Clinicopathological characteristics and outcomes of gastrointestinal stromal tumors with high progranulin expression

BACKGROUND & AIMS

Progranulin (PGRN) is known to promote tumorigenesis and proliferation of several types of cancer cells. However, little is known about the clinicopathological features of patients with gastrointestinal stromal tumors (GISTs) with regard to PGRN expression.

METHODS

A retrospective analysis was performed on patients with GISTs who underwent curative surgical resection between 2007 and 2017. PGRN expression was evaluated by immunohistochemical (IHC) analysis and semi-quantitatively categorized (no expression, 0; weak, 1+; moderate, 2+; strong, 3+). Tumors with a staining intensity of 2+ or 3+ were considered high PGRN expression.

RESULTS

Fifty-four patients were analyzed; 31 patients (57%) were male. The median age at surgery was 60 years (range, 33-79), and the most common primary site was the stomach (67%). Thirty-five patients (65%) had spindle histology; 42 patients (78%) were separated as a high-risk group according to the modified National Institutes of Health (NIH) classification. High PGRN-expressing tumors were observed in 27 patients (50%), had more epithelioid/mixed histology (68% vs. 32%; p = 0.046), and KIT exon 11 mutations (76% vs. 24%; p = 0.037). Patients with high PGRN-expressing tumors had a worse recurrence-free survival (RFS) (36% of 5-year RFS) compared to those with low PGRN-expressing tumors (96%; p<0.001). Multivariate analysis showed that high PGRN expression and old age (>60 years) were independent prognostic factors for poor RFS.

CONCLUSIONS

High PGRN-expressing GISTs showed more epithelioid/mixed histology and KIT exon 11 mutations. PGRN overexpression was significantly associated with poor RFS in patients with GISTs who underwent curative resection.

The Impact of Androgen Receptor and Histone Deacetylase 1 Expression on the Prognosis of Ductal Carcinoma In Situ

Purpose

Factors associated with invasive recurrence (REC) of ductal carcinoma in situ (DCIS) are less known. This study was aimed at identifying better biomarkers to predict the prognosis of DCIS.

Methods

RNA extracted from formalin-fixed paraffin-embedded blocks of twenty-four pure DCIS cases was subjected to differential gene expression analysis. The DCIS cases were selected by matching age and estrogen receptor status. Sixteen REC-free and 8 invasive-REC cases with disease-free interval of > 5 years were analyzed. Immunohistochemistry (IHC) staining was used to validate sixty-one independent pure DCIS cases, including invasive-REC (n = 16) and REC-free (n = 45) cases.

Results

Eight differentially expressed genes (DEGs) were statistically significant (log 2-fold change [FC] < -1 or > 1 and p < 0.001). Less than ½ fold expression of CUL1, androgen receptor (AR), RPS27A, CTNNB1, MAP3K1, PRKACA, GNG12, MGMT genes was observed in the REC group compared to the no evidence of disease group. AR and histone deacetylase 1 (HDAC1) genes were selected for external validation (AR: log 2-FC - 1.35, p < 0.001, and HDAC1: log 2-FC - 0.774, p < 0.001). External validation showed that the absence of AR and high HDAC1 expression were independent risk factors for invasive REC (hazard ratio [HR], 5.04; 95% confidence interval [CI], 1.24-20.4; p = 0.023 and HR, 3.07; 95% CI, 1.04-9.04; p = 0.042). High nuclear grade 3 was also associated with long-term invasive REC.

Conclusion

Comparative gene expression analysis of pure DCIS revealed 8 DEGs among recurring cases. External validation with IHC suggested that the absence of AR and overexpression of HDAC1 are associated with a greater risk of long-term invasive REC of pure DCIS.

The role of postoperative radiotherapy after primary tumor resection in patients with de novo stage IV breast cancer

AIM

This study was undertaken to investigate the role of postoperative radiotherapy (PORT) including post-breast conserving radiotherapy (PBCRT) and post-mastectomy radiotherapy (PMRT) in stage IV breast cancer patients who underwent planned primary tumor resection (PTR).

METHODS

This study enrolled 112 patients diagnosed with de novo stage IV breast cancer who were treated with potentially curative PTR with or without PORT. The primary outcome was overall survival (OS), and the secondary outcomes were locoregional recurrence-free survival (LRRFS) and distant progression-free survival (DPFS).

RESULTS

At a median follow-up of 48.9 months (range, 3.5-183.4 months), the median OS was 54.9 months (range, 5.3-185.9 months) with a 5 year OS rate of 59.6%. Lower clinical T stage, Luminal A or B type tumors and PBCRT were significantly predictive of longer OS. The 5 year LRRFS and DMFS rates were 79.0% and 34.3%, respectively. In multivariate analysis for LRRFS, the PBCRT arm demonstrated significant superiority compared to the No PORT arm. A comparison of patients who did and did not receive PORT showed that patients with disseminated metastasis more likely did not receive PORT and were excluded from the analysis. PBCRT arm demonstrated significantly superior LRRFS of 100% while PMRT and No PORT arm demonstrated 81.5% and 84.0%, respectively CONCLUSIONS: De novo stage IV breast cancer patients who received planned PTR showed favorable survival outcomes compared with historical cohorts. PTR may be predictive of a good prognosis, especially in patients with luminal A or B type tumors. PORT, especially PBCRT was predictive of LRRFS, suggesting that patients may benefit from this treatment.

Potential of MALDI-TOF-based serum N-glycan analysis for the diagnosis and surveillance of breast cancer

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS)-based serum N-glycan analysis has gained acknowledgment for the diagnosis of breast cancer in recent years. In this study, the possibilities of expanding its application for breast cancer management and surveillance were discovered and evaluated. First, a novel MALDI-TOF platform, IDsys RT, was confirmed to be effective for breast cancer analysis, showing a maximum area under the curve of 0.91. Multiple N-glycan markers were identified and validated using this process, and they were found to be applicable for differentiating recurring breast cancer samples from healthy control or ordinary breast cancer samples. Recurrence samples were especially distinct from non-recurrence samples when N-glycan signatures were sampled in multiple time points and monitored via MALDI-TOF, throughout the therapy. These results suggested the feasibility of MALDI-TOF-based N-glycan analysis for tracking the molecular signatures of breast cancer and predicting recurrence.

Change in Estradiol Levels among Premenopausal Patients with Breast Cancer Treated Using Leuprolide Acetate 11.25 Milligrams 3-Month Depot and Tamoxifen

The combination of luteinizing hormone-releasing hormone analogs (LHRHa) with tamoxifen is used as a standard postoperative adjuvant therapy in patients with hormone receptor-positive/premenopausal breast cancer. Long-acting LHRHa formulations offer advantages in terms of patient convenience. However, data on the effectiveness of the 3-month (3M) acting formulation are still insufficient. This study was performed on patients who received the 3M LHRHa after surgery. The serum estradiol (E2) and follicle-stimulating hormone levels were measured before surgery, and periodically after surgery. In total, 318 patients were included in the study and analyzed. The mean E2 level before surgery was 63.7 pg/mL, while the mean E2 level during the administration of 3M LHRHa was 4.9 pg/mL. None of the patients were menstruating and had E2 values above 30.0 pg/mL. It is thought that the 3M LHRHa formulation can suppress the ovarian function effectively and be safely used to improve compliance.

The effects of poloxamer and sodium alginate mixture (Guardix-SG®) on range of motion after axillary lymph node dissection: A single-center, prospective, randomized, double-blind pilot study

PURPOSE

Restricted shoulder mobility is a major upper extremity dysfunction associated with lower quality of life and disability after breast cancer surgery. We hypothesized that a poloxamer and sodium alginate mixture (Guardix-SG®) applied after axillary lymph node dissection (ALND) would significantly improve shoulder range of motion (ROM) in patients with breast cancer.

METHODS

We conducted a double-blind, randomized, prospective study to evaluate the clinical efficacy and safety of Guardix-SG® for the prevention of upper extremity dysfunction after ALND. The primary outcome measure was shoulder ROM at baseline (T0) and 3 (T1), 6 (T2), and 12 months (T3) after surgery. Secondary outcome measures were the Disabilities of the Arm, Shoulder, and Hand score(DASH), pain associated with movement, which was assessed using a numeric rating scale, and lymphedema assessed using body composition analyzer.

RESULTS

A total of 83 women with breast cancer were randomly assigned to either the Guardix-SG® group or the control group. In the Guardix-SG® group (n = 37), Guardix-SG® was applied to the axillary region after ALND. In the control group (n = 46), ALND was performed without using Guardix-SG®. Comparing ROM for shoulder flexion before surgery (178.2°) and 12 months after surgery (172.3°), that was restored 12 months after surgery in the Guardix-SG® group, and there was no statistically significant difference between that at before surgery and 12 months after surgery (p = 0.182). No adverse effect was observed in either group.

CONCLUSIONS

The results of this study have shown that Guardix-SG® help improve shoulder ROM without causing adverse effects in patients who underwent breast cancer surgery. However, there was no statistically significant difference from the control group. A further large-scale study is needed to obtain a more conclusive conclusion.

TRIAL REGISTRATION

CRISKCT0003386; https://cris.nih.go.kr (20181207).

Long-term survival outcomes of repeat lumpectomy for ipsilateral breast tumor recurrence: a propensity score-matched analysis

PURPOSE

This study aimed to compare long-term survival outcomes of repeat lumpectomy with total mastectomy after ipsilateral breast tumor recurrence (IBTR) using propensity score matching (PSM).

METHODS

We retrospectively analyzed patients with IBTR who had undergone initial breast-conserving surgery for breast cancer at our institution between January 1990 and December 2013. The Kaplan-Meier method and Cox proportional hazards model were used to compare survival rates between the two groups. PSM was performed using the following covariates: age at initial operation, initial T stage, N stage, hormone receptor status, human epidermal growth factor receptor 2 status, chemotherapy, radiotherapy, and IBTR tumor size.

RESULTS

We enrolled 335 IBTR patients with a median follow-up of 126.6 months. No significant differences were observed in the 5-year overall survival (OS), breast cancer-specific survival (BCSS), OS after IBTR, and BCSS after IBTR and 10-year survival probability between the two groups in a multivariate analysis. After PSM, patients who had undergone repeat lumpectomy and total mastectomy (n = 90 in both groups) were included. No significant differences were observed in the 10-year OS (hazard ratio [HR] 1.08, 95% confidence interval [CI] 0.49-2.39), BCSS (HR 0.83, 95% CI 0.35-1.95), OS after IBTR (HR 0.83, 95% CI 0.38-1.83), and BCSS after IBTR (HR 0.64, 95% CI 0.28-1.47) between the two groups.

CONCLUSIONS

No significant differences were observed in survival outcomes between patients with IBTR who underwent repeat lumpectomy or total mastectomy. Our results can be helpful in selecting the appropriate surgical method for IBTR.

Performance evaluation of an amplicon-based next-generation sequencing panel for BRCA1 and BRCA2 variant detection

BACKGROUND

As next-generation sequencing (NGS) technology matures, various amplicon-based NGS tests for BRCA1/2 genotyping have been introduced. This study was designed to evaluate an NGS test using a newly released amplicon-based panel, AmpliSeq for Illumina BRCA Panel (AmpliSeq panel), for detection of clinically significant BRCA variants, and to compare it to another amplicon-based NGS test confirmed by Sanger sequencing.

METHODS

We reviewed BRCA test results done by NGS using the TruSeq Custom Amplicon kit from patients suspected of hereditary breast/ovarian cancer syndrome (HBOC) in 2018. Of those, 96 residual samples with 100 clinically significant variants were included in this study using predefined criteria: 100 variants were distributed throughout the BRCA1 and BRCA2 genes. All target variants were confirmed by Sanger sequencing. Duplicate NGS testing of these samples was performed using the AmpliSeq panel, and the concordance of results from the two amplicon-based NGS tests was assessed.

RESULTS

Ninety-nine of 100 variants were detected in duplicate BRCA1/2 genotyping using the AmpliSeq panel (sensitivity, 99%; specificity, 100%). In the discordant case, one variant (BRCA1 c.3627dupA) was found only in repeat 1, but not in repeat 2. Automated nomenclature of all variants, except for two indel variants, was in consensus with Human Genome Variation Society nomenclature.

CONCLUSION

Our findings confirm that the analytic performance of the AmpliSeq panel is satisfactory, with high sensitivity and specificity.

Effect of standard low-dose anthracycline chemotherapy on late congestive heart failure in breast cancer survivors aged between 50 and 59 at diagnosis: A nationwide study

Objectives

Although chemotherapy-induced congestive heart failure (CHF) is a well-known adverse event in cancer survivors, the long-term risk of standard low-dose anthracycline has not yet been reported. This study aimed to investigate the long-term effects of standard anthracycline on late CHF in breast cancer survivors.

Materials and methods

A nationwide retrospective cohort study was conducted using the national insurance claims data for nearly 98% of Korean citizens. Between Jan 2010 and Dec 2015, a total of 56,338 newly diagnosed female breast cancer survivors were included.

Results

The total number of person-years was 199,648 and the incidence rate of late CHF was 3.57 per 1000 person-years. In multivariate analysis according to the subject’s age at diagnosis, only in the 50–59 age group, anthracycline-based [hazard ratio (HR) 1.765, 95% confidence interval (CI) 1.206–2.583] and taxane plus anthracycline-based regimens (HR 1.816, 95% CI 1.192–2.768) significantly increased the risk of late CHF. In the 50–59 age group, standard low-dose anthracycline significantly increased the risk of late CHF (HR 1.627, 95% CI 1.080–2.451) in Cox proportional hazard regression models. In competing risk model with recurrence and in-hospital death as competing risks, standard low-dose anthracycline was a significant risk factor for late CHF [subdistribution hazard ratio (SHR) 1.553, 95% CI 1.029–2.340].

Conclusion

This nationwide study showed that standard chemotherapy with low-dose anthracycline is a risk factor for late-onset CHF in breast cancer survivors who were in their 50 s at breast cancer diagnosis. Long-term monitoring of late CHF should be considered in these younger breast cancer survivors.

•

Standard low-dose anthracycline increased the risk of late-onset heart failure.

•

Breast cancer survivors aged between 50 and 59 at diagnosis are at higher risks.

•

Clinicians should be aware of the long-term risk of heart failure in those patients.

Neoadjuvant endocrine therapy versus neoadjuvant chemotherapy in young women with breast cancer: Prognosis and axillary node surgery

e12626

Background: We aimed to evaluate patient-reported outcomes (PROs) in the NEST phase III trial, in which neoadjuvant endocrine therapy (NET) compared to conventional neoadjuvant chemotherapy (NCT) for hormone-responsive lymph node-positive premenopausal breast cancer. Methods: Premenopausal women with estrogen receptor (ER)-positive, HER2-negative, and lymph node-positive premenopausal breast cancer patients were enrolled. Patients were randomized to either 24 weeks of neoadjuvant chemotherapy with adriamycin plus cyclophosphamide (AC) followed by taxane (T) or neoadjuvant endocrine therapy with zoladex and tamoxifen. PROs were assessed at day 1 (baseline) and at the end of treatment, using the breast cancer module of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 23 (EORTC QLQ BR23). ClinicalTrials.gov: NCT01622361. Results: 187 patients were randomly assigned to chemotherapy (n = 95) or endocrine therapy (n = 92), and 174 patients completed the 24 weeks of neoadjuvant treatment period (n = 87, both). Baseline scores were similar between arms. No statistically significant between-treatment differences were observed for the function scales including body image, sexual functioning, and sexual enjoyment although endocrine treatment showed significant improvement in future perspective (HR = 8.3, 95% CI:1.72-18.38; P= 0.021). Even though no alopecia was reported in NET group, no statistically significant difference between both arms in the “upset by hair loss” was observed, in which NET group showed even worse score. Conclusions: Patients who received NET had significant improvement in a future perspective, however, a similar emotional negative impact on hair loss was observed compared with NCT despite no reported alopecia. Key words: breast cancer, patient-reported outcomes, quality of life, hair loss, EORTC QLQ-BR 23. Clinical trial information: NCT01622361.

A Mobile Technology for Collecting Patient-Reported Physical Activity and Distress Outcomes: Cross-Sectional Cohort Study

Background

Electronic patient-reported outcome (PROs) provides a fast and reliable assessment of a patient’s health-related quality of life. Nevertheless, using PRO in the traditional paper format is not practical for clinical practice due to the limitations associated with data analysis and management. A questionnaire app was developed to address the need for a practical way to group and use distress and physical activity assessment tools.

Objective

The purpose of this study was to assess the level of agreement between electronic (mobile) and paper-and-pencil questionnaire responses.

Methods

We validated the app version of the distress thermometer (DT), International Physical Activity Questionnaire (IPAQ), and Patient Health Questionnaire–9 (PHQ-9). A total of 102 participants answered the paper and app versions of the DT and IPAQ, and 96 people completed the PHQ-9. The study outcomes were the correlation of the data between the paper-and-pencil and app versions.

Results

A total of 106 consecutive breast cancer patients were enrolled and analyzed for validation of paper and electronic (app) versions. The Spearman correlation values of paper and app surveys for patients who responded to the DT questionnaire within 7 days, within 3 days, and on the same day were .415 (P<.001), .437 (P<.001), and .603 (P<.001), respectively. Similarly, the paper and app survey correlation values of the IPAQ total physical activity metabolic equivalent of task (MET; Q2-6) were .291 (P=.003), .324 (P=.005), and .427 (P=.01), respectively. The correlation of the sum of the Patient Health Questionnaire–9 (Q1-9) according to the time interval between the paper-based questionnaire and the app-based questionnaire was .469 for 14 days (P<.001), .574 for 7 days (P<.001), .593 for 3 days (P<.001), and .512 for the same day (P=.03). These were all statistically significant. Similarly, the correlation of the PHQ (Q10) value according to the time interval between the paper-based questionnaire and the app-based questionnaire was .283 for 14 days (P=.005), .409 for 7 days (P=.001), .415 for 3 days (P=.009), and .736 for the same day (P=.001). These were all statistically significant. In the overall trend, the shorter the interval between the paper-and-pencil questionnaire and the app-based questionnaire, the higher the correlation value.

Conclusions

The app version of the distress and physical activity questionnaires has shown validity and a high level of association with the paper-based DT, IPAQ (Q2-6), and PHQ-9. The app-based questionnaires were not inferior to their respective paper versions and confirm the feasibility for their use in clinical practice. The high correlation between paper and mobile app data allows the use of new mobile apps to benefit the overall health care system.

Trial Registration

ClinicalTrials.gov NCT03072966; https://clinicaltrials.gov/ct2/show/NCT03072966

Breast cancer diagnosis by analysis of serum N-glycans using MALDI-TOF mass spectroscopy

Blood and serum N-glycans can be used as markers for cancer diagnosis, as alterations in protein glycosylation are associated with cancer pathogenesis and progression. We aimed to develop a platform for breast cancer (BrC) diagnosis based on serum N-glycan profiles using MALDI-TOF mass spectroscopy. Serum N-glycans from BrC patients and healthy volunteers were evaluated using NosQuest’s software “NosIDsys.” BrC-associated “NosID” N-glycan biomarkers were selected based on abundance and NosIDsys analysis, and their diagnostic potential was determined using NosIDsys and receiver operating characteristic curves. Results showed an efficient pattern recognition of invasive ductal carcinoma patients, with very high diagnostic performance [area under the curve (AUC): 0.93 and 95% confidence interval (CI): 0.917–0.947]. We achieved effective stage-specific differentiation of BrC patients from healthy controls with 82.3% specificity, 84.1% sensitivity, and 82.8% accuracy for stage 1 BrC and recognized hormone receptor-2 and lymph node invasion subtypes based on N-glycan profiles. Our novel technique supplements conventional diagnostic strategies for BrC detection and can be developed as an independent platform for BrC screening.

Effect of Tamoxifen on the Risk of Osteoporosis and Osteoporotic Fracture in Younger Breast Cancer Survivors: A Nationwide Study

Background: Although international guidelines recommend bone screening for premenopausal breast cancer patients taking adjuvant tamoxifen, the effects of tamoxifen on osteoporosis and related risks remain controversial. The objective of this study was to investigate the incidence of and risk factors for osteoporosis and osteoporotic fractures in younger breast cancer patients.

Methods: A nationwide retrospective cohort study was conducted using South Korea Health Insurance Review and Assessment Service claims data. The rates of osteoporosis and osteoporotic fracture were calculated as incident cases per person-year and disease-free probability rates were analyzed with the Kaplan-Meier method. To identify risk factors for osteoporosis and osteoporotic fracture, a multivariable Cox proportional hazard regression model was applied.

Results: From January 2009 to December 2014, a total of 47,649 breast cancer patients were included. The incidence rates of osteoporosis and osteoporotic fracture were 23.59 and 2.40 per 1,000 person-years, respectively. In the overall population, tamoxifen was significantly associated with a decreased risk of osteoporosis and osteoporotic fractures 0.76). However, tamoxifen was not associated with the risk of osteoporosis (HR 1.24, CI 0.85–1.82) and osteoporotic fracture (HR 8.15, CI 0.36–186.70) in patients under age 40. In the 40–49 years subgroup, tamoxifen significantly decreased the risk of osteoporosis (HR 0.74, CI 0.65–0.84) and osteoporotic fracture (HR 0.49, CI 0.31–0.76).

Conclusions: Tamoxifen is not associated with an increased risk of osteoporosis and osteoporotic fracture in premenopausal breast cancer patients. Tailored screening strategies for breast cancer survivors with different osteoporosis risks are needed.

Precis: Tamoxifen is not associated with an increased risk of osteoporosis and osteoporotic fracture in premenopausal breast cancer patients. Tailored screening strategies for breast cancer survivors who are at different risks of developing osteoporosis are needed.

Changes in bone mineral density during 5 years of adjuvant treatment in premenopausal breast cancer patients

PURPOSE

Adjuvant treatment for breast cancer in postmenopausal women is a risk factor for bone loss. However, the association between bone mineral density (BMD) changes in premenopausal breast cancer patients and various adjuvant treatment regimens is not well characterized. In this study, we evaluated the changes in BMD according to adjuvant treatment in premenopausal women with breast cancer.

METHODS

Between 2006 and 2010, BMD data of 910 premenopausal women with breast cancer before operation and 1, 2, 3.5, and 5 years post-operation were retrospectively analyzed. The patients were divided according to the type of treatment: observation (O), tamoxifen (T), chemotherapy (C), C followed by T (C → T), and gonadotropin-releasing hormone (GnRH) agonist with T (G + T).

RESULTS

After 5 years of follow-up, BMD changes were similar between the T and O groups (all p > 0.05). Within 1 year of treatment, the C group showed the most significant BMD loss. The C → T and G + T groups showed more significant BMD loss in the lumbar spine and femur than the O and T groups (both p < 0.001, both). After 1 year of treatment, BMD loss in the lumbar spine was significantly greater in the C → T and G + T groups than in the T group; this tendency was maintained for 5 years of treatment (all p < 0.005).

CONCLUSION

Premenopausal women who received adjuvant treatment which induced menopause showed significant bone loss which lasted for 5 years. Although no significant difference was observed between the O and T groups, tamoxifen treatment during chemotherapy or GnRH agonist treatment might prevent bone loss.

Recurrence of Breast Carcinoma as Paget's Disease of the Skin along the Core Needle Biopsy Tract after Skin-Sparing Mastectomy

We report a case of recurrence as Paget's disease at the core needle biopsy (CNB) entry site in a patient with microinvasive ductal carcinoma who underwent nipple-areola-skin sparing mastectomy (NASSM) and autologous reconstruction. Clinically diagnosed recurrences associated with previous needle procedures for malignant breast lesions are rare and usually occur in patients who have not received radiation therapy. The present case involved local recurrence at the skin puncture site of a patient diagnosed based on CNB findings who underwent NASSM without receiving radiation therapy. Although the removal of the CNB tract with resected breast tissue is not always emphasized, the skin puncture site should be recorded to detect abnormal skin changes after surgery for the timely detection and management of complications.

Abstract P2-13-04: Risk of osteoporosis and osteoporotic fracture in breast cancer survivors: A nation-wide study

Background: Referring to American Society of Clinical Oncology (ASCO) 2015 guidelines, they recommend bone screening every two years for premenopausal women receiving tamoxifen, considering it as a risk factor for developing osteoporosis. This nationwide study aimed to investigate the incidence of osteoporosis and osteoporotic fractures, and to assess whether the known factors increase the risk of osteoporosis and/or osteoporotic fractures among breast cancer survivors in South Korea.

Methods: A nationwide retrospective study was conducted using the Health Insurance Review and Assessment Service (HIRA) data. The incidence rates of osteoporosis and osteoporotic fracture were calculated by dividing the number of incident cases by the total follow-up period (person-years). The risk factors for osteoporosis and osteoporotic fracture were investigated using Cox proportional hazard regression models.

Results: From Jan 2009 to Dec 2014, a total of 47,649 breast cancer survivors were included in this analysis. During the study period, 5,955 osteoporosis events were observed from 252,396 person-year. The incidence rate of osteoporosis in breast cancer survivors was 23.59 per 1000 person-year (95% CI 23.00 - 24.20). Osteoporotic fracture incidence was assessed 2.40 per 1000 person-year (95% CI 2.23 - 2.60), with 647 events out of 269,075 person-years. In age&lt;40 subgroup, use of ovarian function suppression (OFS) was significantly related to incidence of osteoporosis (Incidence rate 7.06 95% CI 5.47 - 9.11). However, the use of tamoxifen did not show an increased risk of osteoporosis (HR 1.24, 95% CI 0.85 - 1.82). Nine osteoporotic fracture was found in 7,121 patients in age under 40. In 40-49 age group, use of chemotherapy (HR 1.41, 95% CI 1.24-1.60, p&lt;.0001), aromatase inhibitor (HR 2.45, 95% C.I. 2.05- 2.92, p&lt;.0001), and OFS (HR 1.19, 95% CI 1.01-1.40, p =.0113) showed a significant increase of osteoporosis. Osteoporotic fracture were associated with use of AI and OFS in 40-49. Use of tamoxifen significantly decreased osteoporosis diagnosis in age 40-49, 50-59, and 60-69. Tamoxifen was also related to decreased incidence of osteoporotic fracture in age 40-49 (HR 0.49, 95% CI 0.31-0.76, p&lt;.0001) and 50-59 (HR 0.37, 95% CI 0.23-0.60, p&lt;.0001).

Conclusions: Tamoxifen is not associated with the increased risk of osteoporosis and osteoporotic fracture in breast cancer survivors.

Keywords: Breast Neoplasms, Survivorship, Osteoporosis, Bone Fractures, adverse effects

Citation Format: Il Yong Chung, Jihyoun Lee, Heba Alqudaihi, Jong Won Lee, Byung Ho Son, Sei Hyun Ahn, Ji Sung Lee. Risk of osteoporosis and osteoporotic fracture in breast cancer survivors: A nation-wide study [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 P2-13-04.

Abstract P5-01-11: Tracking anchor mutations in serial cell-free DNA using ultra-high sensitive mass spectrometry method provide risk of subsequent recurrence during surveillance after standard therapy

Cell-free DNA (cfDNA), as a non-invasive strategy, provides substantial benefit to overcome temporal/spatial tumor heterogeneity. Surveillance of recurrence after standard treatment in early breast cancer (BC) using cfDNA, enables to detect minimal residual disease (MRD), also to identify genomic alterations driving recurrences. We aimed to assess whether cfDNA can detect metastasis during surveillance after standard treatment by tracking mutations using mass spectrometry method from minimal plasma volume. Thirty breast cancer patients with serial plasma adequately drawn for cfDNA analysis were analyzed. Twenty cases were who subsequently developed clinical recurrence while ten were clinically disease free till last follow up. Primary tumor DNA extracted from paraffin blocks of surgical specimen and germline DNA were sent for deep targeted sequencing using in-house Oncopanel (382 genes, 184 hotspots, 8 fusions, 0.82Mb) Mean sequencing depth of tumor was x284.5 and somatic mutations with &gt;5-10% variant allelic fraction (VAF) were chosen as anchor mutations for serial analyses. Hotspot mutations eg. PIK3CA H1047 or E545K were selected for serial tracking. We applied in-house developed mass stectrometry UHS-platform (Ultra-high sensitive) -detects 0.01% frequency mutant allele in colorectal and lung cancer- from plasma processed from 2ml whole blood. Mean number of anchor mutations is 5.95 and 74.6% of mutation sites were successfully designed as multiplex-probe for UHS-platform. Anchor mutations were searched in each patients’ blood drawn every 3-6months after surgery or after time of recurrence. Among 20 patients who were clinically diagnosed to have recurrence after standard treatment, 14 displayed ctDNA positive of at least one of anchor mutations (sensitivity, 70%, false negative rate (FNR) 30%). Sensitivity was not associated with input DNA amount nor with disease free interval. It was not associated with whether patients were receiving systemic therapy at time of recurrence. Among the 6 false negative cases, 3 cases were local/or regional recurrences and the other three had distant metastasis (2 lung, 1 bone metastasis). The FNR was 0% (sensitivity 100%) however, when number of anchor mutations was more than 5. Among 10 patients with no evidence of recurrence after standard therapy, 1 patient had cfDNA positive during follow up. No patient had minimal residual disease (MRD), within 1 month after surgery (+/- prior neoadjuvant systemic therapy). One case displayed cfDNA positive during surveillance (DDR2; c.2411T&gt;C; p.F804S, TP53; c.743G&gt;A; p.R248Q), at time-point of 7mos after surgery. The patient undergone mammogram, ultrasound and systemic work-up and yet, no evidence of recurrence was found till 6months after cfDNA positive conversion. Follow-up cfDNA analyses are necessary to evaluate mutation status whether, positive/increase VAF or negative conversion. At the same time, systemic radiology work-up needs to be done to investigate the development of clinically relevant recurrence after positive cfDNA, to confirm whether cfDNA positive finding was a false positive call or a matter of longer lead time.

Anchor mutations selected from primary tumor was analyzed in serial cell-free DNA using mass spectrometry based UHS platform. With sufficient number of anchor mutations for tracking (&gt;5), 100% sensitivity was observed with 0-10% false positivity. While liquid biopsy enable non-invasive surveillance, and yet needs substantial amount of blood draw 5-10ml each time, our platform using mass spectrometry can detect anchor mutation from less than 2ml whole blood. Clinical utility of cfDNA surveillance using UHS platform needs further evidence with longer follow-up analyses in larger prospective cohort.

Citation Format: Jisun Kim, Whee Kyung Jo, Soo Jeong Choi, Hwan Park, Jiyoung Lee, Sae Byul Lee, Hee Jin Lee, Hee Jeong Kim, Il Yong Chung, Beom Seok Ko, Jong Won Lee, Byung Ho Son, Sei Hyun Ahn, Sung-Bae Kim, Kyung Hae Jung, Jin-Hee Ahn, Sung-Min Chun. Tracking anchor mutations in serial cell-free DNA using ultra-high sensitive mass spectrometry method provide risk of subsequent recurrence during surveillance after standard therapy [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 P5-01-11.

Abstract P2-16-25: Young age breast cancer who achieve pathologic complete response after neoadjuvant chemotherapy display excellent outcome than older age breast cancers

Introduction: Patients with pathologic complete response (pCR) after neoadjuvant chemotherapy (NCT) is known to have a good prognosis compared with patients with no residual disease necessitating additional adjuvant systemic therapy for some population. Also there are cases of recurrence and/or death among patients with pCR. We aimed to 1)analyze whether prognostic impact of pCR differ across subtypes and age groups and 2)investigate factors associated with outcome after achieving pCR.

Methods: Among 1930 patients who underwent NCT at Asan Medical Center between 1890 to 2018, 1688 patients with clinico-pathological, follow-up data available were analyzed. 339 (20.1%) patients had pCR defined as ypT0/Tis with no residual nodes(N0) after NCT. Pathologic CR rate were 10.2% (102/1003), 40.0% (100/250) and 31.6% (137/434) in each HR positive, HRneg/HER2pos and triple negative tumors. Pathologic CR rate were 19.7% (232/1175) and 20.9% (107/513) in young age and old age group respectively.

Results: Median follow up period was 62 months (6-129 months). Five-year disease free survival (5yr-DFS) of ‘total’ patients and patients with ‘no-pCR’ and ‘pCR’ were 81.7%, 79.1% and 92.4% respectively (p=&lt;0.01). Pathologic complete response was significant favorable indicator across all subtypes and both in young/old age group (Cox regression analysis in each group, Table 1).

Among patients with pCR, residual in-situ disease (p=&lt;0.01, HR 3.889), tumor size&gt;5cm (p=0.006, HR=1.45), and negative hormone receptor (p&lt;0.01, HR=9.269) were independently associated with worse disease free survival. These prognostic factors were similar in patients with residual disease as well.

Intriguingly, magnitude of impact affecting prognosis differed by age groups that younger patients

(≤50) who achieved pCR displayed excellent outcome similar to older age group (HR=1.33, CI 0.57-3.12, p=0.51). On the other hand, young age patients who did not achieve pCR had the worst outcome with 5yr-DFS 77.3% indicating the necessity of additional systemic therapy. Also, while HR negative tumors are known to have worse outcome, HRneg/pCR group had longer 5yr-DFS than HRpos/no-pCR groups (90.6% vs 83.9%, p=0.009). The outcomes were similarly observed for overall survival analysis.

Conclusion: Patients with pCR after NCT showed better DFS and OS across all subtypes. Achieving pathologic complete response was a good prognostic indicator especially in young age population. Younger patients with residual disease after NCT may be candidates for additional adjuvant systemic therapy after surgery.

Table1. Cox regression analysis in each grouppCRNo-pCRHazard ratio (ref, pCR)95%CIP value5yr-DFS (%)5yr-DFS (%)SubtypesHR positive96.183.93.081.35-7.020.007HRneg/HER2pos89.672.02.431.13-5.220.023HRneg/HER2pos91.567.83.591.87-6.89&lt;0.001AgeYoung age (≤50)93.377.34.502.53-8.08&lt;0.001Old age (&gt;50)90.183.42.251.06-4.750.033

Citation Format: Young Joo Lee, Yung Il Shin, Jisun Kim, Sae Byul Lee, Hee Jeoung Kim, Il Yong Chung, Beom Seok Ko, Jong Won Lee, Byung Ho Son, Sei-Hyun Ahn. Young age breast cancer who achieve pathologic complete response after neoadjuvant chemotherapy display excellent outcome than older age breast cancers [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 P2-16-25.

Abstract P2-08-20: Long-term outcomes after breast conserving surgery compared with mastectomy in early breast cancer in Korea

Introduction: In some recent studies, breast conserving surgery (BCS) has been reported to improve survival rates compared with modified radical mastectomy (MRM) in early breast cancer.

The purpose of this study was to evaluate long term outcome of Korean women with early breast cancer and compare the recurrence rate and overall survival according to operation methods; BCS vs MRM.

Method: In this population-based study, we used information from two databases including the nationwide Korean Breast Cancer Registry (KBCR) and Asan Medical Center (AMC).

We identified patients from KBCR who were diagnosed breast cancer stage 1-3 between 1998-2012 and were given either BCS or MRM regardless of axillary staging or dissection or use of adjuvant systemic therapy. To minimize confounding bias caused by variables other than operation method, we used exact match pairing of variables such as age, tumor stage and subtypes except for adjuvant radiotherapy. We compared overall survival (OS) and cancer specific survival (CSS) of BCS group and MRM group. As KBCR is multi-centered and online based registry program, we used a single center database to validate the result of KBCR. We selected patients who were diagnosed with breast cancer stage 1-3 between 1998-2008 from AMC and divided them into BCS group and MRM group. We used exact match pairing of all variables except adjuvant radiotherapy in this cohort as well and compared OS, CSS and disease-free survival (DFS).

Result: Of 59121 patients who were selected from KBCR, 26581 patients received MRM and 32540 patients received BCS. 18989 patients in each group were remaining after exact match pairing. After exact matching to adjust variables other than operation method, BCS was significantly associated with better OS and CSS compared with MRM. After exact matching HR for OS and CSS were 1.47 [0.36-1.59 p&lt;0.001], 1.37 [1.20-1.57 p&lt;0.001] respectively.

Of 8710 patients who from AMC, 2490 patients were excluded as they had unknown variables we needed to know for exact matching. 3095 patients received MRM and 3125 patients received BCS. 1790 patients in each group were remaining after exact match pairing. In this cohort after exact BCS was also significantly associated with better OS, CSS and DFS compared with MRM. After exact matching HR for OS, CSS and DFS were 1.64 [1.30-2.06 p&lt;0.001], 1.71 [1.33-2.20, p&lt;0.001], 1.37 [1.14-1.64, p&lt;0.001] respectively. Median follow up was 88.6 month before matching and 89.2 month after matching.

Conclusion: When we adjusted confounding variables by exact matching BCS showed better overall and cancer specific survival and in AMC database better recurrence free survival compared to MRM in early breast cancer patients.

These results suggest that BCS is at least equivalent to mastectomy in terms of recurrence free survival and overall survival and may affect treatment decisions in early breast cancer patients.

Citation Format: Hakyoung Kim, Sei Hyun Ahn, Byung Ho Son, Jong Won Lee, Il Yong Chung, Beom Seok Ko, HeeJeong Kim, Jisun Kim, Young Ju Lee, Yungil Shin, Soojeong Choi, Ho Hyun Ryu, Sae Byul Lee. Long-term outcomes after breast conserving surgery compared with mastectomy in early breast cancer in Korea [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 P2-08-20.

Exercise Promotion and Distress Reduction Using a Mobile App-Based Community in Breast Cancer Survivors

Physical activity (PA) enhancement and mental distress reduction are important issues in cancer survivorship care. Mobile technology, as an emerging method for changing health behaviors, is gaining attention from many researchers. This study aimed to investigate the effect of a mobile app-based community on enhancing PA and decreasing distress in breast cancer survivors. We conducted a non-randomized, prospective, interventional study that had a mobile community-later arm and mobile community-first arm. With an Android smartphone app (WalkON®), daily walk steps and weekly distress scores using app-based Distress Thermometer (DT) questionnaires were collected from participants for about 12 weeks. To examine the difference in weekly step counts before and during the community activity, we used a paired t-test method. For a comparative analysis, we referred to a previous prospective observational study without a mobile community intervention that had the same setting as the present study. After propensity score matching (PSM), multivariable regression modeling with difference-in-difference (DID) was performed to estimate the effect of the mobile app-based community on PA and mental distress. From January to August 2018, a total of 64 participants were enrolled in this study. In the univariate analysis, after participation in the mobile community, the participants showed a significant increase in total weekly steps (t = -3.5341; P = 0.00208). The mean of the differences was 10,408.72 steps. In the multivariate analysis after PSM, the mobile community significantly increased steps by 8,683.4 per week (p value <0.0001) and decreased DT scores by 0.77 per week (p value = 0.009) in the mixed effect model. In the two-way fixed effect model, the mobile community showed a significant increase in weekly steps by 8,723.4 (p value <0.0001) and decrease in weekly DT by 0.73 (p value = 0.013). The mobile app-based community is an effective and less resource-intensive tool to increase PA and decrease distress in breast cancer survivors. Trial Registration: NCT03190720, NCT03072966.

Recurrence Outcomes After Nipple-Sparing Mastectomy and Immediate Breast Reconstruction in Patients with Pure Ductal Carcinoma In Situ

BACKGROUND

Nipple-sparing mastectomy (NSM) has become increasingly prevalent for patients with ductal carcinoma in situ (DCIS) requiring mastectomy. However, few data regarding recurrence outcomes after NSM are available for this patient population. This study evaluated the locoregional recurrence (LRR) rate for patients with pure DCIS who underwent NSM followed by immediate breast reconstruction without adjuvant radiotherapy and investigated potential risk factors for LRR and/or nipple-areola complex recurrence (NR).

METHODS

A retrospective chart review was performed for 199 consecutive patients with pure DCIS who underwent NSM and immediate breast reconstruction between March 2003 and December 2015. Risk factors for LRR and NR were analyzed using univariate (Chi square test) and multivariate (Cox model) methods.

RESULTS

The median follow-up duration after surgery was 97 months (range, 39-186 months). At 10 years, the LRR rate was 4.5%, and the NR rate was 3%. The univariate analysis showed that high nuclear grade, negative receptor status, positive human epidermal growth factor receptor 2 (HER2) status, and negative hormone receptor/positive HER2 subtype were associated with increased risk for NR. The multivariate analysis demonstrated that negative progesterone receptor status was an independent risk factor for LRR. However, margin status and tumor-to-nipple distance (TND) were not associated with increased risk for either LRR or NR.

CONCLUSIONS

The study findings suggest that NSM can be a feasible surgical option even for DCIS with a TND of 1 cm or less if the retroareolar resection margin is negative for malignancy. Determining the molecular subtype of DCIS might be helpful in identifying patients at high risk for recurrence.

GeneReader NGS System Is a Useful Sequencing Platform for Clinical Testing of BRCA1 and BRCA2

Although next-generation sequencing (NGS) is widely used for BRCA1/2 sequencing analysis, it involves a fragmented workflow along with complex bioinformatic analysis and interpretation. In this study, the performance characteristics and workflow of the GeneReader NGS System (QIAGEN), including BRCA1/2 sequencing, were evaluated. For BRCA1/2 genetic testing, we conducted library preparation, emulsion PCR, and sequencing. QCI Analyze software was used for read alignment, quality control, variant calling, and clinical report generation. GeneReader and Sanger sequencing utilized 63 patients with breast or ovarian cancer for comparison. Reproducibility, precision, variant calling, turnaround time, and hands-on time were evaluated. The read percentage in the on-target regions was 90.5%. More than 99.99% of target regions showed read depths ≥100x. Variants generated from GeneReader showed 100% accuracy compared to the Sanger sequencing results. Annotation with GeneReader showed >99.8% concordance with HGVS nomenclature. Single-nucleotide variations and indel variants showed 100% calling reproducibility; the precision for variant frequency showed a 0.3-3.6% coefficient of variation. Most processes involved hands-off time (3714 min, 88.6% of total run time). The GeneReader NGS System for BRCA1 and BRCA2 testing showed good analytical performance and a short hands-on time. Because of its integrated sample preparation for bioinformatic interpretation, this system is practical for clinical laboratories.

Risk stratification system for groups with a low, intermediate, and high risk of subsequent distant metastasis and death following isolated locoregional recurrence of breast cancer

PURPOSE

This study aimed to identify prognostic factors for long-term outcomes among patients with isolated locoregional recurrence (ILRR) of breast cancer as their first failure event. Many prognostic tools have been developed to inform systemic treatment choices in the adjuvant setting, but tools for predicting post-ILRR prognosis are scarce.

METHODS

A total of 495 patients who experienced ILRR after primary surgery at the Asan Medical Center between 1989 and 2008 were included. All patient information and tumor characteristics at the initial surgery were retrieved from our retrospectively collected database, and ILRRs were categorized as local recurrence or regional recurrence (RR). Distant metastasis-free survival (DMFS), breast cancer-specific survival (BCSS), and overall survival post-ILRR were calculated.

RESULTS

The median follow-up from the ILRR was 65 months (range 1-249 months), and the 5-year post-ILRR DMFS rate was 58.9%. We found three factors-lymph node metastasis, a disease-free interval < 30 months, and RR as the ILRR type-that were independent prognostic factors for both DMFS [hazard ratio (HR) = 2.08, 1.60, and 1.59; P < 0.001, 0.002, and 0.003, respectively] and BCSS (HR = 2.28, 1.99, and 1.48; P < 0.001, < 0.001, and 0.016, respectively) post-ILRR. Patients were classified into four groups according to the presence these three prognostic indicators: the low-, intermediate-, high-, and extremely high-risk groups. The 5-year post-ILRR DMFS rates were 79.4%, 68.1%, 47.6%, and 36.0%, respectively.

CONCLUSIONS

This risk stratification system for subsequent distant metastases after ILRR can be used to make more informed decisions regarding prognosis-based local or systemic management strategies.

Single vertical incision thoracoabdominal flap for chest wall reconstruction following mastectomy of locally advanced breast cancer

Purpose

Skin grafts have been widely used in managing extensive chest wall defects after mastectomy for advanced breast cancer. However, their durability and tolerability to radiotherapy is still controversial. A thoracoabdominal (TA) flap with a few technical refinements can safely transfer a larger flap while minimizing complications.

Methods

From January 2007 to February 2018, a retrospective review was performed to compare 2 groups after wide breast excision: skin graft group (group 1) and lateral-based, single vertical incision rotation-advancement TA flap (group 2). Patients' demographics, operative details, complications, hospital stay, postoperative outpatient visits, cost, and start of adjuvant therapy were analyzed between the 2 groups.

Results

During the study period, 34 patients received skin graft and 41 patients received TA flap. group 2 had a shorter hospital stay (6.41 ± 2.64 days vs. 12.62 ± 4.60 days, P < 0.001) and shorter time to complete wound healing (29.27 ± 18.68 days vs. 39.24 ± 27.70 days, P = 0.03) than group 1. There was also a difference in the period from surgery to initiation of adjuvant therapy (group 1, 45.04 days ± 17.79 days; group 2, 37.07 ± 15.38 days, P = 0.073). Although limitation in shoulder motion was more frequent in group 2, limitation of motion for >1 year was observed in 4 patients in only group 1 (43.90% vs. 38.24%, P = 0.613).

Conclusion

TA flap has a simple design that minimizes concerns involving the donor site. Moreover, it does not require complicated procedures and allows for re-elevation whenever necessary. Finally, it guarantees faster wound recovery than skin graft with fewer complications.

Change in neutrophil-lymphocyte ratio after initiation of chemotherapy can be a prognostic indicator in de novo stage IV breast cancer patients

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Background: The de novo stage IV breast cancer has poor prognosis, predicting response to treatment in the affected patients is difficult. We investigated whether the initial neutrophil to lymphocyte ratio (NLR) at diagnosis and NLR change after the first palliative chemotherapy cycle can be a prognostic indicators. Methods: We retrospectively reviewed 218 de novo stage IV breast cancer patients with available NLR values who underwent palliative chemotherapy as an initial treatment. We analyzed cancer specific survival (CSS) according to initial NLR (iNLR), NLR change after the first chemotherapy cycle (ΔNLR), and a combination of these two. Results: The mean patient age was 47.2 years; the median follow-up period was 29.8 months. The mean iNLR and ΔNLR values were 2.83 ± 2.19 and 0.39 ± 3.74, retrospectively, amd were used as cut off points. There was no significant difference between low and high iNLR groups (p = 0.431); however, there was a significant correlation between ΔNLR and CSS (p = 0.031). The 1-, 3-, and 5- year CSS rates of patients in the increased ΔNLR group were significantly lower than those of patients in the stationary or decreased group. (78.4%, 35.4%, 20.8% vs 88.9%, 52.6%, 27.1%; p = 0.031). Multivariate analysis suggested that ΔNLR was an independent prognostic factor (hazard ratio (HR) = 1.748, 95% confidence interval (CI) = 1.084 - 2.818). The analysis of the combination of iNLR and ΔNLR showed that patients in the high iNLR and increased ΔNLR group had poorer prognosis than those in the low iNLR and stationary or decreased ΔNLR group (HR = 4.294, 95% CI = 1.586 - 11.629). Conclusions: Initial NLR alone was not a prognostic indicator among de novo stage IV breast cancer patients. However, patients with increased NLR after palliative chemotherapy exhibited worse CSS. Patients with high initial NLR and increased NLR after treatment might be a non responder to treatment.

Salivary Duct Cancer Metastasis Mimicking Primary Breast Cancer: A Case Report and Review

Secondary breast malignancy is a rare occurrence, accounting for less than 2% of all breast malignancies. Salivary duct carcinoma (SDC) metastasizing to the breast has not been reported previously. This report presents the case of a woman who was initially diagnosed with and treated for parotid carcinoma. Two years later, during a follow-up visit, a breast lump was discovered, which was diagnosed as primary breast cancer and managed surgically. After surgery, hematoxylin and eosin and immunohistochemical staining revealed that the breast tumor had the same features as her primary SDC. Here, we present a confusing case of SDC metastasis to the breast that mimicked triple-negative breast cancer.

An Assessment of Physical Activity Data Collected via a Smartphone App and a Smart Band in Breast Cancer Survivors: Observational Study

Background

Although distress screening is crucial for cancer survivors, it is not easy for clinicians to recognize distress. Physical activity (PA) data collected by mobile devices such as smart bands and smartphone apps have the potential to be used to screen distress in breast cancer survivors.

Objective

The aim of this study was to assess data collection rates of smartphone apps and smart bands in terms of PA data, investigate the correlation between PA data from mobile devices and distress-related questionnaires from smartphone apps, and demonstrate factors associated with data collection with smart bands and smartphone apps in breast cancer survivors.

Methods

In this prospective observational study, patients who underwent surgery for breast cancer at Asan Medical Center, Seoul, Republic of Korea, between June 2017 and March 2018 were enrolled and asked to use both a smartphone app and smart band for 6 months. The overall compliance rates of the daily PA data collection via the smartphone walking apps and wearable smart bands were analyzed in a within-subject manner. The longitudinal daily collection rates were calculated to examine the dropout pattern. We also performed multivariate linear regression analysis to examine factors associated with compliance with daily collection. Finally, we tested the correlation between the count of daily average steps and distress level using Pearson correlation analysis.

Results

A total of 160 female patients who underwent breast cancer surgeries were enrolled. The overall compliance rates for using a smartphone app and smart bands were 88.0% (24,224/27,513) and 52.5% (14,431/27,513), respectively. The longitudinal compliance rate for smartphone apps was 77.8% at day 180, while the longitudinal compliance rate for smart bands rapidly decreased over time, reaching 17.5% at day 180. Subjects who were young, with other comorbidities, or receiving antihormonal therapy or targeted therapy showed significantly higher compliance rates to the smartphone app. However, no factor was associated with the compliance rate to the smart band. In terms of the correlation between the count of daily steps and distress level, step counts collected via smart band showed a significant correlation with distress level.

Conclusions

Smartphone apps or smart bands are feasible tools to collect data on the physical activity of breast cancer survivors. PA data from mobile devices are correlated with participants’ distress data, which suggests the potential role of mobile devices in the management of distress in breast cancer survivors.

Trial Registration

ClinicalTrials.gov NCT03072966; https://clinicaltrials.gov/ct2/show/NCT03072966

MRI-based 3D-printed surgical guides for breast cancer patients who received neoadjuvant chemotherapy

Magnetic resonance imaging (MRI) is the most accurate technique for evaluating residual tumor after neoadjuvant chemotherapy. However, precise determination of the extent of dispersed residual tumor in the breast following treatment remains a difficult task. We hereby introduce three-dimensional (3D)-printed surgical guides for use in breast cancer patients undergoing breast-conserving surgery after receiving neoadjuvant chemotherapy. We prospectively applied the 3D-printed surgical guides on breast cancer patients who underwent partial breast resection after receiving neoadjuvant chemotherapy. Breasts and tumors were modeled in 3D by using pretreatment magnetic resonance images, and surgical guides were created by using a 3D printer to mark the primary tumor. Out of the five patients who participated in the study, all patients had clear resection margins, and two patients experienced complete pathological remission. There were no recurrences during the median follow-up period of 21.9 months. Thus, our newly-developed 3D-printed surgical guides were useful for accurately marking the extent of breast tumor based on pretreatment magnetic resonance images, which is important for designating the extent of surgery needed in patients who have received neoadjuvant chemotherapy.

Prediction of Late Breast Cancer-Specific Mortality in Recurrence-Free Breast Cancer Survivors Treated for Five Years with Tamoxifen

Purpose

The extension of endocrine therapy beyond 5 years for recurrence-free survivors of breast cancer improves survival; however, the issue on how to clinically identify appropriate candidates remains controversial. This study aimed to identify prognostic factors for breast-cancer-specific mortality in patients who have had 5 years of tamoxifen treatment and categorize subgroups based on the risk of death using combinations of these prognostic factors to assist in the clinical decision to perform further endocrine therapy.

Methods

In total, 3,158 patients with breast cancer were enrolled. Breast cancer-specific survival rates after 5 years of tamoxifen treatment were calculated, and associated prognostic factors were analyzed using a Cox proportional-hazards model.

Results

An age extreme at diagnosis (i.e., < 40 or ≥ 60 years), tumor size > 2 cm, and positive lymphovascular invasion were robust independent prognostic factors for late breast cancer-specific death in tamoxifen-treated patients (hazard ratio [HR] = 2.162, 1.739, and 1.993; p = 0.001, 0.047, and 0.011, respectively). Lymph node metastasis and progesterone receptor negativity had borderline significance in this regard (HR = 1.741 and 1.638, p = 0.099 and 0.061). The study patients were classified into four groups according to the number of prognostic indicators, i.e., low, intermediate, high, and extremely high risk. The additional 5- and 10-year cumulative risks of breast cancer-specific death were 0.8% and 1.5% in the low-risk group, 0.9% and 3.9% in the intermediate-risk group, 1.3% and 7.3% in the high-risk group, and 4.8% and 13.8% in the extremely high-risk group, respectively.

Conclusion

This new risk stratification system for late mortality in breast cancer can be used to identify the right candidates for extended endocrine therapy after 5 years of tamoxifen treatment.

Clinical Implication of HER2 Status in Hormone Receptor-Positive Mucinous Breast Cancer

PURPOSE

Mucinous carcinoma (MC) is a rare breast cancer with favorable outcome. Unlike typical breast cancer, the current guidelines do not recommend chemotherapy or anti-human epidermal growth factor receptor 2 (HER2) therapy for hormone receptor (HR)-positive MC, regardless of HER2 status. We evaluated the prognostic implication of HER2 status in HR-positive MC.

METHODS

We retrospectively reviewed the data of 471 patients with pure MC (stages I-III) who underwent curative surgery. We analyzed 5-year disease-free survival (DFS) and distant metastasis-free survival (DMFS), according to clinicopathological characteristics.

RESULTS

The median follow-up duration was 79.0 months. Overall, the 5-year DFS rate was 95.7% and the 5-year DMFS rate was 96.2%. Nodal status was the only significant factor for DFS (relative risk [RR], 3.40; 95% confidence interval [CI] 3.40-9.67, p = 0.021). Among HR-positive/node-negative patients with tumor size ≥ 3 cm, HER2-positive patients showed significantly worse DFS (RR, 8.76; 95% CI 1.45-52.76, p = 0.018) and DMFS (RR, 11.37; 95% CI 1.37-74.70, p = 0.011). This finding was consistently significant, when combining both "HR-positive/node-negative/tumor size ≥ 3 cm" and "HR-positive/node-positive" MC (n = 125) for DFS (RR, 4.30; 95% CI 1.43-12.97, p = 0.009) and DMFS (RR, 4.93; 95% CI 1.63-14.90, p = 0.005). Intriguingly, within this subgroup, among HER2-positive tumors, whereas 5-year DFS was 60.2% in patients who did not receive trastuzumab, 100% of those who received trastuzumab were disease free (p = 0.053).

CONCLUSIONS

In HR-positive, node-negative MC with tumor size ≥ 3 cm, patients with HER2-positive MC showed worse survival, suggesting a potential role of an anti-HER2 strategy in this subgroup.

Prescription Refill Gap of Endocrine Treatment from Electronic Medical Records as a Prognostic Factor in Breast Cancer Patients

Purpose

Discontinuation of hormone therapy is known to lead to a poorer prognosis in breast cancer patients. We aimed to investigate the prescription gap as a prompt index of medication adherence by using prescription data extracted from patient electronic medical records.

Methods

A total of 5,928 patients diagnosed with invasive, non-metastatic breast cancer, who underwent surgery from January 1, 1997 to December 31, 2009, were enrolled retrospectively. The prescription data for 4.5 years of hormonal treatment and breast cancer-related events after treatment completion were analyzed. We examined the characteristics and prognoses of breast cancer in patients with and without a 4-week gap.

Results

Patients with a gap showed a significantly higher risk of breast cancer recurrence, distant metastasis, breast cancer-specific death, and overall death after adjustment (hazard ratio [HR], 1.389; 95% confidence interval [CI], 1.089–1.772; HR, 1.568; 95% CI, 1.158–2.123; HR, 2.108; 95% CI, 1.298–3.423; and HR, 2.102; 95% CI, 1.456–3.034, respectively). When patients were categorized based on gap summation, the lower third (160 days) and fourth (391 days) quartiles showed a significantly higher risk of distant metastasis (HR, 1.758; 95% CI, 1.186–2.606 and HR, 1.844; 95% CI, 1.262–2.693, respectively).

Conclusion

A gap of > 4 weeks in hormonal treatment has negative effects on breast cancer prognosis, and can hence be used as a sentinel index of higher risk due to treatment non-adherence. Further evaluation is needed to determine whether the gap can be used as a universal index for monitoring the adherence to hormonal treatment.

Abstract P2-14-21: Not presented

This abstract was not presented at the conference.

Citation Format: Lee S, Ahn SH, Lee JW, Chung IY, Ko BS, Kim HJ, Kim J, Shon G, Son BH. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-21.

Abstract P6-09-09: Analysis of serial circulating tumor cell count during neoadjuvant systemic therapy in breast cancer patients

Background: We aimed to evaluate the clinical implication of circulating tumor cell (CTC) counts in correlation with prognosis and radiologic/pathologic response to therapy in locally advanced breast cancer patients undergoing preoperative systemic therapy.

Methods: From Feb 2014 to May 2017, 207 patients without distant metastasis were prospectively enrolled from AMC. CTC counts were analyzed before-during-after the therapy. CTC isolation was performed using a SMART BIOPSY™ SYSTEM Isolation kit (Cytogen, Inc., Seoul, Korea). Recurrence-free and overall survival was analyzed according to CTC counts.

Result: The mean follow-up period was 22.46 months and mean age was 46.48 years. One or more CTC was identified in 132 of 203 patients(65.0%) before NST, in 135 of 186 patients(72.0%) during NST and 103 of 171 patients(60.2%) after NST. Initial tumor burden at diagnosis -tumor size, lymph node metastasis- was not correlated with CTC positivity. Overall, CTC count ((≥1 CTC, ≥2 CTCs, and ≥5 CTCs) was not correlated with response to therapy. Using RECIST criteria, 86.5% (179/204) were responders (complete, partial response, CR/PR) and 12.1% (25/204) were non-responders (stable, progressive disease, SD/PD). 14.5% (30/207) showed a pathologic complete response (pCR), yet no association was found between CTC count/changes and radiologic/pathologic response to therapy. Also, CTC count was not correlated with prognosis among the whole population. However, HR+ tumors, CTC detection before NST was significantly associated with treatment response by RECIST criteria (responder vs. non-responder) (p=0.003, p=0.017 and p=0.023, respectively).

Conclusions: Our findings support limited value of CTC count for locally advanced breast cancers undergoing neoadjuvant systemic therapy.

Citation Format: Gwark S-C, Kim J, Kim YH, Kim MS, Park JY, Lee SB, Sohn G, Chung IY, Ko BS, Kim HJ, Lee JW, Son BH, Ahn SH. Analysis of serial circulating tumor cell count during neoadjuvant systemic therapy in breast cancer patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-09-09.

Abstract P1-02-04: Is asymptomatic surveillance after standard treatment beneficial? : A 10yr-survival analysis of recurrent breast cancer patients by detection method of recurrence

Surveillance of recurrence after standard treatment of breast cancer (BC) for early detection and it's impact on overall survival are known to differ depending on recurrent site. Current guideline recommends asymptomatic surveillance to only detect loco-regional recurrences. As the evidences depend on historical randomized clinical trials we aimed to address questions whether earlier detection might have impact on survival now that plenty of new treatment strategies can be offered. Also to give answers to heterogeneous surveillance strategy in real-world practice we performed a retrospective 10yr-survival analysis of a large cohort of recurrent BC patients according to their detection method.

From 4188 operable breast cancer patients who completed standard treatment Asan Medical Center from 2006 to 2008 469 patients with recurrent BC were analyzed. Median disease free interval was 35.3 months (range 2.8-97.6) and overall survival (OS) was analyzed as time from initial diagnosis/surgery to death. Among 469 patients who developed recurrence 23.7% were local (ipsilateral breast skin chest wall) 22.6% were regional (ipsilateral axillary internal mammary lymph nodes) and 53.7% developed distant metastasis. 10yr-overall survival was analyzed according to recurrent site and it's detection method.

Detection of recurrence were categorized as 'asymptomatic surveillance (N=162, 34.5%)' and 'symptom-guided (N=307, 65.5%)'. Asymptomatic screening method included mammography breast-ultrasound serum tumor marker (CA15-3) and systemic images (eg. chest X-ray bone scan PET scans). Symptom-guided detection rate for local regional and distant metastasis was 14.9%, 5.5% and 15.1% respectively. Overall asymptomatic vs symptomatic 10yr-OS did not differ (81.3 vs 78.8 months, p=0.778). Among patients with distant metastasis 10ys-OS was not significantly different (70.3 vs 66.7 months p=0.846) and was similar according to stage/subtype. Among patients with local recurrence only 10yr-OS was 95.1 months ('symptomatic' vs 'aymptomatic 94.4 vs 94.5, p=0.809) which may be insufficient number of events to show significant difference. Among regional recurrent BCs, longer OS was observed in asymptomatically detected patients than symptom-guided group (86.1 vs 63.4, p=0.004). In Cox regression analyses asymptomatic detection showed significant better survival (HR=3.9, 95%CI:1.6-9.5) and this observation was more evident in patients with hormone receptor(HR) negative primary BCs (69.9 vs 47.9, p=0.029). Intriguingly, only 8.6% (7/80) of regional recurrence were diagnosed by mammography.

We observed survival benefit with asymptomatic screening in detecting regional recurrence especially in HR-negative primary BC patients. And role of systemic radiology even in advanced high risk breast cancer patients were limited. Although with limitation that surveillance method varied widely we emphasize the role of aymptomatic surveillance of regional nodal evaluation including breast-ultrasound. These findings are to be validated from a prospective clinical study along with using cutting edge modalities other than radiology which enable detection of micro-metastasis.

Citation Format: Lee Y, Lee HS, Ahn SH, Son BH, Kim J, Lee SB. Is asymptomatic surveillance after standard treatment beneficial? : A 10yr-survival analysis of recurrent breast cancer patients by detection method of recurrence [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-02-04.

Abstract P2-08-22: Clinical implication of HER2/neu status in hormone receptor positive pure mucinous breast cancer

Background: Mucinous carcinoma of the breast is a rare type of breast cancer with favorable outcome compared with other types of breast cancer. The current guideline does not recommend chemotherapy/anti-HER2 therapy for mucinous breast cancer with hormone receptor-positive subtype regardless of HER2/neu status. In this study, we evaluated the survival of pure mucinous breast cancer according to tumor stage and subtype.

Methods: Between 1989 and 2014, in Asan Medical Center, Korea, total 473 pure mucinous carcinomas (stage I-III) undergone curative surgery were reviewed retrospectively. 5yr disease-free and overall survival were analyzed according to size, lymph node metastasis, hormone receptor/HER2 status and given therapy.

Result: Total of 473 patients with pure mucinous breast cancer were analyzed and median follow-up duration was 78.00 months. 439 patients were hormone receptor-positive, 374 were node negative, 55 were HER2/neu positive. Among 374 patients with hormone receptor-positive and node-negative, tumor size was &lt;1cm in 46 patients, 1-2.9cm in 259 patients, ≥3cm in 69 patients. In HR-positive/Node-positive BCs, 90.8%(59/65)were given chemotherapy and 35.3%(6/17) were also given trastuzumab. Sixteen patients given trastuzumab were only included in the analysis to assess the benefit of trastuzumab among HER2 positive BCs.

Overall, 5-year disease-free survival (DFS) rate was 94.1% and the 5-year overall survival (OS) rate was 95.9%. Using Cox regression analysis, lymph node metastasis was the only significant prognostic factor for both DFS (HR4.0, 95%CI:1.8-9.0, p=0.001) and OS (HR3.5, 95%CI:1.3-8.9, p=0.008). Among HR-positive/node-negative with tumor size ≥3cm, HER2/neu positivity was only significantly associated with 5yr-DFS (71.4% in HER2/neu+ vs. 96.4% in HER2/neu-, HR9.5, 95%CI:1.3-67.5, p=0.024). This observation was consistently combining both 'HR-positive/node-negative/&gt;3cm' and 'HR-positive/node positive' BCs (N=127) that HER2 positive tumors showed worse survival (HR 3.7, 95%CI:1.2-10.8, p=0.015). Intriguingly, within this subgroup of HR-positive/node-negative/&gt;3cm' and 'HR-positive/node positive' BCs, among HER2 positive tumors, while 5yr-DFS was 63.7% in patients who didn't receive trastuzumab, 100% were disease free in patients who were given trastuzumab.

Conclusions: Overall, nodal status was the most significant prognostic factor for pure mucinous breast cancer. In hormone receptor-positive, lymph node negative mucinous breast cancer with tumor of ≥3cm, HER2 positive BCs showed worse survival, suggesting a potential role of anti-HER2 strategy in this subgroup.

Citation Format: Gwark S-C, Lee JW, Lee SB, Sohn G, Kim J, Chung IY, Ko BS, Kim HJ, Son BH, Ahn SH. Clinical implication of HER2/neu status in hormone receptor positive pure mucinous breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-22.

Abstract P4-01-11: Genomic alterations of cell-free DNA in early breast cancer patients with recurrence

Cell-free DNA (cfDNA), as a non-invasive strategy, provides substantial benefit to overcome tumor heterogeneity. Surveillance of recurrence after standard treatment in early breast cancer (BC) using cfDNA, enables to detect minimal residual disease (MRD), also to identify genomic alterations driving recurrences. We aimed to assess the role of cfDNA in detecting MRD by investigating genomic alterations of 1)primary, recurred tumor and 2)cfDNA at time of recurrence using deep targeted sequencing. Fifty-four early BC patients were enrolled prospectively between 2014 and 2017 at time of recurrence. Median disease free interval was 28.5 months (rage 6.2-49.8). 62.7% (32/51) were hormone receptor (HR) positive (28 HRpos/HER2neg, 4 HRpos/HER2pos), 11.8% (6/51) were HRneg/HER2pos and 25.5% (13/51) were triple negative BCs. 59.3% (32/54) patients developed loco-regional recurrence (15 local recurrence only, 13 regional only, 4 with both) and distant metastasis was observed among 40.7% (22/54) patients. Cell-free DNA was extracted from 5cc blood at time of recurrence. Deep targeted sequencing was performed using customized NGS panel –encompassing 426 cancer-related target coding region, 242 fusion and amplification-related region- of cfDNA and FFPE(formalin fixed paraffin embedded) tumor samples archived from surgical resection or biopsy. Deep targeted sequencing data was successfully performed in 72.1% (31/43) plasma samples and sequencing yield was significantly lower when stored for more than 2yrs (46.2% vs 83.3%).

Mutations of cfDNA and tumor (primary, recurred) were analyzed. Mean sequencing depth of cfDNA and FFPE were x425.7 and x777.6 respectively. Median number of pathogenic mutations found in primary tumor, cfDNA and recurred tumor were 27(range 12-99), 25(range 8-85) and 9(range 0-23). Among mutations found in primary tumor, 27.4% were shared mutations (range 8.1%-72.7%) with recurred tumor and 26.1% were shared mutations (range 4.7%-69.2%) observed in cfDNA sample. Among mutations found in recurred tumor, 40.9% were observed in cfDNA (range 17.7-87.5%). In primary tumor, median number of mutations with allelic fraction (MAF)&gt;10% were 12 (range 4-21) and at least one mutation was found in cfDNA at time of recurrence. Among mutations with MAF&gt;10%, 59.4% and 69.1% were found in cfDNA and recurred tumor. Known oncogenic mutations of PIK3CA, TP53, GATA3, AKT1, ESR1, RELN, ERBB2, ERBB3, BRCA1 mutation were found. PIK3CA gene (p.H1047R) was found in two cases both in primary tumor and cfDNA at recurrence (MAF 11.4% vs 5.3% and 12.3% vs 15.4%) suggesting de novo driver mutation. One patient developed regional recurrence during adjuvant aromatase inhibitor with ESR1 V392I mutation in both cfDNA and recurred tumor (MAF 48.1 and 54.5%), while another patient's recurred tumor during aromatase inhibitor harbored ESR1 D538G mutation exclusively in recurred tumor with MAF &lt;1%. Both patients had no ESR1 hotpot mutation in primary tumor.

Our data showed sequencing yield of 83.3% in plasma samples within 2yr. Pathogenic mutations in primary tumor, especially when MAF&gt;10%, half of them was observed in cfDNA at time of recurrence. ESR1 mutation should be included in cfDNA surveillance for patients undergoing endocrine therapy even absent in primary tumor.

Citation Format: Kim J, Jo WK, Kim KY, Kim BJ, Lee SB, Lee HJ, Yu JH, Kim HJ, Chung IY, Ko BS, Kim S-B, Jung KH, Ahn JH, Chang S, Lee JW, Son BH, Ahn SH. Genomic alterations of cell-free DNA in early breast cancer patients with recurrence [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-11.

Abstract P2-08-60: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Lee S, Ahn SH, Son BH, Lee JW, Chung IY, Ko BS, Kim HJ, Kim J, Shon G. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-60.

Clinicopathological characteristics of patients with gastrointestinal stromal tumor according to progranulin expression

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Background: As an autocrine growth factor, progranulin (PGRN) has been known to stimulate tumorigenesis and proliferation of several types of cancer cells. However, little is known about the clinicopathological features of patients with gastrointestinal stromal tumor (GIST) according to the PGRN expression. Methods: A retrospective analysis was performed for patients with GIST who underwent curative surgical resection between March 2007 and March 2018. PGRN expression in tumor cells was evaluated by immunohistochemical (IHC) analysis and semi-quantitatively categorized (no expression, 0; weak, 1+; moderate, 2+; strong, 3+). High expression was considered for tumors graded 2+ or 3+ staining intensity. Results: A total of 54 patients were analyzed, and 31 patients (57%) were male. Median age at surgery was 60 years (range, 33-79), and the most common primary site was stomach (36 patients, 67%). Spindle histology was observed in 35 patients (65%). Median tumor size was 8 cm (range, 2-47), and low mitotic count (≤ 5/50 HPF) was observed in 18 patients (33%). According to the modified NIH classification, 42 patients (78%) were grouped into high risk. With IHC evaluation, KIT and CD34 expression were observed in 51 patients (94%) and 40 patients (80%), respectively, and 27 patients (50%) had high PGRN-expressing tumors. Among the 34 patients whose tumors were genotyped, 25 patients (74%) had an exon 11 mutation, and D842V was observed in 3 patients (9%). According to the PGRN expression, high PGRN-expressing tumors had more epithelioid/mixed histology (68% vs. 32%; p = 0.046), and KIT exon 11 mutation (76% vs. 24%; p = 0.037). Regarding other clinicopathological characters, such as sex, age at surgery, primary site, size, mitotic count, risk classification, and KIT/CD34 expression, there was no significant difference between high PGRN-expressing tumors and low PGRN-expressing tumors. Conclusions: High PGRN-expressing GISTs had more epithelioid/mixed histology and more KIT exon 11 mutation in GIST patients who underwent curative surgical resection.

Reclassification of BRCA1 and BRCA2 variants of uncertain significance: a multifactorial analysis of multicentre prospective cohort

BACKGROUND

BRCA1 and BRCA2 (BRCA1/2) variants classified ambiguously as variants of uncertain significance (VUS) are a major challenge for clinical genetic testing in breast cancer; their relevance to the cancer risk is unclear and the association with the response to specific BRCA1/2-targeted agents is uncertain. To minimise the proportion of VUS in BRCA1/2, we performed the multifactorial likelihood analysis and validated this method using an independent cohort of patients with breast cancer.

METHODS

We used a data set of 2115 patients with breast cancer from the nationwide multicentre prospective Korean Hereditary Breast Cancer study. In total, 83 BRCA1/2 VUSs (BRCA1, n=26; BRCA2, n=57) were analysed. The multifactorial probability was estimated by combining the prior probability with the overall likelihood ratio derived from co-occurrence of each VUS with pathogenic variants, personal and family history, and tumour characteristics. The classification was compared with the interpretation according to the American College of Medical Genetics and Genomics-Association for Molecular Pathology (ACMG/AMP) guidelines. An external validation was conducted using independent data set of 810 patients.

RESULTS

We were able to redefine 38 VUSs (BRCA1, n=10; BRCA2, n=28). The revised classification was highly correlated with the ACMG/AMP guideline-based interpretation (BRCA1, p for trend=0.015; BRCA2, p=0.001). Our approach reduced the proportion of VUS from 19% (154/810) to 8.9% (72/810) in the retrospective validation data set.

CONCLUSION

The classification in this study would minimise the 'uncertainty' in clinical interpretation, and this validated multifactorial model can be used for the reliable annotation of BRCA1/2 VUSs.

A Nomogram for Predicting the Oncotype DX Recurrence Score in Women with T1-3N0-1miM0 Hormone Receptor‒Positive, Human Epidermal Growth Factor 2 (HER2)‒Negative Breast Cancer

Purpose

This preliminary study was conducted to evaluate the association between Oncotype DX (ODX) recurrence score and traditional prognostic factors. We also developed a nomogram to predict subgroups with low ODX recurrence scores (less than 25) and to avoid additional chemotherapy treatments for those patients.

Materials and Methods

Clinicopathological and immunohistochemical variables were retrospectively retrieved and analyzed from a series of 485 T1-3N0-1miM0 hormone receptor-positive, human epidermal growth factor 2‒negative breast cancer patients with available ODX test results at Asan Medical Center from 2010 to 2016. One hundred twenty-seven patients (26%) had positive axillary lymph node micrometastases, and 408 (84%) had ODX recurrence scores of ≤25. Logistic regression was performed to build a nomogram for predicting a low-risk subgroup of the ODX assay.

Results

Multivariate analysis revealed that estrogen receptor (ER) score, progesterone receptor (PR) score, histologic grade, lymphovascular invasion (LVI), and Ki-67 had a statistically significant association with the low-risk subgroup. With these variables, we developed a nomogram to predict the low-risk subgroup with ODX recurrence scores of ≤25. The area under the receiver operating characteristic curve was 0.90 (95% confidence interval [CI], 0.85 to 0.96). When applied to the validation group the nomogram was accurate with an area under the curve = 0.88 (95% CI, 0.83 to 0.95).

Conclusion

The low ODX recurrence score subgroup can be predicted by a nomogram incorporating five traditional prognostic factors: ER, PR, histologic grade, LVI, and Ki-67. Our nomogram, which predicts a low-risk ODX recurrence score, will be a useful tool to help select patients who may or may not need additional ODX testing.

Axillary Lymph Node Dissection Does Not Improve Post-mastectomy Overall or Disease-Free Survival among Breast Cancer Patients with 1-3 Positive Nodes

Purpose

Axillary lymph node dissection (ALND) may be avoidable for breast cancer patients with 1-2 positive lymph nodes (LN) after breast-conserving therapy. However, the effects of ALND after mastectomy remain unclear because radiation is not routinely used. Herein, we compared the benefits of post-mastectomy ALND versus sentinel node biopsy (SNB) alone for breast cancer patients with 1-3 metastatic LNs.

Materials and Methods

A total of 1,697 patients with pN1 disease who underwent mastectomy during 2000-2015 were identified from an institutional database. Outcomes were compared using the inverse probability of treatment weighted method.

Results

Patients who underwent SNB tended to have smaller tumors, a lower histology grade, a lower number of positive LNs, and better immunohistochemical findings. After correcting all confounding factors regarding patient, tumor, and adjuvant treatment, the SNB and ALND groups did not differ in terms of overall survival (OS) and disease-free survival (DFS), distant metastasis and locoregional recurrence. The 10-year DFS and OS rates were 83% and 84%, respectively, during a median follow-up period of 93 months.

Conclusion

ALND did not improve post-mastectomy survival outcomes among patients with N1 breast cancer, even after adjusting for all histopathologic and treatment-related factors.

BRCA1/2-negative, high-risk breast cancers (BRCAX) for Asian women: genetic susceptibility loci and their potential impacts

"BRCAX" refers breast cancers occurring in women with a family history predictive of being a BRCA1/2 mutation carrier, but BRCA1/2 genetic screening has failed to find causal mutations. In this study, we report the findings of the genetic architecture of BRCAX with novel and redefined candidate loci and their potential impacts on preventive strategy. We performed a genome-wide association study involving 1,469 BRCAX cases from the Korean Hereditary Breast Cancer study, and high-risk breast cancer cases (1,482 Asians and 9,902 Europeans) from the Breast Cancer Association Consortium. We also evaluated the previously reported susceptibility loci for their roles in the high-risk breast cancers. We have identified three novel loci (PDE7B, UBL3, and a new independent marker in CDKN2B-AS1) associated with BRCAX, and replicated previously reported SNPs (24 of 92) and moderate/high-penetrance (seven of 23) genes for Korean BRCAX. For the novel candidate loci, evidence supported their roles in regulatory function. We estimated that the common low-penetrance loci might explain a substantial part of high-risk breast cancer (39.4% for Koreans and 24.0% for Europeans). Our study findings suggest that common genetic markers with lower penetrance constitute a part of susceptibility to high-risk breast cancers, with potential implications for a more comprehensive genetic screening test.

Evaluation of the Prognostic Stage in the 8th Edition of the American Joint Committee on Cancer in Patients with Breast Cancer and Internal Mammary Lymph Node Metastasis

BACKGROUND/AIM

This study evaluated the prognostic value of the 8th edition of American Joint Committee on Cancer (AJCC) cancer staging system for patients with internal mammary lymph node (IMN) metastases.

MATERIALS AND METHODS

Of the patients with breast cancer who were treated between 2009 and 2013, 66 were diagnosed as cN3b. We restaged the patients and analyzed the prognostic value of the prognostically staged groups.

RESULTS

With a median follow-up of 53.9 months, the 5-year overall survival rates of patients with IIIA, IIIB, and IIIC stages were 100%, 95%, and 50% (p=0.001), while the progression-free survival rates were 100%, 83%, and 50% (p=0.005).

CONCLUSION

Despite the small number of patients, the prognostic stage provided accurate information for IMN metastasized breast cancer, which will lead to more accurate prognosis predictions and optimal treatment selection.

Sentinel node biopsy after neoadjuvant chemotherapy for breast cancer with axillary node metastasis: A survey of clinical practice

BACKGROUND

A survey of breast surgeons was conducted to evaluate changes in clinical practice regarding sentinel node biopsy (SNB) among clinically node-negative patients after neoadjuvant chemotherapy for breast cancer with axillary node metastasis.

METHODS

We conducted two surveys among 252 members of the Korean Breast Cancer Society. The questionnaire comprised a case presentation and two associated questions. The case outlined a woman diagnosed with right breast cancer; core needle biopsy had confirmed invasive ductal carcinoma and tumor size was 4 cm on imaging examination. Fine needle aspiration examination for axillary lymph node enlargement showed metastatic carcinoma. The patient underwent neoadjuvant chemotherapy and tumor size was decreased by 2 cm; axillary lymph node enlargement was not observed on palpitation or imaging examination. Finally, the patient underwent breast conserving surgery. Survey recipients were asked: 1. Would you perform SNB in this patient? 2. If you perform SNB and no axillary node metastasis is seen, would you perform additional axillary lymph node dissection (ALND)?

RESULTS

The response rate was 28.2% (71/252) and 15.1% (38/252) in 2013 and 2017, respectively. For the first question, the SNB to ALND ratio increased significantly from 54% versus 46% in 2013 to 92% versus 8% in 2017 (p < 0.001). The proportion of surgeons performing no additional ALND versus additional ALND increased from 38% versus 54% in 2013 to 53% versus 37% in 2017, but did not reach statistical significance (p = 0.1).

CONCLUSIONS

These data show that application of SNB among clinically node-negative patients after neoadjuvant chemotherapy for breast cancer with node metastasis has increased among surgeons in Korea.

Uneven recovery patterns of compromised health-related quality of life (EQ-5D-3 L) domains for breast Cancer survivors: a comparative study

BACKGROUND

Although several studies have evaluated health-related quality of life (HRQoL) in breast cancer survivors, few have compared HRQoL between breast cancer survivors and an age-matched general population in terms of improvement patterns according to time after surgery. Thus, we compared the postoperative changes in HRQoL in breast cancer survivors with those of age-matched general population groups using the EuroQoL five-dimension three-level questionnaire (EQ-5D-3 L).

METHODS

EQ-5D-3 L questionnaires were obtained from 686 breast cancer survivors during follow-up visits. They were divided into five groups according to time after surgery: 0-5 months, 6-11 months, 12-35 months, 36-59 months, and ≥ 60 months. Their EQ-5D-3 L data, covering five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), were compared with those of age-matched general population groups.

RESULTS

The mean EQ-5D-3 L index of breast cancer survivors was high in group with longer time after surgery and the mean EQ-5D-3 L index of breast cancer group over 5 years after surgery was similar to that of an age-matched general population (0.919 vs 0.928, p = 0.305). Although there were deficits in all dimensions of breast cancer survivors, motility eventually exceeded that of general population groups and self-care and usual activities of groups over 3 years after surgery matched those of general population however, pain/discomfort and anxiety/depression of survivors over 5 years after surgery remained worse than those of the general population (p = 0.028, p < 0.001).

CONCLUSIONS

Motility, self-care, and usual activities decreased in the early postoperative period for breast cancer survivors but showed recovery after 3 years. However, pain/discomfort and anxiety/depression remained poorer in these patients than in the general population for many years.

Oncologic safety of skin-sparing mastectomy followed by immediate reconstruction in young patients with breast cancer

BACKGROUNDS

This study aimed to compare the oncologic outcomes of nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM) followed by immediate reconstruction with those of conventional mastectomy (CM) in young patients aged under 35 years old with breast cancer.

METHODS

We analyzed retrospectively 2889 patients who underwent mastectomy for breast cancer at Asan Medical Center from January 2003 to December 2008. We compared NSM/SSM followed by immediate reconstruction with CM in patients under 35 years old by analyzing clinicopathologic features, breast cancer specific survival rate (BCSS), distant metastasis free survival rate (DMFS), and local recurrence rate (LRR).

RESULTS

Out of a total of 2889 patients, we performed NSM/SSM in 118 patients and CM in 141 patients aged less than 35 years old. DMFS were 85.3% and 73.4% in NSM/SSM and CM, respectively (p = 0.001). BCSS were 90.7% and 73.0% in NSM/SSM and CM, respectively (p = 0.001). After adjusting for stage, there were no statistically significant differences between the two groups with respect to DMFS and BCSS. The type of surgery was not a prognostic factor in multivariate analysis for DMFS and BCSS (CM vs. NSM/SSM: DMFS HR = 0.67, p = 0.215; BCSS: HR = 0.66, p = 0.265).

CONCLUSIONS

Compared to CM, NSM/SSM followed by immediate breast reconstruction is oncologically safe and could be a viable surgical treatment in young patients under 35 years old with breast cancer.

Cancer panel analysis of circulating tumor cells in patients with breast cancer

Liquid biopsy using circulating tumor cells (CTCs) is a noninvasive and repeatable procedure, and is therefore useful for molecular assays. However, the rarity of CTCs remains a challenge. To overcome this issue, our group developed a novel technology for the isolation of CTCs on the basis of cell size difference. The present study isolated CTCs from patients with breast cancer using this method, and then used these cells for cancer gene panel analysis. Blood samples from eight patients with breast cancer were collected, and CTCs were enriched using size-based filtration. Enriched CTCs were counted using immunofluorescent staining with an epithelial cell adhesion molecule (EpCAM) and CD45 antibodies. CTC genomic DNA was extracted, amplified, and screened for mutations in 400 genes using the Ion AmpliSeq Comprehensive Cancer Panel. White blood cells (WBCs) from the same patient served as a negative control, and mutations in CTCs and WBCs were compared. EpCAM⁺ cells were detected in seven out of eight patients, and the average number of EpCAM⁺ cells was 8.6. The average amount of amplified DNA was 32.7 µg, and the percentage of reads mapped to any targeted region relative to all reads mapped to the reference was 98.6%. The detection rate of CTC-specific mutations was 62.5%. The CTC-specific mutations were enhancer of zeste polycomb repressive complex 2 subunit, notch 1, AT-rich interaction domain 1A, serine/threonine kinase 11, fms related tyrosine kinase 3, MYCN proto-oncogene, bHLH transcription factor, APC, WNT signaling pathway regulator, and phosphatase and tensin homolog. The technique used by the present study was demonstrated to be effective at isolating CTCs at a sufficiently high purity for genomic analysis, and supported the use of comprehensive cancer panel analysis as a potential application for precision medicine.