P4654Clinical and electrocardiographic features of restrictive cardiomyopathy in children

Introduction

Restrictive cardiomyopathy (RCM) is a rare myocardial disease with an impaired diastolic function and poor prognosis. The mean survival duration after a diagnosis of RCM is reported to be around 2 years in children and most need heart transplantations.

Purpose

This study aimed to determine the 12-lead electrocardiogram (ECG) diagnostic criteria of RCM based on the initial diagnostic electrocardiogram.

Methods

ECGs in pediatric cardiomyopathy patients were collected from 15 institutes in Japan between 1979 and 2013. We compared the ECG findings, especially of the P wave, in RCM patients between the cardiomyopathy group and healthy children group separately for each gender and the age. The ECGs in the healthy group were obtained from school heart screening in Japan of first-graders, and seventh-graders. Statistical significance was determined as p<0.001.

Results

Among 376 registered cardiomyopathy patients, 63 had hypertrophic cardiomyopathy (HCM) (36%), 91 (24%) dilated cardiomyopathy (DCM), 106 (28%) a left ventricular myocardial noncompaction (LVNCs), 25 (7%) restrictive cardiomyopathy (RCM), 14 (4%) arrhythmogenic right ventricular cardiomyopathy (ARVC), and 5 (1%) other cardiomyopathies. Of the 25 RCM patients (9.9±3.4 years old, F:M=11:14), 36% were discovered during school heart screening. The first onset was an abnormal ECG in 9, symptoms of heart failure in 6, respiratory tract infections in 3, syncope in 1, and 6 with other. Of those patients, 2 (8%) had a family history of RCM, 24 (92%) no family history. A genetic diagnosis was performed in 5 of the 25 cases, and 3 had genetic abnormalities related to RCM. The mean follow-up period was 65±95 months (mean±standard deviation). During follow up, 19 patients (76%) survived, 6 (24%) died, 7 (28%) had heart transplantations, and 3 (12%) were waiting for heart transplantations with a left ventricular assist device.

The P wave was bimodal in lead I or biphasic in lead V1 in 15 patients (93%), and 13 (81%) patients had both variations. We evaluated the duration and amplitude of the first and second component of the P wave as P1 and P2. The number of control and RCM patients (control/RCM), duration of P1+P2, and sum total absolute value of the amplitude of P1+P2 in lead V1 were 8350/5, 90±9/116±10ms, and 72±28/528±278μV in first grade boys, 8423/3, 91±10/120±22ms, and 66±28/326±229μV in first grade girls, 8943/1, 97±1/100ms, and 71±31/328μV in seventh grade boys, and 9183/5, 98±11/112±10ms, and 55±27/315±56μV in seventh grade girls. Although the number of patients in the RCM group was small, sum total absolute value of the amplitude of P1+P2 in lead V1 showed a significant difference in any group.

Conclusion

The ECG in children with RCM exhibits P wave abnormalities in almost all patients. In particular, not the P wave interval but P wave shape in I and V1 and the sum total absolute value of the amplitude of P1+P2 in lead V1 were observed differences.

Abstract P4-08-29: Lymphatic invasion is an independent risk factor in patients with small node-negative luminal breast cancer

[Background]

In patients with node-negative (N0), hormone receptor-positive, human epidermal growth factor receptor (HER2) -negative (luminal) breast cancer, the impact of lymphatic invasion (ly) on the prognosis remains to be clarified.

[Methods]

Among 3,158 patients with primary breast cancers who underwent surgery in our institute from January 2007 to December 2009, we analyzed 1027 N0 luminal invasive breast cancers without preoperative systemic therapy. The luminal breast cancer was defined as hormone receptor-positive (ER of ≥ 10% or PgR of ≥ 10%) and HER2-negative (immunohistochemistry: 0, 1+ or FISH: ratio &lt; 2.0) cancer in the postoperative pathological specimen. ly was defined as positive when cancer cell nests were detected within the lymph duct in the whole specimen. N0 was confirmed pathologically by the sentinel lymph node biopsy in all the patients. The Fisher's exact test was used for comparison between different categories. The distant recurrence rate (DRR) was analyzed using the Kaplan-Meier method and the log-rank test. For multivariate analysis, Cox's regression analysis was performed.

[Results]

The median follow-up period was 103.8 months (range: 5.6-128.8). Recurrence with distant metastasis occurred in 26 patients (2.5%). There were 5 (0.7%) deaths related to breast cancer. ly was detected in 240 patients (23.4%). In the ly-positive group, the tumor size was larger (p = 0.007), and the nuclear grade (NG) was higher (p &lt; 0.001) than in the ly-negative group. Postoperative endocrine therapy (p &lt; 0.001) and postoperative chemotherapy (p &lt; 0.001) were more frequently employed for patients with ly-positive tumor. The univariate analysis showed that ly positivity (p &lt; 0.001), large tumor size (p &lt; 0.001), high NG (p &lt; 0.001), PgR negativity (p = 0.002) and the history of adjuvant chemotherapy (p &lt; 0.001) were associated with high DRR. In the multivariate analysis, large tumor size (p = 0.007) and PgR negativity (p = 0.015) remained significant. Although positive ly had a risk ratio of 2.2, it was not an independent risk factor.When restricted to T1 tumor (n = 899), the aforementioned factors still showed prognostic value in the univariate analysis, among which ly positivity (p = 0.004)remained significant together with PgR negativity (p = 0.047)in themultivariate analysis.The 8-year DRR was very favorable (0.8%) in patients with ly-negative T1N0 tumor while it was modest (6.6%) in patients with ly-positive T1N0 tumor (p &lt; 0.001). Only 1.3% of the patients had received adjuvant chemotherapy in the ly-negative group while 27% of the patients had in the ly-positive group.

[Conclusion]

Lymphatic invasion was associated with higher DRR although it was not independent in the multivariate analysis among patients with N0 luminal breast cancer. When restricted to patients with T1N0 luminal breast cancer, the presence of ly was independently associated with higher risk of distant recurrence. It suggests that the assessment of ly is clinically more relevant when considering treatment options for small luminal breast cancer.

Citation Format: Abe T, Ito Y, Fukada I, Shibayama T, Ono M, Kobayashi T, Kobayashi K, Takahashi S, Horii R, Akiyama F, Iwase T, Ueno T, Ohno S. Lymphatic invasion is an independent risk factor in patients with small node-negative luminal breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-29.

Abstract P5-18-11: Prognostic impact and possible pathogenesis of lymph node metastasis in ductal carcinoma in situof the breast

Background: By definition, ductal carcinoma in situ (DCIS) does not metastasize to the lymph nodes. However, since the introduction of molecular whole-node analysis using the one-step nucleic acid amplification (OSNA) assay for sentinel node (SN) biopsies, the number of DCIS patients with SN metastasis has increased. The clinical management of node-positive DCIS remains controversial because these patients can be treated as different stages based on the pathogenesis: e.g. occult invasive cancer with true nodal metastasis (T1N1) or true DCIS with iatrogenic dissemination of benign or tumor cells into lymph node (TisN0). In this retrospective cohort study, we aimed to elucidate the pathogenesis of nodal metastasis in DCIS and the clinical management of node-positive DCIS.

Patients and Methods: Subjects comprised of 427 patients with a routine postoperative diagnosis of DCIS who underwent SN biopsy using the OSNA assay between 2009 and 2012. The cut-off values of the OSNA assay for negative/positive results and micro/macrometastasis were defined at 250 and 5,000 copies/μL of cytokeratin 19 mRNA, respectively. In the SN-positive patients, all paraffin blocks containing the primary tumor were step-sectioned with 0.5-mm intervals until the tissue was exhausted, and all microscopic slides were examined for detecting occult invasions. Afterwards, the patients were classified into three cohorts based on the SN status and occult invasion: (1) no SN metastasis (TisN0), (2) SN metastasis without occult invasion (TisN1), and (3) SN metastasis with occult invasion (T1N1). Tumor characteristics including risk factors of occult invasions (e.g. large size, comedo-type), prognosis, and SN and non-SN status were compared among the three cohorts. The median follow-up time was 73.6 months.

Results: Of the 427 patients, 408 (95.6%) were SN-negative and 19 (4.4%) were SN-positive. By examining a total of 1,421 step-sectioned slides, 9 of the 19 SN-positive patients had occult invasions in the primary tumors. Overall, 408 (95.6%), 10 (2.3%), and 9 (2.1%) were classified into the TisN0, TisN1, and T1N1 cohorts, respectively. Either of adjuvant endocrine therapy or chemotherapy was given much more in the TisN1 and T1N1 cohorts than in the TisN0 cohort (80.0% and 88.9% vs. 5.4%).Other tumor characteristics were similar among the three cohorts. Although one patients had distant recurrence in the TisN0 cohort, none had locoregional or distant recurrences in the TisN1 and T1N1 cohorts. Regarding the lymph node status in the TisN1 and T1N1 cohorts, median tumor burdens in the SN are 590 and 310 copies/μL, and 2 (20.0%) and 2 (22.2%) patients had additional non-SN metastasis in the axillary dissection materials, respectively.

Conclusions: Tumor characteristics and prognosis were similar among the three cohorts albeit the TisN1 and T1N1 cohorts tended to received adjuvant systemic therapy. Moreover, the SN and non-SN status were similar between the TisN1 and T1N1 cohorts. Therefore, pathogenesis of nodal metastasis in DCIS cannot uniformly be explained, and tumors with different stages may be mixed in the node-positive DCIS. Thus, considering the favorable prognosis of node-positive DCIS, the clinical management should be determined on a case-by-case basis.

Citation Format: Yonekura R, Osako T, Iwase T, Ogiya A, Ueno T, Ohno S, Akiyama F. Prognostic impact and possible pathogenesis of lymph node metastasis in ductal carcinoma in situof the breast [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-18-11.

Abstract P3-03-23: Which factor of metastatic lymph nodes–The number, tumor volume or anatomical location–Is independently prognostic in breast cancer? - A prospective cohort study using molecular whole-node analysis of all removed axillary nodes

Background: Axillary lymph node status is one of the most powerful prognostic factors in breast cancer. However, it remains unknown which factor of metastatic lymph nodes–the number, tumor volume or anatomical location–is independently prognostic. Conventional pathological examinations of lymph nodes have limited ability to accurately measure metastatic tumor volume due to the partial evaluation of nodes. On the other hand, the one-step nucleic acid amplification (OSNA) assay, a novel molecular method, can quantify the tumor volume in a whole node based on cytokeratin 19 (CK19) mRNA copy number. In this prospective cohort studyusing the OSNA whole-node analysis, we aimed to elucidate the independent prognostic factor of lymph node metastasis in breast cancer.

Patients and Methods: The subjects consisted of 307 cN0 patients with invasive breast cancer, who underwent axillary dissection after a metastatic sentinel node (SN) biopsy and whose SNs and non-SNs were all examined using the OSNA whole-node assaybetween 2009 and 2012.The cut-off values of the OSNA assay for negative/positive results and micro/macrometastasis were defined at 250 and 5,000 copies/μL of CK19 mRNA, respectively. The total tumor volume in the SN or non-SN was defined as the sum of CK19 mRNA copy numbers from all samples in the SN or non-SN. The cut-off value for the total tumor volume in the SN was set at 2,810 copies/μL according to our previous study (Osako et al. Br J Cancer 2017). The anatomical location of metastasis was classified into Level I (confined to SN), Level I (spread to non-SN), or Level II/III. Predictive factors for distant disease-free survival (DDFS) were investigated using the univariate log-rank tests and multivariate Cox proportional hazards models.The median follow-up time was 6.1 years (range, 0.2–8.6).

Results: Of the 307 patients, 130 (42.3%) and 177 (57.7%) had the total tumor volume &lt;2,810 and ≥2,810 copies/μL in the SN, respectively. Five-year DDFS was 96.0% in the entire cohort. In the univariate analysis, DDFS was significantly related to the pT classification, grade, hormone receptor status, triple-negative subtype, total tumor volume in the SN and cytotoxic chemotherapy. However, DDFS was not significantly related to the number of metastatic or macrometastatic nodes in the SN, non-SN, or all nodes (i.e. SN + non-SN); the total tumor volume in the non-SN or all nodes; the AJCC pN classification; or the anatomical location of metastasis. In the multivariate analysis, the total tumor volume in the SN (&lt;2810 vs. ≥2810 copies/μL, hazard ratio 5.2, 95% confidence interval 1.2–23.2, P=0.03) and cytotoxic chemotherapy (- vs. +, hazard ratio 0.05, 95% confidence interval 0.02–0.17, P&lt;0.001) remained significant.

Conclusions: The total tumor volume in the SN was the independent prognostic factor of lymph node metastasis in SN-positive invasive breast cancer. Accurate evaluation of metastatic tumor burden in the SN can be important for predicting prognosis and may help to guide the precise therapeutic decision making for breast cancer patients.

Citation Format: Osako T, Iwase T, Ushijima M, Ogiya A, Ueno T, Ohno S, Akiyama F. Which factor of metastatic lymph nodes–The number, tumor volume or anatomical location–Is independently prognostic in breast cancer? - A prospective cohort study using molecular whole-node analysis of all removed axillary nodes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-23.

Abstract P1-08-12: Trends in incidence of bilateral breast cancer: A Population-based comparative study of the United States and Japan

Background: Previous studies demonstrated that the incidence rate of invasive contralateral breast cancer (CBC) was 5% within the first 10 years after the primary breast cancer (BC). However improving long-term breast cancer survivorship and advancements in diagnostic imaging have resulted in an increased detection of bilateral breast cancer (BBC), and trends of bilateral invasive and in situ breast cancer are not well established. The aim of this study was to assess national trends of BBC incidence of the United States (US) and Japan.

Methods: The Surveillance, Epidemiology, and End Results (SEER) database (1973-2014) and the clinical database of Breast Oncology Center of Cancer Institute Hospital in Tokyo, Japan (Ganken) database (1946-2015) were used to identify nSEER=11,771 and nGanken=1,499 women diagnosed with BBC, respectively. BBC was defined as invasive BC and/or ductal or lobular carcinoma in situ diagnosed in both breasts simultaneously or after primary breast cancer diagnosis. BBC was grouped into synchronous or metachronous BBC by the interval between first BC and contralateral BC; synchronous cases were defined as CBC diagnosed at the same time or within an interval of 1 year from primary BC diagnosis whereas metachronous cases were defined as a diagnosis occuring 1 year following the primary BC. We assessed trends of BBC incidence and characteristics of BBC cases between the two countries. To determine temporal trends in the incidence of BBC and proportion of the characteristics, we compared them using the Cochrane-Armitage test for trend.

Results: The rates of BBC have significantly increased in both countries (Table 1, 2) [1975: 2.6%; 2014: 7.5% in SEER (p&lt;0.001), 1946-1980: 3.3%; 2011-2015: 10.7% in Ganken (p&lt;0.001)]. The increase was identified in both synchronous and metachronous BBC. In SEER, 40% of synchronous BBC were found as in situ BC and about 15% of BBC presented as invasive lobular carcinoma. More recently, CBC was more likely to be diagnosed at early stages (in situ and local disease) than in previous years [1975: 65%; 2014: 85% in SEER (p&lt;0.001)]. The interval between first BC and contralateral BC have shortened, and CBC were more likely to be operated simultaneously in both countries [1985: 40%; 2014: 51% in SEER, 1946-1980: 24%; 2011-2015: 74% in Ganken].

[Table 1]Crude rates of BBC in all breast cancer in SEER 19751985199520052014All breast cancer941813618258766016471505BBC and rates (%)249 (2.6%)790(5.8%)1421(5.5%)3336(5.6%)5381(7.5%)Rates of synchronous BC2.1%2.8%2.3%2.6%3.5%Rates of metachronous BC0.5%3.0%3.2%3.0%4.0%BBC: Bilateral breast cancer

[Table 2]Crude rates of BBC in all breast cancer in Ganken 1946-19801981-19851991-19952001-20052011-2015All breast cancer47772162280637915241BBC and rates (%)157(3.3%)110(5.1%)188(6.7%)298(7.9%)559(10.7%)Rates of synchronous BC1.0%1.9%2.0%2.7%4.9%Rates of metachronous BC2.3%3.2%4.7%5.2%5.8%

Conclusion: In the modern era, the number of BBC cases have increased and are more likely to be found at an early stage. Further studies are needed to demonstrate the usefulness of early detection of CBC and to define the best means to tailor therapy for patients with bilateral disease.

Citation Format: Sakai T, Ozkurt E, Desantis S, Wong S, Rosenbaum L, Zheng H, Ohno S, Golshan M. Trends in incidence of bilateral breast cancer: A Population-based comparative study of the United States and Japan [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-12.

Abstract OT2-07-05: A phase III trial to compare eribulin mesylate + trastuzumab (H) + pertuzumab (P) with paclitaxel or docetaxel + HP for HER2-positive advanced or metastatic breast cancer (JBCRG-M06/ EMERALD)

Background: Docetaxel + Trastuzumab (H) + Pertuzumab (P) provided progression-free survival (PFS) and overall survival (OS) benefits in HER2-positive advanced or metastatic breast cancer (AMBC) in the CLEOPATRA study as a first-line therapy. However, long-term administration of docetaxel at a dose of 75 mg/m2 every 3 weeks in AMBC patients (pts) is difficult due to the toxicities. Eribulin mesylate (E) is a well-tolerated microtubule inhibitor, and we have reported the efficacy and safety of EHP regimen as first- and second-line therapy for AMBC in a multicenter, phase II study (JBCRG-M03/UMIN000012232). In this M06 study, we address the clinical question as to which is the better chemotherapy partner for HP as first line regimen, in terms of efficacy, toxicity and QOL.

Methods: JBCRG-M06 is a multicenter open-label randomized phase III study for HER2-positive AMBC pts who have received no prior chemotherapy except for the HER2- Antibody-Drug Conjugate (ADC). Pts will be randomized 1:1 to E (1.4mg/m2 on day 1 and 8) + H (8 mg/kg loading dose followed by 6 mg/kg) +P (840 mg loading dose followed by 420 mg) q3wks or standard taxanes (docetaxel 75mg/m2 on day1 or paclitaxel 80mg/m2 on day 1, 8 and 15) + HP q3wks. Stratification factors for randomization are; presence of visceral metastases, number of prior taxanes on perioperative adjuvant treatment, and treatment with prior anti-HER2-ADC. Primary endpoint is PFS and secondary endpoints include overall response rate, duration of response, OS, patient-reported outcomes (PRO) relating to QOL and peripheral neuropathy, new-metastases free survival, and safety. Translational research to search for biomarker for individual precision therapy will be performed. Main eligibility criteria are as follows: pts with HER2-positive AMBC, female aged 20-70 years old, ECOG PS of 0-1, LVEF ≥ 50% at baseline and adequate organ function. Pts who had progressive MBC within 6 months after the end of primary adjuvant systemic chemotherapy are excluded. The sample size was calculated by type1 error (2-sided) of 0.05 and 80% power to estimate the noninferiority margin 1.33 with an expected median PFS of 14.2 months. The target number of pts is 480 recruited over the duration of 3-years. The first patient in was achieved on August 2017. (ClinicalTrials.gov Identifier:NCT03264547).

Citation Format: Masuda N, Yamashita T, Saji S, Araki K, Ito Y, Takano T, Takahashi M, Tsurutani J, Koizumi K, Kitada M, Kojima Y, Sagara Y, Tada H, Iwasa T, Kadoya T, Iwatani T, Hasegawa H, Morita S, Ohno S. A phase III trial to compare eribulin mesylate + trastuzumab (H) + pertuzumab (P) with paclitaxel or docetaxel + HP for HER2-positive advanced or metastatic breast cancer (JBCRG-M06/ EMERALD) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-07-05.

Abstract P3-10-16: Predicting pathological complete response by the combination of microRNAs in patients with HER2-positive primary breast cancer who received neoadjuvant combination therapy of trastuzumab, lapatinib and paclitaxel: Results from JBCRG-16 (NeoLath) study

[Background] JBCRG-16 (NeoLath) study is a five-arm study to evaluate the efficacy and safety of lapatinib and trastuzumab (6 weeks) followed by lapatinib and trastuzumab plus weekly paclitaxel (12 weeks) with/without prolongation of anti-HER2 therapy prior to chemotherapy (18 vs. 6 weeks), and with/without endocrine therapy in patients with HER2+ and/or estrogen receptor (ER)+ disease. The primary endpoint was pathological complete response (pCR) rate and pCR rate was 47.9% (Masuda N, et al. Breast Cancer, 2018). It is recently reported that microRNAs (miRNAs) are stably present in serum and potentially useful in the diagnosis and evaluation of treatment of cancer. We performed exploratory analysis of detecting pCR by comprehensive analysis of serum miRNAs.

[Materials and Methods] Serum samples were obtained from study participants who received neoadjuvant systemic therapy with trastuzumab, lapatinib and paclitaxel. Before profiling of miRNAs, the overall serum samples were randomly devided in two sets, namely the training set and the testing set with pCR or non-pCR. Pathological complete response (pCR) was defined as the absence of residual invasive cancer of the resected breast specimen and all sampled regional lymph nodes. Total RNA was extracted from a 300 ul serum sample using 3D-Gene® RNA extraction reagent from a liquid sample kit. A comprehensive quantitative expression analysis of miRNA was performed using the by DNA chip 3D-Gene®, which was designed to detect 2565 miRNA sequences registered in miRBase release 21 (http://www.mirbase.org/). The expression level of miRNAs were normalized by internal control (miR-2861, miR-149-3p and miR-4463). Clinicopathological data was retrieved from trial data.

[Results] A total of 112 samples were obtained. Seventy were used in the training set and others were used in the testing set. Median age was 54 years (range 26-70). Sixty-five (58%) patients were pre-menopausal. ER was positive in 59 patients (52.7%). Fourteen (12.5%) were T1c, 78 (69.6%) were T2 and 20 (17.9%) were T3. Fifty-seven (50.9%) patients were node-positive. Fifty-nine (52.7%) patients achieved pCR. The formula with the combination of three miRNAs (miR-A, miR-B, miR-C) was found to be able to predict pCR. This set had a sensitivity of 62.5%, specificity of 86.7% and accuracy of 71.8% in the testing cohort. Area under curve of receiver operationg characteristic curve was 0.753.

[Conclusion] The combination of three miRNAs has potential to predict pCR in patients who received neoadjuvant combination therapy of trastuzumab, lapatinib and paclitaxel in HER2-positive primary breast cancer. The further analysis of changing expression of miRNAs during neoadjuvant therapy is underway and further results will be presented in the symposium.

Citation Format: Shimomura A, Masuda N, Kawauchi J, Takizawa S, Ichikawa M, Matasuzaki J, Kuroi K, Hara H, Yamamoto N, Inoue K, Suganuma N, Aogi K, Ohno S, Tamura K, Ochiya T, Toi M. Predicting pathological complete response by the combination of microRNAs in patients with HER2-positive primary breast cancer who received neoadjuvant combination therapy of trastuzumab, lapatinib and paclitaxel: Results from JBCRG-16 (NeoLath) study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-16.

Abstract P2-09-28: New quantitative diagnostic method by fluorescence nanoparticle for HER2 positive breast cancer treated with neoadjuvant lapatinib and trastuzumab: The Neo LaTH study (JBCRG-16TR)

Background: HER2 (human epidermal growth factor receptor 2) testing performed by IHC (immunohistochemical) methods and FISH (fluorescence in situ hybridization) is semi-quantitative. Exact quantification of HER2 is needed to predict which patients are more or less likely to response to anti HER2 therapy. To improve the method for cancer patients' HER2 status, we developed a novel fluorescence IHC method using new fluorescence nanoparticle. The fluorescent intensity of this new nanoparticles, termed phosphor-integrated dot (PID), was approximately 100-fold brighter than that of Quantum dots. Because of its increased brightness and analyzing technology, this PID-based fluorescent IHC(IHC-PIC) has an ability of quantifying the biomarker protein in the cancer tissue sample at single particle level. In this study, the primary objective was to investigate if pathological complete response (pCR) rate in HER2- positive breast cancer treated by trastuzumab and lapatinib containing neoadjuvant systemic therapy would depend on the level of HER2, EGFR, HER3, Ki67, ER and PgR protein quantified by this new method.

Methods: The Neo-LaTH study is a randomized phase II multicenter trial evaluating the efficacy and safety of lapatinib and trastuzumab followed by lapatinib and trastuzumab plus weekly paclitaxel with or without prolongation of anti-HER2 therapy prior to chemotherapy (18 weeks vs. 6 weeks). The primary endpoint was the comprehensive pCR rate. We evaluated the HER2, EGFR, HER3, Ki67, ER and PgR amount by nano-patho method using PID in formalin-fixed paraffin-embedded core biopsy samples taken at diagnosis retrospective analysis. Univariate and multivariate analyses were performed to determine the association between pCR and variables, including HER2, EGFR, HER3, Ki67, ER and PgR nano-patho score and clinicopathological factors including histological grade, tumor status, nodal status and HER2 FISH ratio.

Results: A total of 96 tumor samples from patients were used for the present analysis.The pCR rate was 60.4%. We obtained the images of only PID signal by the image analyses, and calculated the number of PID particles in a cell and defined it as IHC-PID score that reflects the level of HER2, EGFR, HER3, Ki67, ER and PgR protein expression in cancer cells. Univariate analysis showed that HER2 IHC-PID score(p&lt;0.0001), ER IHC-PID score(p=0.009) and PgR IHC-PID score(p=0.019) were associated with pCR and multivariate analysis showed that HER2 IHC-PID score was significantly associated with pCR (adjusted odds ratio, 0.990 [95% CI, 0.984–0.996]; P &lt; .0001).

Conclusion: We successfully performed the quantitative IHC-PID for HER2, EGFR, HER3, Ki67, ER and PgR. And we propose using HER2 IHC-PID score as a predictive factor for trastuzumab and lapatinib containing neoadjuvant systemic therapy. This quantitative diagnostic method would be expected to contribute to the development of a molecular therapeutic strategy.

Citation Format: Tada H, Miyashita M, Gonda K, Watanabe M, Suzuki A, Watanabe G, Harada N, Sato A, Hamanaka Y, Masuda N, Toi M, Ohno S, Bando H, Ishiguro H, Inoue K, Yamamoto N, Kuroi K, Ohuchi N, Ishida T. New quantitative diagnostic method by fluorescence nanoparticle for HER2 positive breast cancer treated with neoadjuvant lapatinib and trastuzumab: The Neo LaTH study (JBCRG-16TR) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-28.

Abstract P3-13-06: Tailored neoadjuvant endocrine and chemo-endocrine therapy for postmenopausal patients with estrogen receptor-positive human epidermal growth factor receptor 2-negative primary breast cancer

Aims We investigated the efficacy and safety of initial neoadjuvant endocrine therapy with exemestane (EXE) alone followed by subsequent tailored treatment with EXE alone for responders or EXE plus oral metronomic cyclophosphamide (CPA) for non-responders.

Methods In this multicenter open-label phase II study, we enrolled postmenopausal patients with primary invasive estrogen receptor (ER)-positive, HER2-negative, stage I–IIIA (T1c–T3 N0–2 M0) breast cancer and Ki67 index ≤ 30%. Patients first received EXE 25mg/day for 12 weeks. Based on clinical response and change in Ki67 index in response to the initial therapy, patients who achieved complete response (CR), partial response (PR) with Ki67 index ≤5% after treatment, or stable disease (SD) with Ki67 index ≤5% both before and after treatment were defined as responders. Non-responders were defined as patients with PR and Ki67 index &gt;5% after treatment, or SD and Ki67 index &gt;5% before or after treatment. For the subsequent 24 weeks, responders continued the EXE monotherapy (continued EXE group), whereas non-responders switched to combination therapy with EXE plus CPA 50mg/day (EXE+CPA group). The primary endpoint was clinical response (CR and PR) at weeks 24 and 36.

Results A total of 59 patients (median age 69 years, range 53–86 years) were enrolled between January 2011 and July 2015. After exclusion of 3 (2 with progressive disease, 1 with an adverse event, AE) who discontinued treatment in the initial 12-week EXE monotherapy period, 56 remained enrolled to receive subsequent treatment. After 8–12 weeks of the initial EXE monotherapy, 14 patients were classified as responders (9 with PR and Ki67 index ≤5% after treatment; 5 with SD and Ki67 index ≤5% before and after treatment), whereas 42 were classified as non-responders (3 with PR and Ki67 index &gt;5% after treatment; 39 with SD and Ki67 index &gt;5% before or after treatment). Clinical response rates at weeks 24 and 36 were 85% (12/14, 95%CI 57.2–98.2%) and 76% (10/13, 95%CI 46.2–95.0%), respectively, in the continued EXE group, and 56% (23/41, 95%CI 39.7–71.5%) and 76% (30/39, 95%CI 60.7–88.9%), respectively, in the EXE+CPA group. At week 36, no significant difference was found in median Ki67 index between the continued EXE and EXE+CPA groups (3.5% and 4.0%, respectively). The proportion of patients with preoperative endocrine prognostic index (PEPI) 0 was also similar between the continued EXE and EXE+CPA groups (21.4% and 23.8%, respectively). The breast-conserving surgery rate was 71.4% and 69.0%, respectively. Grade 3 AEs were elevated liver enzymes (1 patient) in the continued EXE group, and gastritis, hypertriglyceridemia, and bone mineral density loss (1 patient each) in the EXE+CPA group.

Conclusion Switching from EXE monotherapy to EXE+CPA combination therapy based on clinical response and biological response (change in Ki67 index) to initial therapy improved subsequent clinical response in non-responders. Favorable clinical response to EXE alone was maintained in responders. Tailored neoadjuvant endocrine and chemo-endocrine therapy was shown to be effective in postmenopausal ER-positive breast cancer patients. (JBCRG-11CPA; UMIN000004751)

Citation Format: Masuda N, Sato N, Morimoto T, Ueno T, Kanbayashi C, Kaneko K, Yasojima H, Saji S, Sasano H, Morita S, Ohno S, Toi M. Tailored neoadjuvant endocrine and chemo-endocrine therapy for postmenopausal patients with estrogen receptor-positive human epidermal growth factor receptor 2-negative primary breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-13-06.

Abstract P5-21-07: Phase II study of eribulin in combination with pertuzumab plus trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive advanced or metastatic breast cancer

Background: Pertuzumab provided overall and progression-free survival (PFS) benefits in HER2-positive metastatic breast cancer patients (pts) in the CLEOPATRA (Clinical evaluation of docetaxel, pertuzumab and trastuzumab) study. However, few studies have described the efficacy of other drugs in combination with pertuzumab plus trastuzumab. Here, we present a pre-specified analysis of eribulin in combination with pertuzumab plus trastuzumab as first- and second-line therapy for advanced or metastatic breast cancer (AMBC) in a multicenter, open-label phase II study (UMIN000012232, JBCRG-M03).

Methods: HER2-positive AMBC with no or single prior chemotherapy for AMBC were enrolled. All pts were administered trastuzumab and taxane as adjuvant or first-line chemotherapy. Treatment consisted of eribulin 1.4 mg/m2 on days 1 and 8 of a 21-day cycle and trastuzumab (8 mg/kg loading dose, then 6 mg/kg) plus pertuzumab (840 mg/body loading dose, then 420 mg/ body) once every 3 weeks, all administered intravenously. The primary endpoint was PFS, and secondary endpoints included overall response rate (ORR) and safety. PFS was determined using Kaplan–Meier analysis. Tumor response was assessed according to RECIST ver. 1.1.

Results: Fifty pts were enrolled from November 2013 to April 2016. Forty-nine pts were eligible for safety analysis and the full analysis set (FAS) included 46 pts. The median age was 56 years (23–70), and 8 (16%) and 41 (84%) pts were treated in first- and second-line settings, respectively. Eleven pts (23.9%) were de-novo Stage 4, and 35 pts (76.1%) had progressed in metastatic disease after completion of local therapy. Median PFS was 9.3 months (M) (95% confidence interval [CI]: 6.4–12.3). Table 1 shows the efficacy data for each treatment line and includes ORR, complete response rate (CR), partial response rate (PR), stable disease rate (SD), progressive disease rate (PD), not evaluable rate (NE) and PFS in the FAS. The median relative dose intensities of eribulin, trastuzumab, and pertuzumab were 93.3% (77.0%–100%), 100% (96.0%–100%), and 100% (89.7%–100%), respectively, in the FAS. The grade 3/4 adverse events (AE) were neutropenia in 5 pts (10.2%), including 2 pts (4.1%) with febrile neutropenia; hypertension in 3 pts (6.1%), and other AEs in only one patient. The average of the ejection fraction did not decrease significantly. Symptomatic left ventricular systolic dysfunction was not observed.

Conclusion: In pts with HER2-positive AMBC, first- and second-line therapy of eribulin in combination with pertuzumab plus trastuzumab demonstrated substantial antitumor activity with an acceptable safety profile. We are planning a phase III study comparing eribulin with taxanes in combination with pertuzumab plus trastuzumab for the treatment of HER2-positive AMBC.

Efficacy data for each treatment lineTreatment LineTotal (n=46)First line (n=8)Second line (n=38)PFS (95% CI), months9.3 (6.4-12.3)20.8 (2.8-38.7)8.7 (7.2-10.2)ORR (%)28 (60.9)7 (87.5)21 (55.3)CR (%)8 (17.4)3 (37.5)5 (13.2)PR (%)20 (43.5)4 (50.0)16 (42.1)SD (%)11 (23.9)1 (12.5)10 (26.3)PD (%)5 (10.9)05 (13.2)NE (%)2 (4.3)02 (5.3)

Citation Format: Kawaguchi H, Yamashita T, Masuda N, Kitada M, Narui K, Hattori M, Yoshinami T, Matsunami N, Yanagihara K, Kawasoe T, Nagashima T, Bando H, Yano H, Hasegawa Y, Nakamura R, Kashiwaba M, Morita S, Ohno S, Toi M. Phase II study of eribulin in combination with pertuzumab plus trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive advanced or metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-07.

Abstract P2-09-31: Predictive impact of absolute lymphocyte counts for progression-free survival in HER2-positive advanced breast cancer treated with pertuzumab and trastuzumab plus eribulin or nab-paclitaxel

Background: Tumor-infiltrating lymphocytes might be a one of predictive outcome of human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer (ABC) patients (pts) who treated with trastuzumab and pertuzumab (TP) plus docetaxel. Although peripheral blood-based parameter (PBBP) is reported as a prognostic indicator of patients with early breast cancers, utility of PBBP has not been studied in HER2-positive ABC.

Objective:The aim of our study was to determine whether PBBP is significant for predictive efficacy in HER2-positive ABC treated with TP combined with eribulin (ERI) or nab-paclitaxel (Nab-PTX).

Methods: The 51 patients' data from two single arm phase II trials was included in this retrospective-prospective study; ERI + TP (n=30) or Nab-PTX + TP (n=21) registered with UMIN000012375 or UMIN000006838, respectively. We assessed the PBBP in prospectively collected data and investigated their association with progression-free survival (PFS). In consideration of PBBP, we evaluated absolute lymphocyte count (ALC), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR). The cutoff values of ALC, NLR, and PLR were set at 1000 cells/μL, 2, and 250, respectively.

Results:Median age at baseline was 58 years (range: 31-77). Median number of previous chemotherapy was 3 (range: 1-10). Pts had multiple metastases, 53% with LNs, 35% with bone, 25% with lung, 20% with liver, and 6% with brain. The objective response rate (CR+PR) and clinical benefit rate (CR+PR+ more than 6 month SD) were 37% (n=19) and 59% (n=30), respectively. The median PFS of all pts was 301 days (range: 21-1281). The PFS of pts with ALC-High was significantly better than those of ALC-low (hazard ratio (HR): 2.74, 95% confidence interval (CI): 1.28 to 5.86; p= .0097). Furthermore, improved PFS was obtained in pts with ALC greater than 1500 cells/μL compared with less than 1000 cells/uL (HR: 4.05, 95% CI: 1.60 to 11.6; p= .0029). Significant associations seem to exist irrespective of number of previous chemotherapy. Since we combined different studies for evaluating PBBP, ERI and Nab-PTX were calculated separately. Marginally significant associations between ALC and PFS were obtained both in ERI (HR: 2.18, 95% CI: 0.87 to 5.60; p=.0973) and Nab-PTX (HR: 3.26, 95% CI: 0.80 to 12.4; p=.0939). The PFS of NLR-low pts was significantly better than those of NLR-high (HR: 2.29, 95% CI: 1.01 to 5.90; p= .0477), but this statistical difference was inferior to those of ALC. There was no significant association between PLR and PFS.

Conclusions: Pre-treatment ALC-High was significantly correlated with favorable PFS of pts treated with TP irrespective of combination chemotherapy in HER2-positve ABC. Prolonged PFS of TP combination therapy might be obtained mediating through host systemic onco-immunity. These data obtained here suggest that a usefulness of ALC for selecting pts who might have clinical benefit from TP combination therapy for heavily treated HER2-positve ABC.

Citation Format: Araki K, Ito Y, Fukada I, Kobayashi K, Ohno S, Miyagawa Y, Imamura M, Kira A, Takatsuka Y, Egawa C, Suwa H, Miyoshi Y. Predictive impact of absolute lymphocyte counts for progression-free survival in HER2-positive advanced breast cancer treated with pertuzumab and trastuzumab plus eribulin or nab-paclitaxel [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-31.

Efficacy and safety of trastuzumab, lapatinib, and paclitaxel neoadjuvant treatment with or without prolonged exposure to anti-HER2 therapy, and with or without hormone therapy for HER2-positive primary breast cancer: a randomised, five-arm, multicentre, open-label phase II trial

Background

Dual blockade of HER2 promises increased pathological complete response (pCR) rate compared with single blockade in the presence of chemotherapy for HER2-positive (+) primary breast cancer. Many questions remain regarding optimal duration of treatment and combination impact of endocrine therapy for luminal HER2 disease.

Methods

We designed a randomised phase II, five-arm study to evaluate the efficacy and safety of lapatinib and trastuzumab (6 weeks) followed by lapatinib and trastuzumab plus weekly paclitaxel (12 weeks) with/without prolongation of anti-HER2 therapy prior to chemotherapy (18 vs. 6 weeks), and with/without endocrine therapy in patients with HER2+ and/or oestrogen receptor (ER)+ disease. The primary endpoint was comprehensive pCR (CpCR) rate. Among the secondary endpoints, pCR (yT0-isyN0) rate, safety, and clinical response were evaluated.

Results

In total, 215 patients were enrolled; 212 were included in the full analysis set (median age 53.0 years; tumour size = T2, 65%; and tumour spread = N0, 55%). CpCR was achieved in 101 (47.9%) patients and was significantly higher in ER− patients than in ER+ patients (ER− 63.0%, ER+ 36.1%; P = 0.0034). pCR with pN0 was achieved in 42.2% of patients (ER− 57.6%, ER+ 30.3%). No significant difference was observed in pCR rate between prolonged exposure groups and standard groups. Better clinical response outcomes were obtained in the prolongation phase of the anti-HER2 therapy. No surplus was detected in pCR rate by adding endocrine treatment. No major safety concern was recognised by prolonging the anti-HER2 treatment or adding endocrine therapy.

Conclusions

This study confirmed the therapeutic impact of lapatinib, trastuzumab, and paclitaxel therapy for each ER− and ER+ subgroup of HER2+ patients. Development of further strategies and tools is required, particularly for luminal HER2 disease.

Electronic supplementary material

The online version of this article (10.1007/s12282-018-0839-7) contains supplementary material, which is available to authorized users.

Research needs in breast cancer

New research questions emerge as medical needs continue to evolve and as we improve our understanding of cancer biology and treatment of malignancies. Although significant advances have been made in some areas of breast cancer research resulting in improvements in therapies and outcomes over the last few decades, other areas have not benefited to the same degree and we continue to have many gaps in our knowledge. This article summarizes the 12 short and medium-term clinical research needs in breast cancer deemed as priorities in 2016 by a panel of experts, in an attempt to focus and accelerate future research in the most needed areas: (i) de-escalate breast cancer therapies in early breast cancer without sacrificing outcomes; (ii) explore optimal adjuvant treatment durations; (iii) develop better tools and strategies to identify patients with genetic predisposition; (iv) improve care in young patients with breast cancer; (v) develop tools to speed up drug development in biomarker-defined populations; (vi) identify and validate targets that mediate resistance to chemotherapy, endocrine therapy and anti-HER2 therapies; (vii) evaluate the efficacy of local-regional treatments for metastatic disease; (viii) better define the optimal sequence of treatments in the metastatic setting; (ix) evaluate the clinical impact of intra-patient heterogeneity (intra-tumor, inter-tumor and inter-lesion heterogeneity); (x) better understand the biology and identify new targets in triple-negative breast cancer; (xi) better understand immune surveillance in breast cancer and further develop immunotherapies; and (xii) increase survivorship research efforts including supportive care and quality of life.