Abnormal T regulatory cells (Tregs: FOXP3+, CTLA-4+), myeloid-derived suppressor cells (MDSCs: monocytic, granulocytic) and polarised T helper cell profiles (Th1, Th2, Th17) in women with large and locally advanced breast cancers undergoing neoadjuvant chemotherapy (NAC) and surgery: failure of abolition of abnormal treg profile with treatment and correlation of treg levels with pathological response to NAC.

BACKGROUND: Host defences play a key role in tumour growth. Some of the benefits of chemotherapy may occur through modulation of these defences. The aim of this study was to define the status of regulatory cells in women with large and locally advanced breast cancers (LLABCs) undergoing neoadjuvant chemotherapy (NAC) and surgery. METHODS: Bloods were collected from patients (n=56) before, during and following NAC, and surgery. Controls (n=10) were healthy, age-matched females donors (HFDs). Blood mononuclear cells (BMCs) were isolated and T regulatory cells (Tregs) (n=31) determined. Absolute numbers (AbNs) of Tregs and myeloid-derived suppressor cells (MDSCs) were ascertained from whole blood (n=25). Reverse transcriptase polymerase chain reaction analysis determined Treg mRNA (n=16). In vitro production of Th1, Th2 and Th17 cytokines (n=30), was documented. Patients were classified as clinical responders by magnetic resonance mammography after two cycles of NAC and as pathological responders using established criteria, following surgery. RESULTS: Patients with LLABCs had significantly increased circulating Tregs (≥ 6 fold AbN and percentage (%)) and MDSCs (≥ 1.5 fold AbN (p=0.025)). Percentage of FOXP3+ Tregs in blood predicted the response of the LLABCs to subsequent NAC (p=0.04). Post NAC blood Tregs (%) were significantly reduced in patients where tumours showed a good pathological response to NAC (p=0.05). Blood MDSCs (granulocytic, monocytic) were significantly reduced in all patients, irrespective of the pathological tumour response to chemotherapy. NAC followed by surgery failed to restore blood Tregs to normal levels. MDSCs, however, were reduced to or below normal levels by NAC alone. Invitro Th1 profile (IL-1ß, IL-2, INF-γ, TNF-α) was significantly reduced (p ≤ 0.009), whilst Th2 (IL-4, IL-5) was significantly enhanced (P ≤ 0.004). Th1 and Th2 (IL-5) were unaffected by NAC and surgery. IL-17A was significantly increased (p ≤ 0.023) but unaffected by chemotherapy and surgery. CONCLUSION: Women with LLABCs have abnormal blood regulatory cell levels (Tregs and MDSCs) and cytokine profiles (Th1, Th2, Th17). NAC followed by surgery failed to abolish the abnormal Treg and Th profiles. There was a significant correlation between the circulatory levels of Tregs and the pathological response of the breast cancers to NAC.

Effects on quality of life, anti-cancer responses, breast conserving surgery and survival with neoadjuvant docetaxel: a randomised study of sequential weekly versus three-weekly docetaxel following neoadjuvant doxorubicin and cyclophosphamide in women with primary breast cancer.

BACKGROUND: Weekly docetaxel has occasionally been used in the neoadjuvant to downstage breast cancer to reduce toxicity and possibly enhance quality of life. However, no studies have compared the standard three weekly regimen to the weekly regimen in terms of quality of life. The primary aim of our study was to compare the effects on QoL of weekly versus 3-weekly sequential neoadjuvant docetaxel. Secondary aims were to determine the clinical and pathological responses, incidence of Breast Conserving Surgery (BCS), Disease Free Survival (DFS) and Overall Survival (OS). METHODS: Eighty-nine patients receiving four cycles of doxorubicin and cyclophosphamide were randomised to receive twelve cycles of weekly docetaxel (33 mg/m2) or four cycles of 3-weekly docetaxel (100 mg/m2). The Functional Assessment of Cancer Therapy-Breast and psychosocial questionnaires were completed. RESULTS: At a median follow-up of 71.5 months, there was no difference in the Trial Outcome Index scores between treatment groups. During weekly docetaxel, patients experienced less constipation, nail problems, neuropathy, tiredness, distress, depressed mood, and unhappiness. There were no differences in overall clinical response (93% vs. 90%), pathological complete response (20% vs. 27%), and breast-conserving surgery (BCS) rates (49% vs. 42%). Disease-free survival and overall survival were similar between treatment groups. CONCLUSIONS: Weekly docetaxel is well-tolerated and has less distressing side-effects, without compromising therapeutic responses, Breast Conserving Surgery (BCS) or survival outcomes in the neoadjuvant setting. TRIAL REGISTRATION: ISRCTN: ISRCTN09184069.

Ex vivo recovery and activation of dysfunctional, anergic, monocyte-derived dendritic cells from patients with operable breast cancer: critical role of IFN-alpha.

BACKGROUND: Dendritic cells (DCs) play a crucial role in initiating effective cell-mediated immune responses, but are dysfunctional and anergic in breast cancer. Reversal of this dysfunction and establishment of optimal DC function is a key prerequisite for the induction of effective anti-cancer immune responses. RESULTS: Peripheral blood DCs (PBDCs) and lymph node DCs (LNDCs) generated in vitro from adherent cultures of peripheral blood monocytes (PBMs) and lymph node monocytes (LNMs), respectively, using the 4 cytokine conditioned medium (CCM) (GM-CSF+IL-4+TNF-alpha+IFN-alpha) or 3 CCM (GM-CSF+IL-4+TNF-alpha) demonstrated a significantly higher degree of recovery and functional capacity in a mixed lymphocyte DC reaction (MLDCR, p < 0.001), expressed significantly higher levels of HLA-DR, CD86, compared with 2 CCM (GM-CSF+IL-4) or medium alone generated DCs from PBMs and LNMs (p < 0.001). The PBDCs generated with 3 CCM or 4 CCM showed a significantly (p < 0.001) enhanced macropinocytotic capability (dextran particles) and induced increased production and secretion of interleukin-12p40 (IL-12p40) in vitro (p < 0.001), compared with PBDCs generated from monocytes using 2 CCM or medium alone. Lipopolysaccharide (LPS) stimulation of PBDCs generated with 4 CCM demonstrated enhanced secretion of IL-6 but not IL-12p70, compared with control DCs unstimulated with LPS (p < 0.001). CONCLUSION: Dysfunctional and anergic PBDCs and LNDCs from patients with operable breast cancer can be optimally reversed by ex vivo culturing of precursor adherent monocytes using a 4 CCM containing IFN-alpha. Maximal immunophenotypic recovery and functional reactivation of DCs is seen in the presence of IFN-alpha. However, 4 CCM containing IFN-alpha generated-PBDCs, do not produce and secrete IL-12p70 in vitro.

18F-FDG dual-headed gamma camera PET in detection of axillary nodal disease in patients with large or locally advanced breast cancer: possible alternative staging of axilla.

Positron emission tomography (PET) has been used in staging the axilla. Gamma Camera PET (GCPET) is a cost effective alternative, but poorly studied. The aim of this study was to assess GCPET in demonstrating metastatic deposits in axillary nodes in patients with a high likelihood of nodal disease. Twenty-seven women with large (T2, T3 or T4) or advanced breast cancer (N1, N2 or M1) were recruited. All patients underwent axillary lymph node removal or biopsy (fine needle aspiration cytology (FNAC) or core cut) and whole body GCPET imaging. Images were reported anonymously and compared with the histological findings. Twenty-one patients proceeded to surgery and 10 had tumour-involved axillary nodes; GCPET was positive in 8 of these. The remaining 6 patients underwent core cut or FNAC of the axillary nodes, 2 of which contained a tumour. GCPET was positive in both cases. Thus, the diagnostic values were: sensitivity 83%, specificity 100%, positive predictive value 100%, negative predictive value 88% and accuracy 93%. In conclusion, GCPET is a reliable method and can be performed in a district general hospital and detecting disease in axillary nodes in certain patients, possibly obviating the need for surgery.

A comparison of 18F-FDG gamma camera PET, mammography and ultrasonography in demonstrating primary disease in locally advanced breast cancer.

BACKGROUND: Positron emission tomography (PET) imaging using [18F]fluorodeoxyglucose (18F-FDG) is recognized to have a major role in oncological imaging. Over recent years there has been a steady increase in the use of gamma camera PET (GCPET) systems as these are less expensive than dedicated PET scanners and facilitate the full range of nuclear medicine imaging. However, there is ongoing debate about their application and usefulness in the management of oncological patients. OBJECTIVES: To assess the feasibility of GCPET in a nuclear medicine department in a district general hospital remote from a cyclotron, compared with other imaging modalities in demonstrating disease in patients with large or locally advanced breast cancer. METHODS: 18F-FDG was transported by road from a production unit 100 miles from the imaging department. Twenty-five patients (mean age 68 years) with primary breast tumours measuring > or =20 mm on clinical examination were studied. All patients underwent triple assessment prior to PET imaging with an ADAC Solus camera with molecular coincidence detection capability. Histopathology was obtained in 20 cases following surgery. RESULTS: GCPET detected 24/25 primary breast tumours (sensitivity 96%). This compared with 22/25 (88%) for ultrasound and 15/25 (60%) for mammography. The lesion missed by PET was a grade 1 tumour, 8 mm in size. CONCLUSION: In this pilot study GCPET has been shown to be feasible in a district general hospital, enabling a limited on-site PET imaging service to be provided. In the cases studied it was more sensitive than mammography or ultrasonography. GCPET may provide additional information that could be important in planning the management of some patients with breast cancer.

Dendritic cells are dysfunctional in patients with operable breast cancer.

BACKGROUND: Dendritic cells (DCs) play a crucial role in presenting antigens to T lymphocytes and inducing cytotoxic T cells. DCs have been studied in patients with breast cancer to define the factors leading to failure of an effective systemic and locoregional anticancer host response. METHODS: Purified DCs were obtained from peripheral blood (PB) and lymph nodes (LNs) of women with operable breast cancer, using immunomagnetic bead selection. The stimulatory capacity of DCs in the allogeneic mixed leukocyte reaction (MLR) and autologous T cell proliferation test (purified protein derivative (PPD) as stimulator), the expression of surface markers on DCs and the production of cytokines in vitro by DCs from patients with operable breast cancer and from healthy donors (controls) were studied. RESULTS: 70-75% purified DCs were isolated from PB and LNs. PBDCs and LNDCs from patients with operable breast cancer demonstrated a reduced capacity to stimulate in an MLR, compared with PBDCs from normal donors (p<0.01). Autologous T cell proliferation in patients had a decreased ability to respond to PPD, when compared with controls (p<0.01). However, T cells from patients responded as well as control T lymphocytes in the presence of control DCs. PBDCs and LNDCs from patients expressed low levels of HLA-DR and CD86, and induced decreased interleukin-12 (IL-12) secretion in vitro, compared with DCs from normal donors (p<0.01). CONCLUSION: These data suggest a defective DC function in patients with operable breast cancer. Switched-off DCs in patients with early breast cancer and decreased IL-12 production may be important factors for progressive tumour growth.