Victoria Seewaldt, M.D. Duke University
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1 A Testing for Atypia in Random Periareolar Fine Needle Aspiration (RPFNA) Cytology after 12 months Metformin Chemoprevention versus Placebo Control Victoria Seewaldt, M.D. Duke University
2 Pre-registration - BMI>25 - Premenopausal - High-risk >20% Gail, biopsy atypia, DCIS, LCIS BRCA mutation RPFNA t=0 Atypia, Masood Cytology >14 DU-268L DU-266L DU-295R DU-229.2L Alliance A DU-256L DU-252L DU-294L DU-292R DU-277R DU-267R DU-168.5R DU-238.2L DU-228.3L DU-221.3R DU-254R DU-247R DU-255L DU-288R DU-280L DU-39.5L DU-96.5R DU-39.5R DU-287R DU-287L DU-258L DU-290R DU-249R DU-248L DU-248R DU-249L DU-238.2R ErbB3_Y1289 PKCpanBII.S660 pikb.s32.36 Paxillin.Y118 Vimentin IGF1R.IR_Y p70s6k.t389 ErbB3 pchk1.s345 p90.rsk.s380 Stat3 mtor.s2448 pacc.s79 patpcl.s454 p38mapkinase_t180.y182 X zeta..gamma..eta E.Cadherin perk.1.2.t202.y204 EGFR pcreb.s133 IGF1R.IR.YY.YY HIF1_alpha GSK2ab.S21.9 pgsk3.alpha.beta.y279.y216 pb.catenin.t41.s45 pakt.s473 MEK1.2.S217.S221 pegfr.y1068 ErbB2 cl.casp.7.d198 Bcl.xL VEGFR2 Bad PTEN pbad.s136 Bax pegfr.y1148 pstat3.s727 ppten.s380 pbcl2.s70 pirs1.s612 pret.y905 pvegfr2.y951 Src_Y416 p53.s15 prasgrf1.s916 ER.alpha cl.casp3.d175 Akt pnfkappa.bs536 pegfr.y992 peif4g.s1108 Readout - pampk - pakt/mtor - ps6k Metformin 850 po bid (ramp up) Can back down to 850 qd Placebo 850 po bid Unblinded at 12 mos Can opt for drug RPFNA t=12 months DU-268L DU-266L DU-295R DU-229.2L DU-256L DU-252L DU-294L DU-292R DU-277R DU-267R DU-168.5R DU-238.2L DU-228.3L DU-221.3R DU-254R DU-247R DU-255L DU-288R DU-280L DU-39.5L DU-96.5R DU-39.5R DU-287R DU-287L DU-258L DU-290R DU-249R DU-248L DU-248R DU-249L DU-238.2R ErbB3_Y1289 PKCpanBII.S660 pikb.s32.36 Paxillin.Y118 Vimentin IGF1R.IR_Y p70s6k.t389 ErbB3 pchk1.s345 p90.rsk.s380 Stat3 mtor.s2448 pacc.s79 patpcl.s454 p38mapkinase_t180.y182 X zeta..gamma..eta E.Cadherin perk.1.2.t202.y204 EGFR pcreb.s133 IGF1R.IR.YY.YY HIF1_alpha GSK2ab.S21.9 pgsk3.alpha.beta.y279.y216 pb.catenin.t41.s45 pakt.s473 MEK1.2.S217.S221 pegfr.y1068 ErbB2 cl.casp.7.d198 Bcl.xL VEGFR2 Bad PTEN pbad.s136 Bax pegfr.y1148 pstat3.s727 ppten.s380 pbcl2.s70 pirs1.s612 pret.y905 pvegfr2.y951 Src_Y416 p53.s15 prasgrf1.s916 ER.alpha cl.casp3.d175 Akt pnfkappa.bs536 pegfr.y992 peif4g.s1108 Readout - pampk - pakt/mtor - ps6k
3 Inclusion: Increased risk for breast cancer Gail > 1.6 five year Biopsy atypia, DCIS/LCIS Family history breast and/or ovarian cancer Atypia on RPFNA in non-excised breast tissue (Masood 14-17). Subjects may have a new diagnosis of DCIS or LCIS, however, in subjects with DCIS only the nonradiated breast can be aspirated. Premenopausal Age 25 to 55. BMI > 25 Mammogram within the last 3 months. At least one year from pregnancy, lactation or chemotherapy. Exclusions: Metastatic malignancy of any kind. Subjects on warfarin or other anticoagulants. Bilateral breast implants or tram flap reconstruction. Radiation to both breasts. Elevated Cr.
4 Primary Outcomes Test for the presence or absence of atypia in RPFNA after 12, and 24 months Metformin versus placebo control.
5 Secondary Outcomes Test the reproducibility of RPPM in duplicate RPPM determination from single RPFNA specimen. RPPM analysis of the initial RPFNA cytology in women with disappearance of atypia versus persistent atypia after 12, and 24 mos Metformin. Determine the change in percent breast density from prior to the initiation of metformin or placebo treatment through one year of therapy in subjects.
6 Correlative Research Surrogate biomarkers of breast cancer risk: Atypia - surrogate endpoint biomarker/risk biomarker Mammographic density surrogate/risk biomarker Phosphoprotein expression exploratory biomarker Circulating insulin growth factor and other cytokines - surrogate biomarker and risk biomarker Markers of obesity and insulin resistance: Waist to hip ratio Fasting serum insulin, fasting serum glucose Circulating Homeostatic Model Assessment (HOMA) Other Measures: Tissue/serum Metformin levels exploratory Estrogen/Progesterone exploratory biomarker.
7 Pre-registration - BMI>25 - Premenopausal - High-risk >20% Gail, biopsy atypia, DCIS, LCIS BRCA mutation RPFNA t=0 Atypia, Masood Cytology >14 DU-268L DU-266L DU-295R DU-229.2L Alliance A DU-256L DU-252L DU-294L DU-292R DU-277R DU-267R DU-168.5R DU-238.2L DU-228.3L DU-221.3R DU-254R DU-247R DU-255L DU-288R DU-280L DU-39.5L DU-96.5R DU-39.5R DU-287R DU-287L DU-258L DU-290R DU-249R DU-248L DU-248R DU-249L DU-238.2R ErbB3_Y1289 PKCpanBII.S660 pikb.s32.36 Paxillin.Y118 Vimentin IGF1R.IR_Y p70s6k.t389 ErbB3 pchk1.s345 p90.rsk.s380 Stat3 mtor.s2448 pacc.s79 patpcl.s454 p38mapkinase_t180.y182 X zeta..gamma..eta E.Cadherin perk.1.2.t202.y204 EGFR pcreb.s133 IGF1R.IR.YY.YY HIF1_alpha GSK2ab.S21.9 pgsk3.alpha.beta.y279.y216 pb.catenin.t41.s45 pakt.s473 MEK1.2.S217.S221 pegfr.y1068 ErbB2 cl.casp.7.d198 Bcl.xL VEGFR2 Bad PTEN pbad.s136 Bax pegfr.y1148 pstat3.s727 ppten.s380 pbcl2.s70 pirs1.s612 pret.y905 pvegfr2.y951 Src_Y416 p53.s15 prasgrf1.s916 ER.alpha cl.casp3.d175 Akt pnfkappa.bs536 pegfr.y992 peif4g.s1108 Readout - pampk - pakt/mtor - ps6k Metformin 850 po bid (ramp up) Can back down to 850 qd Placebo 850 po bid Unblinded at 12 mos Can opt for drug RPFNA t=12 months DU-268L DU-266L DU-295R DU-229.2L DU-256L DU-252L DU-294L DU-292R DU-277R DU-267R DU-168.5R DU-238.2L DU-228.3L DU-221.3R DU-254R DU-247R DU-255L DU-288R DU-280L DU-39.5L DU-96.5R DU-39.5R DU-287R DU-287L DU-258L DU-290R DU-249R DU-248L DU-248R DU-249L DU-238.2R ErbB3_Y1289 PKCpanBII.S660 pikb.s32.36 Paxillin.Y118 Vimentin IGF1R.IR_Y p70s6k.t389 ErbB3 pchk1.s345 p90.rsk.s380 Stat3 mtor.s2448 pacc.s79 patpcl.s454 p38mapkinase_t180.y182 X zeta..gamma..eta E.Cadherin perk.1.2.t202.y204 EGFR pcreb.s133 IGF1R.IR.YY.YY HIF1_alpha GSK2ab.S21.9 pgsk3.alpha.beta.y279.y216 pb.catenin.t41.s45 pakt.s473 MEK1.2.S217.S221 pegfr.y1068 ErbB2 cl.casp.7.d198 Bcl.xL VEGFR2 Bad PTEN pbad.s136 Bax pegfr.y1148 pstat3.s727 ppten.s380 pbcl2.s70 pirs1.s612 pret.y905 pvegfr2.y951 Src_Y416 p53.s15 prasgrf1.s916 ER.alpha cl.casp3.d175 Akt pnfkappa.bs536 pegfr.y992 peif4g.s1108 Readout - pampk - pakt/mtor - ps6k
8 Contact Victoria Seewaldt, M.D. for RPFNA training subject line RPFNA TRAINING Training options - Skype - Visit Duke we can make this easy Best patient aspirate in OR during DCIS surgery: years old, pre-menopausal, BMI Contralateral breast biopsy proven DCIS and low suspicion for invasive cancer Aspirate contralateral breast - >90% chance atypia Has to refuse tamoxifen or not be eligible Can be BRCA mutation carrier
9 Phosphoprotein analysis of INTRINSIC: Phosphoprotein Profiling RPFNA Cytology in High Risk Women RPFNA cytology RPFNA 50 proteins in triplicate 20,000 - Catherine epithelial Ibarra cells PhD Catherine Ibarra, PhD Capture Signal generation Cytospin. Microdissection of epithelium and stroma Petricoin, Nature Rev, 2006; Pilie-Ibarra et al, CEBT, 2011; Ibarra, Br Ca Res, 2012
10 Cytological Sampling of High-Risk INTRINSIC: Phosphoprotein Profiling RPFNA Cytology in High Risk Women women using Random Periarolar FNA RPFNA - Catherine Ibarra PhD 5 institutions, n=78; Not affected by: Age p=0.249, BMI p=0.115, Gail p=0.938, BRCA p=0.2151, 1 o family p= Non-proliferative hyperplasia atypia Capture Masood #2 Signal generation Cytospin. Microdissection of epithelium and stroma Masood #1 Petricoin, Nature Rev, 2006; Pilie-Ibarra et al, CEBT, 2011; Ibarra, Br Ca Res, 2012
11 Atypia in RPFNA predicts risk for progression to cancer in women from non-brca high-risk families Atypia n= 68 No Atypia n= 186 Total n= % African American (34% AA entire cohort) Cancer Y Atypia Y N Probability of Developing Cancer Hazard Ratio = 6.3 p=0.007 Atypia Present at Baseline Atypia Absent at Baseline No atypia n= Peterson et al. in revision JNCI, 2013 Atypia n= 68 N Invasive cancer 9 DCIS 24 Total cancers
12 Atypia Cluster 1 31 high risk AA women Akt/mTor, p53/stress, Wnt/AMPK Low Masood High Masood BMI<30 BMI>30 CLUSTER 1 ErbB3 Y1289 PKC Paxillin- Y118 Vimen8n IGF1R Wnt10B p70s6k- T389 pchk1- S346 p90rsk- S380 p53 mtor- Ser2448 ps6k- Thr389 patpcl- Ser454 pacc- Ser79 p38mapk- Thr180/Tyr zeta Lopez-Contreras Fernandez-Capetillo allele Chk1 limits oncogene replicative stress and promotes transformation JEM, 2012
13 CLUSTER 1 ErbB3 Y1289 PKC Paxillin- Y118 Vimen8n IGF1R pstat3 p70s6k- T389 pchk1- S346 p90rsk- S380 Snail1 6 mtor- Ser2448 ps6k- Thr389 patpcl- Ser454 pacc- Ser79 p38mapk- Thr180/Tyr zeta Low Masood High Masood BMI<30 BMI>30 vimentin negative vimentin positive
14 DU-368 Markers of EMT vimentin(+) snail1(+) pericentrin
15 Non-BRCA1 mutation carrier 40 yr old woman. First pregnancy age 37, breast cancer R found after weaning. Masood=11 Masood=12 Masood=10 Masood=10 Atypia/one foci DCIS Masood=16 Masood=17 Arimidex Masood=10
16 Breast MRI in High-Risk Women 42 yr old woman. Sister died metastatic TNBC breast cancer (normal mammogram). No BRCA mutation. 0 mos R Masood=14 L Masood=12 6 mos 12 mos ER/PR- Her2- T1N0 R Masood=16 L Masood=17
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