P5-03-01: Cytoplasmic Cyclin E and P-CDK2 Expression in Triple Negative Breast Carcinomas Measured by Immunohistochemistry Correlates with Poor Outcome

Background: Triple negative breast carcinomas (TNBCs) are aggressive malignancies that lack effective therapeutic targets but express low molecular isoforms of cyclin E (LMW-E). These LMW-E, generated primarily from NH2-terminal elastase cleavage of full length cyclin E (EL), preferentially accumulate in the cytoplasm of cancer cells. Using a transgenic mouse model system, our laboratory has recently shown that cyclin-dependent kinase 2 (CDK2) is required for LMW-E-mediated mammary tumorigenesis. These results lead us to hypothesize that immunohistochemical cytoplasmic detection of LMW-E and phospho-CDK2 in TNBC provides a valuable screening tool for those patients most likely to have a poor prognosis who could then be treated with anti-CDK2 therapy currently clinically available. Material and Methods: Tissue micro-arrays from 168 TNBC patients were IHC stained for cyclin E and p-CDK2. Cyclin E staining intensity and percentage of positivity were evaluated both in the nucleus and cytoplasm of cancer cells and four different phenotypes of cyclin E were distinguished with respect to predominant nuclear or cytoplasmic localization of staining: cyclin E negative, predominantly nuclear, both nuclear and cytoplasmic and predominantly cytoplasmic. p-CDK2 IHC was achived using an antibody, which recognizes phospho-threonine 160 on CDK2. Immunoreactive scores were determined by multiplying the intensity with the extent of staining of nuclei and cytoplasm. We sought correlations between different cyclin E and p-CDK2 expression patterns and disease-free survival (DFS). Results: Cytoplasmic cyclin E accumulation on IHC of TNBCs correlated with poor outcome. Within the median follow up of 7.3 years tumors with both nuclear and cytoplasmic cyclin E expression demonstrated higher recurrence rate compared to entirely negative for cyclin E (p=0.0117). In contrast patients with exclusively nuclear cyclin E showed only a trend toward decreased DFS compared to patients with cyclin E negative tumors (p=0.0896). Furthermore we identified the new phenotype of cyclin E immunoreactivity, which is characterized by negative nucleus and positive cytoplasmic staining. This phenotype was the most significantly associated with poor DFS compared to cyclin E negative phenotype (p=0.0026) and as the only one distinguished at high risk of early recurrence among TNBC patient without axillary nodes involvement (p=0.0105). The expression of p-CDK2 was significantly higher in this phenotype than the cytoplasmic cyclin E.negative tumors. High p-CDK2 tumors were also correlated to worse DFS then p-CDK2 low tumors (P=0.019). Lastly, our analyses revealed that tumors positive for both cytoplasmic cyclin E and p-CDK2 had higher recurrence rate compared to negative for both or positive for one of them (p=0.003).

Discussion: Cytoplasmic cyclin E may help to predict recurrence, especially in early stage, node negative TNBCs. We present a new concept in assessing cyclin E expression. Poor outcome due to TNBCs overexpressing LMW-E provide a rationale to investigate the treatment strategies that could specifically target high LMW-E tumors. These patients could particularly benefit from treatment with CDK2 inhibitors.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-03-01.

A novel staging system for disease-specific survival in patients with breast cancer treated with surgery as the first intervention

92

Background: American Joint Committee on Cancer (AJCC) staging of breast cancer is used to determine prognosis, yet survival of patients within each stage shows wide variation and remains unpredictable. We hypothesized that differences in underlying biology might influence some of this variation and that the addition of biologic markers to current AJCC staging parameters would improve predictions of prognosis.

Methods: We identified an initial cohort of 3,728 patients at our center who underwent surgery as the first intervention between 1997 and 2006. We used a Cox proportional hazards model, with backward stepwise exclusion of factors and stratified on pathologic stage (PS), to test the added significance of modified Black’s nuclear grade (G), the presence of lymphovascular invasion (L), estrogen receptor status (E), progesterone receptor status (P), or combined ER and PR status (EP), or combined receptor subtype (ER+PR+HER2 [M]). We assigned values 0-2 to these disease-specific survival (DSS)–associated factors and then used different combinations to assess different staging systems. Surveillance Epidemiology and End Results (SEER) data was used as the external cohort (n=26,711) to validate the scoring system.

Results: Median follow-up time for the initial cohort was 6.5 years, and the 5-year DSS rate was 97.4%. Six different staging systems were used to predict 5-year patient outcomes: PS, PS+G, PS+GL, PS+EG, PS+GEP, and PS+GM. We compared 5-year DSS rates, Akaike’s information criterion (AIC) and Harrell’s concordance index (C-index) for each staging system. We found that the PS+GEP staging system was most precise with lowest AIC (1927.3) and had the highest C-index (0.80). The ability of the PS+GEP system to stratify outcomes was confirmed in the internal bootstrapping samples and the external validation cohort.

Conclusions: Our results validate a new staging system that incorporates tumor grade, ER and PR status into current AJCC staging for breast cancer. We recommend that biologic markers be incorporated into revised versions of the AJCC staging system for patients undergoing surgery as their first intervention.

Impact of chemotherapy timing on local-regional failures in patients with breast cancer undergoing breast-conserving therapy

82

Background: Debate continues as to whether BCT after neoadjuvant chemotherapy (chemo) can achieve long-term local control rates similar to those experienced by patients undergoing surgery first, especially in those presenting with large tumors. This study was performed to evaluate long-term results of BCT for patients undergoing surgery first versus chemotherapy.

Methods: 2,984 patients underwent BCT with whole breast irradiation from 1987 to 2005. Clinicopathologic and outcomes data were reviewed and comparisons made between surgery first and chemotherapy patients.

Results: 2,331 (78%) patients underwent surgery first; 653 (22%) received chemotherapy first. Overall, chemotherapy patients had more adverse clinicopathologic features (Table). 5 and 10-yr local-regional recurrence (LRR)-free survival rates were 97% (95% CI: 96%-98%) and 94% (93%-95%) for surgery first patients. Chemotherapy downstaged patients presenting with clinical stage II/III disease (608/653; 93%) allowing for BCT, and pathologic findings revealed stage II/III disease in only 305/653 (46%) (p<.001). 5 and 10-yr LRR-free survival rates were 93% (91%-95%) and 90% (87%-93%) after chemotherapy. After adjusting for clinical stage at presentation, there were no differences in LRR between surgery first and chemotherapy patients. On multivariate analysis, age<50, clinical stage III, grade 3, ER neg status, associated DCIS on final pathology, and close/positive margins were associated with LRR.

Conclusions: LRR after BCT is driven by biologic factors and not the timing of chemotherapy. Chemotherapy downstages a significant number of patients with stage II/III disease allowing appropriately selected patients to achieve high rates of local-regional control with BCT.

[Table: see text]

Quality assurance review center: Role in multi-institutional breast cancer trials

205

Background: Central review is an important trial management and validation tool. Multisite trials require data systems to accommodate diverse image acquisition and review. Breast cancer is challenging as its imaging objects are not always easily shared across departments. Quality Assurance Review Center (QARC) has a diverse portfolio of facile data acquisition and powerful informatics support that meets these needs. We report on the role of QARC in three of the current breast cancer trials from the American College of Surgeons Oncology Group.

Methods: QARC data management system includes secure network infrastructure and a validated relational operating database (MAX). QARC has data acquisition/imaging re-distribution expertise for real time response reviews, response measuring tools and corresponding data archive for secondary reviews. MAX includes query ability; records link to digital information. QARC underwent systematic information systems validation process for 21 CFR Part 11. DICOM/non-DICOM files are stored in the QARC PACS. On-site/remote reviewers use MAX to retrieve, view, annotate and save images. Data extracted is securely sent to partner statistical centers.

Results: In Z1031, a neoadjuvant endocrine therapy trial, all of the mammographic exams are archived at QARC. For Z1071, a sentinel lymph node trial, pre- and post-treatment ultrasound (US) images of 321 patients were remotely reviewed. For Z1072, the cryoablation US, pre and post-cryoablation MRI for 40 of 47 cases were remotely archived, retrieved and transferred to investigator workstation for post-processing and review. The other 7 patients did not have evaluable imaging studies. In all three trials, the costs of shipping hardcopies of exams and travel to QARC for central review functions were eliminated.

Conclusions: QARC data management systems provide diverse informatics supports for multi-institutional trials, ranging from archives of images, provide remote access and download of data, and central review. The vibrant informatics supports meet the growing needs of clinical trials. Future directions include radiation field review for breast cancer trials and the incorporation of pathology microarray analysis as DICOM objects.

Capecitabine in operable triple receptor–negative breast cancer: A subgroup analysis of a randomized phase III trial

292

Background: Recent data suggest that patients with operable triple negative breast cancer (TNBC) may derive greater benefit from the addition of capecitabine to anthracycline-taxane regimens.

Methods: We examined pathological complete response (pCR), relapse-free survival (RFS) and overall survival (OS) in patients with TNBC randomized to paclitaxel 80mg/m2 weekly (WP) x 12 followed by fluorouracil (500mg/m2), epirubicin (100mg/m2), cyclophosphamide (500mg/m2) every 3 weeks x 4 cycles (FEC) vs. docetaxel (75mg/m2) 3 weekly and capecitabine D1-14 (1500mg/m2 daily; DX) followed by FEC. Patients were stratified by timing of chemotherapy (preoperative vs. adjuvant).

Results: 149 patients with TNBC comprising 25% of all patients randomized (N=601). Median age; 49 years (IQR; 41 to 55). The number and proportion of patients by stage were; I (n=32: 21.5%), IIA (n=72: 48.3%), IIB (n=34: 22.8%), IIIA (n=9: 6.0%) and IIIC (n=2; 1.3%). Preoperative therapy was administered to 58 patients (39%) and adjuvant to 91 (61%). There were 17 events (21%) in the DX arm and 10 events (15%) in the WP arm (P=0.36) including 11 distant recurrences in the DX arm and 9 in the WP arm (P=0.99). We observed a pCR in 11 patients (37%) and 10 (36%) in the DX and WP arms respectively (P=0.94). The odds ratio for pCR for patients with TNBC given DX vs. WP was 0.98 (95% CI; 0.33 to 2.80: P=0.94). At 50-months median follow-up the RFS and OS in patients with TNBC randomized to DX or WP was 77% (66 to 86%) and 83% (73 to 92%) (P=0.41) and 78% (67 to 87%) and 87% (77 to 95%) (P=0.16) respectively. RFS and OS for WP vs. DX for non-TNBC was 93% (87 to 95%) and 92% (88 to 96%) (p=0.91) and 96% (92 to 98%) and 97% (94 to 99%) for WP and DX respectively (P=0.39).

Conclusions: In this unplanned subgroup analysis there was no difference in pCR, RFS or OS in patients with operable TNBC randomized to WP or DX however, power is limited and should be considered when interpreting these data.

Prevalence, sensitivity, and specificity of chronic cerebrospinal venous insufficiency in MS

BACKGROUND

Chronic cerebrospinal venous insufficiency (CCSVI) was recently described in patients with multiple sclerosis (MS). A subject is considered CCSVI positive if ≥ 2 venous hemodynamic (VH) criteria are fulfilled.

OBJECTIVE

To determine prevalence of CCSVI in a large cohort of patients with MS, clinically isolated syndrome (CIS), other neurologic diseases (OND), and healthy controls (HC), using specific proposed echo-color Doppler (ECD) criteria.

METHODS

Transcranial and extracranial ECD were carried out in 499 enrolled subjects (289 MS, 163 HC, 26 OND, 21 CIS). Prevalence rates for CCSVI were calculated in 3 ways: first, using only the subjects for whom diagnosis was certain (i.e., borderline subjects were excluded); secondly, including the borderline subjects in the "no CCSVI" group; and finally, taking into account subjects who presented any of the VH criteria.

RESULTS

CCSVI prevalence with borderline cases included in the "no CCSVI" group was 56.1% in MS, 42.3% in OND, 38.1% in CIS, and 22.7% in HC (p < 0.001). The CCSVI prevalence figures were 62.5% for MS, 45.8% for OND, 42.1% for CIS, and 25.5% for HC when borderline cases were excluded (p < 0.001). The prevalence of one or more positive VH criteria was the highest in MS (81.3%), followed by CIS (76.2%), OND (65.4%), and HC (55.2%) (p < 0.001). CCSVI prevalence was higher in patients with progressive than in nonprogressive MS (p = 0.004).

CONCLUSIONS

Our findings are consistent with an increased prevalence of CCSVI in MS but with modest sensitivity/specificity. Our findings point against CCSVI having a primary causative role in the development of MS.

Resection of liver metastases from breast cancer: Effect of timing of surgery and estrogen receptor status on outcome

288

Background: The oncologic benefit of resecting liver metastases (LM) in breast cancer patients is unclear. Identifying predictors of improved outcome would be useful in selecting appropriate candidates for surgery.

Methods: From 1997 to 2010, 86 breast cancer patients underwent LM resection. RECIST criteria were used to define the best response to chemotherapy as the optimal response at any time during the course of metastatic disease and the preoperative response to chemotherapy as the response immediately before LM resection. Univariate and multivariate analyses were used to identify predictors of survival.

Results: Sixty-four patients (74%) had primary tumors that were either estrogen receptor (ER) or progesterone receptor (PR) positive. Fifty-three patients (62%) had solitary LM, and 73 patients (85%) had LM smaller than 5 cm. Sixty-five patients (76%) received preoperative chemotherapy, and 10 patients (12%) received 2 or more chemotherapy regimens before LM resection. Only 2 patients (3%) had progressive disease (PD) as a best response to chemotherapy, whereas 19 patients (29%) had PD as preoperative response to chemotherapy (p < 0.001). No perioperative mortality was observed. At a median follow-up of 62 months, the median durations of overall and disease-free survival were 57 and 14 months. Univariate analysis revealed that ER and PR primary tumor status, best response to chemotherapy, and preoperative response to chemotherapy were associated with overall survival after LM resection. On multivariate analysis, an ER-negative primary tumor (p=.009, hazard ratio [HR] = 3.3, 95% confidence interval [CI] =1.4-8.2) and preoperative disease progression (p=.003, HR = 3.8, 95% CI = 1.6-9.2) were independently associated with worse survival after LM resection.

Conclusions: Resection of liver metastases in breast cancer patients with ER positive disease that is responsive to chemotherapy is associated with prolonged survival. Timing of surgery is critical and resection before progression is associated with better outcome.

No significant financial relationships to disclose.

Evolution of multimodality management of gastrointestinal stromal tumors of the stomach

94

Background: Gastrointestinal stromal tumor (GIST) treatment has changed considerably with introduction of imatinib in 2001, initiation of ACOSOG adjuvant trial in 2002, and FDA adjuvant approval in 2008. However, little is known about how imatinib has been incorporated over time. Our objective was to examine the evolution of multimodality management of GISTs.

Methods: Patients coded specifically as gastric GISTs were identified (n = 4,508; 443 hospitals) from the National Cancer Data Base (2001-2007). Changes over time were assessed with chi-squared test for trend. Separate multivariable regression models were developed to examine factors associated adjuvant and neoadjuvant practices.

Results: Gastric GISTs reported to NCDB steadily increased: 463 in 2001 to 831 in 2007. 3,289 underwent resection: 78% partial/wedge, 6% total/near-total, and 14% multivisceral. From 2001 to 2007, use of adjuvant therapy increased from 29% to 47% (p < 0.001), although patients were less likely to get adjuvant therapy if older, tumors < 3cm, low grade, negative margins, or treated at low-volume hospitals (p < 0.01). Adjuvant systemic therapy for lesions < 3 cm also increased (17% to 25%, p = 0.001). For GISTs > 6 cm, use of adjuvant therapy increased from 41% to 49% overall, with increases of 45% to 70% at high-volume centers and of 39% to 48% at low-volume centers (all p < 0.001). Neoadjuvant therapy increased from 0% to 15% (p < 0.001) with patients more likely to receive neoadjuvant treatment if size > 6 cm, treated at high-volume centers, or treated in 2006-2007 (p < 0.001). Multivisceral resections decreased over time (19% to 12%, p < 0.001). The proportion of patients treated at high-volume centers increased slightly over time (22.2% to 26.9%, p = 0.006).

Conclusions: Adjuvant systemic therapy use for GISTs was increasing and widespread prior to FDA approval of adjuvant imatinib, suggesting contemporaneous advances in advanced GIST management were being translated into the adjuvant setting more than expected. As relatively costly therapies are integrated into practice, more robust tracking systems are needed to follow and guide the incorporation of new treatments.

No significant financial relationships to disclose.

M. Abstract PD07-03: A Genomic Predictor of Survival Following Taxane-Anthracycline Chemotherapy for Breast Cancer

Background: There is currently no predictive assay for patients with clinical Stage II-III breast cancer from which predicted sensitivity to treatment is associated with high probability of survival following chemotherapy.

Patients & Methods: We performed Affymetrix gene expression microarrays of prospectively collected tumor biopsies from 508 patients with newly diagnosed HER2-normal invasive breast cancer prior to neoadjuvant taxane-anthracycline chemotherapy followed by adjuvant endocrine therapy (if hormone receptor-positive). The predictor was developed from 310 samples (from MDACC & I-SPY) by combining: 1) a signature to predict sensitivity to endocrine therapy (SET); 2) estrogen receptor (ER)-stratified predictive signatures of resistance to chemotherapy, defined as extensive residual cancer burden (RCB-III) or relapse within 3 years; and 3) ER-stratified predictive signatures of response to chemotherapy, defined as pathologic complete response (pCR) or minimal RCB (RCB-I). The predictor classified tumors as treatment sensitive if high or intermediate SET, or if predicted to be responsive (and not resistant) to chemotherapy. Otherwise, tumors were classified as treatment insensitive. The predictor was then tested on an independent cohort (N= 198, 98% with clinical Stage II-III) who received neoadjuvant (N= 180) or adjuvant (N= 18) taxane-anthracycline chemotherapy (from MDACC, USO, GEICAM, Peru, LBJ). Distant relapse-free survival (DRFS) was evaluated at a 3-year median follow up using negative predictive value (NPV, absence of event if predicted to be sensitive), and absolute risk reduction (ARR) for those predicted to be sensitive (versus insensitive), with 95% confidence interval (CI). The independent predictive value was assessed in multivariate Cox regression analysis based on the likelihood ratio test (P≥0.05). Results: Patients in the independent validation cohort who were predicted to be treatment sensitive (28%) had excellent DRFS, with NPV 92% (CI 85-100) and significant absolute risk reduction (ARR 18%, CI 6-28) at 3 years, compared to those predicted to be insensitive. This was similar to the DRFS observed in patients who achieved pCR after they completed neoadjuvant chemotherapy (NPV 93%, CI 85-100). Predictions were accurate in each phenotypic subset: ER+/HER2- (30% predicted sensitive, NPV 97%, CI 91-100; ARR 11%, CI 0.1-21) and ER-/HER2- (26% predicted sensitive, NPV 83%, CI 68-100; ARR 26%, CI 4-28). Predicted treatment sensitivity (HR 0.20, CI 0.07-0.57), ER+ status (HR 0.32, CI 0.17-0.63), clinical tumor stage T3-4 (HR 2.04, CI 1.07-3.88) and age &gt;50 (HR 0.50, CI 0.25-0.98) were significant in a multivariate model that also included clinical nodal status, grade, and type of taxane used.

Conclusion: We report validation results for the first molecular predictor of sensitivity to neoadjuvant/adjuvant systemic therapy for clinical Stage II-III breast cancer that is independently associated with excellent DRFS in those predicted to be sensitive. Predictions were accurate for both ER+/HER2- and ER-/HER2- invasive breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD07-03.

ACOSOG Z1031: A randomized phase II trial comparing exemestane, letrozole, and anastrozole in postmenopausal women with clinical stage II/III estrogen receptor-positive breast cancer

LBA513

Background: Neoadjuvant aromatase inhibitor (AI) therapy is a rational and effective approach to improving the breast conservation surgery (BCS) rate for postmenopausal patients with large, estrogen receptor (ER) rich breast cancers. Barriers to adopting this strategy include lack of experience in this management approach in the US and uncertainty regarding the comparative effectiveness of the three approved aromatase inhibitors for this indication.

Methods: ACOSOG Z1031 is a multicenter, open-label, neoadjuvant phase III screening study that randomized postmenopausal women with clinical stage II/III ER rich (Allred score 6-8) breast cancer to 16 weeks of either exemestane (EXE) 25 mg daily, letrozole (LET) 2.5 mg daily, or anastrozole (ANA) 1 mg daily. At baseline study participants were either marginal for BCS (MBCS), candidates for mastectomy only (MO), or inoperable (IO). Planned enrolment was 125 patients per arm in order that the likelihood of the treatment with the “best” 16-week clinical response rate (based on caliper measurements) by WHO criteria (cRR) was included among the subset of treatments with “similar” cRR (90% power). Secondary endpoints included: extent of surgery, radiologic and pathologic response rates.

Results: From 4/1/2006 to 10/1/2009, 377 postmenopausal women with clinical stage II or III ER rich breast cancer were enrolled. 374 women began treatment and were included in an intent-to-treat analysis. Median age was 66 yrs (range: 43-90 yrs), Median tumor size was 4.0 cm (range: 2-13 cm). The 16-week cRR was 60.5% (95%CI: 51.3-69.1%) for EXE; 70.9% (95% CI: 62.2-78.6%) for LET, and 66.7% (95% CI: 57.6-74.9%) for ANA. Seventeen patients did not have surgery due to refusal (12 pts), progression (3 pts) or other medical conditions (2 pts). The BCS rate was 78% (163/207) in MBCS group; 42% (77/163) in MO group; and 75% in IO group (3/4). Surgeons made the decisions regarding procedure choice 75% of the time in both the MBCS and the MO categories.

Conclusions: This large multicenter screening trial selected non-steroidal AIs for further development due to their higher observed cRR. The study demonstrates that high response and breast conservation rates and low rates of disease progression can be achieved through patient selection based on high ER expression. We are currently refining our approach for early detection of poor response to AIs through an assessment of the tumor Ki67 proliferation index at 2 to 4 weeks (Z1031 Cohort B).

[Table: see text]

ACOSOG Z0010: A multicenter prognostic study of sentinel node (SN) and bone marrow (BM) micrometastases in women with clinical T1/T2 N0 M0 breast cancer

CRA504

Background: SN biopsy (SNB) with immunohistochemistry (IHC) of histologically negative SN identifies metastases (mets) not seen by standard histology. The impact of IHC-detected BM mets has been reported in several large single-institution studies. 5,539 patients (pts) were entered into this prospective multicenter observational study to determine the clinical significance of SN and BM mets.

Methods: Patients underwent lumpectomy and SNB with bilateral iliac crest BM aspiration. BM and histologically negative SN were evaluated with IHC in a central laboratory (results not clinically reported). Overall survival (OS), disease-free survival, and locoregional recurrence were determined. Results with OS (the primary endpoint) are reported here.

Results: SN were successfully identified in 5,184 of 5,485 pts (94.5%). Histologic SN mets were found in 1,239 pts (23.9%). IHC detected an additional 350 pts (10.5%) with SN mets. BM mets were identified by IHC in 105 of 3491 examined (3.0%). 5-yr overall survival is shown in the Table . BM IHC positivity significantly predicted decreased OS (p=0.015). A multivariable analysis that included SN and BM status, ER, PR, grade, size, and age showed that neither IHC detected mets in SN (p=0.66) or BM (p=0.08) were independent predictors of OS, although BM status showed a strong trend.

Conclusions: The detection of BM mets by IHC in pts with clinical T1/2 N0M0 breast cancer identifies those pts at significantly increased risk for death; the impact of BM mets on outcome supports and confirms prior studies. In this study, SN IHC-detected mets appear to have no significant impact on OS. The routine examination of SN by IHC is not supported in this patient population by this study.

[Table: see text]

[Table: see text]

ACOSOG Z0011: A randomized trial of axillary node dissection in women with clinical T1-2 N0 M0 breast cancer who have a positive sentinel node

CRA506

Background: Sentinel node biopsy (SNB) eliminates the need for axillary dissection (ALND) in patients whose sentinel node (SN) is tumor-free. However, completion ALND remains the gold standard for patients with a tumor-involved sentinel node. ALND achieves regional control, but its effect on survival remains controversial. The main objective of ACOSOG Z0011 was to compare outcomes of patients with hematoxylin and eosin (H&E) detected metastasis in SN managed with or without ALND and no axillary irradiation.

Methods: Clinically node-negative patients who underwent SN biopsy and had 1 or 2 SN with metastases detected by H&E were randomized to ALND or no further axillary specific treatment. All patients were treated with lumpectomy and opposing tangential field irradiation. Adjuvant systemic therapy was at the discretion of their physicians. Overall survival (OS), disease-free survival (DFS), and locoregional control were evaluated.

Results: 446 patients were randomized to SNB alone and 445 to SNB plus ALND. Patients treated with SNB alone were similar to those treated with SNB + ALND with respect to age, tumor size, Bloom-Richardson score, estrogen receptor status, adjuvant systemic therapy, tumor type, and T stage. Patients randomized to SNB alone had a median of two lymph nodes removed whereas patients randomized to ALND had a median of 17 lymph nodes removed. 17.6% of ALND patients had 3 or more involved nodes compared to 5.0% of SNB patients (p < 0.001). Median follow-up is 6.2 years. 5-year in breast recurrence after ALND was 3.7% compared to 2.1% for SNB (p = 0.16) while 5-year nodal recurrence was 0.6% compared to 1.3% (p = 0.44) respectively. The five-year OS for patients undergoing SNB + ALND is 91.9% compared to 92.5% for SNB alone (p = 0.24), and DFS is 82.2% compared to 83.8% respectively (p = 0.13).

Conclusions: Despite the widely held belief that ALND improves survival, no significant difference was recognized by this study of SN node-positive women. Although the study closed early because of low accrual/event rate, it is the largest phase III study of ALND for node-positive women, and it demonstrates no trend toward clinical benefit of ALND for patients with limited nodal disease.

[Table: see text]

Predictors of Persistent Micrometastatic Disease after Neoadjuvant Chemotherapy

Introduction: Patients who receive neoadjuvant chemotherapy (NAC) for breast cancer typically do not receive further cytotoxic chemotherapy after surgery. We hypothesized that some patients would have micrometastatic disease in the bone marrow (disseminated tumor cells, DTCs) or peripheral blood (circulating tumor cells, CTCs) after NAC. This study documented rates and factors predicting DTCs and CTCs after NAC.Methods: We prospectively evaluated patients undergoing surgery for stage I-III breast cancer. All patients had blood and bone marrow samples taken after completing systemic NAC. CTCs (per 7.5ml blood) were detected using the CellSearchTM system (Veridex). CTCs were defined as nucleated cells lacking CD45 but expressing cytokeratins (CK) 8, 18, or 19. DTCs were assessed using anti-CK antibody cocktail (AE1/AE3, CAM5.2, MNF116, CK8 and 18) following cytospin. The presence of ≥1 CK positive cells and ≥1 epithelial cells meeting morphologic criteria for malignancy was considered a positive result for DTCs and CTCs, respectively. Clinicopathologic factors correlated with DTCs and CTCs and response after NAC included: Her2/neu, estrogen receptor (ER), progesterone receptor (PR) and COX2 status as well as tumor size and grade. Complete pathologic response (pCR) was defined as lack of any residual invasive disease in primary tumor and regional lymph nodes after NAC. Statistical analyses used chi-square and Fischer's exact test.Results: Results were available for 53 patients who had bone marrow and blood collected after NAC. Median follow-up was 26 months. Mean age was 52 years. NAC included anthracyclines and taxanes +/- trastuzumab. Forty percent of patients had either DTCs or CTCs after NAC. Six patients had DTCs amongst 11 patients (55%) who received trastuzumab as compared to those who did not 6/33 (18%), P=0.019. DTCs and CTCs were found in 10/43 patients (23%) and 11/43 patients (27%), respectively. Factors predicting the presence of DTCs after NAC were Her2/neu positivity (P=0.001) and COX2 positivity determined in the primary tumor at diagnosis (P=0.04). No statistically significant correlations were found between CTCs after NAC and primary tumor characteristics. Thirty percent of patients with evidence of DTCs and 10% with CTCs had a pCR. Among the 7 patients with pCR after NAC, 2 (28%) had DTCs and 2 (28%) had CTCs. Factors predicting pCR following NAC were Her2/neu positivity (P=0.0003) and ER negativity (P=0.044). In our analysis, the best predictor of the presence of DTCs and the most likely reason for pCR following NAC was Her2/neu positivity.Conclusions: A significant number of patients have persistent DTCs and/or CTCs after NAC. Interestingly, HER2 positive patients were more likely to have pCR but were also more likely to show persistence of DTCs following NAC. Follow-up is needed to determine if these patients comprise groups at higher risk for recurrence, and therefore benefit from additional chemotherapy or targeted therapies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3020.

Tumor Ki67 Proliferation Index within 4 Weeks of Initiating Neoadjuvant Endocrine Therapy for Early Identification of Non-Responders

Background: The Preoperative Endocrine Prognostic Index (PEPI) scores the independent prognostic effects of tumor pathologic staging and expression levels of ER and the “proliferation” marker Ki67 in the surgical sample to predict long term outcomes after completion of neoadjuvant endocrine treatment (Ellis et al JNCI 100:1380, 2008). A limitation of the PEPI is that the prognostic information becomes available only after 4 months of treatment. We therefore evaluated the value of an early assessment of the Ki67 level in a tumor biopsy sample taken two to four weeks after initiating treatment in two neoadjuvant endocrine therapy trials for the purposes of the early identification of non- respondersMethods: A Ki67 cut point of greater than 10% for poor outcome in ER+ breast cancer was derived by comparing the PAM50 intrinsic subtype profile using a qRT-PCR assay with Ki67 data in a 700+ sample data set. A baseline level of 10% or less correlated most closely with a PAM50-based definition of LumA breast cancer and above 10% LumB breast cancer. We subsequently applied the 10% cut point to the baseline and early on-treatment Ki67 data in two trials, POL (Olson et al JACS 208:906, 2009) and IMPACT (Smith et al JCO: 23, 5108, 2005).Results: At baseline the dichotomized Ki67 definition was not significantly predictive for surgical Ki67 level, PEPI score or RFS in this modest size sample set. In contrast, in a result that emphasizes the enhaced prognostic properties of the on-treatment Ki67 approach, the one month POL sample Ki67 values (62 patients) predicted a higher level of Ki67 in the surgical samples at four months after treatment initiation (P=.01), a poorer PEPI score (P=0.01), a smaller number of patients in the PEPI risk point zero group (P=0.08) and worse relapse free survival (P=0.003). The IMPACT data (153 patients) confirmed that a two week Ki67 &gt;10% predicted higher Ki67 in the surgical specimen (P=0.001), a poorer PEPI score (P=0.001), smaller numbers of patients in the PEPI 0 risk point group (P= 0.004) and worse relapse free survival (P=0.008).Ki67 and OutcomePOL 4W Ki67% PEPI 0RFS (events)10%&gt;1/19 (5%)5/21 (23%)10%≤10/36 (28%)1/41 (2.4%)P ValueP=0.08 (Fisher)P=0.003 (log rank)IMPACT 2W Ki67% PEPI 0RFS (events)10%&gt;0/32 (0%)9/35 (26%)10%≤21/101 (21%)13/118 (11%)P ValueP=0.004 (Fisher)P=0.008 (log rank) Conclusions: A tumor Ki67 assessment taken a short time (2 to 4 week window) after the initiation of neoadjuvant AI identifies patients with poor outcome ER+ disease. Amendment 6 of the neoadjuvant endocrine therapy protocol ACOSOG Z1031 will triage patients with an “on treatment” Ki67 value above 10% to chemotherapy in order to assess the pathological response rate to cytotoxic therapy in this important tumor subset.Supported by R01 CA095614, Avon PFP award 3P50 CA68438-07S2, U01 CA114722, ACOSOG U10 CA 76001, Breakthrough Cancer UK and AstraZenica (IMPACT trial).

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 78.

Reporting of MMR evidence in professional publications: 1988-2007

OBJECTIVE

To examine how journals and magazines disseminate research evidence and guidance on best practice to health professionals by aligning commentaries on measles, mumps, and rubella vaccine (MMR) evidence in journals with key events in the MMR controversy.

DESIGN

Content analysis.

DATA SOURCES

Comment articles in six commonly read UK publications.

MAIN OUTCOME MEASURES

Number of comment pieces by publication, year and article type; trends in the focus, tone and inclusion of recommendations on MMR.

RESULTS

860 articles met the inclusion criteria (BMJ n = 104, Community Practitioner n = 45, Health Visitor n = 24, Practice Nurse n = 61, Nursing Standard n = 61 and Pulse n = 565). Of these 860 comment pieces, 264 made some reference to evidence endorsing the safety of MMR. Around one in 10 were rated as negative (10.9%, n = 29) or neutral (11.3%, n = 30) in relation to MMR safety, and nearly a quarter (22.7%, n = 60) were rated as mixed. Following the publication of Wakefield et al's 1998 paper there was a period of neutrality. In 2000, despite growing public concerns and widespread media coverage, fewer than 20 comment pieces were published. Less than a quarter of comment pieces (n = 196, 22.7%) included recommendations.

CONCLUSION

While a period of neutrality may reflect a professional response to uncertainty by holding back until consensus emerges, it may also represent a missed opportunity to promote evidence-based practice.

'The average Scottish man has a cigarette hanging out of his mouth, lying there with a portion of chips': prospects for change in Scottish men's constructions of masculinity and their health-related beliefs and behaviours

Men's apparent resistance to recommended health practices and their engagement with 'high-risk' behaviours has been associated with an increased risk of morbidity or mortality. Recent work has highlighted the need to think critically about the health-promoting behaviours that men appear reluctant to engage in, as well as examining those they embrace, and explore the gendered meanings that men attribute to their beliefs and behaviours. This article presents men's discussions of the 'practices of masculinity' and examines their relation to, and implications for, men's health-related behaviours as articulated in 15 focus group discussions (59 participants in total). The data capture both the experiences of men who felt pressured to engage in behaviours that may be harmful to their health in order to appear masculine and the accounts of those who regarded themselves as freer to embrace salutogenic health practices. Less is known about the circumstances that might encourage men to re-think their engagement in performances of masculinity that have potentially detrimental effects on their health. The data presented here suggest that ageing, illness, and fatherhood were some of the experiences that prompted men to re-evaluate their health practices.

Effect of modest delays in primary surgical treatment on progression of tumor size in breast cancer patients

622

Background: Evaluation of medical co-morbidities, coordination of reconstructive surgery and referral to tertiary care centers can delay surgical treatment in breast cancer. These delays raise concerns for tumor progression in the interim. We evaluated the time from initial imaging at a cancer center to surgical treatment and the change in tumor size. Methods: We identified 823 patients who underwent surgery as their first therapeutic modality for invasive breast cancer diagnosed from December 2003 to September 2005. Baseline tumor size was determined by mammogram (MMG) and ultrasound (US) reports, and tumor size at surgery was determined by pathology reports. Results: The median time from imaging at our facility to surgery was 0.69 months (range 0.03 to 4.34). Multivariate modeling indicated that older patient age, undergoing total mastectomy, and undergoing reconstruction predicted a longer time from initial imaging to surgery. Comparing radiographic to pathologic size, a moderate correlation was demonstrated for both MMG (Spearman r = 0.58; p < 0.0001) and US (Spearman r = 0.66, p < 0.0001). Pathologic size was the same as MMG size in 14%, smaller in 49%, and larger in 37% of patients. Differences in tumor size estimates were not significantly associated with time lapse between MMG and surgery, but in a multivariate model, MMG tumor size, tumor histology, and tumor grade were significant predictors (p < 0.0001 for all) of differences in mammographic and pathologic size. The pathologic tumor size was the same as US in 10%, smaller in 38%, and larger in 52% of patients. Time lapse to surgery was not significantly associated with differences in US and pathologic tumor size. In a multivariate model, US tumor size (p < 0.0001), tumor histology (p = 0.0006) and tumor grade (p = 0.005) were significant predictors of differences in US and pathologic tumor size estimates. Conclusions: There is no evidence that time lapse from initial imaging to surgical intervention leads to significant changes in tumor size thus allowing patients to complete preoperative workup and planning without significant clinical disease progression.

No significant financial relationships to disclose.

Value of adjuvant radiation therapy in breast cancer patients with one to three positive lymph nodes undergoing a modified radical mastectomy and systemic therapy

507

Background: Whether adjuvant radiation therapy should be utilized for patients (pts) with early stage breast cancer with up to 3 positive axillary lymph nodes treated with mastectomy and systemic therapy is controversial. This retrospective study was performed to determine if adjuvant radiation therapy had an impact on survival for this cohort of pts. Methods: 4240 pts with T1–2N0–1 breast cancers, diagnosed between 1980–2007, who underwent either mastectomy without adjuvant radiation therapy or segmental mastectomy with adjuvant radiation therapy were identified. All pts received systemic treatment. Women with >3 positive axillary lymph nodes were excluded. Overall (OS) and distant disease free survival (DDFS) were estimated using the Kaplan-Meir product method. Cox proportional hazards were used to determine associations between OS/DDFS and type of surgery after controlling for pt and disease characteristics. Results: 1336 (18.8%) had T1N0 disease, 1114 (26.27%) had T2N0 disease, 989 (23.33%) had T1N1 disease and 801 (18.89%) had T2N1 disease. Median follow-up was 54 months.5- year DDFS among women who underwent mastectomy and segmental mastectomy was 81% (95% 78%-83%) and 86% (95% CI 84%-87%), respectively (p < 0.0001). In the Cox analysis, pts who had mastectomy without radiation had a significantly increased risk of distant recurrence (HR= 1.39, 95% CI 1.14–1.70, p= 0.0013) than pts treated with segmental mastectomy and radiation. When looking at subgroups, no significant difference in DDFS was observed between the two groups in pts with lymph node negative disease. However, for pts with 1–3 positive lymph nodes, pts treated with mastectomy without radiation had significantly increased risk of distant recurrence compared to pts treated with segmental mastectomy with radiation (HR=1.614, 95% CI 1.198–2.177, p= 0.002). This difference was most pronounce in the subset of patients with T2N1 disease (HR= 1.794, 95% CI 1.220–2.637, p=0.003). Similar trends were observed for OS. Conclusions: This study provides provocative evidence for benefit of radiation therapy among pts with 1–3 positive axillary lymph nodes who are treated with surgery and systemic therapy.

No significant financial relationships to disclose.

Local-regional recurrence with and without radiation after neoadjuvant chemotherapy and mastectomy for T3N0 breast cancer patients

Abstract #74

Purpose: The goal of this study was to compare the local-regional recurrence (LRR) risk in patients with clinical T3N0 breast cancer who were treated with neoadjuvant chemotherapy (NeoChemo) and mastectomy (Mastx) according to the use of adjuvant radiation (RT).&#x2028; Methods: Clinicopathologic data from 164 patients with clinical T3N0 breast cancer who received NeoChemo and Mastx from 1985 to 2004 were retrospectively reviewed. In this cohort, 121 (74%) patients received adjuvant radiation (RT) while 43 (26%) patients did not. The median number of axillary lymph nodes (LN) dissected was 15. After NeoChemo, 54% of patients (n=89) had no pathologically involved lymph nodes at the time of surgery (ypLN-) while 46% (n=75) had at least 1 lymph node pathologically positive (ypLN+). Actuarial rates were calculated using Kaplan-Meier analysis and compared using log-rank test. Cox proportional hazards models were fit to determine the association of RT with the risk of LRR after adjustment for other patient and disease characteristics.&#x2028; Results: At a median follow-up of 77 months, 17 of the 164 patients had a LRR. For all patients, the 5-year local-regional control rates (5-yr LRC) were 90%. The 5-yr LRC for those who received RT (n=121) was 95% and for those who did not received RT (n=43) was 76% (p = 0.002), with a higher proportion of the patients who received RT having pathologically involved LN (+RT 53% vs –RT 23%, p=0.002).&#x2028; Among the entire cohort, the 5-yr LRC was 85% for patients with ypLN+ disease and 94% for patients with ypLN- disease (p=0.093). In patients with ypLN+, the 5-yr LRC with no RT (n=11) was 47% and with RT (n=64) was 92% (p&lt;0.001). In patients with ypLN-, the 5-yr LRC with no RT (n=32) was 86% and with RT (n=57) was 98% (p=0.063). Patients who had tumors with high nuclear grade had worse 5-yr LRC (Grade low 100%, intermediate 97%, high 81%, p=0.023). The presence of lymphovascular invasion, close/positive margin, or estrogen receptor status did not statistically correlate with LRC. In a Cox regression model, patients with tumor exhibiting high nuclear grade (Hazard Ratio (HR) 5.0, 95% Confidence Interval (CI) 1.6-15.4), ypLN+ (HR 6.6, 95% CI 2.0-22.1) and no adjuvant RT (HR 7.6, 95% CI 2.4-24.0) had increased risk of LRR.&#x2028; Conclusions: Post mastectomy adjuvant RT appears to improve LRC in clinical T3N0 breast cancer patients treated with neoadjuvant chemotherapy and mastectomy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 74.

Gaps in parental understandings and experiences of vaccine-preventable diseases: a qualitative study

OBJECTIVE

To explore parents' understandings of the diseases included in the current UK Childhood Immunization Programme (CIP), and the role of first- and second-hand experiences of these diseases in assessments of their severity.

METHODS

A qualitative study in which 66 parents (58 mothers and 8 fathers) of children aged 6 years and below, and six mothers of immuno-compromised children, took part in 18 focus group discussions between November 2002 and March 2003.

RESULTS

There were many gaps in parents' knowledge about some vaccine-preventable diseases, most notably diphtheria, tetanus and haemophilus influenzae type b, three of the diseases covered by the pentavalent vaccine (introduced into the UK CIP in 2004). These gaps led some parents to question the need for vaccination. First-hand experiences of the diseases reinforced the need for vaccination in some cases (e.g. Men C), but undermined it in others (e.g. pertussis, measles, rubella, mumps). Poliomyelitis and diphtheria were no longer seen as a threat to children's health in Britain. Some parents saw mumps as only a threat to boys' health and rubella as only having relevance to girls'.

CONCLUSIONS

As fewer parents have direct experiences of vaccine-preventable diseases, there is an increasing need to provide parents with accessible information about these diseases. It is also important to recognize that direct or indirect experiences of any of the diseases may either heighten or diminish parents' assessments of the severity of these diseases.

Assessing the needs of pregnant women and mothers with severe mental illness: the psychometric properties of the Camberwell Assessment of Need - Mothers (CAN-M)

There is an absence of standardized validated instruments to assess the complex needs of pregnant women and mothers with severe mental illness. We aimed to develop a standardized assessment of need for pregnant women and mothers with severe mental illness. Staff and service users were asked to identify relevant domains of need. Professional experts and service users were then surveyed and asked to rate the importance of the domains of the Camberwell Assessment of Need - Mothers version (CAN-M). Reliability was established using 36 service user-staff pairs. Concurrent validity was assessed with the Global Assessment of Functioning. Inter-rater reliability (concordance) coefficients for unmet needs were 0.93 (95% confidence interval 0.89 to 0.98) (service users) and 0.83 (95% confidence interval 0.73 to 0.94) (staff); test-retest reliability coefficients were 0.91 (95% confidence interval 0.86 to 0.97) and 0.85 (95% confidence interval 0.73 to 0.96), respectively. Relevant CAN-M domains correlated with the Global Assessment of Functioning-symptom (Spearman's r correlation coefficient = -0.36, 95% confidence interval = -0.62 to -0.04, p = 0.05) and Global Assessment of Functioning-disability subscales (Spearman's r correlation coefficient = -0.52, confidence interval = -0.73 to -0.23, p < 0.01). We conclude that the CAN-M is a reliable and valid instrument for assessing the needs of pregnant women and mothers with severe mental illness.

Prevalence and risk factors for joint pain among men and women in the West of Scotland Twenty-07 study

OBJECTIVE

To examine the association between three modifiable risk factors (obesity, smoking, and alcohol consumption) and reported joint pain.

METHODS

Cross sectional data were collected on 858 people aged 58 years living in the West of Scotland and on the same individuals four years later, aged 62 years.

RESULTS

There was a positive relation between obesity and reported pain in the hips, knees, ankles, and feet. The strongest relation was with knee pain (odds ratio = 2.42 (95% confidence interval, 1.65 to 3.56)). There were no strong consistent associations between smoking habits and pain in any joint after adjusting for sex, alcohol consumption, body mass index, social class, and occupational exposures. Similarly, alcohol was not consistently related to pain in any joint in the fully adjusted models.

CONCLUSIONS

Obesity had consistent and readily explained associations with lower limb joint pain. The data suggest that smoking behaviour and alcohol consumption are not consistently associated with joint pain across the body.

Gastrointestinal stromal tumors: overview of pathologic features, molecular biology, and therapy with imatinib mesylate

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. These tumors develop at any site but are most commonly reported in the stomach. They originate from the neoplastic transformation of the intestinal pacemaker cell, the interstitial cell of Cajal. GISTs strongly express the receptor tyrosine kinase KIT and have mutations in the KIT gene, most frequently in exon 11 encoding the intracellular juxtamembranous region. Expression of KIT is seen in almost all GISTs, regardless of the site of origin, histologic appearance, or biologic behavior, and is therefore regarded as one of the key diagnostic markers. Distinction from smooth muscle tumors, such as leiomyosarcomas, and other mesenchymal tumors is very important because of prognostic differences and therapeutic strategies. Predicting the biologic behavior of GISTs is often difficult by conventional pathologic examination; tumor size and mitotic rate are the most important prognostic indicators. The prognostic significance of KIT mutations is controversial and thus far has not been clearly linked with biologic behavior. KIT mutations are associated with tumor development, and cytogenetic aberrations are associated with tumor progression. The pathogenesis of GISTs involves a gain-of-function mutation in the KIT proto-oncogene, leading to ligand-independent constitutive activation of the KIT receptor. KIT-wild-type GISTs have shown mutually exclusive platelet-derived growth factor receptor (PDGFR) mutation and activation. The use of imatinib mesylate (also known as Gleevec or STI-571) has greatly increased the therapeutic efficacy for this otherwise chemotherapy-resistant tumor. GISTs with very low levels of KIT expression may respond to imatinib mesylate therapy if the receptors are activated by specific mechanisms. KIT-activating mutations fall into two groups: the regulatory type and the enzymatic site type. The regulatory type of mutation is conserved at the imatinib binding site, whereas the enzymatic site mutation has a structurally changed drug-binding site, resulting in drug resistance. Resistance to the drug is the major cause of treatment failure in cancer therapy, emphasizing the need for researchers to understand KIT signaling pathways so as to identify new therapeutic targets. This review summarizes the pathologic features of GISTs, recent advances in understanding their molecular and biologic features, and therapy with imatinib mesylate.

Control of posture with FES systems

One of the major obstacles in restoration of functional FES supported standing in paraplegia is the lack of knowledge of a suitable control strategy. The main issue is how to integrate the purposeful actions of the non-paralysed upper body when interacting with the environment while standing, and the actions of the artificial FES control system supporting the paralyzed lower extremities. In this paper we provide a review of our approach to solving this question, which focuses on three inter-related areas: investigations of the basic mechanisms of functional postural responses in neurologically intact subjects; re-training of the residual sensory-motor activities of the upper body in paralyzed individuals; and development of closed-loop FES control systems for support of the paralyzed joints.

Re-evaluating gender and smoking in Thunderbirds 35 years on

The rescreening of a cult children's puppet show made originally in the 1960s, showing the main characters smoking on occasion, raises questions over the appropriateness of such images for today's young viewers.