Abstract P3-02-05: Does MRI influence surgical planning more than clinical outcome? A cohort study of breast cancer patients receiving neoadjuvant therapy

Background: While magnetic resonance imaging (MRI) is a powerful diagnostic tool, there is currently no consensus on its role for breast cancer patients prior to the initiation of neoadjuvant therapy (NAT). In the adjuvant setting, there is evidence that the use of MRI is correlated with an increase the rate of mastectomies performed. There is currently no data describing how MRI is influencing treatment decisions or surgical management in the neoadjuvant setting. This study aimed to determine the impact of MRI on patients' surgical plan, and to understand the demographic differences in patients who had an MRI compared to those that did not in the neoadjuvant setting.

Methods: A secure database containing all potential NAT patients seen by medical oncologists at the BC Cancer Agency Vancouver Centre since 2012 was searched. Breast cancer patients who were treated with NAT and had undergone breast surgery before March 30, 2016 were identified. Tumour characteristics, surgical plan and surgical outcome were assessed retrospectively and compared between patients who had an MRI and patients who did not have an MRI.

Results: 270 patients were identified who met the inclusion criteria. Of those, 107 patients had a breast MRI and 163 patients did not. The two groups showed no significant pre-treatment differences with regards to type of breast cancer, receptor status, or clinical stage. The median age was 10 years younger in the MRI group (47 years) compared to the non-MRI group (57 years), p < 0.0001. Patients who had an MRI had a non-significant higher rate of pathological complete response (pCR) than those who did not (30.8% and 21.5%, respectively, p=0.08). The surgical treatment did differ between these two groups; those who had MRI were more likely to have bilateral mastectomy (36.4% vs 23.3%, p=0.019) and less likely to have breast conserving surgery (BCS) (19.6% vs 31.9%, p=0.026). In the cohort that had an MRI, there was no significant difference in percentage of patients whose surgical plan was changed compared to the patients who did not have an MRI (33.6% and 28.8%, respectively). A change in surgical plan from a mastectomy to a BCS was more common in patients who did not have an MRI than those that did (31.9% and 13.9%, respectively). 45% of the surgeons who dictated a follow-up surgery consultation stated that the MRI was used to inform the surgical plan.

Discussions/Conclusions: In this real-world cohort, patients who had an MRI were more likely to undergo a bilateral mastectomy and less likely to have a BCS than the patients who did not have an MRI, despite having a higher rate of pCR. Age was the only baseline demographic difference between the two groups. These findings suggest that the role of MRI in the neoadjuvant setting needs to be refined further in order to avoid over-treatment.Background: While magnetic resonance imaging (MRI) is a powerful diagnostic tool, there is currently no consensus on its role for breast cancer patients prior to the initiation of neoadjuvant therapy (NAT). In the adjuvant setting, there is evidence that the use of MRI is correlated with an increase the rate of mastectomies performed. There is currently no data describing how MRI is influencing treatment decisions or surgical management in the neoadjuvant setting. This study aimed to determine the impact of MRI on patients' surgical plan, and to understand the demographic differences in patients who had an MRI compared to those that did not in the neoadjuvant setting.

Methods: A secure database containing all potential NAT patients seen by medical oncologists at the BC Cancer Agency Vancouver Centre since 2012 was searched. Breast cancer patients who were treated with NAT and had undergone breast surgery before March 30, 2016 were identified. Tumour characteristics, surgical plan and surgical outcome were assessed retrospectively and compared between patients who had an MRI and patients who did not have an MRI.

Results: 270 patients were identified who met the inclusion criteria. Of those, 107 patients had a breast MRI and 163 patients did not. The two groups showed no significant pre-treatment differences with regards to type of breast cancer, receptor status, or clinical stage. The median age was 10 years younger in the MRI group (47 years) compared to the non-MRI group (57 years), p < 0.0001. Patients who had an MRI had a non-significant higher rate of pathological complete response (pCR) than those who did not (30.8% and 21.5%, respectively, p=0.08). The surgical treatment did differ between these two groups; those who had MRI were more likely to have bilateral mastectomy (36.4% vs 23.3%, p=0.019) and less likely to have breast conserving surgery (BCS) (19.6% vs 31.9%, p=0.026). In the cohort that had an MRI, there was no significant difference in percentage of patients whose surgical plan was changed compared to the patients who did not have an MRI (33.6% and 28.8%, respectively). A change in surgical plan from a mastectomy to a BCS was more common in patients who did not have an MRI than those that did (31.9% and 13.9%, respectively). 45% of the surgeons who dictated a follow-up surgery consultation stated that the MRI was used to inform the surgical plan.

Discussions/Conclusions: In this real-world cohort, patients who had an MRI were more likely to undergo a bilateral mastectomy and less likely to have a BCS than the patients who did not have an MRI, despite having a higher rate of pCR. Age was the only baseline demographic difference between the two groups. These findings suggest that the role of MRI in the neoadjuvant setting needs to be refined further in order to avoid over-treatment.

Citation Format: McDermott M, Wilson C, Xu J, Illmann C, Simmons C. Does MRI influence surgical planning more than clinical outcome? A cohort study of breast cancer patients receiving neoadjuvant therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-02-05.

Anisotropic stress orients remodelling of mammalian limb bud ectoderm

The physical forces that drive morphogenesis are not well characterized in vivo, especially among vertebrates. In the early limb bud, dorsal and ventral ectoderm converge to form the apical ectodermal ridge (AER), although the underlying mechanisms are unclear. By live imaging mouse embryos, we show that prospective AER progenitors intercalate at the dorsoventral boundary and that ectoderm remodels by concomitant cell division and neighbour exchange. Mesodermal expansion and ectodermal tension together generate a dorsoventrally biased stress pattern that orients ectodermal remodelling. Polarized distribution of cortical actin reflects this stress pattern in a β-catenin- and Fgfr2-dependent manner. Intercalation of AER progenitors generates a tensile gradient that reorients resolution of multicellular rosettes on adjacent surfaces, a process facilitated by β-catenin-dependent attachment of cortex to membrane. Therefore, feedback between tissue stress pattern and cell intercalations remodels mammalian ectoderm.

Impact of a palliative care program on end-of-life care in a neonatal intensive care unit

OBJECTIVE

Evaluate changes in end-of-life care following initiation of a palliative care program in a neonatal intensive care unit.

STUDY DESIGN

Retrospective study comparing infant deaths before and after implementation of a Palliative Care Program comprised of medication guidelines, an individualized order set, a nursing care plan and staff education.

RESULT

Eighty-two infants died before (Era 1) and 68 infants died after implementation of the program (Era 2). Morphine use was similar (88% vs 81%; P =0.17), whereas benzodiazepines use increased in Era 2 (26% vs 43%; P=0.03). Withdrawal of life support (73% vs 63%; P=0.17) and do-not-resuscitate orders (46% vs 53%; P=0.42) were similar. Do-not-resuscitate orders and family meetings were more frequent among Era 2 infants with activated palliative care orders (n=21) compared with infants without activated orders (n=47).

CONCLUSION

End-of-life family meetings and benzodiazepine use increased following implementation of our program, likely reflecting adherence to guidelines and improved communication.

Microfabricated perfusable cardiac biowire: a platform that mimics native cardiac bundle

Tissue engineering enables the generation of three-dimensional (3D) functional cardiac tissue for pre-clinical testing in vitro, which is critical for new drug development. However, current tissue engineering methods poorly recapitulate the architecture of oriented cardiac bundles with supporting capillaries. In this study, we designed a microfabricated bioreactor to generate 3D micro-tissues, termed biowires, using both primary neonatal rat cardiomyocytes and human embryonic stem cell (hESC) derived cardiomyocytes. Perfusable cardiac biowires were generated with polytetrafluoroethylene (PTFE) tubing template, and were integrated with electrical field stimulation using carbon rod electrodes. To demonstrate the feasibility of this platform for pharmaceutical testing, nitric oxide (NO) was released from perfused sodium nitroprusside (SNP) solution and diffused through the tubing. The NO treatment slowed down the spontaneous beating of cardiac biowires based on hESC derived cardiomyocytes and degraded the myofibrillar cytoskeleton of the cardiomyocytes within the biowires. The biowires were also integrated with electrical stimulation using carbon rod electrodes to further improve phenotype of cardiomyocytes, as indicated by organized contractile apparatus, higher Young's modulus, and improved electrical properties. This microfabricated platform provides a unique opportunity to assess pharmacological effects on cardiac tissue in vitro by perfusion in a cardiac bundle model, which could provide improved physiological relevance.

Extending Neoadjuvant Care through Multi-Disciplinary Collaboration: Proceedings from the Fourth Annual Meeting of the Canadian Consortium for Locally Advanced Breast Cancer

The use of systemic therapy before surgery (“neoadjuvant therapy”) is the standard of care for the treatment of locally advanced and nonoperable breast cancer. The advantages of neoadjuvant therapy include improved rates of breast-conserving surgery, the possibility of early measurement of response, and potentially improved outcomes for certain subgroups of high-risk patients. The use of neoadjuvant therapy in operable breast cancer is increasing, although there are no clear guidelines in Canada to help guide patient selection and management. Multidisciplinary experts in the diagnosis and treatment of locally advanced breast cancer (labc) converged at the fourth annual meeting of the Canadian Consortium for LABC (colab) to further their goals of improved standards for neoadjuvant care and clinical research through education and collaboration. Canadian clinical researchers were joined by Dr. Michael Untch of the Helios Hospital Berlin–Buch—representing the German neoadjuvant treatment groups German Gynecologic Oncology Working Group (Arbeitsgemeinschaft Gynakologische Onkologie) and German Breast Group—to discuss the advancement of research in the neoadjuvant setting and important issues of clinical care and investigator-led research. The group reached a consensus on the importance of multidisciplinary collaboration, the use of clips to mark tumour location, and core biopsy testing for the estrogen and progesterone receptors and the human epidermal growth factor receptor 2 at the time of diagnosis. Other initiatives—including creation of a prospective database, inception of the colab Neoadjuvant Network, and development of a clinical survey to evaluate current practice—continue to further the colab mandate of transforming the neoadjuvant treatment landscape in Canada.

P5-08-04: Mammographic Microcalcifications and Breast Cancer Tumorigenesis: A Radiologic-Pathologic Analysis

Background

Microcalcifications (MCs) are tiny deposits of calcium in breast soft tissue. They serve as key diagnostic radiological features for localization of malignancy. Approximately 30% of early invasive breast cancers have fine, granular MCs detectable on mammography; however, their role in breast cancer tumorigenesis is currently unknown. The purpose of this study was to investigate the relationship between mammographic MCs and breast cancer pathology.

Methods: A retrospective chart review was performed for 882 women treated for breast cancer between 2000–2010 at St. Michael's Hospital. Demographic information (age and menopausal status), tumor pathology (size, histology, grade, nodal status and lymphovascular invasion), hormonal status (ER and PR), HER-2 overexpression and presence of MCs were collected for breast cancer patients. Chi-square tests were performed for categorical variables and t-tests were performed for continuous variables. All tests were two-sided and p-values less than 0.05 were considered statistically significant.

Results: A total of 826 patient charts were included; 56 (6.4%) patients had metastatic carcinoma and were excluded from analysis. Only 37.0% (326/882) of the patients presented with mammographic MCs. Patients were more likely to have MCs if they were HER-2 positive (51%) as opposed to being HER-2 negative (33.4%) (p=0.001). There was a significant association between MCs and being perimenopausal with a mean age of 50 (65.2%) (p=0.012). Patients with invasive ductal carcinomas (39.7%) were more likely to present with MCs than were patients with other tumor histology (p=0.001). There was a positive correlation between MCs and tumor grade (p=0.051), with grade III tumors (41.85%) presenting with the most MCs, followed by grade II (37.95%) and grade I (29.8%). There was no significant association between mean age, mean tumor size, ER and PR status with the presence of MCs.

Conclusion: This is the largest study that suggests the appearance of MCs on mammograms is strongly associated with HER-2 overexpression, invasive ductal carcinoma and perimenopausal status. Since HER-2 is implicated in mediating aggressive tumor growth and metastasis, future studies should investigate the molecular pathways underlying HER-2 overexpression and MC development. This would help better understand the role of MCs in breast cancer tumorigenesis.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-08-04.

Assessment of health-related quality of life with the European Organization for Research and Treatment of Cancer QLQ-C15-PAL after palliative radiotherapy of bone metastases

AIMS

To assess health-related quality of life (HRQOL) after palliative radiotherapy for painful bone metastases using a palliative questionnaire (European Organization for Research and Treatment of Cancer QLQ-C15-PAL).

MATERIALS AND METHODS

Patients scheduled to receive palliative radiotherapy for painful bone metastases (n=178) completed the QLQ-C15-PAL questionnaire before treatment and at week 1, week 2, month 1 and month 2 after the first day of radiotherapy. A partial response (PR) or a complete response (CR) to radiotherapy was defined according to the International Consensus criteria. General linear regression was used to analyse changes in QOL in the entire cohort and within responders and non-responders to radiotherapy at all follow-up periods.

RESULTS

The overall radiotherapy response was 45% at week 1 (n=21) (41% PR, 4% CR), 62% at week 2 (n=28) (58% PR, 4% CR), 62% at month 1 (n=58) (60% PR, 2% CR) and 65% at month 2 (n=38) (60% PR, 5% CR). In general, a significant decrease in pain (P<0.0001), insomnia (P<0.0001) and constipation (P=0.004) was seen by month 1 after radiotherapy. In patients who responded to radiotherapy, overall QOL significantly improved by month 2 after radiotherapy (P=0.002). Radiotherapy responders also reported an improvement in emotional functioning together with a decrease in symptoms such as insomnia and constipation at month 1. No improvements were seen in any of the QLQ-C15-PAL scores for patients whose pain did not respond to radiotherapy.

CONCLUSION

Radiotherapy responders showed not only an improvement in pain, but also in HRQOL as assessed by QLQ-C15-PAL. As early as 1 week after radiotherapy for bone metastases, a pain relief response was reported by patients.

A primer of bone metastases management in breast cancer patients

Bone is the most common site for distant spread of breast cancer. Following a diagnosis of metastatic bone disease, patients can suffer from significant morbidity because of pain and skeletal related events (SRES). Bisphosphonates are potent inhibitors of osteoclastic function and the mainstay of bone-directed therapy for bone metastases. The aims of bisphosphonates are to prevent and delay SRES, to reduce bone pain, and to improve quality of life. Bisphosphonate therapy appears to have revolutionized treatment of bone metastases, but bisphosphonate use has several limitations. Those limitations include the high cost of the agents and the need for return trips to the clinic for intravenous treatment. Moreover, many uncertainties surround bisphosphonate use-for example, the timing of bisphosphonate initiation, the choice of bisphosphonate to use, the optimal duration of treatment, and the appropriate means to identify patients who will and will not benefit. In addition, potentially serious adverse effects have been associated with bisphosphonate use-for example, renal toxicity, gastrointestinal side effects, and osteonecrosis of the jaw. The present review is intended as a primer for oncology specialists who treat patients with bone metastases secondary to breast cancer. It focuses on bisphosphonate treatment guidelines, the evidence for those guidelines, and a discussion of new therapeutic agents. It also discusses the use of biochemical markers of bone metabolism, which show promise for predicting the risk of a patient's developing a SRE and of benefiting from bisphosphonate treatment.

Abstract PD10-05: Do the Results of Metastatic Breast Tumour Biopsies Affect Patient Survival Outcomes? Results from a Large Prospective Trial

Background: Differences in receptor status between primary and metastatic breast cancer are well recognized. We have previous demonstrated substantial receptor discordance rates resulting in a change in management in 14% of patients. However, while retrospective studies suggest that discordance can be associated with a worse patient prognosis, there are currently no prospective data assessing the impact of such discordance on survival outcomes.

Methods: A single-center prospective biopsy study was performed. Patients with either recurrent or progressive disease underwent biopsy of their metastases. Subsequent treatment choices were modified according to the results and patients were followed up for progression or death. To account for the differing times at which patients entered the study, progression-free survival (PFS) was calculated as the duration between biopsy and either progression or death. Overall survival (OS) was defined as the duration from diagnosis of metastatic disease to death. A Cox propotional hazards model accounting for duration of metastatic disease and visceral versus non-visceral metastatic disease was utilized.

Results: 121 biopsies were completed and 38% of cases showed discordance between the primary and the recurrence. Survival data were available from 96 patients. After a median follow-up of 11 months, 76 patients (79%) had progressed and 38 (40%) had died. There was no difference in median PFS between concordant and discordance cases (5.9 vs. 6.5 months, HR 0.89, p=0.61). There was a non-significant trend towards worse OS in discordant cases (50.6 vs. 57.8 months, HR 0.77, p=0.47). When compared with the primary tumour a gain of HER2 was associated with a poor survival, while loss of HER2 was associated with improved outcome. Metastatic biopsies showed a trend towards better prediction of response to endocrine therapy with tumors losing progesterone receptor expression between primary and metastatic disease having worse DFS on endocrine therapy. Conclusion: We have previously shown that performing metastatic biopsies is associated with a substantial rate of receptor discordance between primary and metastatic disease. The current analysis demonstrates that this discordance is associated with a trend towards worse OS, but not PFS. Knowledge of the receptor status of metastatic disease allows better prognostication between HER2-postive and HER2-negative disease and also allows for improved prediction of response to endocrine therapy. Metastatic biopsies should therefore be considered in patients with recurrent breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD10-05.

Abstract P1-10-05: The Impact of Resource Setting and Guidelines on Global Early Breast Cancer Practice

Background: We developed an international physician survey to identify variations in early breast cancer practice, use of guidelines, and key challenges facing clinicians (MDs) globally in implementing guideline-based care. Methods: The survey was administered at an international breast oncology meeting, and also online using a secure platform. Results were analyzed using descriptive statistics and the chi-squared test was used for bivariate analysis. Results: 691 respondents from 70 countries completed the survey. 38% of respondents were from low income (LIC) or middle income (MIC) countries. More respondents in LICs (89%) and MICs (74%) practice in academic centres; 34% of MDs in high income countries (HICs) practice in community settings (P&lt;0.001). More LIC physicians (74%) rely on clinical breast exam for diagnosis versus in MICs (58%) and HICs (55%) (P&lt;0.001). 87% of LIC physicians say that hormone receptor status is routinely reported on pathology, versus in MICs (91%) and HICs (95%) (p=0.011). The reporting of HER2 status also varies by income setting: 83% in LICs, 89% in MICs, and 95% in HICs (P&lt;0.001). Reporting seems to be the lowest in African nations (78% for hormone and 74% for HER2 status, p &lt;0.001 for each). 46% of LIC and 61% of MIC physicians offer sentinel lymph node dissection, versus 94% in HICs (P&lt;0.001). Adjuvant radiation is available in 93% of all surveyed practices. 99% of respondents give eligible patients endocrine treatment; tamoxifen is prescribed almost universally (&gt;96% of respondents). Aromatase inhibitors are given by 87% of LIC, 93% of MIC, and 94% of HIC physicians (p=0.042). 75% of MDs in LICs give chemotherapy to high risk patients; 81% of those in MICs and HICs do the same (NS). More LIC oncologists give classical CMF (21%, p=0.006), and 77% give anthracycline-taxane combinations, compared to 84% of MIC and 88% of HIC physicians (p=0.017). Trastuzumab is given to a majority (&gt;75%) of eligible patients by only 11% of LIC and 36% of MIC physicians, compared to 80% of HIC clinicians (P&lt;0.001). Trastuzumab use is most prominent in North America (85%) and Europe (75%), and lowest in Africa (19%) and Asia (32%) (P&lt;0.001). 94% of LIC and 63% of MIC physicians said trastuzumab use is limited by drug cost (P&lt;0.001); lack of HER2 testing was cited as an issue by only 8-9% of all respondents. 63% of LIC and 76% of MIC physicians say international guidelines impact their clinical practice, compared to 56% of HIC physicians (P&lt;0.001), who are more likely to rely on local/regional guidelines (33%, P&lt;0.001). Conclusions: Global practice patterns in early breast cancer care vary by resource setting but also by continent. More costly therapies such as trastuzumab are used less often in LICs and MICs. Surveyed physicians from LICs and MICs also rely on international guidelines to direct their practice more than HIC physicians. This may reflect that many guidelines with international influence are created in HICs. In order to improve breast cancer outcomes worldwide, global collaboration is required to create guidelines which not only recommend best practice, but are applicable in various resource and cultural settings, and are followed by implementation research efforts.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-05.

Abstract P5-15-05: Applicability of Breast Cancer Guidelines and Knowledge Translation in a Community Oncology Setting

Background: The quality of a guideline may impact adherence to that guideline. Cancer Care Ontario (CCO) produces guidelines to help manage all stages of disease. CCO's staging and follow-up guideline suggests patients (pts) with stage I breast cancer require no further staging investigations, bone scan for stage II disease, and for stage III disease in addition to bone scan, chest and abdominal imaging. The guideline on bisphosphonate (BP) use in metastatic breast cancer pts indicates that all pts with bone metastases should be offered a BP. We assessed the efficacy of knowledge translation of these guidelines at a community oncology centre by correlating rate of adherence with the quality of the guideline as scored using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument.

Methods: The quality of 2 breast cancer guidelines from CCO were assessed using the AGREE instrument. Two cohort studies of breast cancer pts seen were then conducted to evaluate the adherence to these guidelines. Specifically, staging investigations ordered on pts seen in our multidisciplinary clinic between January 2009 and April 2010 were recorded and correlated to pathological stage of disease. Our second cohort study reviewed breast cancer pts with bone metastases who died between 1999 and 2009, and initiation of a BP was recorded in order to determine adherence to the second guideline.

Results: Inadequate adherence was identified and correlated with low applicability scores for these two guidelines (58% and 33% respectively). Only 68 pts (61%) with bone metastases received BP for treatment between 1999 to 2009. 129 pts (56%) underwent unnecessary staging investigations.

Discussions: Non-chemotherapy breast cancer guidelines by CCO scored low in the field of applicability; this was confirmed by two retrospective cohort studies. Improvement in knowledge translation strategies are needed to improve adherence to practice guidelines set out by this national organization.

The emerging role of Krüppel-like factors in endocrine-responsive cancers of female reproductive tissues

Krüppel-like factors (KLFs), of which there are currently 17 known protein members, belong to the specificity protein (Sp) family of transcription factors and are characterized by the presence of Cys(2)/His(2) zinc finger motifs in their carboxy-terminal domains that confer preferential binding to GC/GT-rich sequences in gene promoter and enhancer regions. While previously regarded to simply function as silencers of Sp1 transactivity, many KLFs are now shown to be relevant to human cancers by their newly identified abilities to mediate crosstalk with signaling pathways involved in the control of cell proliferation, apoptosis, migration, and differentiation. Several KLFs act as tumor suppressors and/or oncogenes under distinct cellular contexts, underscoring their prognostic potential for cancer survival and outcome. Recent studies suggest that a number of KLFs can influence steroid hormone signaling through transcriptional networks involving steroid hormone receptors and members of the nuclear receptor family of transcription factors. Since inappropriate sensitivity or resistance to steroid hormone actions underlies endocrine-related malignancies, we consider the intriguing possibility that dysregulation of expression and/or activity of KLF members is linked to the pathogenesis of endometrial and breast cancers. In this review, we focus on recently described mechanisms of actions of several KLFs (KLF4, KLF5, KLF6, and KLF9) in cancers of the mammary gland and uterus. We suggest that understanding the mode of actions of KLFs and their functional networks may lead to the development of novel therapeutics to improve current prospects for cancer prevention and cure.

Change in Receptor Status in Locally Advanced Breast Cancer Patients after Treatment with Neoadjuvant Therapy (NAT)

Background: Systemic treatment decisions for locally advanced breast cancer (LABC) are made upfront, prior to surgery. ER, PR and Her2 status is often assessed on the initial core biopsy, and used to guide systemic therapy options. Hormone receptor and Her2 status may or may not be repeated after definitive surgery. Studies completed in the metastatic setting indicate that hormone receptor status may change between primary and metastatic lesion in up to 40% of cases after adjuvant treatment1. There is limited data with regards to any change occurring in the neoadjuvant setting. This study aimed to determine if a change in receptor status occurs after NAT by reassessing the ER, PR and Her2 status of locally advanced breast cancer specimens after definitive surgery, and to quantify any change observed.Methods: Patients with LABC (stage 2B or stage 3) who were entered into the prospective LABC database at the Sunnybrook Odette Cancer Centre between January 2002 and January 2008 were included. ER and PR status by IHC and Her2 status by IHC and FISH was evaluated in both the pre-treatment core biopsy specimen and in the post-treatment mastectomy specimen using the same technique. ER and PR status was also quantified and reported as percentage postivity.Results: One hundred and fifty (150) patients were enrolled in the LABC database between January 2002 and January 2008. Of these, 9 had mastectomy at a different centre, 15 had a pathological complete response, 13 did not undergo surgery for various reasons post NAT (refusal, progression, comorbidities), and 7 had missing data. The remaining 106 patients had ER and PR status reassessed post mastectomy, and 93 had Her2 status available from both pre and post-treatment specimens. Only 6 patients had a change in ER status, (5.6%, P = NS), but 25 had a change in PR status (23.6%, p = 0.0007). The majority of cases involved a loss in hormone receptor status, with only 4 patients experiencing a gain in PR status. Seven patients had a change in Her2 status (7.5%, P=NS). There was significant discordance in the quantitative analysis of PR but not ER status between specimens pre- and post-treatment, (p = 0.84 for ER, p &lt; 0.0001 for PR). There was no correlation with change in ER or PR and response to NAT.Conclusions: This study has demonstrated a significant discordance of 24% in hormone receptor status between core biopsy and final definitive surgery, primarily as a loss of PR status. Further follow up of these cases may help to determine if loss of PR or significant change in quantization confers predictive or prognostic information.Change in ER status Biopsy ER-Biopsy ER+Mastectomy ER-392Mastectomy ER+461 Change in PR status Biopsy PR-Biopsy PR+Mastectomy PR-514Mastectomy PR+2129 1. Simmons C, Miller N, Geddie W, Gianfelice D, Oldfield M, Dranitsaris G, Clemons M. “Changes in breast tumour receptor status with time – does performing a confirmatory tissue biopsy at the time of metastatic recurrence alter patient management? The results of a prospective study.” Annals of Oncology, March 18, 2009.Change in Her2 status Biopsy Her2-Biopsy Her2+Mastectomy Her2-683Mastectomy Her2+418 

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1083.

Biopsy Confirmation of Metastatic Disease in Breast Cancer: Results from a Large Prospective Study

Purpose: Decisions about systemic treatment of women with metastatic breast cancer are often based on estrogen receptor (ER), progesterone receptor (PgR), and HER2/neu status of the primary tumour. This study prospectively investigated concordance in receptor status between primary tumour and distant metastases at various stages of progression and assessed the impact of any discordance on patient management.Methods: Biopsies of suspected metastatic lesions were obtained from patients and analyzed for ER/PgR and HER2/neu. Receptor status of metastases was compared to the primary tumour. The treating physician completed questionnaires before and after biopsy to determine whether the biopsy result lead to a change in treatment plan.Results: One hundred and sixteen women were enrolled and 102 underwent biopsy. Of these 52 (51%) were newly diagnosed with metastatic disease, 17 (17%) had received one line of metastatic treatment and 35 (34%) had received 2 or more lines of treatment in the metastatic setting. 86/102 (84%) of samples were sufficient analysis; of these 5/86 biopsies (6%) showed benign disease and one biopsy (1%) confirmed a different malignancy (indolent lymphoma). Changes in hormone receptor status were observed in 33%. Among these, ER discordance was seen in 11%, PgR discordance in 27% and discordance in both ER and PgR in 5%. Loss of PgR was the most common change in hormone receptor status (25%). HER2/neu showed 4% discordance. Three patients (3%) gained and one patient (1%) lost HER2/neu expression. Biopsy results led to a change of management in 12% of patients. Patients with newly diagnosed metastatic disease were more likely to show discordance than those previously treated in the metastatic setting. Among triple negative primary tumours, no changes in receptor expression of metastases were seen.Conclusions: This is the largest prospective biopsy study we are aware of. Results demonstrate the presence of substantial discordance in receptor status between primary tumour and metastases. The number needed to biopsy to alter immediate management was 8.5, although biopsy information could also be useful in planning subsequent treatments. Tissue confirmation should therefore, be considered in all patients with suspicion of metastatic recurrence or progression.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2023.

Reduced helminth burden increases allergen skin sensitization but not clinical allergy: a randomized, double-blind, placebo-controlled trial in Vietnam

BACKGROUND

Observational evidence suggests that infection with helminths protects against allergic disease and allergen skin sensitization. It is postulated that such effects are mediated by helminth-induced cytokine responses, in particular IL-10.

OBJECTIVE

We tested this hypothesis in a rural area of central Vietnam where hookworm infection is endemic.

METHODS

One thousand five hundred and sixty-six schoolchildren aged 6-17 were randomly allocated to receive either anti-helminthic therapy or a placebo at 0, 3, 6, and 9 months. We compared changes in the prevalence of exercise-induced bronchoconstriction, allergen skin sensitization, flexural eczema on skin examination, questionnaire-reported allergic disease (wheeze and rhinitis symptoms), and immunological parameters (hookworm-induced IFN-gamma, IL-5, IL-10) between 0 and 12 months.

RESULTS

One thousand four hundred and eighty-seven children (95% of these randomized) completed the study. The most common helminth infections were hookworm (65%) and Ascaris lumbricoides (7%). There was no effect of the therapy on the primary outcome, exercise-induced bronchoconstriction (within-participant mean percent fall in peak flow from baseline after anti-helminthic treatment 2.25 (SD 7.3) vs. placebo 2.19 (SD 7.8, P=0.9), or on the prevalence of questionnaire-reported wheeze [adjusted odds ratio (OR)=1.16, 95% confidence interval (CI) 0.35-3.82, P=0.8] and rhinitis (adjusted OR=1.39, 0.89-2.15, P=0.1), or flexural dermatitis on skin examination (adjusted OR=1.15, 0.39-3.45, P=0.8). However, anti-helminthic therapy was associated with a significantly higher allergen skin sensitization risk (adjusted OR=1.31, 1.02-1.67, P=0.03). This effect was particularly strong for children infected with A. lumbricoides at baseline (adjusted OR=4.90, 1.48-16.19, P=0.009). Allergen skin sensitization was inversely related to hookworm-specific IL-10 at baseline (adjusted OR=0.76, 0.59-0.99, P=0.04). No cytokine tested, including IL-10, changed significantly after the anti-helminthic therapy compared with the placebo.

CONCLUSION

A significant reduction in worm burden over a 12-month period in helminth-infected children increases the risk of allergen skin sensitization but not of clinical allergic disease. The effect on skin sensitization could not be fully explained by any of the immunological parameters tested.

Does confirmatory tumor biopsy alter the management of breast cancer patients with distant metastases?

BACKGROUND

Decisions about systemic treatment of women with metastatic breast cancer are often based on estrogen receptor (ER), progesterone receptor (PgR), and Her2 status of the primary tumor. This study prospectively investigated concordance in receptor status between primary tumor and distant metastases and assessed the impact of any discordance on patient management.

MATERIALS AND METHODS

Biopsies of suspected metastatic lesions were obtained from patients and analyzed for ER/PgR and Her2. Receptor status was compared for metastases and primary tumors. Questionnaires were completed by the oncologist before and after biopsy to determine whether the biopsy results changed the treatment plan.

RESULTS

Forty women were enrolled; 35 of them underwent biopsy, yielding 29 samples sufficient for analysis; 3/29 biopsies (10%) showed benign disease. Changes in hormone receptor status were observed in 40% (P = 0.003) and in Her2 status in 8% of women. Biopsy results led to a change of management in 20% of patients (P = 0.002).

CONCLUSIONS

This prospective study demonstrates the presence of substantial discordance in receptor status between primary tumor and metastases, which led to altered management in 20% of cases. Tissue confirmation should be considered in patients with clinical or radiological suspicion of metastatic recurrence.