Purpose Discordances between the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2), expression between primary breast tumors and their subsequent brain metastases (BM) were investigated in breast cancer patients. Methods We collected retrospective data from 11 institutions in 8 countries in a predefined-standardized format. Receptor status (positive or negative) was determined according to institutional guidelines (immunohistochemically and/or fluorescence in situ hybridization). The study was subject to each institution’s ethical research committee. Results A total of 167 breast cancer patients with BM were included. 25 patients out of 129 with a complete receptor information from both primary tumor and BM (ER, PR, HER2) available, had a change in receptor status: 7 of 26 (27%) ER/PR-positive/HER2-negative primaries (3 gained HER2; 4 lost expression of ER/PR); 10 of 31 (32%) ER/PR-positive/HER2-positive primaries (4 lost ER/PR only; 3 lost HER2 only; 3 lost both ER/PR and HER2); one of 33 (3%) ER/PR-negative receptor/HER2-positive primaries (gained ER); and 7 of 39 (18%) triple-negative primaries (5 gained ER/PR and 2 gained HER2). Conclusions The majority of breast cancer patients with BM in this series had primary HER2-enriched tumors, followed by those with a triple-negative profile. One out of 5 patients had a receptor discrepancy between the primary tumor and subsequent BM. Therefore, we advise receptor status assessment of BM in all breast cancer patients with available histology as it may have significant implications for therapy.

Purpose:Recently an ultrafast automatic planning system for breast irradiation using tangential beams was developed by modeling relationships between patient anatomy and achieved dose distribution. This study evaluates the performance of this system when applied to a different patient population and dose calculation algorithm.Methods:The system and its anatomy‐to‐dose models was developed at institution A based on 20 cases, which were planned using manual fluence painting technique and calculated WITH heterogeneity correction. Institution B uses field‐in‐field planning technique and dose calculation WITHOUT heterogeneity correction. 11 breast cases treated at Institution B were randomly selected for retrospective study, including left and right sides, and different breast size (irradiated volumes defined by Jaw/MLC opening range from 875cc to 3516cc). Comparisons between plans generated automatically (Auto‐Plans) and those used for treatment (Clinical‐Plans) included: energy choice (single/mixed), volumes receiving 95%/100%/105%/110% Rx dose (V95%/V100%/V105%/V100%) relative to irradiated volume, D1cc, and LungV20Gy.Results:In 9 out of 11 cases single/mixed energy choice made by the software agreed with Clinical‐Plans. For the remaining 2 cases software recommended using mixed energy and dosimetric improvements were observed. V100% were similar (p=0.223, Wilcoxon Signed‐Rank test) between Auto‐Plans and Clinical‐Plans (57.6±8.9% vs. 54.8±9.5%). V95% is 2.3±3.0% higher for Auto‐Plans (p=0.027), indicating reduced cold areas. Hot spot volume V105% were significantly reduced in Auto‐Plan by 14.4±7.2% (p=0.004). Absolute V105% was reduced from 395.6±359.9cc for Clinical‐Plans to 108.7±163cc for Auto‐Plans. D1cc was 107.4±2.8% for Auto‐Plans, and 109.2±2.4% for Clinical‐Plans (p=0.056). LungV20Gy were 13.6±4.0% for Auto‐Plan vs. 14.0±4.1% for Clinical‐Plans (p=0.043). All optimizations were finished within 1.5min.Conclusion:The performance of this breast auto‐planning system remained stable and satisfactory when applied to a different patient population and dose calculation algorithm. The auto‐planning system was able to produce clinically similar Rx dose coverage with significantly improved homogeneity inside breast tissue, in less than 1.5min.

Despite availability of standard cancer therapies such as radiation, it is known that presence of metabolic profiles such as obesity and diabetes leads to worse outcomes. Studies have shown that caloric restriction can provide clinical benefit in patients with altered metabolism. Previously, our laboratory has shown that caloric restriction (CR) can augment the response of tumors to irradiation (IR) in aggressive breast cancer models. However, the molecular underpinnings associated with improved response have yet to be elucidated. We sought to determine if CR and IR caused significant alterations in metabolomic profiles. Forty BALB/c mice received orthotopic injections of a highly metastatic luciferase tagged breast cancer cell line (4T1). Once primary tumors were palpable, mice were treated with one of 4 conditions: ad libitum (AL) diet, 8 Gy IR to the primary tumor, 30% reduction in calories (CR), and CR + IR. Serum was collected from the mice at 28 days and 40 days after tumor injection. Targeted metabolomic profiling was performed using liquid chromatography/mass spectrometry (LC/MS) and a Biocrates p180 kit, which can assess 180 metabolites including amino acids, biogenic amines, acyl carnitines, glycerophospholipids, and sphingomyelins. Mathematical modeling was used to identify alterations in tumor regression curves among the different treatment groups. Metabolic profiling revealed significant differences in patterns for each treatment group. Clustering of each treatment group was highly correlated at 28 days but less so at 40 days after tumor injection, which correlated with mathematical modeling of tumor regression curves. Two polyamines, spermine and spermidine, were amongst the metabolites most significantly contributing to the metabolic signature differences among the treatment groups. IR increased serum polyamines 40 days after tumor initiation (p = 0.04), which was dampened in mice also treated with CR. Distinct metabolic profiles were identified between mice treated with CR, IR or a combination. Of the metabolites identified, the polyamines spermine and spermidine contributed to variability. Polyamines are shown to stabilize DNA and protect against reactive oxygen species. Although IR increased polyamine levels, the addition of CR resulted in decreased magnitude of elevation of the polyamines in our breast cancer model, which suggests they may play a role in the radiosensitization that we have seen in our model when CR is added to IR. Moreover, the observed differences of the metabolite patterns amongst the different treatment group at distinct time points suggests a potential role for these metabolites in monitoring treatment response in breast cancer.

Aim: The primary aim in the management of DCIS is the prevention of ipsilateral and contralateral invasive tumors. African American (AA) women and younger age experience a higher incidence of disease recurrence and worse overall survival. The use of endocrine treatment significantly reduces recurrence rate and contralateral disease in hormone receptor positive (HR+) DCIS, but with significant costs and side effects. We analyzed the efficacy of tamoxifen (TAM) as preventive strategy and outcome according to age and ethnicity in DCIS patients.

Triple negative breast cancers (TNBC) are an aggressive subset of breast cancers associated with poor prognosis. They are often resistant to standard treatments and are associated with low or null PTEN, a known tumor suppressor protein. EZH2 is the catalytic subunit of the polycomb repressive complex 2 (PRC2), which is a highly conserved histone methyltransferase. Overexpression of EZH2 has been found in a wide range of cancers and is thought to be an epigenetic driver of disease. The primary activity of the EZH2 protein complex is to trimethylate histone H3 lysine 27 (H3K27) at target gene promoters, leading to epigenetic silencing of tumor suppressor genes, including PTEN. We hypothesize that caloric restriction (CR) can induce epigenetic reprogramming in triple negative breast cancers through EZH2-mediated pathways, and that this change can be harnessed to augment existing standard therapies. An in vivo syngeneic murine model of TNBC was utilized to assess the effect of caloric restriction on EZH2 mediated pathways. The highly metastatic 4T1 cell line was injected into the mammary fat pads of Balb/c mice. Once tumors nodules were palpable, mice were exposed to an ad libitum diet (AL), radiation therapy (RT+AL), caloric restriction (CR, 30% reduction of calories) or RT+CR. Tumors from each condition were measured grossly and evaluated for proliferation (Ki-67), apoptosis (Caspase-3), EZH2, and PTEN. To confirm activity of EZH2 signaling pathways in a triple-negative model, we transfected siRNA of EZH2 in a triple negative MDA-MB-468 cell line and measured downstream trimethylated H3K27 levels. Tumor regression was noted in mice undergoing both RT and CR, and the combination of the two interventions appeared synergistic. EZH2 expression was also decreased with either intervention and was further decreased with the combination of RT+CR. Conversely, PTEN expression was inversely related to EZH2 levels and significantly increased with combination treatment. In our in vitro model, siRNA mediated knockdown of EZH2 was noted to significantly decrease trimethylated histone H3 lysine 27, confirming epigenetic-mediated changes in triple negative breast cancer by EZH2. CR and RT+CR treatment groups were also associated with significantly lower Ki-67 indices and increased cleaved caspase-3 expression. Due to the poor outcomes associated with triple negative breast cancers, novel approaches to safely augment existing treatments are necessary. EZH2-mediated pathways appear to be an attractive therapeutic target due to its interaction with multiple oncogenic pathways. We have demonstrated that the combination of RT and CR may induce reversible epigenetic silencing by EZH2-mediated pathways of key tumor suppressor genes such as PTEN, suggesting a potential therapeutic benefit in triple negative breast cancer.

Breast conservation therapy (BCT) is commonly adopted with the reasoning that breast preservation leads to improved cosmetic outcomes and a better quality of life. There is limited data directly comparing long-term cosmetic outcomes between BCT vs modified radical mastectomy (MRM) with reconstruction. Breast irradiation is associated with a number of potential cosmetic side effects, many of which may present later in life. We sought to assess late cosmesis and quality of life from the National Cancer Institute (NCI) randomized trial of BCT vs MRM. Two hundred forty-seven patients with Stage I or II invasive breast cancer were randomized from 1979-1987 at the NCI to either MRM or BCT. With a median follow-up time of 25.7 years, 102 of the 237 patients were alive following treatment. A total of 56 patients (28 patients in the MRM and 28 patients in BCT group) were available for evaluation. All patients in the MRM arm were offered reconstruction and none received post-MRM radiation. Patients underwent a modified LENT-SOMA assessment with measurement of telangiectasias, fibrosis, lymphedema, and skin changes. Breast-related surgeries after initial treatment were analyzed, including reconstruction, augmentation, and surgical management of IBTRs. Breast asymmetry was determined with a radiologist blinded to treatment arms measuring soft tissue differences between treated region and contralateral breast. Quality of life measures included satisfaction, regret, and future reconstruction plans. Patients in the BCT group had increased fibrosis (92.3% vs 28.6%, p < 0.001) and hyperpigmentation (30% vs 1%, p = 0.02) vs patients receiving MRM, although no grade 3 or higher toxicities were found in either group. Patients in the MRM group had nearly twice the amount of surgical procedures following initial treatment (0.96 in BCT vs 2.2 in MRM). Only one patient experienced long-term complications of lymphedema in either group. Breast asymmetry was not statistically different, with average breast difference of 3.3 cm in BCT patients, and breast mound difference of 2.3 cm in MRM patients (p = 0.20). There was no statistical difference in overall satisfaction (93% in BCT vs 85% in MRM, p = 0.057) regret (31.0% in BCT vs 33.3% in MRM, p = 0.64) or desire for further reconstruction (34.5% in BCT vs 29.6% in MRM, p = 0.71). With extended follow-up of over 25 years, there does not appear to be significant differences in cosmetic outcomes and quality of life measurements between BCT and MRM. An increased number of radiation-associated toxicities were noted to be offset by surgical morbidity (ie increased number of surgeries). Future studies will need to focus on the long-term sequelae of newer radiation techniques such as hypofractionation and accelerated partial breast radiation.

Purpose: To explore whether tumor biomarkers and pre-treatment factors correlate with treatment outcome in patients with oropharyngeal squamous cell carcinoma (S CC).Methods: Fifty-seven consecutive patients diagnosed with oropharyngeal SCC were treated using intensity modulated radiotherapy (IMRT). Thirty-four (60%) patients were treated with definitive chemoradiotherapy to a median total dose of 70 Gy and 23 (40%) were treated with postoperative RT to a median total dose of 66 Gy. Concurrent platinum-based chemotherapy was used in 51 patients (90%) and cetuximab in 3 (5%) patients.Results: Forty-four (77%) cases were positive and 13 (23%) were negative for p16 expression. Eighty-eight percent of non-smokers, 87% of smokers in their remote past and 56% of active smokers were diagnosed with p16-positive cancer. After 22 months median follow up, 51(89%) patients were alive. Forty-five (77%) patients were without evidence of disease at their last follow up, 82% of the patients with p16-positive tumors vs 58% of those with p16-negative cancer, respectively (p= 0.04). Locoregional disease-free survival was 82% for the entire cohort, 91% for patients treated postoperatively and 76% for patients treated with definitive chemoradiotherapy. Five (9%) patients developed distant metastases, and 3 (5%) developed new malignancies. One third of the patients with pre-RT hemoglobin level of 11 g/dL experienced persistent/recurrent disease; 80% of patients with hemoglobin <= 11 g/dL were smokers and 42% had p16-negative tumors.Conclusions: Smoking, p16 expression and pre-RT anemia are interrelated and influence outcome in oropharyngeal cancer patients and should be evaluated as stratifying variables in further clinical trials.

Purpose: Target motion requires a large treatment margin, causing normal tissue toxicity and limiting dose acceleration to the target in stereotactic body radiotherapy (SBRT). 4DRT with motion tracking promises maximal sparing of normal tissue, but demands ∼10-fold increase of planning workload and/or new planning tools, such as deformable image registration, based on 4DCT. We proposed a simplified 4DRT strategy via CT simulation (3.5D) of motion-compensated target for 3D planning. Methods: Four patients' 4DCT images were used to synthesize the 3.5DCT by aligning the target in all respiratory phases and then averaging these CTs, mimicking a CT acquired using a target motion-compensating platform under the patient on CT couch. A custom-built 3D treatment planning system (3D-TPS) was employed and two new tools were developed for synthesizing the 3.5DCT and an integrated dose-volume histogram (iDVH) based on multi-phase plans. A 3mm margin was applied to the GTV to form the PTV. Dosimetry evaluation of the 4DRT plans was based on the iDVH and 3.5D DVH. Results: The 3.5DCT-based and 4DCT-based planning produced similar DVH and iDVH to the PTV, while the DVH may slightly over-estimate the dose to normal tissues, since the motion blurring may not fully account for the effect of moving normal tissues into and out of the beam fields. The artificially blurred image may also affect the accuracy of the 3.5D DVH to the normal tissues. However, the 10-fold workload reduction is clinically significant. If any critical structure is in the motion direction and within the motion range (∼2 cm), verification should be conducted based on each phase CT. Conclusion: The 3.5DCT-based 4DRT planning with a motion-free target shows equivalency and simplicity, comparing to 4DCT-based plans. It reduces the 4D planning workload substantially by using the 3.5DCT with 3D-TPS and eliminates the need for deformable image registration.

Purpose: A major obstacle to achieve motion-tracking 4DRT for optimal therapeutic ratio is 4D planning, which requires planning in multi-phase CTs and maps dose distributions to a reference CT via deformable image registration. A simplified 3.5D approach was studied, in which a 3.5DCT is acquired using a motion-tracking platform on CT couch, providing a motion-free target for 3D planning. Methods: A customized phantom (C-phantom) was mounted on a Quasar mobile phantom (Q-phantom)♯, which served as a motion-tracking platform. A Teflon ball (diameter=2.54cm) was used to mimic a moving target with a sinusoidal waveform (period=6.70s) and multiple motion ranges. Mobile and stable control balls were used. The dual phantom system was placed on CT and RT couches for 3.5D/4D simulation and delivery. Eclipse planning system was used for 3D planning with 8-mm margin based on the 3.5DCT. The EPID was used for IGRT setup, and two radiochromic films (in the ball and on the couch) were utilized for measuring 2D dose distribution from a lateral beam orthogonal to the motion. Results: Both 3.5DCT and 4DCT were acquired. For fully-compensated ball, the 3.5DCT appeared similar to that of stable ball, while for under-compensated ball, the 3.5DCT contained a residual motion as the net motion. Phase-shifts (18°&36°) produced residual motion artifacts. 4D delivery of the 3.5DCT-based plan showed excellent dose conformality, comparing to that of stable ball. A proper margin is needed in case of residual motions. This approach simplified 4DRT as 3.5D simulation, 3D planning and 4D delivery. Conclusion: This 3.5D approach to 4DRT is demonstrated to be feasible, provided that the 3.5DCT simulation could produce a stable target. The motion-free target allows 3D planning, reducing the 4D planning workload substantially. ♯ The authors thank Drs. Nesrin Dogan and Mihaela Ruso at VCU Massey Cancer Center for landing the Quasar phantom.

Dietary calcium is well known to decrease gastrointestinal lead absorption and thereby reduce the risk for lead poisoning. Because children in economically deprived urban centers are especially likely to have excessive lead exposure, we surveyed dietary calcium intakes of 314 children from the greater Newark, New Jersey, area. The areas of Newark and adjacent communities studied had been previously identified as containing significant sources of environmental lead by geographic information systems technology. An abbreviated National Cancer Institute Health Habits and History Questionnaire, modified to focus on foods high in calcium, was used to determine dietary calcium. Calcium intakes were then compared to the new Dietary Reference Intake (DRI) guidelines. The respondents were primarily the parents of African-American and Hispanic children ranging in age from 1 to 8 years, with a mean age of 3.5 years. The most recent blood lead concentration was 11.4 +/- 0.8 microg/dL (mean +/- standard error), and 48.6% had concentrations at or above the current guideline of 10 microg/dL. Quintiles of calcium intake were: 221 +/- 13; 488 +/- 9; 720 +/- 6; 885 +/- 6; and 1,389 +/- 49 mg/day. Fifty-five of 175 (31.4%) children aged 1-3 years had calcium intakes below the DRI, as did 82 of 139 (59.0%) children aged 4-8 years. The percentage of mothers reporting lactose intolerance in their children was 2.5%. The observation that the children in the highest quintile easily exceeded the DRIs for calcium suggests that urban parents who include dairy foods in their childrens' meals can provide a diet that meets the DRI guidelines. Children in the lowest quintiles are at risk of increased absorption of the environmental lead to which they are inevitably exposed, as well as other problems associated with a low intake of dietary calcium. The data suggest that both lead exposure and low dietary calcium continue to pose significant health risks to urban minority children.