Ki67 and lymphocytes in the pretherapeutic core biopsy of primary invasive breast cancer: positive markers of therapy response prediction and superior survival.

Background Core needle biopsy plays a crucial role as diagnostic tool for BC. Both Ki67 and likely tumor-infiltrating lymphocytes (TILs) in the near future are determining the kind of systemic therapy. The role of TILs in BC is still an issue for clinical research, albeit preliminary results of neoadjuvant and adjuvant clinical studies already now highlight the crucial impact of TILs on therapy response and survival. Methods Evaluation of related publications (pubmed) and meeting abstracts (ASCO, SABCS). Results The monoclonal antibody Ki67 recognizing a nuclear antigene in proliferating cells is a positive marker of therapy response and superior survival. Endocrine responsive tumors of low proliferation (Ki67 < 14%/11%) respond to tamoxifen, in contrast postmenopausal tumors with higher proliferation respond better to aromatase-inhibitors. Pathological complete response (pCR)-rates increase in tumors with higher proliferation (Ki67 > 19%) vs. tumors with lower proliferation after neoadjuvant chemotherapy (NAC). pCR-rates of up to 60% can be seen in TNBC and HR-, HER2+BC, lower pCR-rates, however, in HR+, HER2- BC. Increased stromal TILs are found in 30% of TNBC and in 19% of HR-, HER2+BC. The percentage of TILs is a significant independent parameter for pCR after NAC. Lymphocyte-predominant BC (LPBC) respond with higher pCR-rates than non-LPBC or tumors without any TILs. Increased TILs in TN and HR-, HER2+ subtypes predict benefit from addition of carboplatin to NAC. TILs are also associated with improved DFS and OS among patients with TNBC and HR-, HER2+ BC. Conversly and interestingly increased TILs in patients with HR+, HER2-(luminal) BC are associated with a 10% higher risk of death per 10% increase of TILs. Interactions between immune system and cancer are complex. The cancer-immunity cycle characterizes these interactions. BC subtypes with higher number of mutations such as TNBC and HR-, HER2+BC are considered to provide a raising number of tumor-associated antigens, thereby capable to build up a higher endogenous immune response. TILs may serve as surrogate marker of both an existing endogenous immune response and the probability to respond to cancer immune therapies. As cancer co-opt immune checkpoint-pathways as a major mechanism of immune resistance, in particular, against cytotoxic T-cells, blockades of checkpoint-pathways by antibodies are one of the goals of the current cancer immunotherapy studies. Therapy studies with antigene-based strategies (vaccines) and antibodies against the immune checkpoints PD-1 and CTLA-4 and their inhibitory pathways in order to enhance cytotoxic T-cell activities against cancer cells with or without chemotherapy are underway. Conclusions It can be suggested that the use of multigene expression testing will increase in order to select more clearly primary HR+, HER2- BC patients with intermediate recurrence risk who likely may benefit from chemotherapy. Furthermore Ki67 and the multigene expression test Oncotype DX can act as dynamic markers to avoid cytostatic overtreatment and endocrine undertreatment. A data-derived optimal Ki67 cut point for pCR and DFS as well as OS is currently not feasible. The integration of stromal TILs into the immunohisto-pathological report after their evaluation has been standardized is likely helpful to determine patients who profit by additional carboplatin chemotherapy. Oncologists need an enlarged information about the tumor-microenvironment in future. The preliminary results of current BC immunotherapy studies are encouraging.

Systematic analysis of in vitro chemosensitivity and mib-1 expression in molecular breast cancer subtypes.

BACKGROUND: Molecular breast cancer subgroups show differences with regard to prognosis and response to chemotherapy. In vitro chemotherapy sensitivity and resistance assays (CSRAs) are a means to directly evaluate tumour cell response to a given drug. METHODS: Using tissue microarray (TMA) analysis, 550 invasive breast cancers were investigated for the expression of oestrogen receptor (ER), progesterone receptor (PR), vimentin, Ck5, Ck14, Ck19, HER2 and Mib-1/Ki-67. All carcinomas were subjected to in vitro CSRA analysis using three separate chemotherapy combinations. In vitro chemotherapy sensitivity was established using an adenosine triphosphate (ATP) bioluminescence assay. Results of immunohistochemical staining and in vitro response were correlated. RESULTS: Mib-1 expression was associated with sensitivity against Paclitaxel/Epirubicin (p = 0.014) and Docetaxel/Epirubicin (p = 0.014). Mib-1 expression was positively/negatively correlated with expression of basal/luminal markers, respectively. Hierarchical clustering revealed three subtypes, resembling luminal, basal-like and HER2-like breast cancer subtypes. In vitro response for Paclitaxel/Epirubicin was most frequently observed for cases in the basal category (40.3%) compared to HER2-like (25.8%) and luminal cases (28.6%). In multivariate analysis expression of Mib-1 was not a significant independent predictor of in vitro response to chemotherapy. CONCLUSION: Breast cancer molecular subclasses show differences regarding in vitro chemotherapy sensitivity. These may in part explain differences observed between breast cancer molecular subtypes in vivo.

Molecular targeted therapies for breast cancer treatment.

Targeting the oestrogen receptor, HER2 (human epidermal growth factor receptor 2) and vascular endothelial growth factor has markedly improved breast cancer therapy. New targeted therapeutic approaches to induction of apoptosis or inhibition of anti-apoptosis, cell cycle progression, signal transduction and angiogenesis are described. The molecular pathways and their inhibitory or repair mechanisms are discussed in the preclinical and clinical settings.

Surgery in the tri-modality treatment of small cell lung cancer. Stage-dependent survival.

OBJECTIVE: Patients with small cell lung cancer (SCLC) are frequently denied surgical treatment despite growing body of evidence for a longer duration of remission and overall survival, if surgical intervention is integrated in a tri-modality therapy concept including chemotherapy, surgery, and radiotherapy. METHODS: A retrospective analysis was performed using data derived from 95 patients with SCLC operated upon over a period of 9 years. A subset of these patients was primarily operated upon and being diagnosed as SCLC only after thoracotomy, received radio-/chemotherapy postoperatively (n=64, group I). The second cohort had surgery after neoadjuvant chemotherapy which was continued postoperatively in addition to thoracic and cranial radiotherapy (n=31, group II). The patients in the second group were further divided into two subgroups: complete histological regression of tumor tissue in the mediastinal lymph nodes (group IIA), and those with persistent mediastinal lymph nodal involvement detected after thoracotomy (group IIB). RESULTS: Group I patients had stage I or II disease, whereas group II patients had clinical stage IIIA or IIIB. The overall 30-day mortality rate was as low as 5%. The median survival was 31.3 months for patients in group I, 31.7 months for adjuvant surgery with complete regression of mediastinal nodes (group IIA), and 12.4 months for adjuvant surgery without regression of mediastinal nodes (group IIB). CONCLUSIONS: Surgical intervention is promising and warrants prospective trials to be evaluated as an important adjunct to multi-modality therapy regimen in SCLC as regards to its impact on relapse free and overall survival.

Breast tumour growth inhibition in vitro through the combination of cyclophosphamide/metotrexate/5-fluorouracil, epirubicin/cyclophosphamide, epirubicin/paclitaxel, and epirubicin/docetaxel with the bisphosphonates ibandronate and zoledronic acid.

Breast cancer has a significant capacity to metastasize to bone. Bisphosphonates are the standard treatment for hypocalcaemia of malignancy (HCM), which is a common complication of bone metastasis. The combination of bisphosphonates with standard anticancer drugs such as paclitaxel or tamoxifen results in a synergistic apoptotic effect greater than that produced by either single agent alone. Potential antitumour effects in vitro of the two bisphosphonates zoledronic acid (Zol) and ibandronate (Ib) (each at 30 microM) combined with different anticancer drug combinations: cyclophosphamide/metotrexate/5-fluorouracil (CMF), epirubicin/cyclophosphamide (EC), epirubicin/paclitaxel (ET), and epirubicin/docetaxel (EDoc) were investigated using ATP-cell viability assay (ATP-CVA). Twenty cases of female primary, invasive breast cancer were assessed. Ibandronate and zoledronic acid alone showed an inhibitory effect on breast cancer tumour cells in vitro. The breast tumour growth inhibition effect for those two drugs amounted to 22 and 25% respectively. Inhibitory effects were clearly visible for all four combinations of anticancer drugs together with both bisphosphonates. Combinations of anticancer drugs with zoledronic acid seem to be more effective with respect to tumour growth inhibition than combinations with ibandronate.

High-throughput analysis of genome-wide receptor tyrosine kinase expression in human cancers identifies potential novel drug targets.

Novel high-throughput analyses in molecular biology allow sensitive and rapid identification of disease-related genes and drug targets. We have used quantitative real-time reverse transcription-PCR reactions (n = 23000) to analyze expression of all human receptor tyrosine kinases (n = 56) in malignant tumors (n = 313) of different origins and normal control samples (n = 58). The different tumor types expressed very different numbers of receptor tyrosine kinases: whereas brain tumors and testicular cancer expressed 50 receptor tyrosine kinases, acute myeloid leukemia (AML) samples expressed only 20 different ones. Specimens of similar tumor origin exhibited characteristic receptor tyrosine kinase expression patterns and were grouped together in hierarchical cluster analyses. When we focused on specific tumor entities, receptor tyrosine kinases were identified that were disease and/or stage specific. Leukemic blasts from AML bone marrow samples differed significantly in receptor tyrosine kinase expression compared with normal bone marrow and purified CD34+ cells. Among the differentially expressed receptor tyrosine kinases, we found FLT3, c-kit, CSF1 receptor, EPHB6, leukocyte tyrosine kinase, and ptk7 to be highly overexpressed in AML samples. Whereas expression changes of some of these were associated with altered differentiation patterns (e.g., CSF1 receptor), others, such as FLT3, were genuinely overexpressed in leukemic blasts. These data and the associated database (http://medweb.uni-muenster.de/institute/meda/research/) provide a comprehensive view of receptor tyrosine kinase expression in human cancer. This information can assist in the definition of novel drug targets.

A phase II single-institution study of neoadjuvant stage IIIA/B chemotherapy and radiochemotherapy in non-small cell lung cancer.

BACKGROUND: The relevance of a trimodal strategy in the treatment of lung cancer, consisting of neoadjuvant radiochemotherapy followed by surgery, is a subject of ongoing clinical trials. We tested whether improvement of long-term survival can be achieved for patients with stage III non-small cell lung cancer by this therapeutic approach. METHODS: We performed a retrospective analysis of a single-institution phase II study. Of 33 patients enrolled in the protocol between 1992 and 1995, we reviewed the clinical outcomes of 26 patients with locally advanced non-small cell lung cancer (stage IIIA and IIIB), which had been resected after combined chemotherapy and radiochemotherapy. RESULTS: After neoadjuvant therapy, resection of the tumor was accomplished in all patients, and R0 resection was achieved in 92%. Histologic remission was found in 76% of these patients. Involvement of mediastinal lymph nodes was crucially important for the outcome. First, histologic clearance of the mediastinal compartment by neoadjuvant therapy resulted in a 27% 5-year survival rate. Second, patients with viable tumor in any of the mediastinal lymph nodes removed had a poor outcome (median survival 11.4 and 34.7 months in patients with and without viable tumor cells in the specimens, respectively; p = 0.01). CONCLUSIONS: Histopathologic regression after neoadjuvant multimodal therapy including chemotherapy and radiotherapy was an important prognostic factor in a selected group of patients with locally advanced lung cancer.

C-myc, not HER-2/neu, can predict recurrence and mortality of patients with node-negative breast cancer.

BACKGROUND: At present, node-negative, high-risk breast cancer patients cannot be identified with sufficient accuracy. Consequently, further strong prognostic factors are needed. METHODS: Among 181 node-negative breast cancer (NNBC) patients, c-myc and HER-2/neu oncogenes were identified prospectively using double differential PCR. The possible impact of amplification of those oncogenes on disease-free survival (DFS) and overall survival was examined. Furthermore, the possible effects of adjuvant therapies on rate of recurrence and mortality in oncogene-amplified NNBC patients were investigated. RESULTS: The prevalence rates for amplification of c-myc and HER-2/neu were 21.5% and 30.4%, respectively. On univariate analysis, c-myc-amplified NNBCs were associated with significantly shorter DFS at 36 months after the initial diagnosis (85.3% versus 97.3%). As compared with nonamplified cancers, HER-2/neu-amplified NNBCs did not exhibit any significant differences after 36 months and 95 months. Multivariate analysis indicated that c-myc amplification and tumour size, in contrast to HER-2/neu amplification, oestrogen receptor status, grading and age, were the only independent parameters for DFS. During the period of observation, we found no evidence for an impact of amplification of the oncogenes on overall survival in all cases. With respect to various adjuvant systemic therapies such as chemotherapy (cyclophosphamide, methotrexate, 5-fluorouracil; fluorouracil, epirubicin, cyclophosphamide) and endocrine therapy (tamoxifen), no significant differences were identified in oncogene-amplified NNBC patients in terms of DFS and overall survival. However, those c-myc-amplified NNBC patients who did not receive adjuvant systemic therapy exhibited significantly shorter DFS and overall survival as compared with c-myc-nonamplified patients. CONCLUSION: C-myc amplification appears to be a strong prognostic marker with which to predict early recurrence in NNBC patients. C-myc-amplified NNBC patients without adjuvant systemic therapy experienced shorter DFS and overall survival.

Cyclin A1 is highly expressed in aggressive testicular germ cell tumors.

Cyclin A1 is a tissue-specific A-type cyclin that is essential for spermatogenesis. Overexpression of cyclin A1 was found in acute myeloid leukemia and cyclin A1 induced leukemia in a transgenic mouse model. We used quantitative real-time reverse transcription-polymerase chain reaction to analyze cyclin A1 expression in solid tumors. Cyclin A1 expression was very low in breast cancer, non-small cell lung cancer and in cervical carcinoma. However, substantial expression of cyclin A1 was found in testicular and ovarian cancer and in endometrial cancer. In testis specimens, cyclin A1 expression was much higher in testicular tumors compared to Sertoli cell only syndrome that lacks spermatogenesis. Compared to normal spermatogenesis, testicular cancers expressed on average lower levels of cyclin A1. Among the different histological subtypes of testicular tumors, embryonal cell carcinomas and immature teratomas expressed the highest levels of cyclin A1. The cyclin A1 levels in these tumors were similar to those seen in normal testis. Seminomas and yolk sac tumors expressed intermediate levels, whereas cyclin A1 expression was very low in mature teratomas. These findings indicate that cyclin A1 is expressed in selected solid tumors. Its known oncogenic function and the high expression levels in aggressive testicular tumors suggest a role for cyclin A1 in germ cell tumorigenesis.