Abstract P3-10-20: The Prognostic Relevance of Serum CA27.29 level in Primary Breast Cancer Patients before Adjuvant Chemotherapy — Results of the German SUCCESS Trial

Background: While tumor markers are frequently used to assess treatment efficacy in metastatic breast cancer, there is lack of evidence regarding the role of MUC-1 markers in primary disease. The value of CA27.29 in the adjuvant setting was prospectively evaluated in the German multicenter SUCCESS study.

Material and Methods: The German SUCCESS trial is a multicenter phase III study comparing FEC-Docetaxel (Doc) vs. FEC-Docetaxel-Gemcitabine (Doc-G) and 5 versus 2 years of Zoledronate as adjuvant treatment in patients with node positive or high risk node negative primary breast cancer. In this trial serum CA27.29 level has been prospectively evaluated in 3202 patients before and immediately after adjuvant chemotherapy as well as 2 and 5 years thereafter. CA27.29 was measured with the ST AIA-PACK CA27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium). The cutoff for positivity was >31 U/ml. Results: Mean CA27.29 serum level before adjuvant chemotherapy was 19,3 U/ml (SD +/− 15,5) in both arms. 8,0% (n=127) of patients in the FEC-Doc-G arm and 7,4% (n= 120) in the FEC-Doc arm had marker levels of more than 31 U/ml. Mean CA27.29 serum levels were significantly higher in patients with lobular carcinoma (p=0.001), with positive lymph nodes (p=0.02) and post-menopausal patients (P<0.001). After a median follow-up period of 34 months 233 patients relapsed and 108 patients died. CA27.29 before chemotherapy was a significant prognostic marker for disease-free survival (DFS) (P<0.0001) and overall survival (OAS) (P<0.0001) in univariate and multivariate analysis. Conclusion: These findings indicate the independent prognostic relevance of serum CA27.29 levels in primary breast cancer patients before adjuvant treatment. Further follow-up within the SUCCESS trial will show whether initial CA27.29 level could serve as a tool for adjuvant treatment monitoring.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-20.

Inhibin A is down-regulated during chemotherapy in patients with breast cancer

BACKGROUND

Inhibins are dimeric glycoproteins, composed of an alpha-subunit (INH-α) and one of two possible beta-subunits (βA or βB), with substantial roles in human reproduction and in endocrine-responsive tumours. Aims of this study were to determine the serological measurement of inhibin A (α-βA) in breast cancer patients during chemotherapy.

PATIENTS AND METHODS

A series of 30 breast cancer patients who underwent standardised chemotherapy were prospectively evaluated before chemotherapeutic treatment as well as four weeks after chemotherapy and two years after chemotherapy for the serological expression of inhibin A. For statistical analysis the Wilcoxon rank sum test was used for paired samples. Statistical significance was assumed at p<0.05.

RESULTS

The concentration of inhibin A showed a significant decrease between data obtained before chemotherapy and after chemotherapy (p<0.005) and two-year follow-up (p<0.001). Interestingly, there were no differences in inhibin A concentrations between the four-week and two-year follow-up (p=0.744).

DISCUSSION

Chemotherapy significantly decreases inhibin A concentration during chemotherapy. This might reflect a suppression of ovarian function, being also a marker for chemotherapy-induced amenorrhoea. Moreover, it has been suggested that inhibin A might be a tumour marker for breast cancer, and therefore a sudden increase in its concentration might be indicative of breast cancer recurrence.

Perioperative search for circulating tumor cells in patients undergoing radical cystectomy for bladder cancer

Objective

Despite having an organ confined tumor stage at the time of radical cystectomy, a certain number of bladder cancer patients will develop local or distant metastases over time. Currently there are no reliable serum markers for monitoring and evaluating risk profiles of urothelial cancers. Several studies suggest that detection of Circulating Tumor Cells (CTC) may correlate with disease status and prognosis at baseline and early in the treatment of cancers. The presence of CTCs in whole blood before and during radical cystectomy could provide further information on disease status, and could be used as an indicator to determine the need for adjuvant or even perioperative chemotherapy.

Methods

From 03/2009 to 05/2009, five patients with histologically proven transitional cell carcinoma of the urinary bladder participated in this study. All patients were admitted to the hospital for radical cystectomy (rCx). A standard or extended lymph node dissection was performed in all cases. Preoperative CT or MRI scans revealed no distant or local metastases. Median age was 66.8 years (55-81 yrs). After obtaining informed consent from each patient, approximately 30 mL of peripheral blood was taken immediately before rCx and again during surgical removal of the urinary bladder from the patients' body. As additional parameters, operation time (OR) for surgical removal of the bladder and the amount of blood volume that was used for the detection of CTCs were recorded. Obtained blood samples were processed using the Cell-Search System (Veridex^©) within 48 hours of collection. CTCs were identified and quantitated using the Cell-Search System, followed by re-evaluation of the provided results by specially trained and experienced personal. (CS, SH)

Results

CTCs were detected before and during surgical removal of the urinary bladder in one of five patients (20%). In the one patient positive for CTC, two CTCs were detected in the blood sample that was obtained before surgery (analyzed blood volume was 25 mL). There was one CTC detected in the blood sample that was obtained during surgical removal of the urinary bladder (analyzed blood volume was 27 mL). There was no rise in the amount of CTCs during surgical procedure. The final pathological report of this patient showed an advanced tumor stage (T3b, N0, R1). In the other patients, no CTCs were detected at all, neither before rCX nor right after surgical removal of the bladder. Pathological stage for these patients ranged from pT1m G3 -pT2b G3. None of these patients showed lymph node involvement. An average of 14.6 lymph nodes (5-40 LNs) were obtained. OR time to surgical removal of the urinary bladder ranged from 60 minutes to 150 minutes (mean 82 min.).

Conclusions

Although only a very small group of patients was analyzed in this study, the presence of CTCs seems to be correlated with an advanced tumor stage. Therefore the detection of CTCs could be used for an optimized assessment of a patient's disease status in urothelial cancer. A further aim of this study was to assess whether surgical manipulation during radical cystectomy is associated with a release of CTCs into the vascular system. None of the patients who were negative for CTCs before surgery showed CTCs during surgical removal of the bladder, suggesting that there was no release of CTCs during surgery. However, further study is needed to prove these findings and evaluate the significance of CTCs as an indicator for therapeutic decisions.

Inhibin A Is Downregulated during Chemotherapy in Patients with Early Breast Cancer

Introduction: Inhibins are dimeric glycoproteins, composed of an alpha-subunit (INH-a) and one of two possible beta-subunits (ßA or ßB), with substantial roles in human reproduction and in endocrine-responsive tumours. In breast cancer tissue, the growth factor Inhibin A is involved in cell differentiation and proliferation, thus suggesting a possible role as tumor marker. Aims of this study were to determine the serological measurement of Inhibin A (a- bA) in breast cancer patients during chemotherapy.Material and Methods: A series of 28 high risk N0 and N+ breast cancer patients who underwent standardized chemotherapy (3 x FEC and 3 x Docetaxel) followed by two years of zoledronate in the German SUCCESS trial were prospectively evaluated before chemotherapeutic treatment as well as after chemotherapy and two years after chemotherapy for the serological expression of Inhibin A. For serological analysis the ultrasensitive Inhibin A ELISA (DSL – U.S.A.) was used according to manufactures instruction. For statistical analysis the Wilcoxon rang sum test was used for paired samples. Statistical significance was assumed at p&lt; 0.05.Results: The concentration of Inhibin A showed a significant decrease between data obtained before chemotherapy and after chemotherapy (p&lt;0.005) and two-year follow up (p&lt;0.001). Interestingly, there were seen no differences between the time point four weeks after chemoherapy and at two years (p=0.744).Discussion: Therefore, chemotherapy decreases significantly the Inhibin A concentration during chemotherapy. This might reflect a suppression of ovarian function and might be a marker for chemotherapy-induced amenorrhoea. Moreover, it has been suggested that Inhibin A might be a tumour marker for breast cancer, and therefore a sudden increase of its concentration might be indicative of breast cancer recurrence.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3028.

Evaluation of CA 27.29 as Prognostic Marker in Primary Breast Cancer Patients – Results of the German SUCCESS Trial

Background:While tumor markers are frequently used for the evaluation of treatment efficacy in metastatic breast cancer, the role of Muc-1 markers in primary disease and during recurrence-free follow-up is still under discussion. In the German multicenter SUCCESS trial we evaluated CA 27.29 in 3754 patients before and after adjuvant chemotherapy and 2 and 5 years after primary diagnosis.Methods:The SUCCESS Trial compares FEC-Docetaxel (Doc) vs. FEC-Doc-Gemcitabine (Doc-G) regime and two vs. five year treatment with Zoledronat in patients with primary breast cancer (N+ or high risk N-). CA27.29 has been measured with ST AIA-PACK CA27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium). The cutoff for positivity of CA27.29 is &gt;31 U/ml.Results:In 2807 primary breast cancer patients CA27.29 has been prospectively evaluated before and after chemotherapy. 22% of all patients had a marker &gt;31 U/ml (n=587, mean 19.00, range 3.04-410) before and 39% (n=1058, mean 23.34, range 2.70-330) after chemotherapy.After a median follow-up period of 18 months 138 patients developed a recurrence of their disease. 12% (n=17) of patients with recurrent disease had before chemotherapy a marker &gt;31 U/ml (mean 28.08, range 4.95-410). After completion of chemotherapy 16% of patients (n=22) had a CA 27.29 marker &gt;31 U/ml (mean 21.7, range 5.35-330).7% (n=10) had shown positivity of CA27.29 before and after therapy. 5% (n=07) of patients changed from positive to negative (cutoff for CA27.29) afterwards. 80% (n=109) were negative before and after therapy, whereas 8% (n=12) became positive after treatment.There is no significant difference in positivity of CA27.29 between Patients with an onset of disease recurrence in the first year (n=38), second year (n=68), the third year (n=24) after chemotherapy and all other prospectively evaluated patients with primary breast cancer (n=2784).Before chemotherapy treatment the prevalence of elevated CA27.29 in all 2807 primary breast cancer patients was equally distributed between the FEC-Doc and the FEC-Doc-G arm. After chemotherapy 34% in the FEC-Doc arm showed an increased level vs. 45% in the FEC-Doc-G arm. The correlation analysis showed no significant coherence between hormonal status (ER: p&lt;0.323; PR: p&lt;0.078), HER2/neu status (p&lt;0.308), Grading (p&lt;0.565) and CA27.29 level. Tumor size (p&lt;0.020) and the nodal status (p&lt;0.022) were significant associated with Ca27.29 levels.Conclusion:This marker will be useful for treatment monitoring; first of all because a close relation between Ca27.29 and tumor mass at primary diagnosis is evident. But only further results of the SUCCESS-trial, especially the evaluation of CA27.29 blood level at follow-up examination 2 years and 5 years after chemotherapy, will improve the prognostic relevance of this marker.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3023.

Detect-Study: Comparison of Two Techniques for the Evaluation of the HER2 Expression on Circulating Tumor Cells in Metastatic Breast Cancer

Introduction:There is a growing body of evidence that the HER2 status can change during disease progression (Gancberg et al. 2003). However, the re-assessment of the HER2 status to evaluate the eligibility for HER2 targeted therapy by a tissue biopsy of the metastatic lesion may not always be feasible. In this context, determination of the HER2 status using CTCs might be a strategy with potential clinical application. So far, no large prospective studies were performed comparing different methods for CTCs detection and characterization. The aim of this trial was to determine the HER2 status of CTCs in metastatic breast cancer patients using the antibody based CellSearch©assay and the RT-PCR approach AdnaTest Breast Cancer and to assess the concordance rate between these two techniques. Both techniques are frequently used in clinical trials.Method:A total of 252 metastatic breast cancer patients from 9 different certified breast cancer centers (Düsseldorf, Erlangen, Essen, Freiburg, Hamburg, Heidelberg, Muenchen, Regensburg, Tuebingen) were enrolled in this prospective open trial from 01/2008 until 04/2009. HER2 status of CTCs was assessed using both the FDA approved CellSearch©Assay (Veridex, Warren, NJ, USA) and the AdnaTest Breast Cancer (Adnagen, Langenhagen, Germany) according to the manufacturers' instructions. A web based databank was designed for data management and online-documentation (www. detect-study.de). The study design was approved by the ethics' comittee (2007/B01).Results:Using the CellSearch©Assay, 133 of 252 (55%) metastatic patients had CTCs at the time of first diagnosis or disease progression. HER2 positivity was observed in 39% of CTC positive patients (52 of 133) but only 22 of these had initially a HER2 positive primary tumor. Eighty-eight of 225 (39%) patients were CTC positive using the AdnaTest Breast Cancer. The HER2 positivity rate was 47% (41 of 88). Eight of these patients had a HER2 positive primary tumor whereas 33 patients were initially HER2 negative or unknown. Summarizing the data, the rate of breast cancer patients with HER2 negative primary tumors but HER2 positive circulating tumor cells was 38% (32 of 61) and 48% (28 of 41) using the CellSearch Assay and the AdnaTest Breast Cancer, respectively. Considering only those patients who had CTCs on both tests (n=61), the concordance rate regarding HER2 expression was 51% (32 of 61).Conclusion:Based on CTCs the HER2 status can change during disease progression. However, using different techniques, disconcordant results were obtained. To prove the clinical value of these CTC assays and to implement the HER2 status of CTCs as a stratification parameter in future clinical trials, it will be mandatory to correlate clinical response to HER2 targetd therapy on each method in patients with HER2 positive CTCs.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3004.

Persistance of circulating tumor cells (CTCs) in peripheral blood of breast cancer (BC) patients two years after primary diagnosis

554

Background: In metastatic BC, CTCs have shown to predict treatment efficacy and reduced survival. Recent data also indicate a potential prognostic relevance of CTCs after adjuvant chemotherapy. The SUCCESS trial evaluates the role of persisting CTCs two years after diagnosis in primary BC patients treated with zoledronate. Methods: We analyzed 23 mL of peripheral blood in N+ and high-risk N- primary BC pts receiving 3xFEC(500/100/500)-3xDoc100 q3w vs. 3xFEC(500/100/500)-3xDocgemcitabine (75/1000 d1+8) chemotherapy followed by 2 yrs (4mg q3mx24m) vs. 5 yrs (4mg q3mx24m followed by q6mx36m) of zoledronate. CTC results after two years are shown. CTCs were assessed with the CellSearchSystem (Veridex, Warren, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labelled with anti-cytokeratin (8,18,19) and anti-CD45 antibodies. Pts were examined after a mean of 29 months (range 20–43). Results: The data of 579 pts two years after diagnosis are available. 4.3% of pts (n = 25) presented with >1CTC in peripheral blood. In pts with the detection of CTCs, the mean number of cells was 1 (range 1–29). While we found 1 CTC in 5.9% and 2 CTCs in 1.6% of pts, 1.5% had 3–5 CTCs, 1.2% >5 CTCs. The presence of >1CTC did not correlate with tumor size (p = 0.41), nodal status (p = 0.41), grading (p = 0.45), hormonal status (p = 0.92) or HER-2-Status of the tumor (p = 0.59). In this patient group, 9.7% and 6.9% of pts had presented with >1CTC at primary diagnosis and after chemotherapy, respectively. While the presence of CTCs at diagnosis was associated with CTCs after two years (p = 0.03), there was no correlation of CTCs after chemotherapy with the results at primary diagnosis (p = 0.08) or at two years (p = 0.23). In 184 postmenopausal HR+ pts endocrine treatment data was analyzed. CTCs at two years were detected in 6.8% of pts on tamoxifen (n = 9), while 1.9% of pts were positive on anastrozole treatment (n = 1; p = 0.19). Conclusions: CTCs persisting cytostatic, endocrine and zoledronate treatment, can be observed in a relevant number of clinically recurrence-free BC patients. Longer follow-up within the German SUCCESS study will give further insight in their prognostic relevance and show whether they can be used for real time tumor phenotyping or serve as treatment target.

[Table: see text]

Minimal residual disease detection in peripheral blood of primary breast cancer patients – translational research in the SUCCESS-study

Abstract #5019

Background: The detection of occult tumor cells in the bone marrow of patients with breast cancer has been shown to be an independent predictive and prognostic factor for early disease recurrence and decreased overall survival. However, it is more feasible to monitor treatment efficacy by sampling peripheral blood. The translational research program of the German SUCCESS-trial evaluates Minimal Residual Disease (MRD) in peripheral blood during adjuvant treatment of breast cancer patients. Follow-up results of the detection of MRD at primary diagnosis and after adjuvant chemotherapy (CT) are presented.&#x2028; Patients and Methods: Cells were separated by Oncoquick® (Greiner-bio one, Frickenhausen, Germany) followed by labeling of epithelial cells with an anti-cytokeratine-antibody (directed against cytokeratins 8, 18 and 19) and immunocytochemical staining. Every preparation was screened by two independent persons. MRD was defined as one or more cytokeratine-positive cell.&#x2028; Results: 1237 breast cancer patients were analyzed at primary diagnosis. After completion of adjuvant CT 655 patients returned for a second blood sampling. The majority of the tumors was small (40.1% pT1, 52.7% pT2, 5.9% pT3, 1.1% pT4) but mostly of intermediate or unfavorable grade, (G1 4.6%, G2 48.9%, G3 46.2%). 65% of the patients were node-positive (35% pN0, 45.6% pN1, 13.8% pN2, 5.7% pN3) and a positive hormone receptor status was seen in 69.1%. In 25.4% the Her2 status was positive. In 20.3% of all patients MRD was found at primary diagnosis. After CT MRD was observed in 15,7%. The mean number of detected cells was 2.3 (range: 1-25) before and 2.1 (range 1-23) after chemotherapy. Neither tumor size (p=0.48, p=0.47), lymph node metastases (p=0.34, p=0.81), histopathological grading (p=0.83, p=0.85) nor hormone receptor status (p=0.72, p=0.65) of the primary tumor correlated with the presence of MRD before or after CT respectively. The Her2/neu status of the primary tumor did not correlate before, but after CT with the presence of the MRD (p=0.63, p=0.08).&#x2028; Conclusion: The detection of MRD in peripheral blood can be widely used and is suitable for repeated measurements. Further follow-up of the SUCCESS trial will show this method´s validity for risk stratification and monitoring of treatment efficacy in breast cancer patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5019.