Higher Nottingham Prognostic Index Research Articles

High Inner Centromere Protein Expression Correlates with Aggressive Features and Predicts Poor Prognosis in Patients with Invasive Breast Cancer

Introduction: Inner centromere protein (INCENP) is a member of the chromosomal passenger complex and plays a key role in mitosis and cell proliferation. This study aimed to evaluate the clinical and prognostic significance of INCENP in invasive breast cancer (BC). Methods: INCENP expression was evaluated on a tissue microarray of a large BC cohort (n = 1,295) using immunohistochemistry. At the mRNA level, INCENP expression was assessed using the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) (n = 1,980) and The Cancer Genome Atlas (TCGA) BC cohorts (n = 854). The correlations between INCENP expression, clinicopathological parameters, and patient outcome were investigated. Results: INCENP expression was detected in the nucleus and cytoplasm of the tumour cells. Its expression was significantly associated with features characteristic of aggressive BC behaviour including high tumour grade, larger tumour size, and high Nottingham prognostic index scores. High INCENP nuclear expression was a predictor of shorter BC-specific survival in the whole cohort, as well as in the luminal subtype (p < 0.001). High INCENP nuclear expression was predictive of poor prognosis in BC patients who received hormone treatment or chemotherapy. Conclusion: High INCENP expression is a poor prognostic biomarker in BC with potential therapeutic benefits.

Clinical factors affecting the long-term survival of breast cancer patients.

The average 5-year survival rate of breast cancer (BC) patients has been significantly prolonged with new therapeutic methods. However, their effects on BC patient long-term survival rates are unclear. Therefore, this study aimed to analyze the specific clinical factors that can affect BC long-term survival. Here, we conducted a retrospective study and analyzed long-term survival using data of 3,240 BC patients from 1977 to 2005 from the Genotype-Tissue Expression (GTEx) database using the Kaplan-Meier method. Breast tumor size and stage were negatively correlated with long-term survival, but age showed no significant correlation. Estrogen receptor (ER) and progesterone receptor (PR) expression were each positively correlated with patient survival time, while ERBB2 receptor (HER2) expression was negatively correlated with survival time. Patients with high Nottingham prognostic index (NPI) values did not benefit from available therapies. Furthermore, breast-conserving surgery is more conducive to BC patient long-term survival than mastectomy. Early detection and breast-conserving surgery may support long-term survival for BC patients. Elevated expression of ER and PR were both associated with longer patient survival time, while positive expression of HER2 showed the opposite trend. The long-term survival rates of patients with high NPI values can potentially be increased.

Integrated Molecular Characterization to Reveal the Association between Kynurenine 3-Monooxygenase Expression and Tumorigenesis in Human Breast Cancers.

Kynurenine 3-monooxygenase (KMO) is overexpressed in several tumors and participates in the progression of breast cancer tumorigenesis, including cancer types such as triple-negative breast cancer (TNBC). This malignant gene is an enzyme in the kynurenine pathway, which is involved in the carcinogenesis of cancer through immune function manipulation. However, it remains unclear whether the role of the KMO contributes to tumorigenesis and immune functions in human breast cancer. In this study, we found that KMO was highly expressed in different types of tumors, especially in invasive ductal breast carcinoma. In addition, KMO expression was positively correlated with the malignant clinical features of patients with breast cancer, such as TNBC and a nodal-positive status, along with patients with a higher Nottingham prognostic index (NPI). Furthermore, the top ten KMO-correlated genes were the chemokines and pro-inflammatory cytokines known to be involved in the progression of various cancers, therefore, KMO may facilitate breast cancers via synergistically regulating inflammatory responses in tumors with these hub genes. Taken together, these findings highlight the tumor-promotion role of KMO in breast cancers and suggest that KMO can serve as a biomarker for prognosis prediction in breast cancer patients.

Immunohistochemical assessment of PTEN expression and itsassociation with tamoxifen resistance in ER positive breast cancers

Introduction: Although Estrogen Receptor (ER) positivity is a good prognostic factor in breast carcinoma (BC), a subset of patients experiences poor disease-free survival (DFS). Mutation in phosphatase and tensin homologue deleted on chromosome ten (PTEN) is identified as a poor prognostic feature in BC. This study was designed to find out the impact of lost or poor PTEN expression on ER positive BC, in terms of the recognized prognostic factors and survival outcome to find out its association with tamoxifen resistance. Methods: This was a cross sectional study with a follow up component. BC tissue blocks submitted to our unit from 2006 to 2012 were selected. From the laboratory data, patients who had ER positive BC, undergone mastectomy, treated with tamoxifen were selected. All clinicopathological parameters, DFS and overall survival (OS) were analysed against lost or poor PTEN expression. Clinicopathological features were compared using Chi-square test. Kaplan-Meier model with log-rank test was used for the survival analysis. Results: A total of 130 BC patients satisfied the inclusion criteria. PTEN expression was lost or poor in 82.3% (n=107) patients. PTEN expression had a positive association with the level of ER expression (p=0.011) and a negative association with Nottingham prognostic index (NPI) (p=0.045) and pathological stage (p&lt;0.048). Only 12.1% (n=16) patients had recurrences and 7.69% (n=10) had died over a period of 51 months of mean follow up. There was no significant association between PTEN expression and survival. Conclusions: This study showed that there is a statistically significant association between lost or poor PTEN expression and low ER expression, high NPI and stage 3 in ER positive BC. Further studies including larger study sample with a longer follow up are recommended to find out the association of PTEN with the survival in ER positive BC treated with tamoxifen.

Elevated MMP9 expression in breast cancer is a predictor of shorter patient survival

PurposeMMP9 is a matricellular protein associated with extracellular matrix (ECM) remodelling, that promotes tumour progression, and modulates the activity of cell adhesion molecules and cytokines. This study aims to assess the prognostic value of MMP9 and its association with cytoskeletal modulators in early-stage invasive breast cancer (BC).MethodsMMP9 expression was evaluated by immunohistochemistry using a well-characterised series of primary BC patients with long-term clinical follow-up. Association with clinicopathological factors, patient outcome and ECM remodelling BC-biomarkers were investigated. METABRIC dataset, BC-GenExMiner v4.0 and TCGA were used for the external validation of MMP9 expression. GSEA gene enrichment analyses were used to evaluate MMP9 associated pathways.ResultsMMP9 immunopositivity was observed in the stroma and cytoplasm of BC cells. Elevated MMP9 protein levels were associated with high tumour grade, high Nottingham Prognostic Index, and hormonal receptor negativity. Elevated MMP9 protein expression correlated significantly with cytokeratin 17 (Ck17), Epidermal Growth Factor Receptor (EGFR), proliferation (Ki67) biomarkers, cell surface adhesion receptor (CD44) and cell division control protein 42 (CDC42). Cytoplasmic MMP9 expression was an independent prognostic factor associated with shorter BC-specific survival. In the external validation cohorts, MMP9 expression was also associated with poor patients’ outcome. Transcriptomic analysis confirmed a positive association between MMP9 and ECM remodelling biomarkers. GSEA analysis supports MMP9 association with ECM and cytoskeletal pathways.ConclusionThis study provides evidence for the prognostic value of MMP9 in BC. Further functional studies to decipher the role of MMP9 and its association with cytoskeletal modulators in BC progression are warranted.

Myxovirus resistance 1 (MX1) is an independent predictor of poor outcome in invasive breast cancer

BackgroundBreast cancer (BC) is a disease with variable morphology, clinical behaviour and response to therapy. Identifying factors associated with the progression of early-stage BC can help understand the risk of metastasis and guide treatment decisions. Myxovirus resistance 1 (MX1), which is involved in the cellular antiviral mechanism, plays a role in some solid tumours; however, its role in invasive BC remains unknown. In this study, we aimed to explore the clinicopathological and prognostic significance of MX1 in BC.MethodsMX1 was assessed at the protein level using tissue microarrays from a large well-annotated BC cohort (n = 845). The expression of MX1 mRNA was assessed at the transcriptomic level using the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC; n = 1980) and validated using three publicly available cohorts on Breast Cancer Gene-Expression Miner (bc-GenExMiner version 4.4). The associations between MX1 expression and clinicopathological factors, and outcome were evaluated.ResultsHigh MX1 protein expression was associated with features of aggressiveness, including large tumour size, high tumour grade, high Nottingham prognostic index scores, hormone receptor negativity and high Ki67 expression. High MX1 expression showed an association with poor patient outcome and it was an independent predictor of short BC-specific survival (p = 0.028; HR = 1.5; 95% CI = 1.0–2.2). Consistent with the protein results, high MX1 mRNA levels showed an association with features of aggressive behaviour and with shorter survival.ConclusionThis study identified MX1 as an independent predictor of poor outcome in patients with BC. Further functional studies are needed to investigate the biological role of MX1 in BC and its potential value as a therapeutic target.

Correlation between HER2 Expression and Clinicopathological Features of Breast Cancer: A Cross- Sectional Study in Vietnam.

Background: HER2 is the target of the therapeutic agents which are used to treat HER2-positive breast cancer. Reports have shown that the HER2 oncogene expression and its association with clinicopathological factors remain unclear in breast cancer (BC) patients. This study aimed to determine the correlation between HER2 expression and clinicalpathological characteristics of breast cancer in Vietnamese women. Methods:Between June 2016 and August 2018, paraffin-embedded specimens from 237 patients with primary invasive breast carcinoma in Hue University Hospital and Hue Center Hospital, Hue city, Vietnam were examined for pathological features. The gene expression of HER2, ER, PR and Ki-67 were determined by immunohistochemistry (IHC). The gene amplification of Her2 was assessed by using Dual color in situ hybridization (DISH). Results:The most frequent histological type was invasive carcinoma of no special type (NST) with 77.35%, the highest percentage of patients with Grade II was detected (59.36%), tumor size > 2 cm accounted for 71.31% of cases, Lymph node metastases were available in 57.86% cases. Most patients were diagnosed at stage II (59.18%). The majority of patients were classified as moderate Nottingham prognostic index (54.9%). Estrogen receptor and Progesterone receptor were positive in 53.16% and 50.63%, respectively. 76.37% of cases were in high expression group of Ki-67 (≥14%). HER2 IHC 2+, 3+ were accounted for 28.69% and HER2 gene amplification was detected in 31% cases. HER2 gene amplification and/or overexpression was significantly associated with cell proliferation index Ki67. Furthermore, HER2 gene expression tended to be more frequently found in tumors with large tumor size, high grade, high stage and high Nottingham prognostic index and confirmed their prognostic independent role. Conclusions: Our data indicated that HER2 gene expression was significantly correlated with cell proliferation index Ki67, but not significantly associated with another clinicopathological factors in breast cancer of Vietnamese women.

Clinicopathological significance of lipocalin 2 nuclear expression in invasive breast cancer.

The epithelial-mesenchymal transition (EMT) plays a key role in breast cancer progression and metastasis. Lipocalin 2 (LCN2) is involved in the regulation of EMT. The aim of this study was to investigate the clinicopathological significance of LCN2 expression in breast cancer. The expression of LCN2 protein was immunohistochemically assessed in two well-characterised annotated cohorts of breast cancer (discovery cohort, n = 612; validation cohort, n = 1363). The relationship of LCN2 expression and subcellular location with the clinicopathological factors and outcomes of patients was analysed. Absent or reduced nuclear LCN2 expression was associated with features of aggressive behaviour, including high histological grade, high Nottingham Prognostic Index, high Ki67 labelling index, hormone receptor negativity and human epidermal growth factor receptor 2 positivity. The high cytoplasmic expression of LCN2 was correlated with lymph node positivity. The nuclear downregulation of LCN2 was correlated with the overexpression of EMT associated proteins (N-cadherin and Twist-related protein 2) and basal biomarkers (cytokeratin 5/6 and epidermal growth factor receptor). Unlike the cytoplasmic expression of LCN2, the loss of nuclear expression was a significant predictor of poor outcome. The combinatorial expression tumours with high cytoplasmic and low nuclear expression were associated with the worst prognosis. Tumour cell expression of LCN2 plays a role in breast cancer progression with loss of its nuclear expression which is associated with aggressive features and poor outcome. Further functional analysis is warranted to confirm the relationship between the subcellular localisation LCN2 and behaviour of breast cancer.

Are racial differences in obesity and insulin resistance related to aggressive breast cancer?

e18157 Background: Black women are more likely to die of breast cancer and develop more aggressive subtypes than white women. Black women are also more likely to be obese and have insulin resistance than white women. Insulin resistance has been associated with faster tumor growth but has not been studied as a potential mediator of racial disparities in women with breast cancer. We hypothesized that black women would present with more aggressive breast cancer and this would be associated with obesity and insulin resistance. Methods: We recruited 1017 (80% white, 20% black) women with new primary breast cancer, measured fasting blood glucose and insulin, body mass index (BMI), triple negative breast cancer (TNBC) &amp; Nottingham prognostic index (NPI). We classified aggressive breast cancer as NPI &gt; 4.4. We calculated insulin resistance scores (HOMA) and classified insulin resistance as HOMA &gt; 2.8. Patients self-identified race. Results: Of 1017 women, average age was 58 years (SD = 12.0). 373 (37%) were stage 2+ at time of diagnosis; 19% had an NPI &gt; 4.4. Black women presented with higher stage of cancer than white women (stage 2+: 45% vs 35%; p = 0.01), more TNBC than white women (10% vs 5%, p = 0.01), were more insulin resistant (24% vs 11%, p &lt; .0001), had higher BMI (31.4kg/m2 vs 26.6 kg/m2; p &lt; .0001) and NPI &gt; 4.4 (29% vs. 17%, p = 0.0002) than white women. HOMA score was positively but not significantly associated with NPI score (r = 0.05; p = 0.1). Multivariate mediation regression model suggested that HOMA_IR does not mediate the effect from black race to higher NPI score (β = 0.01; 95%CI: -0.017 to 0.039). Conclusions: In women with newly diagnosed breast cancer, black women are more likely to be obese, have higher HOMA &amp; NPI scores than white women. While these data are consistent with the hypothesized relationship of hyperinsulinemia promoting more aggressive breast cancer, to date, insulin resistance does not appear to mediate the effect of race and poor prognostic breast cancer.

Abstract P4-02-04: Tumor-infiltrating lymphocytes in invasive lobular breast cancer identify a poor prognostic sub-group

Abstract Background: Tumor infiltrating lymphocytes (TILs) are associated with an improved outcome in triple negative and HER2 breast cancers. Conversely, a recent pioneer study showed that TILs in infiltrating lobular carcinoma (ILC) were associated with a worse prognosis. We aimed at assessing the prognostic impact of TILs in a large cohort of primary surgically treated ILC with a long follow-up in a single institution. Methods: We retrospectively reviewed 459 ILC treated at the Curie Institute between 2005 and 2008. Clinico-pathological patients' characteristics were collected and all archived tumor slides were centrally reviewed for TILs quantification. We analyzed stromal TILs scored as a continuous variable. Cox analyses were performed for relapse free survival (RFS) and for overall survival (OS), and chi-square and Fisher test were performed to evaluate the correlation between TILs and other clinico-pathological variables. For statistical analyses, presence or absence of TILs was considered. Results: Patients had a mean age of 60.3 years and a median follow-up of 8.8 years, during which 74 local and/or distant relapse events occurred, among which 37 deaths due to the disease. The presence of TILs were significantly associated with greater tumor size (pT), positive nodal status (pN), molecular class (HER2 amplified), and specific morphological nuclear features such as high nuclear grade, multinucleation, macronucleoli and high Nottingham Prognostic Index class. Presence of intra-tumoral lymphocytes is significantly associated with a worse RFS (HR: 2.07 p=0.003) and OS (HR: 4.58 p&amp;lt;0.001) in a multivariate analysis, independently of chemotherapy. Relapse Free Survival TILs% (IC 95%)% (IC 95%)No95.3 (92.5-98.2)89.0 (84.3-94.0)Yes89.3 (85.1-93.6)74.0 (67.5-81-1) Overall Survival OS at 5 yearsOS at 10 yearsTILs% (IC 95%)% (IC 95%)No99.5 (97.8-100)95.8 (92.3-99.4)Yes95.3 (92.3-98.1)83.5 (77.8-89.7) Conclusion: TILs are an independent prognostic factor associated with a poor outcome in ILC that are easy to assess on diagnostic biopsies. In order to elucidate the role of TILs in ILC, we will further characterize the immune infiltrate and integrate these results with DNA, RNA and protein analyses of the same carcinomas, in order to gain insight into their molecular features and to facilitate the identification of new therapeutic strategies for these ILC with TILs. Citation Format: Tille J-C, Saint Martin C, Fuhrmann L, De Koning L, Reyal F, Piccart M, Kirova Y, Cottu P, Carton M, Vincent Salomon A. Tumor-infiltrating lymphocytes in invasive lobular breast cancer identify a poor prognostic sub-group [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-02-04.

Overexpression of the cancer stem cell marker CD133 confers a poor prognosis in invasive breast cancer.

CD133/ prominin 1 is a cancer stem cell marker associated with cancer progression and patient outcome in a variety of solid tumours, but its role in invasive breast cancer (BC) remains obscure. The current study aims to assess the prognostic value of CD133 expression in early invasive BC. CD133 mRNA was assessed in the METABRIC cohort and at the proteomic level using immunohistochemistry utilising a large well-characterised BC cohort. Association with clinicopathological characteristics, expression of other stem cell markers and patient outcome were evaluated. High expression of CD133 either in mRNA or protein levels was associated with characteristics of poor prognosis including high tumour grade, larger tumour size, high Nottingham Prognostic Index, HER2 positivity and hormonal receptor negativity (all; p < 0.001). High CD133 expression was positively associated with proliferation biomarkers including p16, Cyclin E and Ki67 (p < 0.01). Tumours expressing CD133 showed higher expression of other stem cell markers including CD24, CD44, SOX10, ALDHA3 and ITGA6. High expression of CD133 protein was associated with shorter BC-specific survival (p = 0.026). Multivariate analysis revealed that CD133 protein expression was an independent risk factor for shorter BC-specific survival (p = 0.038). This study provides evidence for the prognostic value of CD133 in invasive BC. A strong positive association of BC stem cell markers is observed at the protein level. Further studies to assess the value of stem cell markers individually or in combination in BC is warranted.

BCL2L12: a multiply spliced gene with independent prognostic significance in breast cancer.

Background Alternative splicing is a key process in carcinogenesis and, from a clinical aspect, holds great promises, as alternatively spliced variants have emerged as an untapped source of diagnostic and prognostic markers. Our aim was to assess the prognostic value of three recently recognized splice variants of the apoptosis-related gene, BCL2L12, in breast cancer (BC). Methods Total RNA was extracted from breast samples (150 BC and 80 tumor-adjacent normal tissues) and, following cDNA synthesis, a variant-specific qPCR was performed for the expressional quantification of BCL2L12 v.1, v.2 and v.4 transcript variants. Extensive statistical analysis, including bootstrap resampling and internal validation, was conducted in order to evaluate the associations of v.1, v.2 and v.4 expression with patients' clinopathological and survival data. Results All examined BCL2L12 variants were significantly upregulated in BC specimens compared to their non-cancerous counterpart (v.1, p<0.001; v.2, p=0.009; v.4, p=0.004). Increased BCL2L12 v.4 mRNA expression was associated with markers of unfavorable prognosis namely, advanced tumor grade (p=0.002), ER- (p=0.015)/PR- (p<0.001) negativity, Ki-67-positivity (p=0.007) and high NPI (Nottingham prognostic index) score (p=0.033). Moreover, v.4 was significantly overexpressed in women with triple negative BC (TNBC) and HER2-positive tumors compared to those harboring luminal tumors (p<0.001). Survival analysis disclosed that BCL2L12 v.2 overexpression, as a continuous variable ([HR]=0.45, 95% CI=0.17-0.82, p=0.010), is a strong and independent marker of favorable prognosis for BC patients. Interestingly, v.2 retains its prognostic value in patients with Grade II/III ([HR]=0.21, 95% CI=0.05-0.57, p=0.006) or HER2-positive/TNBC tumors ([HR]=0.25, 95% CI=0.05-0.74, p=0.042). Conclusions BCL2L12 v.1, v.2, v.4 are aberrantly expressed in BC. Their expressional analysis by cost-effective molecular methods could provide a novel molecular tool for BC management.

Hypofractionated irradiation in elderly patients with breast cancer after breast conserving surgery and mastectomy : Analysis of 205 cases.

BackgroundSeveral randomized trials and meta-analyses confirmed a wide benefit of radiotherapy (RT), both after breast conserving surgery (BCS) and mastectomy. However, many elderly women don't receive RT. Hypofractionated (HF) RT allows « simplified » and more accessible treatments with equivalent results to classic RT in three large randomized trials. However, there are few available data on HF-RT for nodal irradiation, as well as for the boost.MethodsWe evaluated patients treated for IBC by HF-RT between 2004 and 2012 in two regional cancer centres. We used an original scheme delivering 45 Gy in 15 fractions three times a week, both after BCS or mastectomy, with or without nodal irradiation. After BCS, a 9 Gy boost in 3 fractions was delivered. Local, regional and distant recurrences were assessed, as well as acute and late cutaneous, cardiac or pulmonary toxicities.Results205 patients were analysed, 116 after BCS (57 %) and 89 after mastectomy (43 %). Median age was 81 years (range: 52-91); 44 % had axillary nodal involvement (pN+). The Nottingham Prognostic Index (NPI) scored 0, 1, 2 and 3 in 10 %, 27 %, 44 % and 19 % of the cases. A nodal HF-RT was delivered in 65 patients (32 %) and boost in 98 patients (84 % of BCS) by 9 Gy/3 fr scheme. Fifty (24 %) patients underwent chemotherapy and 156 (75 %) hormonal treatment.With a 49-month median follow-up, 3/116 (2.6 %) patients and 4/89 (4.5 %) had local recurrence (LR) after BCS and mastectomy, respectively. The overall 5-year LR rate was 4.4 %. In univariate and multivariate analysis, LR risk factors were: high NPI (HR 5.46; p = 0.028), and triple negative tumour (HR 9.78; p = 0.006). Only 8 (4.5 %) patients had grade III skin toxicity; 29 (14 %) late fibrosis and 16 (8 %) telangiectasia. No pulmonary or cardiac toxicity was observed.ConclusionOur HF-RT scheme (with or without nodal irradiation) confirms in elderly patients the data from randomized trials, both after BCS or mastectomy. Toxicity seems very acceptable but requires a longer follow-up. A larger evaluation is still ongoing in several other centres in France.

Are breast cancers in India different from Western populations? Results of a tertiary center retrospective analysis.

e12039 Background: Breast cancer is the commonest cancer in the urban Indian female population but comprehensive data on the details of tumor types, outcomes post treatment and comparison with Western data is not readily available. We present a robust database of Eastern Indian breast cancers reported from a tertiary center. Methods: Retrospective analysis of 407 unselected medical records of breast cancer cases between June 2011 and October 2012 were undertaken. Clinico-pathological details, Nottingham Prognostic Index (NPI) Score post surgery (conservation and mastectomy) and follow-up were analyzed. Adjuvant chemotherapy details were recorded. Following Institutional guidelines a hypofractionated Radiotherapy (RT) schedule was delivered (40Gy in 15 Fractions over 3 weeks), with boost delivered in patients receiving conservation surgery. Acute radiation toxicity following hypofractionation was recorded. Results: Mean age at presentation was 52.42 years. 383 (94%) underwent surgery; breast-conservation in 37%. 34% received neo-adjuvant anthracycline-taxane sequential chemotherapy prior to surgery. For those who underwent upfront surgery, 12% patients had pT3 disease and 83% pT1/T2. 41%, 31%, 16% and 12% had pN0, N1, N2 and N3 disease respectively. 89% cases had infiltrating ductal carcinoma with 57% Grade III disease. 73% were ER positive and 35% were Her-2 positive. 31% patients were intermediate risk and 36% high risk (&gt;5.5) by NPI Score. After upfront surgery 54% received adjuvant chemotherapy of which 63% received both anthracycline and taxanes sequentially. 67.4% patients received adjuvant RT where the median time between date of surgery and starting of RT was 5 months. Median post hypofractionated RT follow-up was 6 months when 7 out of 97 patients had &gt; Grade 0 Skin toxicity, 4 had breast edema, 6 shrinkage, 8 patients had Grade I Lymphedema. Conclusions: Indian patients were younger and had advanced stage at presentation and higher NPI scores requiring more combined systemic chemotherapy. Hypofractionated RT schedule was tolerated well and further hypofractionation could now be investigated in clinical studies to improve throughput in moderate resource countries like India.

Prognostic significance of RACGAP1 mRNA expression in high-risk early breast cancer: a study in primary tumors of breast cancer patients participating in a randomized Hellenic Cooperative Oncology Group trial

RACGAP1 is a Rac GTPase-activating protein involved in cell growth regulation, cell transformation and metastasis. The aim of the present study was to explore the prognostic and/or predictive significance of RACGAP1 mRNA expression on disease-free survival (DFS) and overall survival (OS) in high-risk early breast cancer patients and compare it to that of Ki67 protein expression and to the Nottingham prognostic index (NPI). A total of 595 high-risk breast cancer patients were treated in a two-arm trial evaluating postoperative dose-dense sequential chemotherapy with epirubicin followed by CMF with or without paclitaxel. RNA was extracted from 314 formalin-fixed paraffin-embedded primary tumor tissue samples followed by one-step quantitative RT-PCR for assessing RACGAP1 mRNA expression. High RACGAP1 mRNA expression (above the median) was associated with poor DFS (log-rank, p = 0.002) and OS (p < 0.001). High histological grade, as well as high Ki67 protein expression, was more frequent in the high-expression group of RACGAP1. Results of the Cox multivariate regression analysis revealed that high RACGAP1 mRNA expression independently predicted poor overall survival (Wald's p = 0.008). High Ki67 protein expression was also an adverse prognostic factor for death (p = 0.016), while high NPI score values were not. High RACGAP1 mRNA expression, as assessed by qRT-PCR, was found to be of adverse prognostic significance in high-risk early breast cancer patients treated with dose-dense sequential chemotherapy. The utility of RACGAP1 mRNA expression in patient selection for treatment with aggressive chemotherapy regimens should be further explored and validated in larger cohorts.

Additional value and potential use of the 70-gene prognosis signature in node-negative breast cancer in daily clinical practice

BackgroundThe 70-gene prognosis signature has strong prognostic value in node-negative breast cancer, independent of established prognostic factors. It is unclear whether all node-negative patients should receive a signature result. We therefore evaluated its additional prognostic information to a combination of established prognostic guidelines. MethodsWe evaluated 701 patients from three previously described series in whom a signature result was available. Clinical risk was on the basis of Adjuvant! Online (AO), St Gallen guidelines (St G) and Nottingham Prognostic Index (NPI). Overall survival (OS) analyses were carried out in patients treated at the Netherlands Cancer Institute (Amsterdam) who did not receive adjuvant systemic treatment (AST). ResultsOnly 6% (10 of 156) of estrogen receptor (ER)-negative tumours had a good prognosis signature. The signature was not useful for ER-positive tumours and concordant high AO, high St G and/or high NPI clinical risks (N = 139). The 10-year OS estimate for good signature tumours with these characteristics was <80% and AST would therefore be appropriate irrespective of the signature result. In contrast, for patients with a concordant low AO, low St G and/or low NPI risk and in discordant clinical risk patients, the signature identified low-risk patients in whom AST could be safely withheld (10-year OS > 90%). ConclusionThe 70-gene prognosis signature provides additional prognostic information especially in ER-positive lymph node-negative breast cancer patients with a predominant low or discordant clinical risk on the basis of AO, St G and/or NPI.

The effects of oncotype DX recurrence scores on chemotherapy utilization in a multi-institutional breast cancer cohort

The use of clinicopathologic features in decision-making in early stage estrogen receptor (ER)-positive breast cancer (BC) may lead to over or under treatment. We investigated the effect of the Oncotype Dx (ODX) on chemotherapy (CTX) utilization in two cancer centers. 276 cases of node-negative ER-positive BC had ODX between 2005 and 2009. Age at diagnosis, tumor size, grade, and progesterone receptor (PR) status were abstracted from records and provided to two medical oncologists blinded to the ODX score. A recommendation for or against CTX was made based on clinicopathologic characteristics. Median age was 55 years. Mean tumor size was 1.6 cm. The median 10-year Adjuvant! Online (AO) mortality risk was 8. The median Nottingham Prognostic Index (NPI) was 3.3. The median ODX recurrence score was 17. Without knowledge of the ODX, oncologists were more likely to recommend CTX to younger women (P < 0.0001), women with negative PR status (P < 0.0001), higher NPI (P < 0.012), and tumors > 1 cm (P = 0.033). On average, CTX recommended patients had larger tumors (2.0 vs. 1.2 cm) and higher AO 10-year mortality (11.4 vs. 4.4%). ODX resulted in a change in management for 38% of women. Of 188 total patients who did not receive CTX, 71 had a recommendation favoring CTX by an oncologist blinded to the ODX score. In our multi-institutional cohort, the ODX score had a significant impact on the receipt of adjuvant CTX and altered management for 38% of women.

Benefits of biomarker selection and clinico-pathological covariate inclusion in breast cancer prognostic models

IntroductionMulti-marker molecular assays have impacted management of early stage breast cancer, facilitating adjuvant chemotherapy decisions. We generated prognostic models that incorporate protein-based molecular markers and clinico-pathological variables to improve survival prediction.MethodsWe used a quantitative immunofluorescence method to study protein expression of 14 markers included in the Oncotype DX™ assay on a 638 breast cancer patient cohort with 15-year follow-up. We performed cross-validation analyses to assess performance of multivariate Cox models consisting of these markers and standard clinico-pathological covariates, using an average time-dependent Area Under the Receiver Operating Characteristic curves and compared it to nested Cox models obtained by robust backward selection procedures.ResultsA prognostic index derived from of a multivariate Cox regression model incorporating molecular and clinico-pathological covariates (nodal status, tumor size, nuclear grade, and age) is superior to models based on molecular studies alone or clinico-pathological covariates alone. Performance of this composite model can be further improved using feature selection techniques to prune variables. When stratifying patients by Nottingham Prognostic Index (NPI), the most prognostic markers in high and low NPI groups differed. Similarly, for the node-negative, hormone receptor-positive sub-population, we derived a compact model with three clinico-pathological variables and two protein markers that was superior to the full model.ConclusionsPrognostic models that include both molecular and clinico-pathological covariates can be more accurate than models based on either set of features alone. Furthermore, feature selection can decrease the number of molecular variables needed to predict outcome, potentially resulting in less expensive assays.

The effects of Oncotype DX recurrence scores on chemotherapy receipt in a multi-institutional breast cancer cohort.

669 Background: The use of traditional clinicopathologic features in decision making in early stage estrogen receptor (ER)-positive breast cancer (BC) may lead to over or under treatment. We investigated the effect of the Oncotype Dx (ODX) genomic profile on receipt of chemotherapy (CTX) in two tertiary cancer centers. Methods: 276 cases of node-negative ER positive BC from two tertiary cancer centers had ODX performed on tumor blocks between 2005 and 2009. Age at diagnosis, tumor size, grade, histology, presence of lymphovascular invasion, and PR status were abstracted from records and provided to 2 medical oncologists specializing in breast cancer. The Adjuvant! Online (AO) relapse risk and the Nottingham Prognostic index (NPI) were calculated. Results: Median age was 55 years (range, 29-82). 13% of patients had a negative PR status. Mean tumor size was 1.58 cm. Fifty percent had grade 2 BC, 38% and 12% were grade 1 and 3. The median 10 year AO relapse risk was 23 (range, 13-60). The median NPI was 3.4 with 80% of patients in the excellent or good category. The median ODX recurrence score was 17. 51%, 40%, and 9% of patients were in the low, intermediate, and high risk categories respectively. Prior to obtaining ODX, medical oncologists were more likely to recommend CTX to women who were younger (p < 0.0001), had negative PR status (p < 0.0001), higher NPI (p < 0.012), and tumors greater than 1 cm (p < 0.015). The average tumor size of patients recommended CTX was 2.0 cm versus 1.2 cm in the group not recommended CTX. The mean AO for those recommended CTX was 28.6 versus 18.9 for those not recommended CTX. ODX resulted in a change in management for 38% of individuals. Of 188 total patients who ultimately DID NOT receive CTX, 71 of them had an initial CTX recommendation. Of 88 patients who DID receive CTX, 34 of them did not have an initial recommendation. CTX was administered to 13/142 patients with low ODX, 52/110 with intermediate ODX, and 23/24 with high ODX. Only 3/24 women with high-risk ODX did not have an initial CTX recommendation. Conclusions: In our multi-institutional cohort, the ODX score had a significant impact on adjuvant chemotherapy decisions. No significant financial relationships to disclose.

Biomarkers of Oxidative Stress in Breast Cancer.

Abstract INTRODUCTIONDespite significant improvements in cancer diagnosis and treatment, approximately one-quarter of breast cancer patients will die of their disease. Oxidative stress has been implicated as a contributory factor in the development of breast cancer. Reactive oxygen species can initiate lipid peroxidation, resulting in generation of reactive secondary products which can induce oxidative DNA damage and mutations in the p53 tumour suppressor gene, which is one of the most frequent mutations associated with breast cancer development. Oxidative stress has also been associated with activation of transcription factors and tamoxifen resistance. The aim of the present study was to identify the levels of lipid peroxdation products; malondialdehyde and 8-iso-Prostaglandin F2α (8-iso-PGF2α), in patients with primary operable breast cancer, and to correlate these levels with pathological factors of disease including tumour grade, ER and HER2 status and also Nottingham prognostic index (NPI) status.METHODS:89 patients with primary operable breast cancer and 10 healthy subjects were studied. Plasma levels of MDA (total and free) and 8-iso-PGF2α were measured.RESULTS:The majority of patients were over 50 years (87%), had grade II/III tumours (68%), were axillary lymph node positive (41%) and had ER-positive tumours (82%). Compared to the control, patients had higher levels of total MDA (p&amp;lt;0.001), free MDA (p&amp;lt;0.001), and 8-iso-PGF2α (p&amp;lt;0.001). Both free (p&amp;lt;0.05) and total MDA (p=0.001) were significantly correlated with increasing tumour grade. Furthermore, total MDA levels were also associated with increased tumour size (p&amp;lt;0.05) and ER-negative tumours (p&amp;lt;0.05). Taken together, both total (p&amp;lt;0.001) and free (p &amp;lt;0.05) MDA were significantly associated with higher NPI categories. 8-iso-PGF2α showed only a correlation with increasing age (p&amp;lt;0.05)CONCLUSION:The present study shows that patients with breast cancer have evidence of increased levels of oxidative stress. Furthermore, MDA concentration was significantly associated with conventional markers of poor prognosis. This data suggests oxidative stress may be involved in tumour progression to a more aggressive phenotype. Thus MDA maybe a useful marker of tumour associated oxidative damage and may provide a promising marker for risk prediction and targets for preventative measures in breast cancer patients. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2141.