SCIENTIFIC REPORT PREVENTIVE GICAL EPIDEMIOLOGY PREDICTIVE ULAR PROFILE IC SUSCEPTIBILITY PARTICIPATORY ITY OF LIFE PERSONALIZED LY DETECTION

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1 PREVENTIVE ION GICAL EPIDEMIOLOGY PREDICTIVE ULAR PROFILE IC SUSCEPTIBILITY Y RESPONSE PARTICIPATORY ADVOCACY GROUPS ITY OF LIFE PERSONALIZED ED THERAPIES LY DETECTION ICAL RESEARCH ET DISCOVERY KERS DISCOVERY AL TRIALS FONDAZIONE IRCCS ISTITUTO NAZIONALE DEI TUMORI IVE CARE SCIENTIFIC REPORT Istituto Nazionale dei Tumori Comprehensive Cancer Center 2011

2 FONDAZIONE IRCCS ISTITUTO NAZIONALE DEI TUMORI SCIENTIFIC REPORT 2011

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4 CONTENTS Introduction 4 Clinical Activity Data 10 RESEARCH ACTIVITY Prostate Cancer Program 14 Breast Cancer: Outline of Clinical and Preclinical Research 18 Lung Cancer Program 22 Melanoma Program 28 Personalized Treatment of Sarcoma 32 Novel Approaches to Determine the Prognosis and Response to Treatment in Mature B-Cell Malignancies 36 Development of Radiopharmaceuticals for Tumor Characterization, Molecular Imaging, and Therapy 40 Pediatric Brain Tumors 44 CLINICAL-SCIENTIFIC STRUCTURE Scientific Directorate 52 Descriptive Studies and Health Planning 58 Tumor Registry and Environmental Epidemiology 59 Preventive and Predictive Medicine Department 61 Epidemiology and Prevention 62 Nutritional Epidemiology 63 Evaluative Epidemiology 64 Analytical Epidemiology 65 Medical Genetics 66 Molecular Basis of Genetic Risk, Polygenic Models 67 Molecular Basis of Genetic Risk and Genetic Testing 68 Hereditary Digestive Tract Tumors 69 Experimental Oncology and Molecular Medicine Department 71 Immunobiology of Human Tumors 73 Molecular Therapies 74 Molecular Immunology 75 Biomarkers 76 Molecular Mechanisms of Cell Cycle Control 77 Molecular Mechanisms 78 Immunotherapy of Human Tumors 79 Tumor Genomics 80 Molecular Targeting 81 Molecular Pharmacology 82 Pathology and Laboratory Medicine Department 85 Anatomic Pathology Units 1, 2 &3 86 SIMT, Immunohematology and Transfusion Medicine 88 Laboratory Medicine 89 Surgery Department 91 Medical Oncology Department 107 Hematology and Allogeneic Bone Marrow Transplantation 108 Medical Oncology Medical Oncology Pediatric Oncology 111 Adult Sarcoma Medical Treatment 112 Head and Neck Cancer Medical Oncology 113 Medical Day Hospital 114 Anesthesia, Intensive Care, Pain Therapy, and Palliative Care Department 117 Clinical Anesthesia 118 Intensive Care 119 Palliative Care, Pain Therapy, and Rehabilitation 120 Supportive Care in Cancer 121 Clinical Nutrition 122 Diagnostic Imaging and Radiotherapy Department 125 Radiology and Diagnostic Imaging Radiology and Diagnostic Imaging Radiology and Diagnostic Imaging Nuclear Medicine 130 Radiotherapy Radiotherapy Medical Physics 136 SHARED RESEARCH RESOURCES Cardiology 140 Tobacco Control 141 Clinical Psycology 142 Medical Statistics, Biometry, and Bioinformatics 143 Tissue Bank 145 Functional Genomics Core Facility 146 Cancer Proteomics - Molecular Mechanisms 147 EDUCATION AND TRAINING 148 PUBLICATIONS 154 INDEPENDENT ETHICS COMMITTEE 178 ONGOING CLINICAL STUDIES 179 ONGOING PROJECTS SUPPORTED BY DIFFERENT ORGANIZATIONS 196 Gastrointestinal, Hepatopancreatobiliary Surgery and Liver Transplantation 92 Colorectal Surgery 93 Breast Surgery 94 Melanoma and Sarcoma 95 Diagnostic Endoscopy and Endoscopic Surgery 96 Otolaryngology Surgery 97 Gynecologic Oncology 99 Thoracic Surgery 100 Plastic and Reconstructive Surgery 101 Urologic Surgery 102 Pediatric Surgery 103 Laser Therapy 104 Day Surgery 105

5 Introduction 4 The Scientific Directorate supported the development of research resources In 2011, the Scientific Directorate supported the development of research resources both at a national and international level by taking part in a variety of conferences and meetings. At a national level, in July a commission comprised of members of the National Commission on Health Research at the Health Ministry and of the Lombardy Region conducted a Site Visit at our Institute to evaluate its scientific contributions and confirm its recognition as a research and care centre. For our IRCCS it was good opportunity to assess the Institute s performance and to provide an overview on some of our achievements such as the genetic counseling procedure established by the Genetic Medicine Unit; the Prostate Program, one of the multidisciplinary core program developed under the auspices of the Scientific Directorate, and the Biomild project, aimed at developing a non-invasive test for early diagnosis of lung cancer. On that occasion, we were also very proud to announce that, after a comprehensive certification process, the Fondazione IRCCS Istituto Nazionale dei Tumori of Milan (INT) has been certified as one of sixteen European Neuroendocrine Tumors Centers of Excellence (CoE) in December Regarding issues related to research funding, number of permanent staff and tenure track, in 2011 the Scientific Directorate has kept the lines of communication open both with the Region and the Health Ministry. Also, we were honored to host the Health Minister who visited the Institute for the inauguration of a state-of-the-art Unit of Metabolic Therapy. As a member of the Technical-Scientific Committee of the CNAO, the new National Center of Oncological Hadrotherapy opened in Pavia, we point with satisfaction to the start of the Center's clinical activity in September 2011 with a treatment on the first of a series of patients with cordoma, a pathology for which INT is a main center of reference. The key role played by our Institute in the regional health sector was confirmed by the participation in the Health and Welfare session of the World Regions Forum (WRF), an initiative established by the Lombardy Region to promote exchanges

6 5 Scientific Report 2011 between regions all over the world where local management is particularly influential because of its vicinity to the most pressing needs of the population. The pilot project of the WRF in the area of Healthcare, Cancer Care and Biobanks, relies on the experience gained by our Institute as a actuator of the Lombardy Oncology Network (ROL): the ROL has in fact been developing a Virtual Biobank as a result of the networking of a series of real biobanks organized according to shared criteria and, whose activities are subject to the same standard of quality and regulations. The collaboration between INT and Nerviano Medical Sciences (NMS) made possible by the coordination of ROL has been developed as a result of an organizational strategy devised by the Scientific Directorate to overcome the crisis of the traditional model of anticancer drugs discovery and development caused by the shift from cytotoxic anti-cancer compounds to the so-called targeted therapies (drugs with specific molecular targets or intelligent drugs). This new strategy is based on the concept of network and aims at developing a synergy between care and research in order to ensure greater appropriateness of the therapies and scale economies both for diagnosis and for treatment of oncology patients in Lombardy, Marco A. Pierotti, Scientific Director

7 Introduction 6 a region with 10 million inhabitants and an incidence of about 50,000 new cases/year. The new strategy is aimed at advancing research by creating the conditions for an integration of the Academy (in its Target Discovery and Validation components), the pharmaceutical industry (3D Phase) and a clinical network structured for clinical studies. As a first result, in 2011 ROL/NMS issued a call for independent clinical research projects and 31 study proposals have been selected to receive scientific and organizational support from INT and from the Department of Clinical Development of NMS. A call for pre-clinical projects has also been issued and 8 research proposals have been selected to be implemented with the collaboration of NMS. The strategy and the new initiatives were illustrated in national (WRF meeting, Sept.; Forum Ricerca Sanitaria in Cernobbio, 7-8 Nov.) and international contexts (WIN Symposium, 6-8 Jul.; Bioeconomy International Conference in Rome, Nov; Conference Molecular Diagnostics for Cancer Drug Development Europe Frankfurt, 6-7 Dec) where they attracted some interest. On an international level, thanks to the cooperation with Nerviano Medical Sciences, our Institute was able to plan and implement an agreement with a nanotechnology team lead by Mauro Ferrari (President of the Methodist Hospital Research Institute, Houston) and Ennio Tasciotti (University of Texas Health Science Center at Houston), which resulted in a research project on nanotechnology in oncology for a new concept of drug delivery in mesothelioma. More in general, concerning its international activity, in 2011 the Scientific Directorate has strengthened the wide network of relations that was built up over the years also thanks to the presence of the Scientific Director in the Board of the Organisation of European Cancer Institutes (OECI). In 2011 two European projects in which our Institute is a partner were started. In January, the kick-off meeting of the Eurocan Platform (EP) took place, a project aimed at improvement in the key areas of prevention, early diagnosis, and therapies. The EP project involves 28 partners from various European Countries among which are all the major European Comprehensive Cancer Centers. Also, the first meeting of the Scientific Advisory Board (SAB) of TRANSCAN was held in TRANSCAN is an inter-european ministerial project where the Scientific Director was chosen as representative for Italy. The SAB identified Validation of biomarkers for personalized cancer medicine as the theme for a first call for collaborative research projects. In 2011, the Scientific Director was invited to continue to contribute to the selection of new Integrated Cancer Research Site (SIRIC) coordinated by the French National Institute of Cancer; the sites that will obtain the SIRIC label will receive substantial support to more efficiently organize their multidisciplinary research programs and disseminate the results. The Scientific Director was also invited to

8 7 Scientific Report 2011 complete the evaluation on the new Translational Research department created at the Deutsche Krebs Forschung Zentrum in Heidelberg. Regarding the research activity conducted within our Institute, a project on tumor microenvironment was granted 1.8 milion Euros per year funding for 3 years (which may be extended for up to a further 2 years) from the Italian association for cancer research ( AIRC 5x1000 funding scheme). In order to improve and facilitate clinical research within the Institute, the creation of a new Clinical Studies Office has been approved; it will support researchers teams - both from organizational and practical points of view. In an initial phase the new office was mainly equipped to provide data management and biostatistical support. The research at our Institute explored a variety of innovative research fields in oncology: an overview of the work and accomplishments of the various Departments and Units can be found, as always, in the pages of this Report. Notwithstanding the difficulties connected with the still unresolved issue of the research staff (lack of a tenure track, stop to the creation of new permanent positions), we note with great satisfaction a further increase of the Institute s Impact Factor for 2011 ( ) and number of publications (450), exceeded last year s already excellent result SHED PAPERS CT FACTOR

9 Introduction 8 Patients are at the heart of the daily activities of our 1920 employees The Fondazione IRCCS - Istituto Nazionale dei Tumori (INT) is one of the main national and international referral center for the treatment and study of cancer. Our organization and management are dedicated to finding solutions to the clinical problems posed by the evolution of cancer types in every stage of their development, through prevention, prediction, diagnosis, and treatment (surgery, medicine, radiotherapy), rehabilitation, psychologic support, pain therapy, and palliative care. Patients are at the heart of the daily activities of our 1920 employees. INT has 482 beds and in 2011 admitted 22,800 patients, performing over 100,000 diagnostic tests, laboratory assays, radiotherapy sessions and medical visits. We value our patients as persons and, knowing that cancer can be a life changing experience, we strive to listen to their voice: we are therefore proud to collaborate with voluntary associations advocating patients right. INT is one of the largest comprehensive cancer centers in Italy. Since its establishment, this public institution has aimed to provide the highest standard of patient care. Our Institute is, however, an IRCCS, that is an institute for cancer treatment and research. Our mission, therefore, is not only to provide existing treatments but also to lay the foundations for new ones by pursuing preclinical and clinical research and swift translation into better prevention, diagnosis, therapy, rehabilitation, and improved quality of life. Revolutionizing cancer care is for us a tradition we want to live up to. Innovation was in our genes from the beginning: in 1925, when the decision to open a new institute entirely and exclusively devoted to the study and care of cancer was taken, the idea was new and controversial at least in Italy. In a more recent past, our Institute was the first in Italy to prepare a tumoral monoclonal antibody and research on biological and molecular characterization of cancers performed in our laboratories led to the identification of oncogenes at the origin of thyroid cancer and to the translation of some biomarkers from bench to bedside.

10 9 Scientific Report 2011 We are the first Italian oncology IRCCS in terms of scientific productivity. Even under hard economic times, we are exceedingly grateful and proud to have the trust and confidence of the major national and international funding institutions: the Ministry of Health and the Regional Authorities, the Ministry of University and Research (MIUR), the European Commission, the Italian Association for Cancer Research (AIRC), the Fondazione Cariplo, and the Association Bianca Garavaglia (supporting the pediatric area) to name but a few of the institutions that enable us to participate in the challenging everyday task of trying to defeat cancer. Finally, we would like to thank the large number of Italian tax payers who chose to assign their 0.5% income tax contribution to this Institution. Marco A. Pierotti, Scientific Director Gerolamo Corno, Director General

11 Clinical activity data 10 clinical activity data Medical Direction is responsible for the management and organization of selected areas of the hospital: environmental health, surveillance and prevention of infectious diseases in both patients and healthcare workers, risk management, organization of outpatient activities and admissions, quality control of services provided, and management of all necessary documentation for patients at the INT. These activities are carried out in accordance with the strategies and objectives of the Foundation, following the normatives of the ISO 9000 and the Joint Commission. The first managerial aspect of Medical Direction is related to risk management, carried out with the aim of providing safe care of patients through control visits and reducing adverse events whenever feasible. A second aspect involves management of clinical data; Medical Direction provides support and drives the collection and elaboration of data that characterize both outpatient and inpatient activities - as well as its management in activities involving the Region and Ministry of Health. Medical Direction also controls the congruency of hospital admissions through verification and eventual correction, in both the immediate and later stages, of monthly data sent to the Region, which are necessary for proper economic reporting. Medical Direction performs verification of healthcare documentation for periodic Regional controls by selecting arbitrary clinical charts to confirm that proper codes have been used, and that there are no anomalies in the services provided. The data shown are derived from those relative to the clinical activities at INT, elaborated by Medical Direction. INPATIENTS BY GEOGRAPHICAL AREAS (OVERALL 12,380) Central Italy 6% Italian Islands s 6% Southern Italy 13% Northwest Italy 6% Northeast Italy Lombardy 62% Outside Italy 6% 1% OUTPATIENTS BY GEOGRAPHICAL AREAS (OVERALL 8,424) Central Italy 3% Italian Islands 3% Southern Italy 7% Northwest Italy 5% Northeast Italy 4% Lombardy 78% OUTPATIENTS VISITS Surgery 64,289 60,602 59,715 61,560 56,217 51,774 52,757 52,358 Medical Oncology 49,481 55,394 61,424 61,983 62,402 90,463 86,060 87,483 Diagnostic Imaging & Radiotherapy 18,685 16,966 17,926 17,537 16,846 14,673 16,702 16,715 Anesthesia, Intensive Care, Palliative Care 32,292 31,141 32,038 33,735 30,929 18,316 25,960 29,487 Transfusion Unit 9,093 7,342 6,997 6,581 6,766 7,163 6,955 6,862 Private Patients 12,937 13,301 14,519 7,932 15,083 14,170 16,201 17,818 Total 186, , , , , , , ,723

12 11 Scientific Report 2011 INPATIENTS: AVERA AVERAGE AGE LENGTH OF STAY (LENGTH (LENGTH OF OF STAY>1 STAY>1 DAY) DAY AY Y)) Average length of stay Surgery Overall Medical Oncology INPATIENTS OVERTHE OVERT THE YEARS (LENGTH (LENGTH OF OF STAY>1 STAY>1 DAY) DAY) Number of inpatients Surgery g y Medical Oncology gy SURGIC SURGICAL CAL PROCEDURES (OVERALL (OVER RALL 6,555) P ediatric surgery Pediatric 6,7% Gastrointestinal and hepatopancreatobiliary surgeryy & Liver transplantation 6,5% Urologic surger ry surgery 7,7% Colorectal surge ery surgery 9,4% Cranio-m maxillo-facial surgery Cranio-maxillo-facial 1 9% 1,9% Senology 17,4% Melano oma and Sarcoma Melanoma 15,6% Otolaryngology surgery 10,1% Gyneco ologic surgery Gynecologic 6,6% Diagnostic and surgical endoscopy 0,1% Plastic and reconstructive nstructive surgery 9,8% Thoracic surgery 8,1% 5427

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14 13 Scientific Report 2011 RESEARCH ACTIVITY Prostate cancer program Breast cancer: outline of clinical and preclinical research Lung cancer program Melanoma program Personalized treatment of sarcomas Novel approaches to determine prognosis and response to treatment in mature B-cell malignancies Development of radiopharmaceuticals for tumor characterization, molecular imaging, and therapy Pediatric brain tumors

15 Multidisciplinary Programs 14 prostate cancer program Riccardo Valdagni Group Leader Nadia Zaffaroni Preclinical activities and protocols Group Leader PROJECT GROUP T. Magnani - Project Manager M.F. Alvisi - Statistician B. Avuzzi - Fellow in Radiation Oncology L. Bellardita - Psychologist A. Candosin - Secretary S. Catania - Data Entry S. Donegani - Psychologist C. Marenghi - Medical Oncologist T. Rancati - Expert in radiation modeling, Data Manager E. Ronchi - Scientific Secretary V. Tresoldi - Psychologist PARTICIPATING DEPARTMENTS AND UNITS Diagnostic Imaging and Radiotherapy Experimental Oncology and Molecular Medicine Medical Oncology Medical Statistics and Biometry Palliative Care, Pain Therapy, and Rehabilitation Pathology and Laboratory Medicine Preventive and Predictive Medicine Psychology Scientific Directorate Supportive Care in Cancer Urologic Surgery PROSTATE CANCER PROGRAM The Prostate Cancer (PC) program is a translational multidisciplinary program with exper tise in epidemiology, experimental oncology, pathology, imaging, urologic surgery, radiation oncology, medical oncology, palliative care, and psychology. Since 2005, the clinical team has been offering patients with PC a multidisciplinary approach in all stages of disease (in 2011, about 980 multidisciplinary visits were carried out as first examinations, second opinions, follow-up of patients on active surveillance or watchful waiting). Clinical cases are discussed weekly to share decisions, individualize therapeutic and observational strategies, enroll patients in trials, and verify adherence to institutional guidelines and quality assurance. Considerable attention is paid to quality of life and psychological issues. Patients and their families can rely on dedicated psychologists in the decision-making phase and throughout the course of the disease. Some of the ongoing research is summarized below.

16 15 Scientific Report 2011 Development of novel approaches for the inhibition of cell survival factors in preclinical models of androgen-independent PC. Based on the observation that G quadruplexes (G4) exist not only in telomeres, but also in the promoter of several oncogenes, we focused our attention on the effects exer ted by a new class of naphthalene diimides, which can reversibly bind to G4 structures, on the expression of the c-myc and htert genes in PC cell lines. Quantitative RT-PCR data showed down-regulation of c-myc, which was paralleled by a significant reduction of the expression levels of htert. Inhibition of the two oncogenes seemed to represent the primary cause of drug-induced impairment of telomerase catalytic activity in PC cell lines. mirnas in PC: expression profiling and functional analysis. We have previously shown that mir-205 is down-regulated in PC compared to adjacent non-neoplastic tissue and acts as a tumor-suppressor in human prostate, as its reintroduction in PC cells rever ts the epithelial-to-mesenchymal transition. To gain insight into this early loss of mir-205 and into the mechanisms of PC development, we investigated the physiological role of mir-205 in normal prostate. We found that mir-205 par ticipates in a network involving Np63, an alternatively spliced isoform of p63, which is essential for maintenance of the basement membrane in prostate epithelium. At the molecular level, Np63 is able to enhance mir-205 transcription by binding to its promoter, whereas mirna can posttranscriptionally limits the amount of Np63 protein, mostly by affecting proteasomal degradation of Np63 rather than through a canonical mirna/target interaction. Functionally, mir-205 is able to control the deposition of laminin-332 and its receptor integrin-4. Hence, pathological loss of mir-205, as widely observed in prostate cancer, may favor tumorigenesis by creating discontinuities in the basement membrane. We also demonstrated that therapeutic replacement of mir-205 in prostate cancer cells can restore basement membrane deposition and 3D organization into normal-like acinar structures, thus hampering cancer progression. Cells and matricellular proteins as accomplices in PC. Mast cells (MC) are c-kit-expressing cells, best known for their primary involvement in allergic reactions, but recently reappraised as impor tant players in cancer promotion and inhibition. In par ticular, we focused on the role of MCs in PC development. In PCs from both tumor-prone transgenic adenocarcinoma of the mouse prostate (TRAMP) mice and human patients, MCs are specifically enriched and degranulated in areas of well-differentiated (WD) adenocarcinoma, but not around poorly differentiated (PD) foci that coexist in the same tumors. We derived novel TRAMP tumor cell lines, representative of WD and PD variants, and through pharmacologic stabilization or genetic ablation of MCs in recipient mice, we showed that MCs promote WD adenocarcinoma growth but are dispensable for PD tumors. WD tumors rely on MCs for matrix metalloprotease 9 (MMP-9) provision, as reconstitution of MC-deficient mice with wild-type but not MMP-9(-/-) MCs was sufficient to promote their growth. In contrast, PD tumors are MMP-9 self-competent, consistent with an epithelial-to-mesenchymal transition. Such a dual source of MMP-9 was confirmed in human tumors, suggesting that MCs may be a good target for early-stage prostate cancer. Interestingly, in testing whether MC targeting could block or delay tumorigenesis in tumor-prone TRAMP mice, we observed a high incidence of early and aggressive tumors, characterized by a neuroendocrine (NE) signature and c- Kit expression. Taken together, these data underscore the contribution of MCs in tumor progression and uncover a new, opposite role of MCs in protecting against the occurrence of aggressive NE variants in prostate cancer.

17 Multidisciplinary Programs 16 Active surveillance evaluated as an alternative to radical therapies in low risk PC. Selected patients are followed-up clinically and diagnostically (PSA and biopsy), and offered curative treatment if the PC appears to progress, thus limiting over treatment. Two protocols are open to enrollment: the PRIAS international prospective study, which, from September 2007 to December 2011, included 209 patients; the SA INT protocol, from March 2005 to December 2011, included 145 patients. The hypothesis to be confirmed is that <5% patients will develop clinical progression by a positive bone scan during their lifetime. Patients on active surveillance are proposed side protocols aimed at evaluating new biomarkers and non-invasive diagnostic tests in blood and urine samples. As of December 2011, more than 90 patients accepted to par ticipate in the collection. Open label Phase II study of vaccination with survivin peptides in PC patients in biochemical failure (PROVAX study). This trial, star ted in late 2010, is evaluating a novel vaccine combination (survivin peptides and IMP321) in 20 hormone-naïve or refractory patients with biochemical recurrence. Vaccine peptides, restricted for different HLA-I alleles, are emulsified in Montanide ISA 51 VG and administered weekly for 8 weeks and then every 4 weeks thereafter. IMP321 is given prior to every second vaccination at the same site. In patients experiencing clinical benefit at the end of vaccination, the entire vaccine cycle will be repeated. A safety run-in phase was included to assess the toxicity of vaccine combination; the first three subjects were treated and observed for 4 weeks before star ting enrolment. No adverse event was experienced during the first vaccinations and enrollment star ted in early The study is still open. In October 2011, the protocol was amended to schedule a new induction phase for patients with increasing levels of PSA ( 2 ng/ml and <5 ng/ml in two consecutive blood samples, compared to baseline values) during the maintenance phase. Predictive models of late rectal toxicity after high-dose PC radiotherapy (RT). New RT techniques to treat PC with high doses and a high level of precision are being studied. However, a significant propor tion of patients still experience acute and late toxicity, since organs at risk are unavoidably included within the high dose region. Although predicting RT morbidity can prevent fur ther deterioration of quality of life and help introduce treatment corrections to personalize therapy, little attention and inadequate effor ts have been devoted to the development of easy-to-use tools that use individual dosimetric, clinical, and genetic risk factors, and which are able to predict the sideeffects of RT. The group involved in the project also participated in two studies (AIROPROS 0101 and AIROPROS 0102) that assessed predictors of rectal toxicity. The results gave impor tant indications about the modeling of rectal bleeding in addition to other acute and late rectal complications. The data from AIROPROS 0102 were also used to develop nomograms and ar tificial neural network models to predict acute and late rectal toxicity after RT of PC. These are the first user-friendly tools reported in the literature for evaluating the probability of individual radio-induced rectal toxicity. A pilot study was also designed to identify genetic markers predicting late rectal bleeding. Patients were selected within the AIROPROS 0101 trial, and this pilot study showed that individual dose-volume information coupled to the patient s genetic profile might help to explain, on the basis of dose-volume histograms, the quality and unexpected rectal bleeders, as well as the unpredicted absence of late toxicity in some individuals. The group is currently involved in a prospective multicenter study (DUE 01, promoted by San Raffaele Scientific Institute) focused on assessing predictors of genitourinary (GU) toxicity and erectile dysfunction (ED) after PC high dose RT. The final aim of the study is the development of predictive models for GU toxicity and ED with inclusion of dosimetric, clinical, and genetic risk factors.

18 17 Scientific Report 2011 In the domain of prediction of rectal toxicity, a new pilot study is recruiting patients with the aim of evaluating the correlation between toxicity insurgence and plasma levels of a panel of inflammatory markers. This study includes patients undergoing radical prostatectomy, radical RT, and adjuvant RT. Both absolute levels of inflammatory markers and their kinetics as a function of radiation dose and follow-up time are being evaluated. Results from this pilot study could be used prospectively to identify radiosensitive patients and to optimize their RT protocol. Keywords: translational research, multidisciplinary approach, experimental therapeutics PUBLICATIONS Gandellini P, Profumo V, Folini M, Zaffaroni N. MicroRNAs as new therapeutic targets and tools in cancer. Expert Opin Ther Targets. 2011; 15(3): Pittoni P, Tripodo C, Piconese S, Mauri G, Parenza M, Rigoni A, Sangaletti S, Colombo MP. Mast cell targeting hampers prostate adenocarcinoma development but promotes the occurrence of highly malignant neuroendocrine cancers. Cancer Res. 2011; 71(18): Valdagni R. Prostate cancer units: has the time come to discuss this thorny issue and promote their establishment in Europe? Eur Urol. 2011; 60(6):

19 Multidisciplinary Programs 18 breast cancer program Maria Grazia Daidone Group Leader PARTICIPATING DEPARTMENTS AND UNITS Breast Imaging Experimental Oncology and Molecular Medicine Medical Oncology Pathology Preventive and Predictive Medicine Senology BREAST CANCER: OUTLINE OF CLINICAL AND PRECLINICAL RESEARCH Major unresolved scientific problems surrounding breast cancer (BC) are related to: increasing incidence, prevention, early diagnosis, disease progression, treatment, and resistance to clinical treatments and their toxicity. The heterogeneity of human BC, in terms of genetic susceptibility, clinical behavior, molecular profiles, and even histomorphologic features, represents a major obstacle to the solution of more effective therapies. Investigations at the genetic and transcriptional levels have shown that such heterogeneity may be explained by: a) varying susceptibility to malignant transformation of different mammary cells; b) progression of breast carcinogenesis that is not necessarily stepwise or linear, from well-differentiated to poorly differentiated tumors, which is also complicated by the finding that; c) no single dominant pathway or histologic presentation has emerged in BC, whereas mutation within a single pathway has a dominant role during progression in vir tually all tumor types. High throughput technical approaches for molecular analyses have prompted a new classification of human BC and provided a new paradigm for reducing disease complexity, unraveling biological heterogeneity. This will help to better identify those destined to develop BC among atrisk women, and, among patients, those who will develop new disease manifestations for more rational planning of therapeutic strategies.

20 19 Scientific Report 2011 INT has traditionally provided the highest quality and level of innovation in designing and developing new approaches to the multidisciplinary treatment of women with BC. This tradition has led to landmark accomplishments, such as the introduction of new standards of therapy that are now common practice in the field of oncology. Investigations designed and conducted at INT have demonstrated the possibility of limiting the extent of surgical removal of BC, thus avoiding mastectomy in many women with relatively small tumors without compromising the chance of successful eradication of disease. These achievements originate in an approach that merges different disciplines into a common effort for the ultimate benefit of patients. There are several key elements of success, but the most relevant are the creation of a dedicated team of clinical investigators suppor ted by a centralized and unique team for data management and analysis, the establishment of exper tise in the development of new drugs against metastatic BC, to rapidly implement new discoveries in the treatment of cases with early BC, and constant exchange among different laboratories of the Depar tment of Experimental Oncology and Molecular Medicine and the Units of the Depar tment of Preventive and Predictive Medicine. In all these respects, the approach to BC at INT has always been translational and multidisciplinary, and this tradition is maintained in the current organization of clinical and experimental services devoted to the treatment and study of BC, also including partnerships with pharmaceutical industry. This project represents one of the first effor ts to outline the biology underlying the distinct risk situations for BC by applying novel approaches for molecular analysis and target validation to case series recruited at INT in the last decades in the context of epidemiologic or chemoprevention studies and adjuvant/neoadjuvant treatments. Investigations are focused on: a) effects of different metabolic/nutritional factors on relevant biomolecular features; b) effects of lifestyle changes on biomarkers and molecular signatures of proven prognostic relevance; c) interaction between host (including ECM features) and tumor factors; d) new genetic risk factors, including variants of uncer tain significance in BRCA genes; e) gene expression fingerprints associated to with distinct new disease manifestations and response to different treatment protocols; f) functional analyses of genes whose expression affects tumor progression and treatment resistance; g) at a preclinical level, effect of novel chemopreventive and/or antitumor therapies. To improve our understanding of BC and to develop clinically-useful strategies, we need better understanding of host factors (including age, diet, life style, metabolic syndrome, environmental factors, polymorphisms, and mutations in susceptibility genes), tumor microenvironment (growth factors, infiltrating cells, and cytokines), and genomic changes occurring in cancer cells. At INT, we have a unique oppor tunity to investigate these aspects taking advantage of: 1) dedicated infrastructure; 2) wellannotated biological samples; 3) a well-established philosophy for cancer and normal tissue acquisition, storage, and distribution to research Units; 4) updated follow-up information and validated dietary questionnaires; 5) improvements to overcome intrinsic limitations for genomic studies due to technical ar tifacts and/or to limited sample size; 6) well-trained teams with specific skills in different disciplines. Specifically, during 2011 we focused on the following: a) Expression of androgen receptors (AR) was evaluated on more than 500 primary BC. Co-expression of AR and estrogen receptors (ER) was observed in 65% of cases, and ER negative tumors were shown to be AR positive in 45% of cases. Such findings, together with the evidence of an association between AR expression and favorable clinicopathologic features, provide suppor t to the hypothesis that AR positive tumors are well differentiated and largely hormone responsive.

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