ER-positive Ductal Carcinomas Research Articles

Abstract GS5-05: Primary endocrine therapy for ER-positive ductal carcinoma in situ (DCIS) CALGB 40903 (Alliance)

Abstract Background: Standard treatment for ductal carcinoma in situ (DCIS) consists of surgery, often followed by adjuvant radiation therapy or endocrine therapy. This current approach is thought to represent overtreatment for some patients. This study was undertaken to determine whether an alternate approach of primary endocrine therapy alone could result in measurable radiographic changes in unresected estrogen receptor (ER)-positive DCIS. Methods: A phase II open-label single arm multi-center cooperative group trial (CALGB 40903) was conducted for postmenopausal patients diagnosed with ER-positive DCIS. All eligible patients underwent baseline mammography and MRI, followed by 6 months of preoperative therapy with letrozole. Follow up breast MRI was obtained at 3 and 6 months of treatment. The primary endpoint was change in total MRI volume of DCIS enhancement from baseline to 3 months and from baseline to 6 months. Secondary endpoints were change in MRI maximum diameter over baseline and change in mammographic extent of disease over baseline. Endpoints were analyzed via 2-sided paired t-tests (a=0.05). Results: From 8/1/12 to 2/1/16 108 patients were enrolled; Of the 77 patients who completed letrozole treatment per protocol, 66 patients were assessable. 2 additional patients who did not complete treatment per protocol were considered assessable and thus included in the analysis for a total of 68 patients. Median age of the cohort was 62.7 years. DCIS nuclear grade was low in 10% of patients, intermediate in 49%, and high in 40%. 82% of patients had ER-positive, PR-positive DCIS. The total mean MRI volume decreased from baseline to 3 months by 1.93 cm3 (p<0.001) and from baseline to 6 months by 1.82 cm3 (p<0.001). There was no significant difference in tumor volume between 3 and 6 months. Mean total mammographic tumor diameter decreased from baseline to 6 months by 3.31 mm2 (p=0.078). Conclusions: In a cohort of postmenopausal women treated with 6 months of preoperative endocrine therapy for ER-positive DCIS, MRI volume decreased markedly by 3 months, while mammographic extent of disease was not altered significantly. Correlation of imaging changes with pathology and baseline biomarkers will be conducted. These results will help determine whether MRI could be an effective modality for monitoring treatment response in some patients treated with primary endocrine therapy for ER-positive DCIS. Citation Format: Hwang ES, Duong S, Bedrosian I, Allred J, Wisner D, Hyslop T, Caudle A, Guenther J, Hudis C, Winer E, Esserman L, Hylton N. Primary endocrine therapy for ER-positive ductal carcinoma in situ (DCIS) CALGB 40903 (Alliance) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr GS5-05.

Immunolocalization of thymidylate synthase as a favorable prognostic marker in estrogen receptor-positive breast carcinoma.

Thymidylate synthase (TS) is an enzyme involved in DNA synthesis, and it is a target for 5-fluorouracil. Previous studies have demonstrated that TS is a potent estrogen-induced gene in breast carcinoma cells, suggesting the importance of TS in estrogen-receptor (ER)-positive breast carcinoma. TS immunolocalization has been reported previously, but the clinicopathological significance of TS in ER-positive breast carcinoma still remains unclear. We immunolocalized TS in 178 breast carcinoma tissues in total, and examined its significance according to the ER-status. TS status was positive in 58% of ER-positive ductal carcinoma in situ (DCIS) cases, and it was significantly associated with the Ki-67 and progesterone receptor (PR). Moreover, in ER-positive DCIS patients who received aromatase inhibitor (AI) before surgery, TS immunoreactivity was significantly decreased after AI treatment. In ER-positive invasive ductal carcinoma (IDC) cases, TS status was significantly associated with PR, and it turned out an independent favorable prognostic factor for recurrence of the patients by multivariate analysis. On the other hand, TS status was positively correlated with pathological T factor in ER-negative IDC cases, and tended to have a worse prognosis for disease-free survival of the patients. These results suggest that TS expression is mainly regulated by estrogen in ER-positive breast carcinoma and is associated with estrogen-mediated proliferation. TS status is a favorable prognostic factor in ER-positive IDC patients, which is different from the ER-negative cases.

Abstract LB-121: Polymorphic variants in PPARGC1A and PCMTD1 associate with earlier age of onset in ER-negative breast cancer

Abstract Background: Breast cancer is the most frequent cancer and leading cause of cancer death among women worldwide. As <10% of breast cancers are due to mutations in BRCA1 and BRCA2, other perturbations such as single nucleotide polymorphisms (SNPs) may be genetic contributors. Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PPARGC1A) enhances estrogen receptor (ER) and estrogen related receptor gamma (ERRγ) activity by acting as a coactivator. ERRγ has been demonstrated to regulate vascular endothelial growth factor mRNA expression in both ER-positive and ER-negative breast cancer cell lines, indicating that it may accelerate angiogenesis and metastasis. PCMTD1 encodes protein-L-isoaspartate O-methyltransferase domain-containing protein 1, a S-adenosylmethionine-dependent methyltransferase whose biological relevance is largely unknown to present. SNPs in PPARGC1A have been correlated with metabolic diseases, but within the three studies evaluating cancer phenotypes for this gene, only Thr612Met (76873 C→T) revealed a significant association with familial breast cancers. Experimental Procedure: SNPs in PPARGC1A and PCMTD1 were selected using a bioinformatics approach based on SNP associations with drug response in NCI-60 cell lines and evidence of selection bias for haplotype frequencies. Allelic discrimination assays were performed on genomic DNA isolated from whole blood from over 900 Caucasian breast cancer patients with ductal carcinomas. Clinical information was linked to genotypes to search for genotype-phenotype correlations, and statistical analyses were carried out. Results: Analysis of PPARGC1A rs4619879 revealed a mean age of diagnosis of ER-negative cases for CC and AA carriers at 50.1 and 43.8 years, respectively (p=0.019). The difference was less striking in ER-positive ductal carcinomas, with only a 2.7year earlier onset for AA carriers (p=0.013). For PCMTD1 rs9298462, the mean age at diagnosis of ER-negative cases for CC carriers was 41.2, compared to 48.8 for the TT carriers (p=0.004). No significant difference was seen in ER-positive ductal carcinomas (p=0.15). Conclusions: Our results indicate that polymorphisms in PPARGC1A and PCMTD1, two transcriptional regulators, may play a role in age at diagnosis in breast cancer, particularly ER-negative ductal carcinomas. We are performing functional studies to further evaluate these findings and to elucidate the molecular mechanisms underlying these observations. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-121. doi:10.1158/1538-7445.AM2011-LB-121

Pathologic and biologic response to preoperative endocrine therapy in patients with ER-positive ductal carcinoma in situ

BackgroundEndocrine therapy is commonly recommended in the adjuvant setting for patients as treatment for ductal carcinoma in situ (DCIS). However, it is unknown whether a neoadjuvant (preoperative) anti-estrogen approach to DCIS results in any biological change. This study was undertaken to investigate the pathologic and biomarker changes in DCIS following neoadjuvant endocrine therapy compared to a group of patients who did not undergo preoperative anti-estrogenic treatment to determine whether such treatment results in detectable histologic alterations.MethodsPatients (n = 23) diagnosed with ER-positive pure DCIS by stereotactic core biopsy were enrolled in a trial of neoadjuvant anti-estrogen therapy followed by definitive excision. Patients on hormone replacement therapy, with palpable masses, or with histologic or clinical suspicion of invasion were excluded. Premenopausal women were treated with tamoxifen and postmenopausal women were treated with letrozole. Pathologic markers of proliferation, inflammation, and apoptosis were evaluated at baseline and at three months.Biomarker changes were compared to a cohort of patients who had not received preoperative treatment.ResultsMedian age of the cohort was 53 years (range 38–78); 14 were premenopausal. Following treatment, predominant morphologic changes included increased multinucleated histiocytes and degenerated cells, decreased duct extension, and prominent periductal fibrosis. Two postmenopausal patients had ADH only with no residual DCIS at excision. Postmenopausal women on letrozole had significant reduction of PR, and Ki67 as well as increase in CD68-positive cells. For premenopausal women on tamoxifen treatment, the only significant change was increase in CD68. No change in cleaved caspase 3 was found. Two patients had invasive cancer at surgery.ConclusionPreoperative therapy for DCIS is associated with significant pathologic alterations. These changes may be clinically significant. Further work is needed to identify which women may be the best candidates for such treatment for DCIS, and whether best responders may safely avoid surgical intervention.Trial RegistrationClinicalTrials.gov NCT00290745

HER2 protein overexpression in estrogen receptor-positive ductal carcinoma in situ of the breast: frequency and implications for tamoxifen therapy

Recent clinical data have suggested that the efficacy of tamoxifen in reducing the risk of local recurrence following lumpectomy and radiation therapy in patients with ductal carcinoma in situ (DCIS) is limited to patients with estrogen receptor (ER)-positive lesions. However, it is currently not known if HER2 protein overexpression might be associated with reduced tamoxifen benefit in patients with ER-positive DCIS, as has been suggested in patients with ER-positive invasive breast cancer and in preclinical models. Moreover, the frequency of HER2 overexpression in ER-positive ductal carcinoma in situ has not been previously evaluated in detail. To address this issue, we studied ER expression and HER2 overexpression in 148 cases of DCIS using a sensitive double immunostaining technique and assessed the frequency of ER expression and HER2 overexpression in relation to each other and in relation to DCIS grade. Overall, ER expression was seen in 114 cases (77%) and HER2 protein overexpression was seen in 42 cases (28%). Of 114 ER-positive ductal carcinoma in situ, 14 (12%) showed concurrent HER2 protein overexpression, and all 14 of these DCIS lesions were of high nuclear grade. In addition, in all 14 ER-positive DCIS cases that showed HER2 overexpression, double immunostaining demonstrated that ER and HER2 protein were coexpressed by the same neoplastic cells. We conclude that a subset of ER-positive DCIS show concomitant overexpression of HER2 protein. Whether or not HER2 overexpression is associated with a diminished response to tamoxifen in patients with ER-positive DCIS will require investigation in clinical outcome studies.

Gene expression profiling of NMU-induced rat mammary tumors: cross species comparison with human breast cancer

Breast cancer is a complex genetic disease characterized by the accumulation of multiple molecular alterations. The NMU breast cancer model induced in the rat is used for the study of mammary carcinogenesis because it closely mimics human breast disease. To assess the validity of this model from a more global molecular perspective, and also to devise a general technique to compare animal profiles with human microarray studies, we have characterized 25 NMU-induced mammary tumors and 11 normal glands using a combination of immunohistochemical and microarray analyses. The rat mammary carcinomas were classified as non-invasive, ER-positive ductal carcinomas with a composition of differentiated epithelial and myoepithelial cell lineages. Gene expression profiles generated using rat Affymetrix arrays containing 15,866 genes demonstrated that the rat mammary tumors are homogeneous and that H-ras mutations did not confer a unique molecular signature. We compared the resulting rat profiles with those obtained from a human dataset by merging the raw microarray data, using an approach that involves a combination of cross-species and cross-platform analysis. Using this novel strategy, we demonstrate the ability of 2305 rat orthologs to recapitulate the classification of human tumors derived from human Affymetrix arrays. The gene expression profiles of the NMU-induced primary tumors were most similar to ER-positive, low to intermediate grade breast cancer. Our technique provides a means to correlate gene expression data from animal models of cancer to human cancer and disease states.

Oestrogen receptor negativity as a marker for high-grade ductal carcinoma in situ of the breast.

To compare the morphological and immunohistochemical characteristics of oestrogen receptor (ER)-negative and ER-positive ductal carcinoma in situ (DCIS) of the breast, in an attempt to establish more objective criteria for the classification of DCIS. Sections of 64 cases of in-situ carcinoma of the breast were stained for ER, progesterone receptors (PgR), androgen receptors (AR), c-erbB-2 and p53, using the immunoperoxidase technique. The cases included 60 DCIS and four lobular carcinoma in situ (LCIS). Four DCIS lesions were associated with foci of microinvasion. The 60 DCIS cases included 31 high grade, 23 intermediate grade and six low grade. Twenty-four DCIS cases (40%) were ER-negative and 36 were positive. ER negativity was significantly associated with high nuclear grade (88% versus 27% for ER-positive cases, P < 0.001), PgR negativity (100% versus 25%, P < 0.001), c-erbB-2 positivity (79% versus 14%, P < 0.001) and p53 positivity (58% versus 6%, P < 0.001). There was no difference between ER-negative and -positive DCIS as regards AR expression, with 91% of cases in each group being AR-positive. Of the four cases of DCIS with microinvasion, three were ER- and PgR-negative, all four were c-erbB-2-positive and AR-positive and one was p53-positive. None of the four LCIS was ER, PgR or AR-negative and none was c-erbB-2- or p53-positive. There is a highly significant direct relationship between ER negativity in DCIS and high nuclear grade, PgR negativity and c-erbB-2 and p53 positivity. We suggest that immunohistological assessment of ER status may help in providing a more objective way of classifying DCIS.