14.96. The minimum age was 29, while the maximum age was 87. While 27 of the cases were pre-menopausal, 24 cases were post-menopausal. The number of hormone receptor-positive cases was found to be 40, 35, and 27 for ER, PR, and cerb2/neu, respectively. While the expressions of LINC00501, LINC00578, LINC01209, LINC02015, LINC02584, ABCC5-AS1, PEX5L-AS2, SHANK2-AS3 and SOX2-OT showed significant differences (p < 0.05), the expressions of LINC01206, LINC01994, SHANK2-AS1, and TPRG1-AS2 showed no significant differences (p > 0.05). In addition, it was determined that the regulation of all lncRNAs could be able to involve in the development of cancer such as the NOTCH1, NFKB, and estrogen receptor signalings. ConclusionAs a result, it was thought that the discovery of novel lncRNAs might be an important player in the diagnosis, prognosis and therapeutic development of breast cancer.

Clinicopathological Features and Prognosis of Gastrointestinal Metastases From Breast Carcinoma: A Clinicopathological Study of 22 Patients.

Background. Breast carcinoma is the most common malignancy in women. Gastrointestinal metastasis is rarely found or diagnosed in patients with breast cancer. Methods. Clinicopathological features, treatment options, and prognosis were evaluated retrospectively for 22 patients with gastrointestinal metastases of breast carcinoma in Chinese women. Results. Presenting symptoms were non-specific: anorexia (21/22), epigastric pain (10/22), and vomiting (8/22), and 2 patients (2/22) presented with nonfatal hemorrhage. The first sites of metastases were skeleton (9/22), stomach (7/22), colorectal (7/22), lung (3/22), peritoneal (3/22), and liver (1/22). ER, PR, GATA binding protein 3 (GATA3), gross cystic disease fluid protein-15 (GCDFP-15), and keratin 7 can effectively confirm the diagnosis, especially in the case of keratin 20 negativity. Histology showed mainly ductal breast carcinoma (n = 11) was the predominant source of gastrointestinal metastases in this study, and lobular breast cancer (n = 9) accounted for a considerable proportion. The disease control rate to systemic therapy was 81% (17 of 21 treated patients), and the objective response rate was 10% (2 of 21 treated patients). Median overall survival was 71.5 months (range, 22-226 months), median survival for distant metastases was 23.5 months (range, 2-119 months) and the median survival for the time of gastrointestinal metastases diagnosis was 6 months (range, 2-73 months). Conclusions. Performing the endoscopy with biopsy was crucial for patients with any subtle gastrointestinal symptoms and a history of breast cancer. It is important to distinguish primary gastrointestinal carcinoma from breast metastatic carcinoma in order to select the optimal initial treatment and avoid unnecessary surgery.

Linac-Based Ultrahypofractionated Partial Breast Irradiation (APBI) in Low-Risk Breast Cancer: First Results of a Monoinstitutional Observational Analysis.

Purpose: For adjuvant radiotherapy of low-risk breast cancer after breast-conserving surgery, there have been many trials of hypofractionation and partial breast irradiation (PBI) over the years, with proven mild long-term toxicity. The aim of this study was to introduce a short-course dose-adapted concept, proven in whole breast irradiation (WBI) for use in accelerated partial breast irradiation (APBI), while monitoring dosimetric data and toxicity. Methods: From April 2020 to March 2022, 61 patients with low-risk breast cancer or ductal carcinoma in situ (DCIS) were treated at a single institution with percutaneous APBI of 26 Gy in five fractions every other day after breast-conserving surgery. Dosimetric data for target volume and organs at risk were determined retrospectively. Acute toxicity was evaluated. Results: The target volume of radiotherapy comprised an average of 19% of the ipsilateral mamma. The burden on the heart and lungs was very low. The mean cardiac dose during irradiation of the left breast was only 0.6 Gy. Two out of three patients remained without any acute side effects. Conclusions: Linac-based APBI is an attractive treatment option for patients with low-risk breast cancer in whom neither WBI nor complete omission of radiotherapy appears to be an adequate alternative.

The expression analysis of long non-coding RNAs and p53 as a possible genetic signature in luminal: An invasive breast ductal carcinoma

Breast cancer is the second most common cause of cancer-related death among females. The long non-coding RNAs (lncRNAs) are a significant population of non-coding RNAs with well-defined functions in both adjacent normal cells and tumorigenesis. Miss expression of them has been associated with the development of different kinds of cancers. The aim of this study was to investigate the alterations in 3 lncRNAs and p53 in tissue samples of a group of women with luminal type A breast adenocarcinoma. In this case-control study, the expression levels of p53 and three lncRNAs were evaluated in association with luminal A breast cancer in 80 ductal carcinoma tumors and adjacent normal breast tissues. Quantitative real-time PCR was used to measure the expression of the mentioned genes. The data were analyzed using t-tests. The expression levels of IGFBP7-AS1, and RHPN1-AS1, showed a significant increase (P> 0.05) while P53 and LINC00861 had a significant decrease in expression level in tumor tissues compared to adjacent normal tissues (P> 0.05). Receiver Operating Characteristic (ROC) curve indicated the diagnostic power of LINC00861 in differentiating tumor tissues from adjacent normal tissue with 90% sensitivity and 96% specificity, which can also interact with P53. P53 and the LncRNAs including Linc00861, RHPN1-AS1, and IGFBP7-AS1 were dysregulated in invasive breast ductal carcinoma samples. Based on the area under the curve (AUC) value, expression of Linc00861, p53, RHPN1-AS1, and IGFBP-AS1 genes can help to differentiate patients from healthy individuals with diagnostic power of 0.855, 0.824, 0.778, and 0.659, respectively. The key roles of the latest genes in the control of cancer-related pathways and the dysregulation of their expression in studied malignancies imply that they can be exploited as biomarkers for cancer diagnosis, prognosis, and possible therapeutic targets. Here, the roles of lncRNAs in invasive breast ductal carcinoma type luminal A and their importance in prognosis and patient treatment are discussed.

Collision metastases of invasive ductal breast carcinoma and malignant melanoma in axillary sentinel lymph node: a case report

Collision metastases of invasive ductal breast carcinoma and malignant melanoma in axillary sentinel lymph node: a case report

Tertiary lymphoid structures in breast ductal carcinoma insitu correlate with adverse pathological parameters.

To investigate tertiary lymphoid structures (TLSs) in ductal carcinoma insitu (DCIS) of the breast and their correlation with pathological features, immune cell markers and clinical outcomes. Morphological identification of TLSs in 198 DCIS cases incorporated B and T cell zones with high endothelial venules. TLS positivity was defined as ≥ 1 TLSs in lesional areas, while TLS area percentage was divided into two categories: low (TLSs < 5%) and high (TLSs ≥ 5%). Previously reported biomarkers included ER, PR, HER2, CD68, CD163, CD4, CD8 and PD-L1. TLSs were observed in 24.7% (49 of 198) of cases, with a mean diameter of 0.44 mm (median=0.4 mm, range=0.12-1.43 mm). TLSs were significantly associated with higher nuclear grade, presence of necrosis, hormone receptor negativity/HER2 positivity, triple negativity, tumour infiltrating lymphocytes (TILs) and immune related biomarkers such as FOXP3, CD163, CD4 and CD4/CD8 ratio (all P< 0.05). There were no significant associations between TLSs and recurrence, but a combination of TLSshigh with FOXP3+ , CD4high , CD4/CD8 ratiohigh and CD68high individually, compared with all other combinations, disclosed significantly poorer disease-free survival (DFS) for ipsilateral invasive recurrence (IIR) on both Kaplan-Meier and multivariable Cox regression analyses (all P< 0.05). TLSs in DCIS were associated with unfavourable prognostic features, TILs and immune cell markers in our study. TLSshigh /FoxP3+ , TLSshigh /CD4high , TLSshigh /(CD4/CD8) ratiohigh and TLSshigh /CD68high were independent factors for poorer DFS for IIR. Further exploration of the pathological significance of TLSs may provide a clinical basis for their recognition as an important structure and functional unit in the tumour immune microenvironment.

Venous thromboembolism incidence in postoperative breast cancer patients

BackgroundVenous Thromboembolism (VTE) is an important cause of morbidity in cancer patients. Breast cancer patients undergoing surgical treatment are at an increased risk of VTE. The aim of this study was to determine the frequency of VTE in patients who underwent surgery for the treatment of breast cancer and to identify the related risk factors. MethodsA historical cohort of patients at the São Paulo State Cancer Institute (ICESP) underwent surgery for breast cancer. The inclusion criteria covered patients with invasive breast cancer or ductal carcinoma in situ who had breast surgery anytime from January 2016 to December 2018. ResultsOf the 1672 patients included in the study, 15 had a confirmed diagnosis of VTE (0.9%), and 3 of these had deep vein thrombosis (0.2%), and 12, had pulmonary thromboembolism (0.7%). Clinical and tumoral characteristics did not differ between the groups. The incidence of VTE was higher in patients who had undergone skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.032). Immediate reconstruction, particularly with abdominal-based flaps (4.7%), increased VTE events (p = 0.033). Median surgical time was higher in patients with VTE episodes (p = 0.027), and total hospital length of stay increased in days (6 days vs. 2 days, p = 0.001). Neoadjuvant chemotherapy and postoperative prophylaxis with Low Molecular Weight Heparin (LMWH) were associated with lower VTE rates (0.2% vs. 1.2%, p = 0.048 and 0.7% vs. 2.7%, p = 0.039; respectively) in these patients. ConclusionsThe incidence of VTE events in breast cancer patients who underwent surgery was 0.9%. Immediate reconstruction (especially with abdominal-based flaps), skin-sparing/nipple-sparing mastectomies, and longer surgeries were associated with increased risk. The LMWH postoperative prophylaxis reduced this risk.

Triple Negative Invasive Ductal Carcinoma of Breast with Oral Metastasis: A Case Report

Metastatic oral malignancies have been reported in the mandible, tongue, and gingiva. Breast cancer oral metastasis usually presents as a benign oral lesion clinically. At histology, it shares several features with metastatic carcinoma. Immunohistochemistry (IHC) can be useful in the differential diagnosis. The clinical presentation consisted of swelling in the upper front tooth region in a 35-year-old woman. The lesion was excised under local anaesthesia and underwent histological and immunohistochemical examination to rule out any malignancy. Histological findings, Pan CK positivity suggesting the epithelial origin and the absence of reactivity to Oestrogen Receptor (ER), Progesterone Receptor (PR), Human Epidermal Growth Factor Receptor-2 (HER2) indicated metastatic triple negative breast carcinoma. The histological diagnosis of metastatic breast carcinoma can be confirmed by IHC. The current case report illustrates the necessity of including a panel of IHC markers in confirming the diagnosis of metastatic lesions in oral cavity. By utilising such panels, one can expedite the prognosis and prevent delay in diagnosis.

The immunohistochemical Galectin-3 expression in tumor and cancer-associated fibroblasts in invasive ductal carcinomas of breast and their relationship with clinicopathological parameters.

Galectin-3 has an important role in metastasis, therefore, Galectin-3-focused therapies have attracted attention for various cancers. We aimed to reveal the relationship between the expression of Galectin-3 within the tumor/cancer-associated fibroblasts (CAF) and clinicopathological parameters in patients with invasive ductal carcinomas. Hematoxylin and eosin-stained slides of breast excision materials diagnosed between 2010 and 2016 were re-examined retrospectively. Accordingly, 118 cases (luminal group = 58, Human epidermal growth factor receptor 2 (HER2) group = 27, and triple-negative breast carcinoma group [TNBC] =33 cases) were included. Galectin-3 levels were evaluated with a calculated H-score in tumor and semiquantitatively in CAFs. Data was analyzed with t-tests and Chi-square tests. Kaplan-Meier and Log-rank tests were used for survival analysis. The presence of Galectin-3 expression in CAFs but not in the tumor was associated with the greater number of axillary metastatic nodes and advanced pN stage. The loss of Galectin-3 expression in CAFs was more frequent in TNBC. There was no significant relationship between the expression level of Galectin-3 and survival status. However, in most of the cases with distant metastasis or patients who died, Galectin-3 was negative in the tumor, whereas it was positive in CAFs. The expression of Galectin-3 in tumors and CAFs may have a role in metastasis to axillary lymph nodes and distant sites. In terms of molecular subtype, TNBCs show a relationship with Galectin-3 negativity in CAFs.

Expression of BRCA1 by immunohistochemistry and its association with ER, PR, Her2neu status in infiltrative ductal carcinoma of breast.

Breast cancer is a heterogeneous disease, which differs in its clinical behaviors and responses to treatment and outcome. The prognosis of breast cancer depends on histopathological parameters and molecular subtypes. Among more than 300 genes, which are involved in the pathogenesis of breast cancer tumor suppressor gene such as BRCA1 is known to play a significant role in hereditary cancers. However, its role in sporadic cases of infiltrating ductal carcinoma is yet to be established. To evaluate the expression of BRCA1 in infiltrative ductal carcinoma and to analyze the association of BRCA1 with histopathological parameters and estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor2 (Her2) neu expression. This was a laboratory-based exploratory study in which 56 patients with infiltrative ductal carcinoma who underwent radical mastectomy from October 2019 to July 2021 were included. Patients with chemotherapy and radiotherapy, trucut biopsies, and incomplete patient details were excluded. Immunostaining for BRCA1 was performed. Individual clinicopathological parameters were compared with the BRCA1 mutation. Statistical analysis was done using SPSS 22. A P value of < 0.05 was considered statistically significant. Among 56 cases of IDC, 18 cases (32.1%) showed BRCA1 mutation. BRCA1 mutation was associated with postmenopausal age, larger tumor size, lower tumor grade, and higher tumor staging. When we analyzed the biomarkers with BRCA1 mutation, it showed a negative association with ER, PR, and Her2 neu and a high Ki67 proliferation index. No family history of breast carcinoma was seen in 34/56 patients where history was available. Our study showed BRCA1 mutation in 32.1% and associated with postmenopausal age group, larger tumor size, and higher staging and negative hormonal status of breast carcinoma.