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Purpose:Young age at breast cancer diagnosis correlates with unfavorable clinicopathologic features and worse outcomes compared with older women. Understanding biological differences between breast tumors in young versus older women may lead to better therapeutic approaches for younger patients.Experimental Design:We identified 100 patients ≤35 years old at nonmetastatic breast cancer diagnosis who participated in the prospective Young Women's Breast Cancer Study cohort. Tumors were assigned a surrogate intrinsic subtype based on receptor status and grade. Whole-exome sequencing of tumor and germline samples was performed. Genomic alterations were compared with older women (≥45 years old) in The Cancer Genome Atlas, according to intrinsic subtype.Results:Ninety-three tumors from 92 patients were successfully sequenced. Median age was 32.5 years; 52.7% of tumors were hormone receptor-positive/HER2-negative, 28.0% HER2-positive, and 16.1% triple-negative. Comparison of young to older women (median age 61 years) with luminal A tumors (N = 28 young women) revealed three significant differences: PIK3CA alterations were more common in older patients, whereas GATA3 and ARID1A alterations were more common in young patients. No significant genomic differences were found comparing age groups in other intrinsic subtypes. Twenty-two patients (23.9%) in the Young Women's Study cohort carried a pathogenic germline variant, most commonly (13 patients, 14.1%) in BRCA1/2.Conclusions:Somatic alterations in three genes (PIK3CA, GATA3, and ARID1A) occur at different frequencies in young versus older women with luminal A breast cancer. Additional investigation of these genes and associated pathways could delineate biological susceptibilities and improve treatment options for young patients with breast cancer.See related commentary by Yehia and Eng, p. 2209

Altered mechanical properties of the tumor matrix have emerged as both the cause and consequence of breast carcinogenesis. Increased tumor stiffness has traditionally provided a viable metric to screen for malignancies via palpation or imaging. Previous studies have demonstrated that the microscale mechanical properties of the cell substrate influence tumor proliferation and invasive migration in vitro. Nevertheless, the association of the mechanical microenvironment with clinical hallmarks of aggressiveness in human breast tumors, including histopathological subtype, grade, receptor expression status, and lymph node involvement is poorly understood. This is largely due to the lack of tools for mapping tumor viscoelastic properties in clinical specimens with high spatial resolution over a large field of view (FoV). Here we introduce laser Speckle rHEologicAl micRoscopy (SHEAR) that for the first time enables mapping the magnitude viscoelastic or shear modulus, |G*(x,y,ω)|, over a range of frequencies (ω = 1–250 rad/second) in excised tumors within minutes with a spatial resolution of approximately 50 μm, over multiple cm2 FoV. Application of SHEAR in a cohort of 251 breast cancer specimens from 148 patients demonstrated that |G*(x,y,ω)| (ω = 2π rad/second) closely corresponds with histological features of the tumor, and that the spatial gradient of the shear modulus, |∇|G*(x,y,ω)||, is elevated at the tumor invasive front. Multivariate analyses established that the metrics, (|G* |) and (|∇|G* ||), measured by SHEAR are associated with prognosis. These findings implicate the viscoelastic properties of the tumor microenvironment in breast cancer prognosis and likely pave the path for identifying new modifiable targets for treatment.Significance:Laser speckle rheological microscopy establishes the links between microscale heterogeneities of viscoelasticity and histopathological subtype, tumor grade, receptor expression, as well as lymph node status in breast carcinoma.

Purpose:The Breast Cancer Index (BCI) HOXB13/IL17BR (H/I) ratio predicts benefit from extended endocrine therapy in hormone receptor–positive (HR+) early-stage breast cancer. Here, we report the final analysis of the Trans-aTTom study examining BCI (H/I)'s predictive performance.Experimental Design:BCI results were available for 2,445 aTTom trial patients. The primary endpoint of recurrence-free interval (RFI) and secondary endpoints of disease-free interval (DFI) and disease-free survival (DFS) were examined using Cox proportional hazards regression and log-rank test.Results:Final analysis of the overall study population (N = 2,445) did not show a significant improvement in RFI with extended tamoxifen [HR, 0.90; 95% confidence interval (CI), 0.69–1.16; P = 0.401]. Both the overall study population and N0 group were underpowered due to the low event rate in the N0 group. In a pre-planned analysis of the N+ subset (N = 789), BCI (H/I)-High patients derived significant benefit from extended tamoxifen (9.7% absolute benefit: HR, 0.33; 95% CI, 0.14–0.75; P = 0.016), whereas BCI (H/I)-Low patients did not (−1.2% absolute benefit; HR, 1.11; 95% CI, 0.76–1.64; P = 0.581). A significant treatment-to-biomarker interaction was demonstrated on the basis of RFI, DFI, and DFS (P = 0.037, 0.040, and 0.025, respectively). BCI (H/I)-High patients remained predictive of benefit from extended tamoxifen in the N+/HER2− subgroup (9.4% absolute benefit: HR, 0.35; 95% CI, 0.15–0.81; P = 0.047). A three-way interaction evaluating BCI (H/I), treatment, and HER2 status was not statistically significant (P = 0.849).Conclusions:Novel findings demonstrate that BCI (H/I) significantly predicts benefit from extended tamoxifen in HR+ N+ patients with HER2− disease. Moreover, BCI (H/I) demonstrates significant treatment to biomarker interaction across survival outcomes.

Purpose: Accurate tumor classification is essential for cancer management as patient outcomes improve with use of site- and subtype-specific therapies. Current clinicopathologic evaluation is varied in approach, yet standardized diagnoses are critical for determining therapy. While gene expression–based cancer classifiers may potentially meet this need, imperative to determining their application to patient care is validation in rigorously designed studies. Here, we examined the performance of a 92-gene molecular classifier in a large multi-institution cohort.Experimental Design: Case selection incorporated specimens from more than 50 subtypes, including a range of tumor grades, metastatic and primary tumors, and limited tissue samples. Formalin-fixed, paraffin-embedded tumors passed pathologist-adjudicated review between three institutions. Tumor classification using a 92-gene quantitative reverse transcriptase polymerase chain reaction (RT-PCR) assay was conducted on blinded tumor sections from 790 cases and compared with adjudicated diagnoses.Results: The 92-gene assay showed overall sensitivities of 87% for tumor type [95% confidence interval (CI), 84–89] and 82% for subtype (95% CI, 79–85). Analyses of metastatic tumors, high-grade tumors, or cases with limited tissue showed no decrease in comparative performance (P = 0.16, 0.58, and 0.16). High specificity (96%–100%) was showed for ruling in a primary tumor in organs commonly harboring metastases. The assay incorrectly excluded the adjudicated diagnosis in 5% of cases.Conclusions: The 92-gene assay showed strong performance for accurate molecular classification of a diverse set of tumor histologies. Results support potential use of the assay as a standardized molecular adjunct to routine clinicopathologic evaluation for tumor classification and primary site diagnosis. Clin Cancer Res; 18(14); 3952–60. ©2012 AACR.

PDF file, 85KB, Supplemental Table 1: Performance characteristics of the 92-gene assay for tumor subclassification. Supplemental Table 2: Pre-analytical variables and effects on 92-gene assay performance

Supplementary Table from Somatic and Germline Genomic Alterations in Very Young Women with Breast Cancer

Purpose:Young age at breast cancer diagnosis correlates with unfavorable clinicopathologic features and worse outcomes compared with older women. Understanding biological differences between breast tumors in young versus older women may lead to better therapeutic approaches for younger patients.Experimental Design:We identified 100 patients ≤35 years old at nonmetastatic breast cancer diagnosis who participated in the prospective Young Women's Breast Cancer Study cohort. Tumors were assigned a surrogate intrinsic subtype based on receptor status and grade. Whole-exome sequencing of tumor and germline samples was performed. Genomic alterations were compared with older women (≥45 years old) in The Cancer Genome Atlas, according to intrinsic subtype.Results:Ninety-three tumors from 92 patients were successfully sequenced. Median age was 32.5 years; 52.7% of tumors were hormone receptor-positive/HER2-negative, 28.0% HER2-positive, and 16.1% triple-negative. Comparison of young to older women (median age 61 years) with luminal A tumors (N = 28 young women) revealed three significant differences: PIK3CA alterations were more common in older patients, whereas GATA3 and ARID1A alterations were more common in young patients. No significant genomic differences were found comparing age groups in other intrinsic subtypes. Twenty-two patients (23.9%) in the Young Women's Study cohort carried a pathogenic germline variant, most commonly (13 patients, 14.1%) in BRCA1/2.Conclusions:Somatic alterations in three genes (PIK3CA, GATA3, and ARID1A) occur at different frequencies in young versus older women with luminal A breast cancer. Additional investigation of these genes and associated pathways could delineate biological susceptibilities and improve treatment options for young patients with breast cancer.See related commentary by Yehia and Eng, p. 2209

PDF file, 83KB, Biopsy sites of validation study cases.

Supplementary Figure from Breast Cancer Index Is a Predictive Biomarker of Treatment Benefit and Outcome from Extended Tamoxifen Therapy: Final Analysis of the Trans-aTTom Study

Supplementary Figure from Somatic and Germline Genomic Alterations in Very Young Women with Breast Cancer

Supplementary Methods 1-5

Altered mechanical properties of the tumor matrix have emerged as both the cause and consequence of breast carcinogenesis. Increased tumor stiffness has traditionally provided a viable metric to screen for malignancies via palpation or imaging. Previous studies have demonstrated that the microscale mechanical properties of the cell substrate influence tumor proliferation and invasive migration in vitro. Nevertheless, the association of the mechanical microenvironment with clinical hallmarks of aggressiveness in human breast tumors, including histopathological subtype, grade, receptor expression status, and lymph node involvement is poorly understood. This is largely due to the lack of tools for mapping tumor viscoelastic properties in clinical specimens with high spatial resolution over a large field of view (FoV). Here we introduce laser Speckle rHEologicAl micRoscopy (SHEAR) that for the first time enables mapping the magnitude viscoelastic or shear modulus, |G*(x,y,ω)|, over a range of frequencies (ω = 1–250 rad/second) in excised tumors within minutes with a spatial resolution of approximately 50 μm, over multiple cm2 FoV. Application of SHEAR in a cohort of 251 breast cancer specimens from 148 patients demonstrated that |G*(x,y,ω)| (ω = 2π rad/second) closely corresponds with histological features of the tumor, and that the spatial gradient of the shear modulus, |∇|G*(x,y,ω)||, is elevated at the tumor invasive front. Multivariate analyses established that the metrics, (|G* |) and (|∇|G* ||), measured by SHEAR are associated with prognosis. These findings implicate the viscoelastic properties of the tumor microenvironment in breast cancer prognosis and likely pave the path for identifying new modifiable targets for treatment. Significance: Laser speckle rheological microscopy establishes the links between microscale heterogeneities of viscoelasticity and histopathological subtype, tumor grade, receptor expression, as well as lymph node status in breast carcinoma.

Brain metastases are refractory to therapies that control systemic disease in patients with human epidermal growth factor receptor 2 (HER2+) breast cancer, and the brain microenvironment contributes to this therapy resistance. Nutrient availability can vary across tissues, therefore metabolic adaptations required for brain metastatic breast cancer growth may introduce liabilities that can be exploited for therapy. Here, we assessed how metabolism differs between breast tumors in brain versus extracranial sites and found that fatty acid synthesis is elevated in breast tumors growing in brain. We determine that this phenotype is an adaptation to decreased lipid availability in brain relative to other tissues, resulting in a site-specific dependency on fatty acid synthesis for breast tumors growing at this site. Genetic or pharmacological inhibition of fatty acid synthase (FASN) reduces HER2+ breast tumor growth in the brain, demonstrating that differences in nutrient availability across metastatic sites can result in targetable metabolic dependencies.

Background: Several biomarkers such as estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR) and Ki67 have been implicated in the pathogenesis and/or as prognostic biomarkers of breast cancer, and are utilized to determine treatment. Given the heterogeneity of response to endocrine therapy, however, predictive biomarkers are critical to better individualize patient care. Previous results from the Trans-aTTom study demonstrated that the Breast Cancer Index HOXB13/IL17BR [BCI (H/I)] biomarker significantly predicts extended endocrine benefit from 10 vs 5y of tamoxifen. In this correlative study, the predictive activity of BCI (H/I) was compared with ER, PR, AR and Ki67 protein expression in node positive patients treated in the aTTom trial. Methods: Patients with available tumor tissue and biomarker analyses were included. ER, PR, AR and Ki67 were centrally assessed by immunohistochemistry (IHC) utilizing tissue microarrays. BCI gene expression analysis by RT-PCR was performed blinded to clinical outcome. Multivariate Cox models adjusting for age, tumor size, tumor grade and HER2 status were used to assess the significance of the interaction between treatment and each biomarker as continuous variables. 17-year risk of recurrence, as a function of each continuous biomarker, was estimated from Cox models in each of the 2 treatment arms. Results: Analysis of 789 HR+, N+ patients showed a weak negative correlation between BCI (H/I) and ER, PR, and AR expression whereas Ki67 and the AR/ER ratio showed no correlation (ER, cor=−0.18; PR, cor=−0.25; AR, cor=−0.14; Ki67, cor=0.04; AR/ER ratio, cor=0.02). The interaction between BCI (H/I) and extended tamoxifen treatment was significant (p=0.014). In addition, analysis of risk of recurrence as a function of continuous BCI (H/I) demonstrated that the magnitude in the reduction in recurrence risk with extended tamoxifen correlated with increasing H/I levels. In contrast, interaction P values were nonsignificant (ER, p=0.829; PR, p=0.659; AR, p=0.783; Ki67, p=0.865; AR/ER ratio, p=0.835) and the magnitude of endocrine benefit did not correlate with expression levels of any of other biomarkers. Conclusion: Results from this post-hoc analysis of the Trans-aTTom study demonstrated that whereas BCI(H/I) is a significant predictive biomarker of endocrine response, analysis of ER, PR, AR, Ki67 and AR/ER expression showed no interaction with treatment, and lacked the ability to predict benefit of extended tamoxifen in HR+ early stage breast cancer. These results add to the growing body of evidence that BCI (H/I) is distinct in its ability to predict benefit from therapy and interrogates distinct tumor biology that is not captured by other traditional biomarkers. Citation Format: Dennis C Sgroi, Kai Treuner, Yi Zhang, Tammy Piper, Ranelle Salunga, Ikhlaaq Ahmed, Lucy Doos, Sarah Thornber, Karen J Taylor, Elena F Brachtel, Sarah Pirrie, Catherine A Schnabel, Daniel W Rea, John MS Bartlett. Correlative studies of the breast cancer index (HOXB13/IL17BR) and ER, PR, AR, AR/ER ratio and Ki67 for prediction of extended endocrine benefit: A trans-aTTom study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr GS4-09.

Purpose Safe breast cancer lumpectomies require microscopically clear margins. Real-time margin assessment options are limited, and 20–40% of lumpectomies have positive margins requiring re-excision. The LUM Imaging System previously showed excellent sensitivity and specificity for tumor detection during lumpectomy surgery. We explored its impact on surgical workflow and performance across patient and tumor types. Methods We performed IRB-approved, prospective, non-randomized studies in breast cancer lumpectomy procedures. The LUM Imaging System uses LUM015, a protease-activated fluorescent imaging agent that identifies residual tumor in the surgical cavity walls. Fluorescent cavity images were collected in real-time and analyzed using system software. Results Cavity and specimen images were obtained in 55 patients injected with LUM015 at 0.5 or 1.0 mg/kg and in 5 patients who did not receive LUM015. All tumor types were distinguished from normal tissue, with mean tumor:normal (T:N) signal ratios of 3.81–5.69. T:N ratios were 4.45 in non-dense and 4.00 in dense breasts (p = 0.59) and 3.52 in premenopausal and 4.59 in postmenopausal women (p = 0.19). Histopathology and tumor receptor testing were not affected by LUM015. Falsely positive readings were more likely when tumor was present Conclusions Intraoperative use of the LUM Imaging System detected all breast cancer subtypes with robust performance independent of menopausal status and breast density. There was no significant impact on histopathology or receptor evaluation.

Purpose: The Breast Cancer Index (BCI) HOXB13/IL17BR (H/I) ratio predicts benefit from extended endocrine therapy in hormone receptor–positive (HR+) early-stage breast cancer. Here, we report the final analysis of the Trans-aTTom study examining BCI (H/I)'s predictive performance. Experimental Design: BCI results were available for 2,445 aTTom trial patients. The primary endpoint of recurrence-free interval (RFI) and secondary endpoints of disease-free interval (DFI) and disease-free survival (DFS) were examined using Cox proportional hazards regression and log-rank test. Results: Final analysis of the overall study population (N = 2,445) did not show a significant improvement in RFI with extended tamoxifen [HR, 0.90; 95% confidence interval (CI), 0.69–1.16; P = 0.401]. Both the overall study population and N0 group were underpowered due to the low event rate in the N0 group. In a pre-planned analysis of the N+ subset (N = 789), BCI (H/I)-High patients derived significant benefit from extended tamoxifen (9.7% absolute benefit: HR, 0.33; 95% CI, 0.14–0.75; P = 0.016), whereas BCI (H/I)-Low patients did not (−1.2% absolute benefit; HR, 1.11; 95% CI, 0.76–1.64; P = 0.581). A significant treatment-to-biomarker interaction was demonstrated on the basis of RFI, DFI, and DFS (P = 0.037, 0.040, and 0.025, respectively). BCI (H/I)-High patients remained predictive of benefit from extended tamoxifen in the N+/HER2− subgroup (9.4% absolute benefit: HR, 0.35; 95% CI, 0.15–0.81; P = 0.047). A three-way interaction evaluating BCI (H/I), treatment, and HER2 status was not statistically significant (P = 0.849). Conclusions: Novel findings demonstrate that BCI (H/I) significantly predicts benefit from extended tamoxifen in HR+ N+ patients with HER2− disease. Moreover, BCI (H/I) demonstrates significant treatment to biomarker interaction across survival outcomes.

Background Breast cancer in young women is more likely to have higher risk features and be associated with germline BRCA1/BRCA2 mutations. We present the clinicopathologic features of breast cancers in a prospective cohort of young women, and associations between surrogate molecular subtype and BRCA1/BRCA2 mutation status. Methods Histopathological features, biomarker status, tumour stage and BRCA status were collected. Invasive tumours were categorised as luminal A-like (ER + and/or PR + , HER2-, grade 1/2), luminal B-like (ER + and/or PR + , HER2 + , or ER + and/or PR + , HER2-, and grade 3), HER2-enriched (ER/PR-, HER2 + ) or triple-negative. Results In all, 57.3% (654/1143) of invasive tumours were high grade. In total, 32.9% were luminal A-like, 42.4% luminal B-like, 8.3% HER2-enriched, and 16.4% triple-negative. Among different age groups, there were no differences in molecular phenotype, stage, grade or histopathology. 11% (131) of tumours were from BRCA mutation carriers; 64.1% BRCA1 (63.1% triple-negative), and 35.9% BRCA2 (55.3% luminal B-like). Discussion The opportunity to provide comparisons across young age groups, BRCA mutation status, surrogate molecular phenotype, and the identification of more aggressive hormone receptor-positive phenotypes in this population provides direction for future work to further understand and improve disparate outcomes for young women with luminal B-like cancers, particularly BRCA2-associated cancers, with potential implications for tailored prevention and treatment.

Background: Optimizing the duration of adjuvant endocrine therapy in patients diagnosed with early stage hormone receptor-positive (HR+) breast cancer requires improved approaches to individualize disease profile and to reduce any unnecessary treatment burden for patients. Current clinical practice guidelines recommend 10 years of adjuvant endocrine therapy for most patients unless there are characteristics of low risk disease. However, approximately 2/3rds of patients have favorable long-term outcomes after completing 5 years of adjuvant therapy. Therefore, consideration of the risk-benefit profile for each patient is critical to identify who may be spared extended endocrine therapy (EET) and its associated toxicities, and which patients will benefit from an additional 5 years of endocrine therapy. The Breast Cancer Index (BCI) is a gene expression-based signature that stratifies patients based on the risk of overall (0-10y) and late (post-5y) distant recurrence (DR) and predicted the likelihood of benefit from extended endocrine therapy in MA.17. The translational-aTTom (Trans-aTTom) study is a multi-institutional, prospective-retrospective study to validate the predictive ability of BCI by HOXB13/IL17BR (H/I) status for EET benefit in early stage HR+, N0 and N+ breast cancer. Methods: Patients treated in the aTTom (Adjuvant Tamoxifen - To Offer More?) trial with available primary tumor tissue were eligible. Biospecimens were retrospectively collected from aTTom study sites and centrally assessed for ER, PR and HER2 status. Median follow-up was 12.6 years. Primary and secondary endpoints were recurrence-free interval (RFI) and disease-free interval (DFI), respectively. Statistical significance level was set at 0.0336 as per statistical analysis plan. Weighted Kaplan-Meier and Cox proportional hazards regression analysis with time-varying coefficients were used to test the predictive activity of BCI by HOXB13/IL17BR (H/I) status (High vs Low). Likelihood ratio test based on Cox regression was used to evaluate treatment by biomarker interaction. Results: Archived tumor specimens from 3328 patients were collected across 62 aTTom trial sites, representing 48% of the parent trial population. Central testing and assessment of ER, PR, HER2, and BCI resulted in 2445 HR+ patients (1367 N0, 789 N+, 289 nodal status unknown) in the overall cohort. At final analysis, the study remained underpowered for evaluating BCI predictive performance in the overall cohort due to an observed limited effect size that was smaller than planned and did not recapitulate the parent aTTom trial. However, evaluation of BCI predictive performance in the updated N+ subset (N=789) showed that patients classified as BCI(H/I)-High (N=404, 51%) experienced a statistically significant benefit from 10y vs 5y of tamoxifen (9.7% RFI: HR=0.33 [95% CI 0.14-0.75]; P=0.016), whereas those classified as BCI(H/I)-Low showed no significant benefit (-1.2% RFI; HR=1.11 [95% CI 0.76-1.64]; P=0.58). A statistically significant interaction between continuous BCI(H/I) and treatment was demonstrated (P = 0.036) adjusted for age, tumor size and grade, whereas no significant interaction was observed between treatment and quantitative ER (P=0.939) or PR (P=0.138) expression. Conclusion: BCI by high H/I expression was predictive of endocrine response and identified a subset of HR+, N+ patients with significant benefit from 10 vs. 5 years of tamoxifen therapy. These data provide further validation, consistent with previous MA.17 data, for BCI as a predictive biomarker of benefit from extended endocrine therapy. Findings from the Trans-aTTom strengthen the clinical validity of BCI for prediction of endocrine response and its clinical utility in optimizing duration of endocrine therapy. Citation Format: John Bartlett, Dennis Sgori, Kai Treuner, Yi Zhang, Tammy Piper, Ranelle Shalunga, Ikhlaaq Ahmed, Lucy Doos, Sarah Thornber, Elena Brachtel, Sarah Pirrie, Catherine Schnabel, Daniel Rea. Breast Cancer Index predicts benefit from extended endocrine therapy in HR+ breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-11-02.

Background: Breast cancer arising in young women is more likely to have higher risk features than in older women and more likely to be associated with germline BRCA1 or BRCA2 mutations. We previously reported a higher distribution of luminal B-like tumors among young women. Here we present the clinical and pathologic features of invasive disease in a large prospective cohort of young women with breast cancer, and associations between surrogate molecular subtype and BRCA 1/2 mutation status. Methods: Among 1,297 young women (aged ≤40 years) with breast cancer enrolled from 2006-2016, tumor histopathological features were examined by central review, and biomarker status was extracted from pathology reports. Based on histologic grade and biomarker expression, invasive tumors were categorized as luminal A-like (LA=ER/PR+ and HER2-, histologic grade 1 or 2), luminal B-like (LB=ER/PR+ and HER2+, or ER/PR+, HER2-, and grade 3), HER2 enriched (E) (ER/PR- and HER2+) or triple negative (TN=ER-, PR- and HER2-). Tumor stage, clinical characteristics, and BRCA status were retrieved by medical record review (and patient survey for BRCA status if not in medical record). Results: The majority of women presented with early stage invasive disease (8% stage 0, 32% stage 1, 40% stage 2, 15% stage 3; 5% stage 4). Among invasive tumors with evaluable molecular phenotype (n=1,136), 57% were high grade and the distribution of subtypes was: 33% LA, 42% LB, 8% HER2E, and 16% TN (Table 1). Among different age groups (≤ 30, 31-35, and 36-40 years), there were no significant differences in molecular phenotype, tumor stage, tumor grade or histopathological features including presence of tumor necrosis, lymphocytic infiltration, and central fibrotic focus. 96% of women were tested for BRCA1 and BRCA2 germline mutations, and 127 (11%) tested positive: 65% were BRCA1+, and 35% were BRCA2+ (table 2). Among BRCA1+ patients, 2% of cancers were LA, 30% LB, 5% HER2E, and 62% TN; among BRCA2+, 29% were LA, 56% LB, 2% HER2E, and 13% TN. These proportions were relatively consistent across age groups. BRCA1+ patients’ tumors were proportionately more TN and BRCA2+ patients’ tumors more likely to be LB/HER2 negative (p Table 1. Subtype by age groupTotal (n=1136)≤30 yrs (n=144)31-35 yrs (n=314)36-40 yrs (n=678)p=0.42Luminal A-like377 (33%)48 (33%)99 (32%)230 (34%)Luminal B-like477 (42%)59 (41%)137 (44%)281 (41%)• ER/PR+, HER2-, grade 3245 (22%)27 (19%)68 (22%)150 (22%)• ER/PR+, HER2+232 (20%)32 (22%)69 (22%)131 (19%)HER2E95 (8%)13 (9%)34 (11%)48 (7%)Triple Negative187 (16%)24 (17%)44 (14%)119 (18%) Table 2. Subtype by BRCA statusTotal(n=1136)BRCA1+(n=82)BRCA2+(n=45)No mutation/not tested(n=1009)p Citation Format: Yaileen D Guzman-Arocho, Shoshana M. Rosenberg, Philip Poorvu, Kathryn J. Ruddy, Greg Kirkner, Craig Snow, Rulla M. Tamimi, Jeffrey Peppercorn, Lidia Schapira, Virginia F. Borges, Steven E. Come, Elena F. Brachtel, Ellen Warner, Ann H. Partridge, Laura C. Collins. Clinicopathological features and BRCA 1/2 status in a large prospective cohort of young women with breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-07-02.

Background: eTNBC remains at high risk for recurrence despite modern (neo)adjuvant chemotherapy. Immunotherapy with checkpoint inhibition is active in early and metastatic TNBC, and vaccines may further induce host immune response. PVX-410 (PVX, OncoPep) is a novel tetra-peptide vaccine with 3 of the 4 antigens (XBP1 [2 splice variants] and CD138) commonly overexpressed in TNBC. Here we present results from a phase1b study evaluating safety, tolerability and immune response of PVX and durvalumab (DUR) as adjuvant therapy in eTNBC. Methods: Eligibility for this phase 1b multi-center, single arm study included: HLA-A2+ female patients (pts) with TNBC and tumor size at least 1 cm or node positive; treatment with at least 4 cycles of adjuvant or neoadjuvant chemotherapy; completion of all planned therapy 1-6 months prior to study entry. Pts with local-regional recurrence without evidence of distant metastases treated with curative were also eligible. Pts received 6 doses of 800ug PVX (subcutaneously) emulsified in Montanide and co-administered with Hiltonol (IM) every 2 weeks, and 2 doses of 1500mg DUR (IV) concurrent with the 4th and 6th vaccine treatments. The study included a 6 pt run-in to assess for dose limiting toxicity (DLT), followed by a 14 pt expansion. Blood samples were collected for immune response assessment via flow cytometry at week 0 (Baseline) and at weeks 6, 10, 14, and 24 post-treatment. The primary objective was safety and tolerability. The key secondary objective was PVX specific immune response assessment defined at week 14 as a 2-fold or greater change over baseline in the proportion of CD3+CD8+ T cells that expressed IFNγ and the proportion of CD3+CD8+ T cells positive for PVX tetramers following an in vitro stimulation of PBMC with PVX peptides and a flow cytometric determination. Other immune response assessments included the proportion of CD3+CD8+ T cells expressing TNFα, IL-2, and CD137 following the in vitro peptide stimulation. Results: Among 22 pts enrolled, median age was 48 yrs (range 34-68) and anatomical stage at diagnosis was: Stage 1 = 1 (4.5%), Stage 2 = 14 (64%), and Stage 3 = 7 (32%). Among 20 pts evaluable for week 14 immune response, all planned PVX doses were given, and 1 DUR dose was held due to toxicity (tox). No DLTs were observed in the 6 pt run-in. The most common adverse events (all grades) include: injection site reaction (96%), flu-like symptoms, fatigue (41% each), arthralgia, pruritis (36% each), ALT elevation (32%), myalgia (27%), pain, diarrhea, AST and amylase elevation (23% each). One pt had grade 3 diarrhea and 1 pt had grade 3 hyponatremia, AST and ALT elevation. There were no grade 4 or 5 events. Immune response assessment for the first 12 pts are available at the time of abstract submission. Comparing baseline to week 14, 10 of 12 patients demonstrated a PVX specific immune response (as defined above). Immune response persisted in all patient samples tested at 6 months. Additionally, most pts tested to date had increases over baseline in the proportions of CD3+CD8+ T cells that expressed TNFα, IL-2, and CD137 following the in vitro stimulation with PVX peptides. Final immune response assessment in all 20 evaluable patients will be updated for presentation. At the time of data cut off (4/29/19), with a median follow up of 15.4 months, 4 of 22 (18%) pts had a local (1) or metastatic (3) recurrence and 2 (9%) have died. Conclusions: PVX plus DUR is safe and tolerable in pts with eTNBC with no new unexpected toxicities identified. Immune response data demonstrate that PVX induces antigen-specific T cell expansion and activation in these pts as observed by increases in PVX tetramer, IFNγ, TNFα, IL-2 and CD137 positive T cells. These immune responses to PVX persisted for up to 6 months in most patients, indicating a prolonged immune response. Citation Format: Steven J Isakoff, Sylvia Adams, Hatem H Soliman, Nadine Tung, William T Barry, Jiani Hu, Lorenzo Trippa, Rachel Deering, Joanne Parker, Hannah Park, Elena F Brachtel, Leif W Ellisen, Mariano Severgnini, Doris Peterkin, Sara M Tolaney. A phase 1b study of PVX-410 (PVX) vaccine plus durvalumab (DUR) as adjuvant therapy in HLA-A2+ early stage triple negative breast cancer (eTNBC) to assess safety and immune response [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-09-15.

Background Obtaining tumor-free margins is critical to prevent recurrence after lumpectomy for breast cancer. Unfortunately, current approaches leave positive margins that require second surgeries in 20–40% of patients. We assessed the LUM Imaging System for real-time, intraoperative detection of residual tumor. Methods Breast lumpectomy cavity walls and excised specimens were assessed with the LUM Imaging System after 1 mg/kg intravenous LUM015, a protease-activatable fluorescent agent. Fluorescence at potential sites of residual tumor in lumpectomy cavity walls was evaluated intraoperatively with a sterile hand-held probe, with real-time predictive results displayed on a monitor intraoperatively, and later correlated with histopathology. Results In vivo lumpectomy cavities and excised specimens were imaged after LUM015 injection in 45 women undergoing breast cancer surgery. Invasive ductal and lobular cancers and intraductal cancer (DCIS) were included. A total of 570 cavity margin surfaces in 40 patients were used for algorithm development. Image analysis and display took approximately 1 s per 2.6-cm-diameter circular margin surface. All breast cancer subtypes could be distinguished from adjacent normal tissue. For all imaged cavity surfaces, sensitivity for tumor detection was 84%. Among 8 patients with positive margins after standard surgery, sensitivity for residual tumor detection was 100%; 2 of 8 were spared second surgeries because additional tissue was excised at sites of LUM015 signal. Specificity was 73%, with some benign tissues showing elevated fluorescent signal. Conclusions The LUM015 agent and LUM Imaging System allow rapid identification of residual tumor in the lumpectomy cavity of breast cancer patients and may reduce rates of positive margins.

Objective: We aimed to assess the risk of malignancy (ROM) and predictive values in prior breast cytology studies as a basis for the new International Academy of Cytology (IAC) Yokohama system for reporting breast fine-needle aspiration biopsy (FNAB) cytology, which classifies cytologic diagnoses into 5 categories: (1) insufficient material, (2) benign, (3) atypical, (4) suspicious of malignancy, and (5) malignant. Study Design: Publications between January 1, 1997, and December 31, 2017, that studied the performance characteristics of FNAB from palpable and nonpalpable breast masses were identified through the PubMed database. Data for number of total cases and cases within each diagnostic category, if available, were collected. Performance characteristics, including absolute sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and ROM for each category were recorded or, when possible, calculated. Results: The literature review resulted in a case cohort of 33,341 breast FNABs, drawn from 27 studies. Pooling these cases together, the ROM for insufficient material, benign, atypical, suspicious, and malignant were 30.3, 4.7, 51.5, 85.4, and 98.7%, respectively. The complete sensitivity and specificity were 96.3 and 98.8%, correspondingly. The PPV and NPV were 98.7 and 95.3%, correspondingly. The false-negative and false-positive rates were 3.7 and 1.0%, respectively. Conclusions: This meta-analysis demonstrates that the diagnostic categories of the new IAC Yokohama System each carry an implied ROM, which increases from the benign to malignant categories. This study also shows the high sensitivity and specificity of FNAB for breast lesions.

The International Academy of Cytology (IAC) gathered together a group of cytopathologists expert in breast cytology who, working with clinicians expert in breast diagnostics and management, have developed the IAC Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy (FNAB) Cytology. The project was initiated with the first cytopathology group meeting in Yokohama at the 2016 International Congress of Cytology. This IAC Yokohama System defines five categories for reporting breast cytology, each with a clear descriptive term for the category, a definition, a risk of malignancy (ROM) and a suggested management algorithm. The key diagnostic cytopathology features of each of the lesions within each category will be presented more fully in a subsequent atlas. The System emphasizes that the crucial requirements for diagnostic breast FNAB cytology are a high standard for the performance of the FNAB and for the making of direct smears, and well-trained experienced cytopathologists to interpret the material. The performance indicators of breast FNAB, including specificity and sensitivity, negative predictive value, positive predictive value and ROM stated in this article have been derived from the recent literature. The current practice of breast FNAB has evolved with the increasing use of ultrasound guidance and rapid on-site evaluation. Two recent publications have shown a range of ROM for the insufficient/inadequate category of 2.6–4.8%, benign 1.4–2.3%, atypical 13–15.7%, suspicious of malignancy 84.6–97.1%, and malignant 99.0–100%. The management algorithm in the System provides options because there are variations in the management of breast lesions using FNAB and core-needle biopsy in those countries utilizing the “triple test” of clinical, imaging, and FNAB assessment, and also variations in the availability of CNB and imaging in low- and middle-income countries. The System will stimulate further discussion and research, particularly in the cytological diagnostic features of specific lesions within each category and in management recommendations. This will lead to continuing improvements in the care of patients with breast lesions and possible modifications to the IAC Yokohama System.

Objective: Differentiation between gynecomastia, a common cause of male breast enlargement, and breast cancer is crucial for appropriate management. Fine-needle aspiration biopsy has been shown to be sensitive and specific in assessing female breast lesions, comparable to core needle biopsy. Few such studies have been conducted in men. We assessed its diagnostic value in a male patient cohort. Study Design: Men who underwent fine-needle aspiration (FNA) for palpable breast lesions at Massachusetts General Hospital from January 2007 to December 2016 were evaluated. Clinical data, radiographic findings, and cytologic diagnoses of 74 breast FNA from 71 men were reviewed. Breast aspirates were classified as nondiagnostic, benign, atypical, suspicious for malignancy, or malignant. Histology was obtained in 37 cases, and clinical and radiological data were used as follow-up in 37 patients. Results: Most FNA biopsies (73%) were performed by cytopathologists, and 93.2% of the breast FNA in men were adequate; 58% showed benign processes, mostly gynecomastia (n = 22), and 28.4% (n = 21) were malignant, most often ductal carcinoma. No false-positive cytologies were obtained, and there was 1 false-negative cytology. In our study, FNA of palpable male breast lesions was 95.8% sensitive and 100% specific. Conclusions: FNA allows sensitive, specific, and safe evaluation and diagnosis of palpable male breast lesions.

A Woman with Back Pain and a Remote History of Breast Cancer A 68-year-old woman presented with back and pelvic pain. Twenty-five years earlier, she had received a diagnosis of invasive carcinoma o...

Breast neoplasia is accompanied by a heterogeneous micromechanical remodeling of the tumor landscape. Nevertheless, the role of these micromechanical heterogeneities in the progression of invasive breast carcinoma remains unclear. We have developed a novel optical tool, termed laser speckle microrheology (LSM) for micro-mechanical mapping of the tissue to investigate mechano-pathological features of breast cancer progression. Results reveal distinct micromechanical properties both between tumor of different diagnosis and within various regions of each tumor. Additionally, distinct stiffness gradients are observed at the interface of tumors with different invasive potential. Taken together, these findings identify key micromechanical features involved in breast cancer progression.

Desmoplastic stiffening of breast carcinoma is the bulk scale manifestation of the extra-cellular matrix (ECM) micromechanical remodeling during neoplastic transformation. We have developed a novel optical imaging technology, termed laser speckle micro-rheology (LSM) for evaluating the micro-mechanical properties of tissue and investigating the implications of the mechano-pathological phenomena to the disease progression. Here, we present a new enhancement to the LSM processing scheme to extract the optical properties from speckle patterns and correct for residual speckle modulations to quantify the shear viscoelastic modulus of breast tissues. By accounting for optical variations, we observed an increased significance in the shear moduli differences between benign lesions and tumors and also between tumors of different histological diagnosis.

The International Academy of Cytology (IAC) Yokohama System for Reporting Breast Fine Needle Aspiration Biopsy (FNAB) Cytology reporting system is an initiative of the IAC that seeks to provide a comprehensive, standardized approach to breast FNAB reporting to facilitate reproducible cytopathology reporting and to establish best practice guidelines. The system is evidence-based, supports a structured reporting format and will aid in maximizing the usefulness of the FNAB technique and optimizing communication with the clinical team and the patient.

We introduce a novel technology, termed laser speckle micro-rheology (LSM) that offers the unique capability to map the viscoelastic properties of the tissue microenvironment. This innovation will provide important insight into mechano-biology of disease progression.

PURPOSE: Based on improvement in pathologic complete response (pCR) in NeoSphere and TRYPHAENA studies, the FDA approved neoadjuvant pertuzumab for HER2+ localized breast cancer. These studies demonstrated high pCR rates with THP (docetaxel+HP), FEC (5-fluorouracil, epirubicin and cyclophosphamide)-THP, and TCHP (docetaxel, carboplatin+HP). However, in the United States, doxorubicin/cyclophosphamide (AC) is favored over FEC despite no data comparing neoadjuvant AC-THP with AC-TH or TCHP. Here we report outcomes for patients with localized HER2+ breast cancer treated with pertuzumab-containing neoadjuvant regimens and AC-TH. METHODS: We reviewed clinicopathological characteristics of patients with HER2+ breast cancer (Stage I-III) treated with either a neoadjuvant pertuzumab-containing regimen or dosedense (dd) AC-TH, from 2011 to 2016 at a large academic medical institution and two affiliated community sites. pCR was defined as ypT0/is ypN0. Fisher’s exact test and logistic regression analysis were used for statistical analysis. RESULTS: In this study (N = 121), pCR was numerically higher with pertuzumab based regimens, including ddAC-THP (60%), TCHP (63%), THP (55%), as compared with ddAC-TH (46%). THP resulted in significantly less cycle delays due to toxicity compared to the other regimens (p=0.02). THP also resulted in the least dose reductions, lowest rate of hospitalization, and lowest rate of treatment discontinuation. CONCLUSIONS: Pertuzumab based regimens, including THP, resulted in higher pCR rates as compared to ddAC-TH, with the THP regimen associated with the best tolerability among patients with localized HER2+ breast cancer. Given the various neoadjuvant regimens, additional studies are needed to determine optimal treatment sequencing and escalation/de-escalation strategies to personalize neoadjuvant regimens for localized HER2+ breast cancer.

Background: Obtaining tumor-free margins is critical for local control in breast conserving surgery. Currently, 20-40% of lumpectomy patients have positive margins that require surgical re-excision. We assessed the LUM Imaging System for real-time, intraoperative detection of residual tumor in breast cancer patients. The LUM System has the particular advantage of assessing in vivo lumpectomy cavity walls rather than excised specimens, to enable more accurate excision of residual tumor. Methods: Lumpectomy cavity walls of patients undergoing lumpectomy for invasive breast cancer or ductal carcinoma in situ (DCIS), were assessed intraoperatively using the LUM Imaging System (Lumicell Inc., Wellesley MA). LUM015, a cathepsin-activatable fluorescent agent, was given IV 4±2 hrs prior to surgery. Areas of fluorescence generated at potential sites of residual tumor in lumpectomy cavities were evaluated with a sterile hand-held device, displayed on a monitor, excised and correlated with histopathology. Results: In vivo lumpectomy cavities were imaged with the LUM Imaging System in 60 breast cancer patients. 5 were imaged without dye. 55 received LUM015 dye preoperatively and were scanned intraoperatively. Median age was 60 years (range 44-79). Mean tumor size was 1.2cm (0.06-3.5cm) with 71% invasive cancers, 29% DCIS. The test set included 569 cavity margin surfaces assessed intraoperatively and excised. Image acquisition for each margin took approximately 1 second. The LUM Imaging System showed 100% sensitivity and 73% specificity for detection of tumor Conclusions: The LUM Imaging System allows real-time identification of residual tumor in the lumpectomy cavity of breast cancer patients. No sites of residual tumor were missed. Additional studies are underway to optimize this approach for reducing positive margins and second surgeries in breast cancer patients. Table: Margin results in 8 patients with positive margins on initial lumpectomy specimenPositive lumpectomy margin histopathologyLUM cavity wall result (+/- for tumor)Tumor found at re-excisionDCIS++DCIS+-DCIS++IDC++ (Mastectomy)ILC++ (Mastectomy)DCIS+-IDC--DCIS-- Citation Format: Lanahan CR, Gadd MA, Specht MC, Ferrer J, Tang R, Rai U, Merrill AL, Biernacka A, Brachtel E, Smith BL. Real-time, intraoperative detection of residual breast cancer in lumpectomy cavity margins using the LUM imaging system: Results of a feasibility study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-05.

Metastases undergo reconstruction Cancer cells from primary tumors can migrate to regional lymph nodes and distant organs. The prevailing model in oncology is that lymph node metastases give rise to distant metastases. This “sequential progression model” is the rationale for surgical removal of tumor-draining lymph nodes. Naxerova et al. used phylogenetic methods to reconstruct the evolutionary relationship of primary tumors, lymph node metastases, and distant metastases in 17 patients with colorectal cancer (see the Perspective by Markowitz). The sequential progression model applied to only one-third of the patients. In the other two-thirds, distant metastases and lymph node metastases originated from independent subclones within the primary tumor. Science , this issue p. 55 ; see also p. 35

Introduction: Tumor heterogeneity presents a significant impediment to identifying appropriate treatments for patients. Genetic mutations and hormone receptors are frequently used as a guide for selecting appropriate targeted or hormonal therapies, however it is possible that these markers may change over time, leading to reduced effectiveness of these treatments. In this study, we review the results of serial and paired biopsies to identify receptor switch in estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status as well as to identify changes in clinically relevant mutations, including spatial and temporal heterogeneity. Methods: We identified a total of 237 patients initially presenting with ER+/HER2 negative breast cancer and who had multiple biopsies during the course of their treatment, including at least one in the metastatic setting. ER, PR, and HER2 status for each of these serial biopsies was gathered from chart reviews. HER2 results by both IHC and FISH were collected. PIK3CA mutations were also assessed by Snapshot utilizing multiplexed PCR of common hotspot mutations using DNA derived from formalin-fixed, paraffin-embedded (FFPE) tissue. Results: From a total of 213 patients with known ER status for multiple serial biopsies, we identified 9.4% (N=20) who had at least one change in ER status over time. From a total of 198 patients who had documented PR status for multiple biopsies, 40.4% (N=80) had at least one change in PR status. Changes in HER2 status were similarly assessed, with 6.7% of patients having at least one change by IHC and 4.4% of patients having at least one change by FISH. Of those patients exhibiting changes in ER status, 6 were noted to have multiple changes over time. Of those with changes in PR status, 18 had multiple changes over time. Changes in hormone receptor status were also noted to occur between serial biopsies in the metastatic setting. A total of 128 patients had ER results available for multiple metastatic specimens, of which 8.6% (N=11) had at least one change in ER status. A total of 116 patients had PR results available for multiple metastatic biopsies, of which 38.8% (N=45) had at least one change in PR status. Changes were also noted in the metastatic setting in HER2 (IHC) with a frequency of 8.7% and in HER2 (FISH) with a frequency of 4.7%. A subset of 108 patients were identified as harboring a mutation in PIK3CA. Within this population, 9.6% of patients had at least one change in ER status over time and 34.1% had at least one change in PR status. 9.0% exhibited at least one change in HER2 (IHC) and 6.5% in HER2 (FISH). Serial changes in genotype, from pre- and post-treatment biopsies, were also detected using NGS based Foundation Medicine platform, including acquired alterations in the ESR1 and PI3K pathway. Conclusion: Serial changes in hormone receptor status and mutation profile are not uncommon among patients initially diagnosed with ER+/HER2 negative breast cancer, and some patients have been noted to have multiple changes over time. Further studies are needed to understand the mechanistic underpinnings governing the emergence of these alterations and their relationship to therapeutic resistance in breast cancer. Citation Format: Henderson L, Brachtel E, Fitzgerald D, Gadd M, Specht M, Thabet A, Gurski J, Sgroi D, Moy B, Isakoff S, Bardia A, Juric D. Serial evolution of hormone receptor status and mutational profile among patients with metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-06-03.

The purpose of this study was to determine (a) the frequency of apocrine metaplasia (ApoM) found on MR core biopsy of suspicious findings, and (b) to determine if there are specific MR imaging features that might obviate the need for biopsy. This HIPAA-compliant retrospective study was performed under IRB exemption for quality assurance studies. Patient demographics, MR imaging features, and pathology were reviewed. Breast lesions which underwent MR-guided biopsy, yielding ApoM on pathology analysis were included. Retrospective review of MR imaging features of these lesions was performed by two radiologists blinded to pathology results except for the presence of ApoM. Imaging features on MR assessed included location, size, morphology, T1 and T2 signals, and enhancement kinetics. Full pathology results were subsequently reviewed during data analysis. The pathology slides and imaging was subsequently reviewed by two fellowship trained radiologists and a breast pathologist to categorize the finding of ApoM into target lesion (imaging corresponds to size of lesion on pathology) versus incidental lesion. Target lesion characteristics were assessed to determine specific MRI features of ApoM. Between January 2011 to November 2012, 155 distinct breast lesions suspicious for malignancy successfully underwent MR-guided biopsy. Of the 155 lesions biopsied, 123 (79%) were benign and 32 (21%) were malignant. Of the 123 benign biopsies, ApoM was found in 57 (46%), of which 35 (61%) had no associated atypia and 22 (39%) had associated atypia. Of the 32 malignant biopsies, three (9%) had associated ApoM (DCIS in two cases and DCIS/LCIS in one case). Of the 60 cases with ApoM, only 11 (18.3%) were target lesions and 49 were incidental lesions (81.7%). Of the 60 cases with ApoM, 35 (58%) were masses (average size 0.8 cm for both with or without atypia) and 25 (42%) were nonmass enhancement (NME) (average size 2.1 cm with and 1.0 cm without atypia). Only five (14%) of 35 masses demonstrated spiculated margins, of which four were associated with atypia (80%). Of 22 lesions with atypia or other high-risk lesion, 14 (64%) were masses, most commonly with irregular margins (64%). Of the 12 T2 hyperintense lesions, only two (1.7)% had associated atypia or high-risk lesion, and none were associated with malignancy. Of the 11 target lesions, seven were T2 hyperintense. Enhancement kinetics were variable: 30 (50%) showed mixed persistent and plateau kinetics, eight (13%) persistent delayed enhancement, 10 (17%) plateau kinetics, four (7%) washout kinetics, and eight (13%) were below threshold for kinetic analysis. ApoM is a common benign pathologic result at MR-guided core biopsy for both masses and NME accounting for 39% of all biopsy results in this series. Although there is considerable variability in imaging characteristics on MR, our results suggest biopsy may be safely obviated for lesions that are subcentimeter T2 hyperintense areas of NME and short term follow-up imaging may be a reasonable alternative for these lesions.

Background Extending the duration of adjuvant endocrine therapy reduces the risk of recurrence in a subset of women with early-stage hormone receptor-positive (HR+) breast cancer. Validated predictive biomarkers of endocrine response could significantly improve patient selection for extended therapy. Breast cancer index (BCI) [HOXB13/IL17BR ratio (H/I)] was evaluated for its ability to predict benefit from extended endocrine therapy in patients previously randomized in the Adjuvant Tamoxifen—To Offer More? (aTTom) trial. Patients and methods Trans-aTTom is a multi-institutional, prospective–retrospective study in patients with available formalin-fixed paraffin-embedded primary tumor blocks. BCI testing and central determination of estrogen receptor (ER) and progesterone receptor (PR) status by immunohistochemistry were carried out blinded to clinical outcome. Survival endpoints were evaluated using Kaplan–Meier analysis and Cox regression with recurrence-free interval (RFI) as the primary endpoint. Interaction between extended endocrine therapy and BCI (H/I) was assessed using the likelihood ratio test. Results Of 583 HR+, N+ patients analyzed, 49% classified as BCI (H/I)-High derived a significant benefit from 10 versus 5 years of tamoxifen treatment [hazard ratio (HR): 0.35; 95% confidence interval (CI) 0.15–0.86; 10.2% absolute risk reduction based on RFI, P = 0.027]. BCI (H/I)-low patients showed no significant benefit from extended endocrine therapy (HR: 1.07; 95% CI 0.69–1.65; −0.2% absolute risk reduction; P = 0.768). Continuous BCI (H/I) levels predicted the magnitude of benefit from extended tamoxifen, whereas centralized ER and PR did not. Interaction between extended tamoxifen treatment and BCI (H/I) was statistically significant (P = 0.012), adjusting for clinicopathological factors. Conclusion BCI by high H/I expression was predictive of endocrine response and identified a subset of HR+, N+ patients with significant benefit from 10 versus 5 years of tamoxifen therapy. These data provide further validation, consistent with previous MA.17 data, establishing level 1B evidence for BCI as a predictive biomarker of benefit from extended endocrine therapy. Trial registration ISRCTN17222211; NCT00003678.

The extra-cellular matrix (ECM) of the tissue significantly remodels during both development and disease. This is often perceived by the apparent changes to the bulk stiffness of the tissue. Nevertheless, the ECM micromechanical alterations and their implications to normal development and pathogenies remain poorly understood, largely due to the absence of high-resolution imaging tool for mapping the ECM stiffness at length scales sensed by cells. We have developed a novel optical imaging technology, termed laser speckle micro-rheology (LSM) that offers the unique capability to map the micro-mechanical properties of ECM, within the tissue. In LSM, the specimen is illuminated by a coherent laser beam and back-scattered speckle patterns are acquired by a high-speed camera. Spatio-temporal analysis of speckle frames yields the map of viscoelastic modulus, G. Here we demonstrate the capability of LSM for micro-mechanical mapping of the tissue through imaging a micro-structured phantoms and a normal human breast tissue specimens. These results open new avenues for investigating the mechano-biological mediators of disease and development in the future.

Breast MRI is the most sensitive imaging modality for assessment of the nipple-areola complex (NAC), which is important both in cancer staging and in high-risk screening. However, the normal appearance of the nipple at MRI is not well defined because of a paucity of scientific literature on this topic. Hence, there is a lack of descriptive terminology and diagnostic criteria, which may account for the wide variability in interpretation among radiologists when assessing the NAC on MR images. In light of the current shift toward possible expanded use of abbreviated (ie, fast) breast MRI for screening in women at average risk for cancer in particular, and because an increasing number of women now undergo nipple-sparing mastectomy for therapeutic and/or prophylactic indications, careful assessment of the NAC at MRI is essential. In this article, the normal pattern of nipple enhancement at MRI is defined on the basis of findings observed in healthy individuals, normal nipple enhancement at MRI is correlated with the structural anatomy of the nipple at histopathologic analysis, and artifacts and pitfalls related to MRI of the NAC are reviewed. Understanding the normal range of nipple morphology and enhancement at MRI is important, as it enables radiologists to better differentiate between normal and abnormal nipple findings with increased diagnostic confidence. ©RSNA, 2018 See discussion on this article by Cohen and Holbrook .

Fine needle aspiration (FNA) is increasingly being supplanted by core needle biopsy. However, breast surgeons continue to rely on FNA at our institution. This retrospective study evaluated breast FNA for its diagnostic accuracy and breast cancer biomarker testing utility. All breast FNAs performed at Massachusetts General Hospital 2009–2015 were reviewed. Cytology diagnoses were compared with subsequent tissue or clinical diagnoses. Immunohistochemistry and fluorescence in situ hybridization (FISH) results using formalin-fixed paraffin-embedded (FFPE) cell blocks and histologic tissue blocks were compared. 1654 consecutive breast FNAs were included. Breast FNA demonstrated the following diagnostic performance: positive predictive value of malignant cytology diagnosis 100 %, negative predictive value of benign cytology diagnosis 97.5 %, complete sensitivity 91.6 %, and specificity 95.5 %. Concordance rates for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) immunohistochemistry, and HER2 FISH were 98.2 % (κ = 0.95, p

When a nipple margin of a nipple-sparing mastectomy (NSM) contains malignancy, current practice includes removal of the nipple or nipple areola complex (NAC). We evaluated rates and trends of positive nipple margins, subsequent management, and oncologic outcomes.A retrospective chart review of all NSM at our institution from 2007 to 2014 was performed. A descriptive analysis was performed of patients with positive nipple/subareolar margins.Among 1,326 NSM, 43 of 642 (6.7%) therapeutic and 3 of 684 (0.4%) prophylactic NSM had positive nipple margins. Nipple or NAC excision was performed for 39 of 46 (85%) positive nipple margins: 20 of 39 (51%) had nipple only and 19 of 39 (49%) had the entire NAC excised. Practice evolved to remove only the nipple and retain the areola for positive nipple margins: in 2007 to 2011, 7 of 17 (41%) underwent nipple-only excision compared with 14 of 22 (64%) in 2012 to 2014. Among 39 excised nipples/NAC, 28 (72%) contained no residual malignancy, while 8 contained ductal carcinoma in situ (DCIS), 2 had invasive lobular carcinoma, and 1 had invasive ductal carcinoma. With experience, rates of positive nipple margins for therapeutic NSM decreased from 11% (17 of 160) in 2007 to 2011 to 5.4% (26 of 482) in 2012 to 2014 (p0.05). At 36 month median follow-up, there were no recurrences in the nipple/NAC.Early results suggest that excision of the nipple with retention of the areola is a safe approach for management of a positive nipple margin after NSM. With experience, low rates of positive nipple margins are possible in therapeutic NSM. Overall risk of nipple/NAC recurrence after NSM remains extremely low.

// Elena F. Brachtel 1 , Theresa N. Operana 2 , Peggy S. Sullivan 3 , Sarah E. Kerr 4 , Karen A. Cherkis 2 , Brock E. Schroeder 2 , Sarah M. Dry 3 and Catherine A. Schnabel 2 1 Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA 2 Biotheranostics, Inc., San Diego, California, USA 3 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA 4 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA Correspondence to: Elena F. Brachtel, email: // Keywords : gene expression profiling, biological markers, molecular targeted therapy, cytology, clinical oncology Received : March 18, 2016 Accepted : March 20, 2016 Published : March 28, 2016 Abstract Background: Detailed molecular evaluation of cytology and limited tissue samples is increasingly becoming the standard for cancer care. Reproducible and accurate diagnostic approaches with reduced demands on cellularity are an ongoing unmet need. This study evaluated the performance of a 92-gene assay for molecular diagnosis of tumor type/subtype in cytology and limited tissue samples. Methods: Clinical validation of accuracy for the 92-gene assay in limited tissue samples such as cytology cell blocks, core biopsies and small excisions was conducted in a blinded multi-institutional study (N = 109, 48% metastatic, 53% grade II and III). Analytical success rate and diagnostic utility were evaluated in a consecutive series of 644 cytology cases submitted for clinical testing. Results: The 92-gene assay demonstrated 91% sensitivity (95% CI [0.84, 0.95]) for tumor classification, with high accuracy maintained irrespective of specimen type (100%, 92%, and 86% in FNA/cytology cell blocks, core biopsies, and small excisions, respectively; p = 0.26). The assay performed equally well for metastatic versus primary tumors (90% vs 93%, p = 0.73), and across histologic grades (100%, 90%, 89%, in grades I, II, and III, respectively; p = 0.75). In the clinical case series, a molecular diagnosis was reported in 87% of the 644 samples, identifying 23 different tumor types and allowing for additional mutational analysis in selected cases. Conclusions: These findings demonstrate high accuracy and analytical success rate of the 92-gene assay, supporting its utility in the molecular diagnosis of cancer for specimens with limited tissue.

Genome-wide-association studies (GWAS) have identified numerous single nucleotide polymorphisms (SNPs) that are associated with an increased risk of breast cancer. Most of these studies were conducted primarily in postmenopausal breast cancer patients. Therefore, we set out to assess whether or not these breast cancer variants are also associated with an elevated risk of breast cancer in young premenopausal patients.In 451 women of European ancestry who had prospectively enrolled in a longitudinal cohort study for women diagnosed with breast cancer at or under age 40, we genotyped 44 SNPs that were previously associated with breast cancer risk. A control group was comprised of 1142 postmenopausal healthy women from the Nurses' Health Study (NHS). We assessed if the frequencies of the adequately genotyped SNPs differed significantly (p≤0.05) between the cohort of young breast cancer patients and postmenopausal controls, and then we corrected for multiple testing.Genotyping of the controls or cases was inadequate for comparisons between the groups for seven of the 44 SNPs. 9 of the remaining 37 were associated with breast cancer risk in young women with a p-value0.05: rs10510102, rs1219648, rs13387042, rs1876206, rs2936870, rs2981579, rs3734805, rs3803662 and rs4973768. The directions of these associations were consistent with those in postmenopausal women. However, after correction for multiple testing (Benjamini Hochberg) none of the results remained statistically significant.After correction for multiple testing, none of the alleles for postmenopausal breast cancer were clearly associated with risk of premenopausal breast cancer in this relatively small study.