Impact of chemotherapy followed by aromatase inhibitors on bone health of women with ER-positive early breast cancer in real world clinical settings in Greece: Results of the POCHARBI trial conducted by the Hellenic Society of Breast Surgeons.

INTRODUCTION: The aim of this observational study was to assess the combined impact of chemotherapy (CT) and aromatase inhibitors (AI) therapy on bone mineral density (BMD) in postmenopausal women with estrogen receptor (ER)-positive early breast cancer. METHODS: Patients were treated with a third generation AI, either as adjuvant therapy (HT cohort, n = 166) or as subsequent endocrine therapy after initial treatment with chemotherapy (CT cohort, n = 124), and were followed up for a 12-month period. BMD was evaluated at lumbar spine (LS) and total hip (HP) before CT, before AI therapy and after 12 months of AI therapy. The primary study objective was changes in LS BMD between pre CT treatment and post 12 months AI therapy in the CT cohort. RESULTS: There were no statistically significant changes in LS BMD, either within CT or HT cohort. In the CT cohort, the mean LS BMD change was -0.72% (95% CI: -2.97%, +1.53%, p = 0.5526) between CT start and month 12 of AI therapy, while it was -0.19% (95% CI: -2.12%, +1.74%, p = 0.8309) and -0.59% (95% CI: -3.18%, +2.00%, p = 0.4759) between CT start and AI start and AI start and month 12 of AI therapy respectively. The mean change in LS BMD in the HT cohort (i.e. after 12 months of AI treatment) was +1.51% (95% CI: -0.96%, +3.98%, p = 0.7420). CONCLUSIONS: The results of this study indicate that, under routine clinical practice, most postmenopausal patients who receive CT before AI therapy do not experience debilitating BMD consequences during the first year of AI treatment. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01298362.

Clinical experience of using Oncotype DX as an additional treatment decision tool in early breast cancer - a retrospective analysis from 5 Greek institutions.

AIMS: The objective of this retrospective study was to describe the results from five institutions' experience of using Oncotype DX(®) to identify patients who need chemotherapy despite the presence of primarily favorable characteristics. PATIENTS AND METHODS: Oncotype DX was performed in 106 pre- and postmenopausal patients with estrogen receptor-positive, HER2-negative, early breast cancer with a combination of favorable prognostic factors or favorable prognostic factors with at least one unfavorable characteristic (tumor size >2 cm, tumor grading of II-III, Ki-67 ≥ 10%, presence of lymph node micrometastases) in which it was unclear whether hormonal therapy only or chemotherapy plus hormonal therapy was the optimal adjuvant treatment. RESULTS: Sixty-four (60.4%) women had Recurrence Score (RS) values <18, 29 (27.4%) intermediate RS values of 18-30, and 13 (12.3%) high RS values of ≥31. Tumor size, grading and presence of micrometastases were not associated with the RS. There was a significant association between Recurrence Score and the number of unfavorable characteristics as a categorical but not as a continuous variable. High Recurrence Scores were predictive of high Ki-67 but the converse was not true. Overall, 29 of 106 (27.4%) patients received chemotherapy because of an intermediate or a high Recurrence Score. CONCLUSION: The Recurrence Score helped in treatment decision-making for estrogen receptor-positive, HER2-negative patients with favorable characteristics or an intermediate risk of recurrence due to the presence of at least one unfavorable factor. The results of the 21-gene assay increased the likelihood for patients with intermediate clinical and histopathological risk factors receiving chemotherapy.

New views on treatment of aromatase inhibitors induced arthralgia.

BACKGROUND: Aromatase Inhibitor (AI) induced arthralgia is one of the most frequent side effects in breast cancer hormonal therapy, which may become severe in some cases affecting patients' quality of life. The purpose of this study is to investigate alternative treatment of arthralgia, as current treatment options may often prove to be inadequate. MATERIAL-METHODS: According to Morales et al, AI-associated arthralgia syndrome is characterized by tenosynovial changes in MRI, including fluid in tendon sheaths and joints. Initially, furosemide (20 mg per two days) was prescribed by our team, in order to minimize peripheral edema in women receiving aromatase inhibitors. The data collected demonstrated that 16 out of 18 patients had benefited from the addition of a diuretic agent in their adjuvant AI treatment as far as AI induced arthralgia is concerned as well. In this retrospective study, data from 288 women receiving an AI for non-metastatic breast cancer are analyzed in order to define whether chronic diuretic therapy could affect the impact of arthralgia on those patients. RESULTS: 42/288 Patients were receiving chronic diuretic therapy for heart disease or hypertension (Group A), while 246/288 patients had never received any diuretic medication (Group B). At 43.03 months of mean follow up, in Group A arthralgia was developed in 3/42 patients (6.97%) as opposed to 39/246 patients in Group B (15.85%) -p value: 0.01. Other parameters that could affect the impact of arthralgia in both Groups are also analyzed and taken under consideration. CONCLUSION: Despite the low number of patients and the retrospective nature of the study, there was a clear trend to a lower incidence of arthralgia in patients receiving chronic diuretic therapy. We believe that based on this hypothesis generating study further research should be done to assess the value of diuretic agents in the treatment of AI-associated arthralgia.

Intermediates of unsaturated fatty acid oxidation are incorporated in triglycerides but not in phospholipids in tissues from patients with mitochondrial beta-oxidation defects.

The fatty acid composition was determined of liver, skeletal muscle and heart obtained post mortem from patients with medium-chain acyl-CoA dehydrogenase deficiency (MCADD), multiple acyl-CoA dehydrogenase deficiency (MADD) and very long-chain acyl-CoA dehydrogenase deficiency (VLCADD). Increased amounts of 4-decenoic acid 10:1(n-6), 5-dodecenoic acid 12:1(n-7), 5-tetradecenoic acid 14:1(n-9), 5,8-tetradecadienoic acid 14:2(n-6) and 7,10-hexadecadienoic acid 16:2(n-6)--intermediates of unsaturated fatty acid oxidation--were found. Fractionation into different lipid classes showed that these fatty acids were exclusively present in the triglyceride fraction. They could not be detected in the free fatty acid fraction or in the phospholipid fraction. Our results suggest that intermediates of unsaturated fatty acid oxidation that accumulate as a consequence of MCADD, MADD and VLCADD are transported to the endoplasmic reticulum for esterification into neutral glycerolipids. The pattern of accumulation is characteristic for each disease, which makes fatty acid analysis of total lipid of post-mortem tissues a useful tool in the detection of mitochondrial fatty acid oxidation defects in patients who died unexpected, for example with sudden infant death syndrome.

Serum soluble vascular cell adhesion molecule-1: role as a surrogate marker of angiogenesis.

BACKGROUND: Angiogenesis, the development of new blood vessels from pre-existing vasculature, is a prerequisite for tumor growth and metastasis. Surrogate markers for angiogenesis would be useful for studying the effectiveness of antiangiogenesis drugs. We examined the potential of three serum glycoproteins-vascular cell adhesion molecule-1 (VCAM-1), endothelial selectin (E-selectin), and von Willebrand factor (VWF)-to serve as markers for angiogenesis. METHODS: Preoperative serum levels of VCAM-1, E-selectin, and VWF were measured by enzyme-linked immunosorbent assay in 93 women with early breast cancer and were compared with microvessel density in each tumor, histologic features, and recurrence after surgery. Serum samples were taken from 55 women with advanced breast cancer who were commencing hormonal therapy, both immediately before therapy and 3 months later. Changes in serum levels of VCAM-1, E-selectin, and VWF were compared with the response of the disease to hormonal therapy assessed 6 months after the start of hormone therapy or at disease progression. All P: values are two-sided. RESULTS: In women with early breast cancer, serum levels of VCAM-1 (but not of E-selectin or VWF) correlated closely with microvessel density in tumors (r =.65; P:<.001), and women who developed early recurrence had higher preoperative levels of serum VCAM-1 than those who remained disease free (P: =.01). Serum VCAM-1 levels rose in women with advanced breast cancer whose disease progressed (P:<.001) but remained unchanged or fell in women with advanced breast cancer whose disease remained stable or showed a partial response to hormonal therapy. CONCLUSION: Serum VCAM-1 appears to be a surrogate marker of angiogenesis in breast cancer. Its measurement may, therefore, help in the assessment of antiangiogenesis drugs currently in phase II trials.

Identification and quantification of intermediates of unsaturated fatty acid metabolism in plasma of patients with fatty acid oxidation disorders.

The free fatty acid and total fatty acid profiles in plasma of nine patients with medium-chain acyl-CoA dehydrogenase (MCAD) deficiency, two with very-long-chain acyl-CoA dehydrogenase (VLCAD) deficiency and two with mild-type multiple acyl-CoA dehydrogenase (MAD-m) deficiency, were analyzed by gas chromatography-mass spectrometry. In the plasma of patients with MCAD deficiency we found increases of octanoic acid (8:0), decanoic acid (10:0), 4-decenoic acid (10:1 omega 6), and 4,7-decadienoic acid (10:2 omega 3), all present almost exclusively in free form. The patients with VLCAD deficiency showed increases of mainly 5-tetradecenoic acid (14:1 omega 9) and to a minor extent 5-dodecenoic acid (12:1 omega 7), 5,8-tetradecadienoic acid (14:2 omega 6), and 7,10-hexadecadienoic acid (16:2 omega 6), in both the free and esterified fatty acid fraction. The MAD-m patients showed variable increases of all the unusual fatty acids present in MCAD- and VLCAD-deficient plasma. The 14:1 omega 9, 14:2 omega 6, and 16:2 omega 6 fatty acids were present mainly in the esterified form. Measurement of these fatty acids in plasma by the relatively simple method presented here provides a sensitive and specific aid in the diagnosis of acyl-CoA dehydrogenase deficiency disorders.

Characterization of glutathione conjugation in humans: stereoselectivity in plasma elimination pharmacokinetics and urinary excretion of (R)- and (S)-2-bromoisovalerylurea in healthy volunteers.

Characterization of glutathione conjugation in vivo was performed in 12 healthy male volunteers by use of the racemic drug bromisovalum (bromisoval; 2-bromoisovalerylurea) as a model substrate. To study whether the pharmacokinetics of both bromisovalum enantiomers was related to the glutathione S-transferase class Mu phenotype, six subjects who were class Mu deficient and six subjects who were not class Mu deficient participated. After oral administration of 600 mg racemic bromisovalum, enantioselective measurement of unchanged bromisovalum (plasma and saliva) and the diastereomeric bromisovalum mercapturates (urine) showed a pronounced stereoselectivity in all subjects. The plasma clearance of R-bromisovalum was about 12 times higher than that of S-bromisovalum (9.3 +/- 3.7 and 0.78 +/- 0.38 L/min, respectively), which was in agreement with the higher urinary cumulative excretion for the mercapturate derived from R-bromisovalum: 26% +/- 4% of the dose versus 8% +/- 3% of the dose for the mercapturate derived from S-bromisovalum. Both the bromisovalum pharmacokinetics in general and the stereoselectivity in bromisovalum pharmacokinetics were not different for the subjects who were glutathione S-transferase class Mu deficient and the subjects who were not glutathione transferase class Mu deficient.

Enantioselective determination of R- and S-(alpha-bromoisovaleryl)urea in plasma using high-performance liquid chromatography after solid-phase extraction.

A stereoselective method has been developed for the determination of R- and S-(alpha-bromoisovaleryl)urea in plasma and saliva after oral administration. The chiral separation was carried out on Chiralcel OJ or OD columns with hexane--2-propanol as the mobile phase. The poor detection properties of the analyte required the development of an effective sample pretreatment procedure to enable ultraviolet detection at 210 nm. Solid-phase extraction using hydrophobic Amberlite XAD-2 in combination with washing steps at alkaline and acidic pH completely removed interfering components of the biological matrix and allowed the detection of the optical isomers at concentrations down to 10 ng/ml (0.05 microM). The method was validated by determining the recovery, linearity, accuracy and within-day and between-day repeatability at 50, 200 and 2000 ng/ml. Application to the analysis of plasma and saliva samples is demonstrated.

An unusual dearomatized adduct formed by reaction of 4'-fluoro-4-(acetylamino)biphenyl N-sulfate with deoxyadenosine.

The sulfate ester of the liver carcinogen N-hydroxy-4'-fluoro-4-(acetylamino)biphenyl (FAABP-N-sulfate) is believed to be a reactive intermediate in the male rat liver in vivo. After reaction of FAABP-N-sulfate with double-stranded calf thymus DNA in vitro, 30% of the adducts was identified as N-(deoxyguanosin-8-yl)-4'-fluoro-4-(acetylamino)biphenyl(dG-C8- FAABP) and 16% was suggested to be 3-(deoxyguanosin-N2-yl)-4'-fluoro-4-(acetylamino)biphenyl. To investigate the identity of the remaining adducts, FAABP-N-sulfate was reacted with deoxyadenosine. Two adducts could be isolated, which were identified by 1H NMR and mass spectrometry as 3-(deoxyadenosin-N6-yl)-4'-fluoro-4-(acetylamino)biphenyl (3-dA-N6-FAABP) and -(deoxyadenosin-N6-yl)-4'-fluoro-4-(acetylimino)-3, 4-dihydrobiphenyl (3-dA-N6-FHAIBP). An additional center of chirality is introduced at C3 (biphenyl) in the latter adduct. Therefore, 3-dA-N6-FHAIPB exists as a pair of two diastereomers with H-3 (biphenyl) in the alpha or beta position. Hydrogen bonding between the proton on N6 (adenine) and the imine nitrogen or the acetylimino oxygen is suggested to stabilize 3-dA-N6-FHAIBP and to prevent its conversion to 3-dA-N6-FAABP by restoration of the aromatic system. The adduct 3-dA-N6-FHAIBP was also formed in the reaction of N-OSO3H-FAABP with DNA; it accounted for 3-6% of total covalent binding.

Sulfation-dependent formation of N-acetylated and deacetylated DNA adducts of N-hydroxy-4-acetylaminobiphenyl in male rat liver in vivo and in isolated hepatocytes.

Administration of 3H-labeled N-hydroxy-4-acetylaminobiphenyl (N-OH-AABP) to male Wistar rats with or without prior partial hepatectomy (PH) resulted in covalent binding of 3H activity to liver macromolecules. Pretreatment with the sulfotransferase inhibitor pentachlorophenol (PCP) 45 min before administration of the arylhydroxamic acid strongly decreased the covalent binding. Analysis of aminobiphenyl adducts after TFA hydrolysis of DNA and RNA showed that PCP decreased the formation of both the N-acetylated adduct N-[deoxy)guanosin-8-yl)-4-acetylaminobiphenyl [(d)G-C8-AABP] and the deacetylated adduct N-[deoxy)-guanosin-8-yl)-4-aminobiphenyl [(d)G-C8-ABP] by 60-80%. In incubations with hepatocytes from male Wistar or Sprague-Dawley rats, omission of inorganic sulfate also strongly decreased the covalent binding of 3H-labeled N-OH-AABP to RNA and protein. Analysis of RNA adducts showed a 70-80% decrease in the formation of G-C8-ABP in the absence of sulfate. Another, as yet unidentified, adduct was only slightly decreased. Similar results were obtained with the structurally related carcinogen N-hydroxy-4'-fluoro-4-acetylaminobiphenyl (N-OH-FAABP). Pretreatment with PCP decreased the incidence of gamma-glutamyltranspeptidase-positive foci in the liver of male rats when analyzed 30 days after a single injection of N-OH-AABP or N-OH-FAABP by 60 and 80% respectively. Thus, both N-acetylated and deacetylated RNA and DNA adducts of N-OH-AABP in rat liver are formed by sulfation and this metabolic activation pathway is responsible for the formation of genotoxic metabolites involved in the generation of preneoplastic cells.