conferred by adjuvant chemotherapy or endocrine therapy was examined in randomized studies [2,3,8,9,35–38].
Because adjuvant therapies may positively impact on outcome in only around 15%, the costs of these therapies make their routine application in all NNBC patients inap- propriate . For this reason, predictive factors that accu- rately define subgroups of NNBC patients who may benefit from adjuvant systemic therapy would be a great advantage.
2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is cited.
Introduction Focal adhesion kinase (FAK) regulates multiple cellular processes including growth, differentiation, adhesion, motility and apoptosis. In breast carcinoma, FAK overexpression has been linked to cancer progression but the prognostic relevance remains unknown. In particular, with regard to lymph node-negativebreastcancer it is important to identify high-risk patients who would benefit from further adjuvant therapy.
was associated with Comedo carcinoma variant. 3-5 Later in subsequent studies HER-2/neu protein expression associated with breast cancers has been confirmed., further evaluation of this receptor appear warranted to confirm whether this marker can be clinically useful in stratifying patients into low risk groups, which may be followed conservatively, and high risk groups that may require extensive post biopsy surgical procedures to prevent recurrence and to rule out invasive disease with an aggressive phenotype. 6-7 HER-2 /neu gene expression has generally not been specifically implicated in progression or prognosis assessment of lobular carcinoma of breast, but it is strongly associated with increased disease recurrence and a poor prognosis. 8 Over expression is also known to occur in ovarian, stomach, and aggressive forms of uterine cancer. 9 Multiple studies reported a significant co-relation of serum HER-2/neu protein levels with recurrence, metastasis or shortened survival. It also predicts the resistance of breastcancer to chemotherapy and absence of clinical response to hormonal therapy even when estrogen assays are positive. 10 Hence it is concluded that HER-2/neu amplification is an independent predictor of shorter disease with free survival in both nodenegativenode and positive note patients. 11
We used a multistep approach to develop an as- say of the expression of tumor-related genes for use with routinely prepared tumor blocks and to val- idate the assay clinically. First, a high-throughput, real-time, reverse-transcriptase–polymerase-chain- reaction (RT-PCR) method was developed to quanti- fy gene expression with the use of sections of fixed, paraffin-embedded tumor tissue. 22 Second, we se- lected 250 candidate genes from the published lit- erature, genomic databases, and experiments based on DNA arrays performed on fresh-frozen tis- sue. 17-19,23 Third, we analyzed data from three inde- pendent clinical studies of breastcancer involving a total of 447 patients, including the tamoxifen-only group of NSABP trial B-20, to test the relation be- tween expression of the 250 candidate genes and the recurrence of breastcancer. 24-26 Fourth, we used the results of the three studies to select a panel of 16 cancer-related genes and 5 reference genes and de- signed an algorithm, based on the levels of expres- sion of these genes, to compute a recurrence score for each tumor sample. The study reported here was performed to validate the ability of the prospective-
Before the decision by the FDA to clear the serum HER-2/
neu test with a standardized cutpoint of 15 ng/ml, many reports used different research assays with various, uncharacterized antibody specificities, calibrators, and cutoff values to measure circulating HER-2/neu level. For instance, in a previous review  it was shown that there were 21 references to the Triton-Ciba-Chiron HER-2/neu assay but 11 different cutoffs, ranging from 5 to 30 units/ml or from 120 or 450 fmol/ml. We found five references to the Nicherei assay, three references to the Calbiochem or the Oncogene Research Products assay, three references to the Dianova assay, and two references to the Bender assay. We could not find any references that described antibody specificities or standardization of these assays, and neither were the findings compared with standardized results. All of the assays mentioned above were available for research use only, which means that the performance characteristics of the assay had not been determined. Unlike FDA-cleared in vitro diagnostic products, there are no manufacturing guidelines for research use only products, which often results in inconsistent findings.
These apparent discrepancies have largely prevented the widespread acceptance of HER-2/neu as a prognostic fac- tor in node-negativebreastcancer up to now .
Several possible reasons could account for these contro- versial findings. One frequently quoted, simple but none- theless unsatisfactory reason could be the rather small sample size of several studies. However, a strong and bio- logically relevant prognostic factor should eventually become evident even within a small sample size. Another possible reason is the remarkable discrepancy in sensitivity between the numerous antibodies used  and differ- ences in tissue fixation and processing . However, per- haps the most important reason is the lack of a standardised evaluation protocol in many of the older stud- ies. The standardisation of IHC has become increasingly important since the successful use of trastuzumab (Her- ceptin™) in the treatment of HER-2/neu-overexpressing metastatic breastcancer [17,20,38]. The United States Food and Drug Administration has approved a standard-
Previous studies in Western countries show that TN breastcancer has aggressive clinical and pathologic features, including onset at a young age, advanced stage at diagnosis, high histopathologic and nuclear grade, high mitotic index, higher frequency of unfavorable histopathology, and more distant recurrence. 8–11 In addition, evidence indicates that the prevalence and clinical outcomes of TN breastcancer dif- fer among races. 11 Bauer et al 8 have reported that TN breastcancer is more prevalent among non-Hispanic black women compared with other ethnic groups, who when affected with this subtype had the worst survival. Carey et al 11 also reported that basal-like breast tumors occurred at a higher prevalence among African American women compared with other racial groups. However, there are limited studies of the prevalence, characteristics, and prognosis of TN breastcancer in Asian populations. A recent study of Korean patients indicated that the basal-like subtype, which is positive for one or more of the basal markers and negative for HRs and HER-2/neu, was not associated with a poor prognosis. This study also showed that the survival rate associated with the basal-like subtype does not differ from that of other subtypes, with the exception of the HER2/neu-overexpressing subtype, which has the worst survival rate. 12 In contrast, a recent study of breastcancerpatients receiving neoadjuvant chemotherapy showed that TN breastcancer was associated with shorter survival than other subtypes, even though it was associated with a higher response rate. 13
nuclear staining along with cytosolic staining for IFN-g Ra in their tumors.
If HER-2/neu-specific IFN-g producing T cells are involved in HER-2/neu loss and tumor recurrence, we might be able to detect such immune responses in patients with HER-2/neunegativebreastcancer, who might have had undetectable HER-2/neu positive pre- malignant tumors in the past, that had lost HER-2/neu expression and progressed to invasive carcinoma under the immune pressure. The fact that 55-75% of patients with premalignant DCIS overexpress HER-2/neu in their tumor lesions and 75% of breast cancers are HER-2/neunegative would suggest the progression of HER-2/neu positive DCIS to HER-2/neunegativebreastcancer is only in the tumor clones that express IFN-g Ra. We have already shown that T cell-mediated tumor antigen loss was due to hypermethylation of the neu promoter and loss of neu both at mRNA and protein levels [3,5].
neu protein, such as the tyrosine kinase inhibitor lapatinib, which appears to have clinical activity after failure of tras- tuzumab therapy. 24
Tumors, including metastatic lesions, shed large numbers of tumor cells into the blood circulation, and the presence of circulating tumor cells is of biologic relevance in the metastatic setting. Based on the hypothesis that the pheno- type of circulating tumor cells may reflect the phenotype of metastatic disease, characterization of circulating tumor cells may be useful for reassessment of HER-2/neu status and additional therapeutic cancer biomarkers. However, this option is limited to those patients with detectable circulating tumor cells. Reported positivity rates for circulating tumor cells in metastatic breastcancerpatients range from 20%
The HER-2/neu (also known as ERBB2) proto-oncogene, which encodes a trans- membrane growth factor receptor with tyrosine kinase activity, has become an important subject for human cancer re- search during the last decade. The impact of HER-2 amplification and expression on prognosis (1–12) and on the response to cytotoxic (4,13–18) and hormonal (15,19–22) therapies in breastcancerpatients have been studied intensively. Studies of HER-2 represent a paradigm of how genetic findings have led to the development of a gene-specific therapy: In September 1998, the U.S. Food and Drug Administration approved trastuzamab (Herceptin), a recombinant monoclonal antibody targeting Her-2, for the treat- ment of metastatic breastcancer. Al- though trastuzumab binds to the Her-2 receptor with high affinity, the mecha- nism of action by which it causes tumor reduction is not understood. Despite the theoretic benefits of such a targeted treat- ment, not all patients respond favorably to trastuzamab treatment in practice. Among the patients with HER-2-positive meta- static breastcancer that is resistant to con- ventional cytotoxic treatment, only about 25% benefit from trastuzamab given in combination with cisplatin (23). The ge- netic features that distinguish the HER-2- positive breast cancers that respond to trastuzamab from those that do not remain unclear. However, it is possible that the extent of HER-2 amplification and/or overexpression in the primary tumor dif- fers from that in the metastases. The HER-2 status of the primary tumor, which is removed from the patient, determines whether or not trastuzamab treatment is prescribed. But trastuzamab works by tar- geting the metastases that remain in the patient. If at least some of the multiple metastases of an HER-2-positive primary breast tumor did not express HER-2, trastuzamab treatment would most likely not affect the course of the disease. A comprehensive, large-scale study compar- ing HER-2 gene copy numbers and pro- tein expression in primary tumors and in multiple different metastases derived from them has not been performed. To gain insight into the patterns of HER-2
Received for publication November 10, 2000, and accepted in revised form January 3, 2001.
CD4 T-cell help is required during the generation and maintenance of effective antitumor CD8 T cell–mediated immunity. The goal of this study was to determine whether HER-2/neu–specific CD8 T-cell immunity could be elicited using HER-2/neu–derived MHC class II “helper” peptides, which contain encompassed HLA-A2–binding motifs. Nineteen HLA-A2 patients with HER-2/neu–overex- pressing cancers received a vaccine preparation consisting of putative HER-2/neu helper peptides p369–384, p688–703, and p971–984. Contained within these sequences are the HLA-A2–binding motifs p369–377, p689–697, and p971–979. After vaccination, the mean peptide-specific T-cell pre- cursor frequency to the HLA-A2 peptides increased in the majority of patients. In addition, the pep- tide-specific T cells were able to lyse tumors. The responses were long-lived and detectable for more than 1 year after the final vaccination in select patients. These results demonstrate that HER-2/neu MHC class II epitopes containing encompassed MHC class I epitopes are able to induce long-lasting HER-2–specific IFN-γ–producing CD8 T cells.
In conclusion, the positive expression of these biomar- kers is associated with biologically aggressive tumors and poor prognostic profile. Although the samples were taken from an area where the exposure to depleted ura- nium is a risk, the incidence of co-expression of both p53 and HER-2/neu markers does not differ from simi- lar cancer samples in areas that have not been exposed to depleted uranium, though, the greater immunoex- pression of Her-2/neu in breastcancer in this popula- tion with risk for DU exposure, compared with findings on other populations not at risk, requires further inves- tigation as it may reflect the possible role of DU in the induction or acceleration of network signaling between different Her-2 receptors. New lines of treatment which includes genetic modulation of the signaling pathway of both genes should be considered in patients’ medical follow up. Unfortunately for DU, knowledge of the exposure time, dose absorbed, route, length of exposure and its health consequences on the Iraqi population is still lacking. This is chiefly due to restricted access of scientists required to conduct such study and should form the basis for future investigations.
Using chi-square test for heterogeneity (for categorical variables) and Fisher exact t-test (for continuous variables), we compared patient and tumor characteristics and treatment. We compared cardiovascular, breastcancer- specific, and overall mortality between patients with left- versus right-sided breastcancer and with inner-quadrant versus outer-quadrant breastcancer by log-rank tests and by Cox regressions. To evaluate the independent effect of breastcancer laterality, we adjusted mortality risk for variables associated to laterality and cardiovascular disease, breastcancer-specific or overall mortality, respectively. To asses the effect of breast quadrants on mortality risks, we adjusted for factors associated to breast quadrants, cardiovascular disease, breastcancer-specific or overall mortality, respectively. As ER status and tamoxifen use were highly correlated, we adjusted only for ER status. In order to examine if the effect of irradiation linked to quadrant on cardiovascular mortality differed across age group, type of surgery, use of chemotherapy, use of hormonal therapy, and laterality, we carried out interaction tests. Interaction terms involved quadrant (inner, outer) and age group (<50, ‡50), surgery (breast-conserving surgery, mastectomy), chemotherapy (yes, no), hormonal therapy (yes, no), or laterality (left, right). We also carried out separate analyses to assess the differences in the use of internal mammary lymph node chain irradiation and in the dose of the boost. We considered the following three categories: high level of IMC irradiation and low boost dose (1980–1987), high-level IMC and high boost dose (1988–1990), and low IMC and high boost dose (1991–2004).
Background: Bladder cancer is one of the commonest malignancies with high morbidity and mortality rates. Human Epidermal Growth Factor Receptor -2 (Her-2/Neu) seems to play role in the pathogenesis and prognosis of bladder carcinomas; However it is expression and prognostic significance were variable between different studies.
our diverse cohorts, including in the chemotherapy arms of our institutional samples and IBCSG trial samples.
In summary, our ﬁ nding of a repeated association between methylation patterns and long-term outcome suggest that further exploration of their potential to better risk-stratify patients in well- characterized TNBC datasets may be warranted. We have identi ﬁ ed patterns of methylation that are associated with prognosis among patients with TNBC, although they are at present not predictive of response to local-regional or systemic therapy. While these ﬁ ndings cannot be exploited to improve clinical decision making today, our results, and the underlying data, collected on an increasingly rare group of TNBC patients treated with locoregional therapy alone, are a valuable contribu- tion to ongoing research on the development, progression and ultimate treatment of TNBC.
Significant differences were found in vascular invasion, grade and molecular subtype between the two groups.
Expression of ER and PR in the ‘poor group’ was lower (P < 0.05). However, positive rates of Ki67, p53 and VEGF in the ‘poor group’ were higher (P < 0.05). Multivariate analysis revealed that molecular subtype, expression of VEGF, tumor grade, and vascular invasion were closely correlated with bad outcome. Analysis of the ‘poor group’ demon- strated that ‘HER2 positive’ and ‘triple negative’ subtypes more commonly suffered from distant metastases and death. No metastasis was found in patients with pure invasive papillary carcinoma, invasive cribriform carcinoma or adenoid cystic carcinoma, whereas the diagnoses of invasive micropapillary carcinoma, invasive apocrine carci- noma, invasive papillary carcinoma mixed with invasive ductal carcinoma, or metaplastic carcinoma were correlated with distant metastasis and death. In conclusion, molecular subtype and expression of VEGF are useful markers for predicting prognosis of ANN breastcancerpatients. ‘Luminal A-like’ subtype has better outcome than others.
currently not mature enough to report and will also reflect the predictive value of different treatment modalities in different receptor subgroups. Another potential weakness of our report may be that we based the ALN status on results from a mixture of complete axillary node dissection and sentinel lymph node procedure. However, it has previously been shown that predictors for ALN status are independent of how the lymph node resection was performed although the metastatic detection rate in lymph nodes may be higher using the sentinel node procedure as more thorough histo- logic examination of the sentinel lymph node results in a higher number of metastases detected . Another weak- ness may be that we did not consider other predictors for ALN status as tumour localisation within the breast, tumour vascularisation, lymphangiogenesis, protein and genetic markers for ALN involvement . Another important information which is missing is whether triple positive breast cancers, apart from being more likely lymph node positive, also involved a higher number of lymph nodes as compared to breast cancers with a non-triple positive phe- notype. Such information may strengthen our findings. A strength of our study is that cases were unselected and consecutively treated in one centre. Also, analyses for ER, PR and HER-2 were confirmed by one pathologist. Suc- cessful quality control and quality assurance programs were guaranteed in our laboratory according to requested guidelines. Another strength of our study is that we defined HER-2 + on the base of membrane staining when they either had a DAKO score 3 + or 2 + with a positive FISH test.
Only the 1% of patients with ipsilateral axillary recur- rence after rSLNB could have had a possible benefit from ALND. The other seven (3.5%) regional recurrences were found outside the ipsilateral axilla. These aberrant sites of recurrence were in concordance with the site of the har- vested rSLNB in three cases. For these patients, the histologic outcome of rSLNB was possibly false negative. In four other patients, the regional recurrence was not concordant with the location of the rSLNB. One explana- tion could be that rSLNB in IBTR is a technically challenging procedure. As published before, injection with a larger amount of tracer leads to a higher identification rate. 32 In this study, patients with regional recurrence had a significantly lower amount of tracer injected. Injection of a higher tracer dose might have led to identification of repeat sentinel lymph nodes in additional basins. It could also be hypothesized that lymph drainage of the IBTR might have been multidirectional, and the rSLNB identified only one basin.
In early breastcancerpatients with negative SLN, no further ALND is recommended. In the case of sentinel node metastasis, most clinical practice guidelines recommend complete ALND. Although additional ALN involvement was found in 35%–60% of positive SLN patients, the axillary recurrence rate is reported to be 0.2%–0.9% for micrometastatic disease of SLN and around 1% for macrometastatic disease [9,12-15]. Based on these results, the hypothesis that ALN metastatic disease does not cause regional recurrence has been accepted. Therefore, several randomized phase 3 trials have been performed to investigate whether ALND can safely be omitted in early breastcancerpatients with positive SLN. In the American College of Surgeons Oncology Group Z0011 trial, clinically node-negative early breastcancerpatients with positive SLN were randomized to ALND or no ALND groups. At the median follow-up of 6.3 years, no difference was observed between groups for OS, progression-free survival (PFS) or locoregional PFS. The International BreastCancer Study Group trial 23-01 trial was designed to determine whether no ALND was inferior to ALND in patients with one or more micrometastatic SLN with a tumor of maximum 5 cm. After a median follow-up of 5 years, no difference was found between the ALND and no ALND groups for OS or PFS. In both trials, axillary recurrence in the no ALND group was about 1%. In the AMAROS trial, ALND and axillary radiotherapy were compared. After a follow-up of 5 years, axillary radiotherapy was equivalent to ALND in OS, PFS, and axillary recurrence [7,9,16].
Our study documents the practice patterns of chemo- therapy use in this select population of breastcancerpatients, and highlights the importance of the Oncotype DX Recurrence Score in influencing treatment recom- mendations. Individualized medicine involves separating patients into specific subsets using scientific knowledge to identify meaningful parameters. The establishment of the Low, Intermediate, and High Risk groups by the Oncotype DX score is an important step in this direction. These types of tests provide more clarity for patients and health- care providers, reduce overtreatment, and potentially re- duce healthcare costs. The application of the Recurrence Score has been modeled to be an economically advanta- geous clinical tool, possibly saving over $1000 per patient [11, 24]. Further partitioning of Low, Intermediate, and High Risk groups of patients will optimize therapy for each individual.