Only 32.3% of Breast Cancer Families with Pathogenic Variants in Cancer Genes Utilized Cascade Genetic Testing.

BACKGROUND: Hereditary cancer predisposition syndromes are responsible for approximately 5-10% of all diagnosed cancer cases. In order to identify individuals at risk in a cost-efficient manner, family members of individuals carrying pathogenic alterations are tested only for the specific variant that was identified in their carrier relative. The purpose of this study was to investigate the clinical use and implementation of cascade family testing (CFT) in families of breast cancer patients with pathogenic/likely pathogenic variants (PVs/LPVs) in cancer-related predisposition genes. METHODS: Germline sequencing was carried out with NGS technology using a 52-gene panel, and cascade testing was performed by Sanger sequencing or MLPA. RESULTS: In a cohort of 1785 breast cancer patients (families), 20.3% were found to have PVs/LPVs. Specifically, 52.2%, 25.1%, and 22.7% of patients had positive findings in high-, intermediate-, and low-penetrance breast cancer susceptibility genes, respectively. Although CFT was recommended to all families, only 117 families (32.3%) agreed to proceed with genetic testing. Among the first-degree relatives who underwent CFT, 70.3% were female, and 108 of 121 (89.3%) were cancer free. Additionally, 42.7%, 36.7%, and 20.6% were offspring, siblings, and parents of the subject, respectively. Our data suggest that CFT was mostly undertaken (104/117, 88.8%) in families with positive findings in high-risk genes. CONCLUSIONS: Cascade family testing can be a powerful tool for primary cancer prevention by identifying at-risk family members. It is of utmost importance to implement genetic counseling approaches leading to increased awareness and communication of genetic testing results.

Copy Number Variations (CNVs) Account for 10.8% of Pathogenic Variants in Patients Referred for Hereditary Cancer Testing.

BACKGROUND/AIM: Germline copy number variation (CNV) is a type of genetic variant that predisposes significantly to inherited cancers. Today, next-generation sequencing (NGS) technologies have contributed to multi gene panel analysis in clinical practice. MATERIALS AND METHODS: A total of 2,163 patients were screened for cancer susceptibility, using a solution-based capture method. A panel of 52 genes was used for targeted NGS. The capture-based approach enables computational analysis of CNVs from NGS data. We studied the performance of the CNV module of the commercial software suite SeqPilot (JSI Medical Systems) and of the non-commercial tool panelcn.MOPS. Additionally, we tested the performance of digital multiplex ligation-dependent probe amplification (digitalMLPA). RESULTS: Pathogenic/likely pathogenic variants (P/LP) were identified in 464 samples (21.5%). CNV accounts for 10.8% (50/464) of pathogenic variants, referring to deletion/duplication of one or more exons of a gene. In patients with breast and ovarian cancer, CNVs accounted for 10.2% and 6.8% of pathogenic variants, respectively. In colorectal cancer patients, CNV accounted for 28.6% of pathogenic/likely pathogenic variants. CONCLUSION: In silico CNV detection tools provide a viable and cost-effective method to identify CNVs from NGS experiments. CNVs constitute a substantial percentage of P/LP variants, since they represent up to one of every ten P/LP findings identified by NGS multigene analysis; therefore, their evaluation is highly recommended to improve the diagnostic yield of hereditary cancer analysis.

Prognostic Significance of Low HER2 Expression in Patients With Early Hormone Receptor Positive Breast Cancer.

BACKGROUND/AIM: A possible role of antibody-drug conjugates against tumors with low HER2-expression, leads to the emergence of a new "low-HER2" classification in breast cancer, encompassing tumors from the hormonal-receptor-positive and the triple-negative subgroups. There is a need for data (clinical trial data and real-world evidence) that will accurately describe this population, the risk of recurrence and the possible benefit of HER2 targeted therapies. PATIENTS AND METHODS: We retrospectively analyzed 949 patients from our Department databases, with hormonal receptor-positive and HER2-negative early breast cancer, for whom detailed data for immunohistochemical HER2-staining could be retrieved. RESULTS: HER2-low expression was detected in 66.6% of patients (472 IHC +1 and 160 IHC +2 and ISH-negative). Lobular, or mixed lobular and ductal cancers had a statistically significantly lower chance of being HER2-low when compared to pure infiltrative ductal carcinomas (53.1% vs. 69.3% respectively). HER2-low status was not prognostic for recurrence-free survival or response to neoadjuvant chemotherapy. There was a non-significant trend for increased risk of recurrence for HER2-low, compared to HER2-0, in patients with lobular or mixed lobular and ductal carcinomas (HR=2.192, 95% CI=0.819-5.912). CONCLUSION: Low expression of HER2 in hormonal receptor-positive early breast cancer does not affect prognosis but may lead to a shorter progression-free-survival in lobular and mixed ductal and lobular cancers. Despite optimal management, a large proportion of hormonal receptor-positive patients will relapse. Targeting HER2 in HER2-low cancers may offer a potential additional treatment strategy to improve survival of this group.

Follow-up of tissue genomics in BRCA1/2 carriers who underwent prophylactic surgeries.

PURPOSE: The genomic status of non-malignant tissues from carriers of pathogenic germline BRCA1/2 (gBRCA1/2) variants may reveal information towards individualized prophylaxis. We performed spatiotemporal tissue genotype comparisons in a real-life cohort of gBRCA1/2 carriers of Greek origin, who underwent multiple risk-reducing/prophylactic surgeries at various time points. METHODS: Fifty-three women (median age 36 years) within cancer families were observed for up to 37.5 years; 43 were cancer carriers and 10 were healthy carriers. Histology review and genotyping were performed for 187 paraffin tissues (average: 3.5 per carrier) including 46 carcinomas (40 breast) and 141 non-malignant breast and gynecological samples. RESULTS: High allelic imbalance (AI) and somatic pathogenic TP53 variants were present in cancer carriers only (p values < 0.0001). High AI was associated with gBRCA1/2 indels (p < 0.0001) and gBRCA2 alterations (p = 0.0109). Somatic (pathogenic) variants were infrequently shared between non-malignant tissues and matched carcinomas. Aberrations of gBRCA1 variant heterozygosity were noticed in tissues from cancer carriers only (13/43, 30.2%). These pertained to classic LOH (neoplastic lesions in 9/43 carriers, 20.9%) and under-representation of the germline variants (5 samples, 4 non-malignant, all in the breast). Both aberrations coexisted in matched samples in one case. Over time, germline variant heterozygosity prevailed in non-malignant tissues; intra-carrier genomic alterations were aggravated (21.1%), ameliorated (26.3%) or remained stable. CONCLUSION: This real-life case study supports the need to address tissue genotypes from prophylactic surgeries in combination with polygenic scores towards personalized prophylaxis. To this end, knowing the traditionally classified pathogenic potential of a gBRCA1/2 variant may not be enough.

Clinical Utility of Functional RNA Analysis for the Reclassification of Splicing Gene Variants in Hereditary Cancer.

BACKGROUND: Classification of splicing variants (SVs) in genes associated with hereditary cancer is often challenging. The aim of this study was to investigate the occurrence of SVs in hereditary cancer genes and the clinical utility of RNA analysis. MATERIAL AND METHODS: 1518 individuals were tested for cancer predisposition, using a Next Generation Sequencing (NGS) panel of 36 genes. Splicing variant analysis was performed using RT-PCR and Sanger Sequencing. RESULTS: In total, 34 different SVs were identified, 53% of which were classified as pathogenic or likely pathogenic. The remaining 16 variants were initially classified as Variant of Uncertain Significance (VUS). RNA analysis was performed for 3 novel variants. CONCLUSION: The RNA analysis assisted in the reclassification of 20% of splicing variants from VUS to pathogenic. RNA analysis is essential in the case of uncharacterized splicing variants, for proper classification and personalized management of these patients.

Real-world experience of neoadjuvant chemotherapy for early breast cancer patients: an observational non-interventional study in Thessaloniki, Greece.

PURPOSE: Neoadjuvant chemotherapy has been increasingly used in early-stage breast cancer. The results of large randomized clinical trials suggest the need for the wider use of preoperative therapy as it can result in a more conservative surgery, and can guide physicians to a more individualized approach in the adjuvant setting. METHODS: We aimed to analyze the outcomes of 203 patients with early-stage breast cancer who had received neoadjuvant chemotherapy at our institutions. RESULTS AND CONCLUSION: Pathological complete responses (pCR) were obtained in 42.4% of all patients, with the highest percentage in hormonal receptor (HR)-negative and human epidermal growth factor receptor-2 (HER2)-positive cancers. Conversion of a clinically and/or cytologically node-positive to node-negative disease was achieved in 55.8% of patients. Patients who achieved a pCR had a significantly better outcome in terms of disease-free and distant disease-free survival. Patients with residual disease experienced a worse prognosis if they had HR-negative cancer compared to HR-positive patients for whom the use of adjuvant endocrine treatment likely led to better outcomes. These results are encouraging as they show that outcomes from large randomized clinical trials can be reproduced in the everyday clinical setting. Neoadjuvant chemotherapy may be the treatment of choice for HR-negative and/or HER2-positive early breast cancer patients. This may also be the case for the majority of HR-positive and HER2-negative patients with either locally advanced disease or disease extending to the axillary lymph nodes, as it may result in more conservative surgical interventions with fewer post-operative complications.

Axillary Lymph Node Tattooing and Targeted Axillary Dissection in Breast Cancer Patients Who Presented as cN+ Before Neoadjuvant Chemotherapy and Became cN0 After Treatment.

INTRODUCTION: Targeted axillary dissection (TAD) is an alternative to axillary dissection for breast cancer patients who presented as cN+ before neoadjuvant chemotherapy (NAC) and became cN0 after treatment. TAD is defined as the removal of sentinel lymph nodes (SLNs) along with the pre-NAC marked positive nodes. Tattooing is an option to mark positive nodes. In this study we aimed to investigate the identification rate of tattooed nodes during surgery, correspondence between tattooed nodes and SLNs, and difficulties and pitfalls of the method. PATIENTS AND METHODS: In 75 patients who were cN+, with axillary lymph nodes known to have or suspected to have disease were tattooed pre-NAC with a sterile carbon suspension (Spot). After NAC completion all patients became cN0 and underwent TAD as an axillary staging procedure. RESULTS: SLNs were identified successfully in 70 of 75 patients (93.3%). All tattooed nodes were identified successfully intraoperatively in 71 of 75 patients (94.6%). Retrieval of all tattooed nodes in surgical specimens was achieved in 74 patients (98.6%). Correspondence between tattooed nodes and SLNs was observed in 53 of 70 patients (75.3%). In 34 patients (45.3%) the number of pigmented nodes in pathological examination was greater than the number of initially tattooed nodes, indicating the possibility of tattoo ink migration. CONCLUSION: Tattoo of axillary lymph nodes is a feasible, accurate, and low-cost method of positive node marking pre-NAC. Pathological confirmation of black pigment in the lymph nodes excised is not by itself warranty of retrieval of all marked node because of tattoo ink migration from one node to another. Intraoperative identification using visual inspection is essential.

Comprehensive BRCA mutation analysis in the Greek population. Experience from a single clinical diagnostic center.

Germline mutations in the BRCA1 and BRCA2 genes are associated with hereditary predisposition to breast and ovarian cancer. Sensitive and accurate detection of BRCA1 and BRCA2 mutations is crucial for personalized clinical management of individuals affected by breast or ovarian cancer, and for the identification of at-risk healthy relatives. We performed molecular analysis of the BRCA1 and BRCA2 genes in 898 Greek families, using Sanger sequencing or Next Generation Sequencing for the detection of small insertion/deletion frameshift, nonsynonymous, truncating and splice-site alterations and MLPA for the detection of large genomic rearrangements. In total, a pathogenic mutation was identified in 12.9% of 898 families analyzed. Of the 116 mutations identified in total 9% were novel and 14.7% were large genomic rearrangements. Our results indicate that different types of mutational events in the BRCA1 and BRCA2 genes are responsible for the hereditary component of breast/ovarian cancer in the Greek population. Therefore the methodology used in the analysis of Greek patients must be able to detect both point and small frameshift mutations in addition to large genomic rearrangements across the entire coding region of the two genes.

Symptom-focused results after laparoscopic fundoplication for refractory gastroesophageal reflux disease--a prospective study.

BACKGROUND AND AIMS: Symptoms of gastroesophageal reflux disease (GERD) are common in the general population. Although the results of laparoscopic fundoplication are well documented, there have been no reports on the operative outcome in patients refractory to or with only partial response to medical therapy for GERD. PATIENTS-METHODS: Thirty-two patients with GERD, whose continuous high doses of medical treatment with proton-pump inhibitors produced no or only partial symptom relief, underwent laparoscopic Nissen fundoplication. Symptoms were evaluated with a standardized questionnaire preoperatively and 12 months after surgery. RESULTS: The complete follow-up evaluation was obtained in 30 out of the 32 patients. The main symptoms before surgery were regurgitation (93%), heartburn (60%), epigastric pain (47%), and globus sensation (47%). All patients were relieved from heartburn, vomiting, and globus sensation. Dysphagia was relieved in 75% of the patients and regurgitation in 86%. Dysphagia as a new symptom occurred in 9%. The overall morbidity rate was 16%. Patient satisfaction rate was 87%. CONCLUSION: Laparoscopic fundoplication seems to be an effective treatment for severe, drug-resistant GERD. The high patient satisfaction rate and the positive therapeutic response in 95% of patients justify this procedure in this strictly selected group of patients.

Metaplastic breast carcinoma in a patient with Von Recklinghausen's disease.

Metaplastic carcinomas of the breast are uncommon lesions and account for < 5% of all breast malignancies. A type of metaplastic carcinoma is carcinosarcoma, an even more rare lesion. We present a case of carcinosarcoma in association with Von Recklinghausen's disease in a 60-year-old woman. Von Recklinghausen's disease is an autosomal dominant disorder that is localized at the long arm of chromosome 17 and affects 1 in 4000 individuals. There are few reports on breast tumor development and incidence in patients with Von Recklinghausen's disease. To our knowledge, there has been no report of breast carcinosarcoma associated with Von Recklinghausen's disease. We comment on the difficulties of diagnosis and treatment and the possibility of breast tumors occurring more frequently in patients with Von Recklinghausen's disease.