Optimization of prediction methods for risk assessment of pathogenic germline variants in the Japanese population.

Predicting pathogenic germline variants (PGVs) in breast cancer patients is important for selecting optimal therapeutics and implementing risk reduction strategies. However, PGV risk factors and the performance of prediction methods in the Japanese population remain unclear. We investigated clinicopathological risk factors using the Tyrer-Cuzick (TC) breast cancer risk evaluation tool to predict BRCA PGVs in unselected Japanese breast cancer patients (n = 1,995). Eleven breast cancer susceptibility genes were analyzed using target-capture sequencing in a previous study; the PGV prevalence in BRCA1, BRCA2, and PALB2 was 0.75%, 3.1%, and 0.45%, respectively. Significant associations were found between the presence of BRCA PGVs and early disease onset, number of familial cancer cases (up to third-degree relatives), triple-negative breast cancer patients under the age of 60, and ovarian cancer history (all P < .0001). In total, 816 patients (40.9%) satisfied the National Comprehensive Cancer Network (NCCN) guidelines for recommending multigene testing. The sensitivity and specificity of the NCCN criteria for discriminating PGV carriers from noncarriers were 71.3% and 60.7%, respectively. The TC model showed good discrimination for predicting BRCA PGVs (area under the curve, 0.75; 95% confidence interval, 0.69-0.81). Furthermore, use of the TC model with an optimized cutoff of TC score ≥0.16% in addition to the NCCN guidelines improved the predictive efficiency for high-risk groups (sensitivity, 77.2%; specificity, 54.8%; about 11 genes). Given the influence of ethnic differences on prediction, we consider that further studies are warranted to elucidate the role of environmental and genetic factors for realizing precise prediction.

Prevalence and risk factors of bone metastasis and skeletal related events in patients with primary breast cancer in Japan.

BACKGROUND: Bone metastasis (BM) is important for studying systemic spread of breast cancer. It often causes skeletal-related events (SREs) that worsen quality of life. We investigated the prevalence and risk factors for BM and SRE using a dataset from the Breast Oncology Research Network (BORN) in Japan. PATIENTS AND METHODS: We collected data on primary breast cancer patients with node-positive or node-negative disease at intermediate to high risk of recurrence. The risk factors affecting the BM-free rate, SRE-free rate and overall survival were analyzed by using the Cox proportional hazard model. RESULTS: Data of 1,779 patients who were diagnosed with breast cancer during 2003-2005 were collected from the BORN and 1,708 cases were used for analysis. The median follow-up duration was 5.71 years. BM developed in 193 cases (11.3 %) and the BM-free rate at 5 years was 89.2 %. The annual hazard ratio of BM development differs remarkably according to the tumor subtype. SREs occurred in 133 (68.9 %) out of 193 patients and the SRE-free rate at 5 years was 92.6 %. In the multivariate analysis, clinical stage (P < 0.0001), number of lymph node (LN) metastases (P = 0.0029), tumor subtype (P = 0.034) and progesterone receptor status (P = 0.038) were independently significant risk factors for BM-free rate, but only clinical stage (P < 0.0001) and number of LN metastases (P = 0.0004) significantly correlated with SRE-free rate. CONCLUSIONS: This retrospective study clarifies the prevalence and risk factors for BM and SRE in Japanese breast cancer patients. Our results show the importance of considering subtype in the care of BM and SRE.

[The case of a patient with peritoneal metastasis from cholangiocarcinoma who responded to adoptive immunotherapy and cetuximab].

A 59-year-old female patient underwent pancreaticoduodenectomy because of bile duct cancer 4 years before the first consultation at our clinic. Because the resected bile duct margin was positive, radiation therapy was administered to the hepatic hilum, 5-fluorouraci(l 5-FU) was continuously infused, and S-1 was administered as adjuvant therapy. Three years later, cancer of the uterine body was diagnosed. At the time of hysterectomy, nodules were observed in the Douglas pouch. Biopsy confirmed the presence of peritoneal metastasis from cholangiocarcinoma (hospital A). At the time of the first consultation, ascites was observed. Symptoms improved after the administration of bevacizumab( Bmab) and gemcitabine (GEM), but recurred after 7 months. The patient was admitted to hospital B because of impaired gastrointestinal passage and massive ascites. OK-432-combined adoptive immunotherapy, in which lymphocytes from the removed ascites were cultured and transferred into the abdominal cavity after OK-432 treatment, was performed. Examination of the specimen resected in hospital A indicated that it was strongly positive for epidermal growth factor receptor (EGFR), and hence, cetuximab( Cmab) was administered both at admission and after discharge. Cmab alone was continued and the tumor marker levels normalized. The patient is currently healthy at 7 years after the onset of peritoneal recurrence (5.5 years after the initiation of Cmab therapy).

[Effective therapeutic regimens for patients with triple-negative (ER/PgR/HER2-negative) metastatic breast cancer].

The so-called triple-negative (TN) metastatic breast cancer (MBC), that is, MBC expressing no hormone receptors or HER2 protein, has attracted attention because of its low response rate to drug therapy and poor prognosis after recurrence. Of 423 MBC patients in our hospital in and after 2001, 54 had TN tumors. The median survival time (MST) of TN patients (25 months) was shorter than the MSTs of HR (+)/HER2 (-), HR (+)/HER2 (+), and HR (-)/HER2 (+) patients (69, 58, and 39 months, respectively). A retrospective analysis of responses to 162 regimens in 54 TN-MBC patients showed that anthracycline regimens produced a response rate of 18. 8% (a PR or higher response in 3 of 16 patients), whereas a taxane regimen yielded a very low response rate of 8. 1% (3/37). A similar low response was observed in monotherapy with MTX, CPT-11, VNR, gemcitabine, or S-1. Of particular note were the high response rate (46. 2%, 12/26) of DMpC therapy (oral 5'-DFUR, MPA, and CPA) and that (28%, 7/25) of MFL-P therapy (MTX, 5-FU, leucovorin, and CDDP), although these were not standard therapies. In addition, the molecular-targeted drug bevacizumab or cetuximab was concomitantly used with chemotherapeutic agents in 3 patients, and 1 each treated with either therapy achieved a PR. Thus, in the future, we can expect further advances in molecular-targeted therapy while using DMpC and MFL-P for the treatment of TN-MBC as an early-line therapy.

Pre-operative intracellular glutathione levels of peripheral monocytes as a biomarker to predict survival of colorectal cancer patients.

The ability to predict anti-tumor immune responses at local tumor growing sites using only peripheral blood specimens would be helpful in determining therapeutic options for patients with solid tumors. Here, we show that the glutathione intracellular content (icGSH) of peripheral monocytes (Mo) correlates positively with T cell infiltration within tumor islets and overall survival in patients with colorectal carcinoma. IcGSH redox status was determined in CD14(+) Mo prior to surgery by staining with monochlorobimane. The tumor-infiltrating T cells (TIL) were quantified as CD45RO(+) T cells in resected tumors using paraffin sections. A positive association was found between the GSH index and TIL in tumor islets (P < 0.001). The 50% cut-off value for the GSH index, that is the determinant between TIL presence or absence in tumor islets, was calculated to be almost 0.7 through logistic regression analysis. Mo with a GSH index of > or =0.7 were termed reductive (R)-Mo, and those with <0.7 were designated as oxidative (O)-Mo. Cox's proportional hazards regression analysis of patients with R-Mo or O-Mo prior to surgery, and the presence or absence of TIL, was found to correlate significantly with the overall survival rate of stage II and III patients. Kaplan-Meier analysis also showed a significant correlation. These results indicate that the Mo icGSH index is a useful biomarker parameter for better understanding the host/tumor relationship prior to surgery, thereby enabling the development of an individual patient-oriented therapeutic strategy.

[Serum HER-2 determination using a centauer HER-2/neu kit (CLIA method) in metastatic breast cancer].

Employing CLIA and EIA methods simultaneously, we determined serum HER-2/neu levels a total of 92 times in 51 patients with metastatic breast cancer(MBC)and 3 patients with non-recurrent breast cancer, and compared the levels measured by both methods with the level of IHC-staining for HER-2 and the clinical course. Among 20 patients with IHC HER-2/3+ MBC (including FISH+MBC), 14(70%)showed high levels by the CLIA method (>cut-off value of 15.2 ng/mL), whereas only 4(20%)revealed high levels by the EIA method(>cut-off value of 6.5 ng/mL). None of the patients with CR or non-recurrent breast cancer exhibited high levels by either method. Some IHC HER-2(-) patients also frequently showed high levels by the CLIA method. The EIA method not only revealed low-level sensitivity, but also was subject to interference(abnormally low levels)due to trastuzumab administration. The results obtained by the CLIA method were in agreement with the clinical course. In 93 MBC patients(except CR patients)whose serum HER-2 levels were determined by the CLIA method, the initial HER-2 levels were compared with the CEA and CA15-3 levels. Of the 32 IHC HER-2/3+ patients, 25, 13, and 12 were noted to have high serum levels of HER-2, CEA, and CA15-3, respectively. These results indicate that the serum HER-2 level as assessed by the CLIA method is the most sensitive marker of HER-2-positive MBC.

Questionnaire survey of treatment choice for breast cancer patients with brain metastasis in Japan: results of a nationwide survey by the task force of the Japanese Breast Cancer Society.

OBJECTIVE: A nationwide survey was performed to investigate the current patterns of care for brain metastasis (BM) from breast cancer in Japan. METHOD: A total of 351 survey questionnaires were sent to community or academic breast oncologists who were members of the Japanese Breast Cancer Society as of December 2005. The questionnaire consists of 40 multiple choice questions in eight categories. RESULTS: Of 240 institutions sent survey questionnaires, 161 (67.1%) answered; 60% of institutions answered with '<5' patients with BM every year; almost half (83 of 161) screened for BM in asymptomatic patients; surgical resection was rarely performed, as ~75% of institutions (118 of 160 institutions) answered 'none or one case of surgery per year'; 27% (41 of 154) preferred stereotactic radiosurgery (SRS) over whole-brain radiotherapy (WBRT) as the initial treatment in all cases, although ~70% (100 of 154) of them answered 'depend on cases'. The preference for SRS over WBRT mainly depends on the impressions of breast oncologists about both safety (late normal tissue damage and dementia in WBRT) and efficacy (better local control by SRS). Eighty-one percent (117 of 144) of institutions did not limit the number of SRS sessions as far as technically applicable. CONCLUSION: SRS is widely used as the first choice for BM from breast cancer in Japan. Considerable numbers of Japanese breast oncologists prefer SRS over WBRT as the initial treatment for BM. A randomized trial comparing SRS and WBRT is warranted.

[Evaluation of therapeutic regimens for taxane-resistant recurrent/metastatic breast cancer].

Taxanes (TX) were administered to 246 of 292 patients with recurrent/metastatic breast cancer (MBC) who were treated in Hiei Hospital between January 2001 and May 2006. Recently, TX has been increasingly prescribed for preoperative treatment and postoperative adjuvant therapy. To improve the prognosis of MBC, regimens effective for TX-resistant cancer patients should be developed. In this study, with respect to hormone receptor (HR) and Her 2/neu (HER 2), we retrospectively investigated whether our series responded to the regimens used after TX resistance was acquired. As post TX-resistance therapy (trastuzumab was combined in HER2-positive patients), 387 treatment regimens were administered to 166 patients. The following regimens achieved a response rate (patients achieving PR or CR/patients who could be evaluated) of 10% or more: combination therapy with TX and capecitabine (11/61, 18%), CPT-11 (10/57, 17.5%), vinorelbine (5/46, 10.9%), MFL-P (continuous treatment with MTX, 5-FU, LV, and CDDP) (12/47, 25.5%), and DMpC (5'-DFUR, MPA, CPA p.o.) (5/16, 31.2%). The latter 2 regimens achieved a high response rate,and some HR (-) and HER 2 (-) patients also responded to these regimens. In HR (+) or HER 2 (+) patients who responded to TX, survival was longer than that of non-responders. However, there was no difference in the treatment responsiveness of post-TX regimens between TX-responders and non-responders, suggesting the survival-prolonging effect of TX.

[Stratification with respect to hormone receptor and HER 2/neu in the treatment of metastatic breast cancer; sensitivity to taxane].

Of 231 patients with recurrent or metastatic breast cancer treated in Hiei Hospital between January 2001 and March 2005, for whom data on hormone receptor (HR) and HER 2/neu were available, we retrospectively analyzed the association of the response rate with HR and HER 2 in 172 patients treated with taxane in whom the treatment response could be evaluated. Among the patients treated with taxane alone,the response rates were 37.5% (n=67) in the HR (+) patients and 14.6% (n=41) in the HR (-) patients (p=0.0131). In particular, taxane resistance was suggested in the HR (-)/HER 2 (-) patients (response rate: 4.2%, n=24). Concerning combination therapy with trastuzumab and taxane, the response rate were 52.8% in the HR (+)/HER 2 (+) patients and 60.4% in the HR (-)/HER 2 (+) patients. In 27 of these patients, single therapy with taxane was switched to combination therapy with taxane and trastuzumab after they became resistant to taxane, and 8.3% of the HR (+)/HER 2 (+) patients and 53.3% of the HR (-)/HER 2 (+) patients responded to this combination therapy (p=0.0192), suggesting the synergistic effects of the two agents in HR (-)/HER 2 (+) patients. Therefore, HR and HER 2 were associated with the sensitivity to a chemotherapeutic agent, taxane. Stratification with respect to HR and HER 2 is important in the treatment of metastatic breast cancer. In particular, therapeutic strategies for HR (-)/HER 2 (-) patients with a poor prognosis must be established in the future.

[Analysis of long-term (5-year) survival in patients with metastatic breast cancer to the liver].

Patients with metastatic breast cancer to the liver are generally considered to have a poor prognosis. The purpose of this study was to identify factors contributing to long term survival in 11 patients who were 35 76 years old at the time of diagnosis with liver metastasis, and survived for 5 years. No patients were treated with a standard systemic chemotherapy alone. All of the 11 patients received OK 432 combined adoptive immunotherapy (OK-AIT), 5 underwent hepatectomy as an additional local therapy, and 2 were additionally treated by hepatic arterial infusion chemotherapy. The liver was the primary and secondary sites of metastasis in 8 and 3 of the 11 patients, respectively. In all of the 128 patients given OK-AIT at 5 years after diagnosis, the 5-year survival rates with primary and secondary liver metastases were 11.8. and 5%, respectively. Hormone receptors (HR) were undetermined in 4 patients, positive in 6, and negative in 1 patient, who was also positive for HER2. To determine the relationships among the prognosis of the liver metastasis, AIT indications, HR, and HER2, we analyzed our 139 liver metastasis patients encountered in 2001 and onwards. Fifty-one patients with primary liver metastasis had a median survival time (MST) of 31 months, and a 5-year survival rate of 25%, indicating an improved prognosis. In particular, a MST of 50 months (n=18) in HR (+), HER2 (-) patients was in sharp contrast to the poor prognosis (a MST of 6 months, n=2) in HR (-) HER2 (-) patients. HER2 (+) patients had a MST of 27 months (n=31). Eighty-eight patients with secondary liver metastasis had a MST of only 11 months and a 5-year survival of only 6%; however, the MST in these patients showed the same tendency as in the primary liver metastasis patients: ER (+) HER2 (-) >HER2 (+) >HR (-) HER2 (-) (17, 13, and 4 months, respectively). The response rates of OK-AIT in the primary and secondary liver metastasis patients were 52 and 34%, respectively, showing no significant difference. However, there was a significant difference in the response rate between the HR (+) and HR (-) patients, at 52 and 12%, respectively (p=0.0041). Of the patients in the past, 18 with primary liver metastasis underwent hepatectomy in combination with OK-AIT. Of these 18 patients, 5 had concurrent metastases to other sites, but achieved a 5-year survival rate of 56%, suggesting that it is incorrect to conclude that patients with liver metastasis have generally a poor prognosis. Key

[Bi-weekly chemotherapy with medium-dose docetaxel for advanced and recurrent breast cancers (The 15th study of Keiji Breast Cancer Study Group)].

The efficacy and safety of bi-weekly administration of medium-dose docetaxel (TXT) were evaluated in patients with advanced and recurrent breast cancers. The additional effect of 5'-DFUR for non-responders was also evaluated. Forty patients with advanced and recurrent breast cancers were treated and 38 cases of 40 were evaluated (34 with recurrent cases and 4 with advanced cases). All cases were female, and their mean age was 56.0 (38-74). TXT of 60 mg/body, which was equivalent to 30-50 mg/m2 for standard-sized Japanese women, was administered every two weeks. 5'-DFUR of 800 mg/body was added for non-responders after 5 weeks. The response rate was calculated from the data of 32 cases with measurable lesions, and side effects were evaluated in about 34 cases with exact records. Two hundred seventy-one courses were performed for 38 patients (4-24 courses per person, average 7.13 courses). The mean dosage per course of TXT was 58.4 mg/body (38.3 mg/ m2). Three complete and 7 partial responses were observed (overall response rate: 31.3%). Ten non-responders were evaluated for the additional effect of 5' DFUR, and one case reached PR. Grade 3/4 bone marrow suppression occurred in 9 patients, and Grade 3/4 general malaise was observed in two patient. According to the results, bi-weekly administration of medium dose TXT is an active and safe regimen in patients with advanced and recurrent breast cancers. The additional effect of 5'-DFUR was observed in one of 10 non-responders of bi-weekly chemotherapy with medium-dose TXT.

[Analysis of 5-year survival among breast cancer patients with malignant pleural effusion receiving intrapleural OK-432 followed by adoptive transfer with cultured effusion lymphocytes].

Since 1984, we have had 151 breast cancer patients with cytologically-confirmed malignant pleural effusions by local transfer of autologous effusion lymphocytes cultured with a conditioned medium containing T-cell growth factor after intrapleural preadministration of a streptococcal preparation, OK-432. Among the 81 patients given this therapy more than 5 years ago, 12 patients have survived 5 or more years, and 4 of these 12 have survived 10 (<) years. Patients surviving 5 (<) years had longer (32-204 months) disease-free periods, except for one patient with stage IV disease. Estrogen receptor was positive in 5 patients, negative in 1 patient, and unknown in 6 patients. Moreover, preceding or concomitant metastases in these patients were not life-threatening (6 chest-wall, 2 lymph-node, 4 lung, 3 bone metastases). In conclusion, effective therapy (effusion disappeared in all patients) and good control of concomitant metastases resulted in long-term survival of patients who had intrinsically better prognostic factors.