Abstract P1-07-02: 5-year overall survival of early breast cancer during pregnancy: A multicenter French case control study

Background: Breast cancer (BC) during pregnancy (BCP) is a rare situation that requires collaboration between oncologists, surgeons and obstetricians. The main objectives of this study were to compare the overall survival (OS) and disease free survival (DFS) of a multicenter cohort of pregnant patients (pts) with those of matched control pts.

Methods: Patients from 27 centers and diagnosed between 2000 and 2006 with histological confirmed M0 invasive BC were included in this retrospective study. For the cohort of BCP, pts whose pregnancy was interrupted were not eligible. Controls were matched to BCP pts on 5 criteria: clinical T (of TNM), hormonal receptor (HR) status, HER2 status, administration of neo-adjuvant chemotherapy and pathological nodal status in the absence of neo-adjuvant chemotherapy. Survival times were estimated from the date of diagnosis using Kaplan-Meier method. OS was calculated until death from every cause, DFS was calculated until relapse or death from every cause; patients alive were censored at the date of last news.

Results: 100 BCP pts were identified. Their clinical and pathological characteristics were described on a previous presentation (SABCS 2013 P6-06-07). Matched controls could not be found for 12 BCP pts. 88 BCP pts were matched with 204 controls. The only differences between the 2 populations in terms of characteristics or treatment were more radical mastectomy (p=0.036) and fewer taxane administrations in the BCP group (p=0.06). The median duration of follow-up was 8.2 years for cases and 7.7 years for controls. There were no differences between BCP pts and controls in 5-year OS: 83.4%, IC 95% (73.5-89.8) vs 83.8%, IC 95% (77.9-88.3) nor 7-year OS: 76.5% (65.5-84.4) vs 78.1% (71.5-83.3) (p=0.52). The 5-year DFS was 58.6% IC 95% (47.3-68.3) vs 67.2% IC 95% (60.2-73.2) (p= 0.16). However, 5-year DFS was lower in HR+ BCP pts subgroup than in HR+ control group (56.7% IC 95% (40.7-69.8) vs 70.9% IC 95% (61.4-78.5) (p=0.023).

Conclusion: This multicenter French large study confirmed that there are no differences on OS and DFS between pregnant and no pregnant pts, though this might not be true for HR subgroup.

Citation Format: Vanlemmens L, Ploquin A, Delaloge S, Rouzier R, Lesur A, Frenel J-S, Loustalot C, Bachelot T, Provansal M, Ferrero J-M, Coussy F, Debled M, Kerbrat P, Vinceneux A, Djelila A, Baron M, Jebert S, Decoupigny E, Tresch E, Bonneterre J. 5-year overall survival of early breast cancer during pregnancy: A multicenter French case control study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-07-02.

A European Organisation for Research and Treatment of Cancer randomized, double-blind, placebo-controlled, multicentre phase II trial of anastrozole in combination with gefitinib or placebo in hormone receptor-positive advanced breast cancer (NCT00066378)

BACKGROUND

Preclinical data suggest that epidermal growth factor receptor (EGFR) inhibitors (e.g. gefitinib) can delay endocrine resistance in breast cancer. A double-blind, placebo-controlled, phase II trial investigated whether adding gefitinib (G) to anastrozole (A) would improve outcome in advanced breast cancer (ABC).

METHODS

Postmenopausal pre-treated hormone receptor-positive ABC patients (locally recurrent or metastatic) were 1:1 randomized to A (1 mg/d) plus G 250 mg/d or plus placebo (P). Patients who had prior treatment with an aromatase inhibitor in metastatic setting or with trastuzumab, anti-EGFR or anti-VEGF agents were excluded. Treatment was given until disease progression, unacceptable toxicity or patient withdrawal. Progression-free survival (PFS) rate at 1 year was assessed according to Response Evaluation Criteria in Solid Tumours, version 1.0.

RESULTS

Of 108 planned patients, 71 were recruited (36 in A/G and 35 in A/P). The trial closed prematurely due to slow recruitment; 31 patients had prior chemotherapy and 53 prior endocrine therapy (all except one received tamoxifen); 60% in adjuvant and 16% in metastatic setting received tamoxifen; 59 patients had visceral disease. Median follow-up was 18 months. PFS rate at 1 year was 35% for A/G and 32% for A/P arm. Objective responses were six (22%) in the A/G and nine (28%) in the A/P arm. Median duration of response was 13.8 and 18.6 months in the A/G and A/P arms, respectively. Fatigue (35%), diarrhoea (31%), rash (32%), dry skin (27%), and arthralgia/myalgia (27%) were the commonest adverse events in the A/G arm.

CONCLUSIONS

This phase II study, although prematurely closed, did not show a signal that adding G to A improves PFS at 1 year and its use is not supported. Gastrointestinal and skin toxicities were more pronounced with G resulting in premature therapy interruption in almost 1 in 3 patients (ClinicalTrials.gov number, NCT00066378).

Comprehensive prognostic analysis in breast cancer integrating clinical, tumoral, micro-environmental and immunohistochemical criteria

Significant morphological, clinical and biological prognostic factors vary according to molecular subtypes of breast tumors, yet comprehensive analysis of such factors linked to survival in each group is lacking. Clinicopathological and micro-environmental criteria, estrogen (ER), progesterone (PR) receptors, HER2, Ki67, basal markers, CD24, CD44, ALDH1, BCL2, E-Cadherin and Trio were assessed in 1070 primary operable breast cancers from a single center according to five main molecular subtypes and associations with distant metastasis-free survival (DMFS) were examined. There were 682 (64 %) luminal A (LA), 166 (16 %) Luminal B HER2 negative (LBH−), 47 (4 %) Luminal B HER2 positive (LBH+), 108 (10 %) triple negative (TN) and 67 (6 %) HER2-enriched tumors (H2+). Median follow-up was 13.7 years. At 5 years, DMFS in LA (90 %) was better than in LBH− (80.9 %), hazard ratio (HR) = 2.22 [1.44–3.43] P < 0.001; LBH+ (74.5 %), HR = 3.14 [1.69–5.84] P < 0.001, TN (71.5 %) HR = 3.63 [2.34–5.63], P < 0.001; and H2+ (65.2 %), HR = 4.69 [2.90–7.59], P < 0.001. In multivariable analysis, factors associated with shorter DMFS varied according to molecular subtype, with tumor size being associated with shorter DMFS in the LBH−, LBH+ and TN groups and the Rho GEF Trio and BCL2 phenotypes in TN tumors only. These findings help to define new clinicophenotypic models and to identify new therapeutic strategies in the specific molecular subgroups.

Relative Effectiveness of Letrozole Compared With Tamoxifen for Patients With Lobular Carcinoma in the BIG 1-98 Trial

PURPOSE

To evaluate the relative effectiveness of letrozole compared with tamoxifen for patients with invasive ductal or lobular carcinoma.

PATIENTS AND METHODS

Patients diagnosed with early-stage invasive ductal carcinoma (IDC) or classic invasive lobular carcinoma (ILC) who were randomly assigned onto the Breast International Group (BIG) 1-98 trial and who had centrally reviewed pathology data were included (N = 2,923). HER2-negative IDC and ILC were additionally classified as hormone receptor-positive with high (luminal B [LB] -like) or low (luminal A [LA] -like) proliferative activity by Ki-67 labeling index. Survival analyses were performed with weighted Cox models that used inverse probability of censoring weighted modeling.

RESULTS

The median follow-up time was 8.1 years. In multivariable models for disease-free survival (DFS), significant interactions between treatment and histology (ILC or IDC; P = .006) and treatment and subgroup (LB like or LA like; P = .01) were observed. In the ILC subset, there was a 66% reduction in the hazard of a DFS event with letrozole for LB (hazard ratio [HR], 0.34; 95% CI, 0.21 to 0.55) and a 50% reduction for LA subtypes (HR, 0.50; 95% CI, 0.32 to 0.78). In the IDC subset, there was a significant 35% reduction in the hazard of a DFS event with letrozole for the LB subtype (HR, 0.65; 95% CI, 0.53 to 0.79), but no difference between treatments was noted for IDC and the LA subtype (HR, 0.95; 95% CI, 0.76 to 1.20).

CONCLUSION

The magnitude of benefit of adjuvant letrozole is greater for patients diagnosed with lobular carcinoma versus ductal carcinoma.

Clinical and genomic analysis of a randomised phase II study evaluating anastrozole and fulvestrant in postmenopausal patients treated for large operable or locally advanced hormone-receptor-positive breast cancer

BACKGROUND

The aim of this study was to assess the efficacy of neoadjuvant anastrozole and fulvestrant treatment of large operable or locally advanced hormone-receptor-positive breast cancer not eligible for initial breast-conserving surgery, and to identify genomic changes occurring after treatment.

METHODS

One hundred and twenty post-menopausal patients were randomised to receive 1 mg anastrozole (61 patients) or 500 mg fulvestrant (59 patients) for 6 months. Genomic DNA copy number profiles were generated for a subgroup of 20 patients before and after treatment.

RESULTS

A total of 108 patients were evaluable for efficacy and 118 for toxicity. The objective response rate determined by clinical palpation was 58.9% (95% CI=45.0-71.9) in the anastrozole arm and 53.8% (95% CI=39.5-67.8) in the fulvestrant arm. The breast-conserving surgery rate was 58.9% (95% CI=45.0-71.9) in the anastrozole arm and 50.0% (95% CI=35.8-64.2) in the fulvestrant arm. Pathological responses >50% occurred in 24 patients (42.9%) in the anastrozole arm and 13 (25.0%) in the fulvestrant arm. The Ki-67 score fell after treatment but there was no significant difference between the reduction in the two arms (anastrozole 16.7% (95% CI=13.3-21.0) before, 3.2% (95% CI=1.9-5.5) after, n=43; fulvestrant 17.1% (95%CI=13.1-22.5) before, 3.2% (95% CI=1.8-5.7) after, n=38) or between the reduction in Ki-67 in clinical responders and non-responders. Genomic analysis appeared to show a reduction of clonal diversity following treatment with selection of some clones with simpler copy number profiles.

CONCLUSIONS

Both anastrozole and fulvestrant were effective and well-tolerated, enabling breast-conserving surgery in over 50% of patients. Clonal changes consistent with clonal selection by the treatment were seen in a subgroup of patients.

[Genomic signature of breast cancer: The quest for the Holy Grail]

The role of molecular signatures in the adjuvant management of breast cancer remains a debated topic. Discussions should take into account the level of scientific validation, the impact on practice, the expected benefits and financing issues. This article presents the limits to be clarified before using commercial molecular signatures.

[Oncofertility and breast cancer: Where have we come from, where are we going?]

BACKGROUND

Focusing on the current context of national and international recommendations, techniques development to evaluate and preserve fertility and patients' claims, this study aims to make a survey about the management of patients' breast cancer regarding oncofertility.

METHODS

Retrospective and analytic study of medical practices at Bergonié Institute of health professionals (medical oncologists, surgical oncologists, nurses) dedicated to the care of non-disseminated breast cancer patients younger than 37, needing medical treatment.

RESULTS

The number of participants was 230. The most interested practitioners in fertility theme are those of multidisciplinary consultation and surgeons (P<0.001), with an increasing interest during last years (P<0.05). The information about hypofertilizing risks of treatments are delivered most of the time by oncologists (57.7%). The motherhood project is expressed by 11 patients (4.9%) before treatment, only 4 of them receive information on the risks and 49 patients (21.7%) during follow-up. Only 24 patients (48% of the 49) are encouraged for motherhood.

CONCLUSION

To satisfy patients' requests, several improvements have to be made regarding the patients' information, the health professionals' awareness and care coordination.

Abstract P4-01-12: Circulating tumor cells (CTC) and endothelial cells (CEC) changes in HER2 negative metastatic breast cancer (MBC) patients treated with first line weekly paclitaxel and bevacizumab: Preliminary results of a prospective cohort from the French Breast Cancer

Background: increased levels of circulating tumor cells (CTC) are associated with worse progression-free survival (PFS) and overall survival (OS) in patients (pts) with MBC (Bidard FC et al, Lancet Oncol 2014). The failure of chemotherapy to reduce CTCs to levels below five CTCs per 7.5 mL whole blood at first follow-up after initiating a new systemic therapy for MBC predicts shorter time to progression and OS. It has been hypothesized that bevacizumab could modify CTC prognostic value due to extravasation or epithelio-mesenchymal transition induction. CEC variations to predict benefit of anti-angiogenic treatment is still controversial.

Patients & methods: the French cohort COMET is a prospective study including first line HER2 negative pts receiving weekly paclitaxel and bevacizumab according to EMEA approved combination. The aim of this cohort is to evaluate clinical, biological and radiological parameters associated with pts outcome (CTC, CEC, VEGFA levels, ctDNA, pharmacogenomic polymorphisms, metabolomic parameters, visceral fat assessed by initial CTscan, serum estradiol level, and quality of life). We present here the first planned analysis on 206 patients evaluated for CTC and CEC using the FDA cleared CellSearch method.

Results: inclusions started in 09/2012. At time of analysis, 219 patients were included, 211 were evaluable for CTC at baseline (failure rate 4%) and 207 for CEC at baseline (failure rate 5%). Due to short follow-up, 173 pts and 166 pts were evaluable for both CTC and CEC at baseline and first day of second cycle of CT (D1C2) respectively. At baseline, 100/211 (47%) pts had ≥ 5 CTC (median 4 (range 0-30,000) and 30% had no detectable CTC (0 CTC). After one cycle of chemotherapy (D28) 38 pts (22%) had still ≥ 5 CTC: 37 pts with initial high level and only one patient with low CTC at baseline had increased CTC above 5. Median number CEC was 21 (0)-2231) at baseline and 22 (1-881) at D1C2. CEC increased in 16% and decreased in 15% of the cases.

CTC & CEC changes after one cycleCTC BaselineCTC at D1C2CEC BaselineCEC at D1C2≥ 5≥ 537 (21%)&gt;20&gt;2065 (39%)≥ 5&lt;545 (26%)&gt;20≤ 2025 (15%)&lt;5≥ 51 (&lt;1%)≤ 20&gt;2027 (16%)&lt;5&lt;590 (52%)≤ 20≤ 2049 (30%)Total173166

CTC number at baseline line and CTC D1C2 were correlated (p&lt;0.01) (Spearman test). There was no correlation between CEC at baseline or at D1C2 with CTC or CTC changes. Final analysis will be completed when 206 couples for both CTC and CEC at baseline and D1C2 will be available. Accrual is still ongoing.

Conclusion: this 22% rate of failure to reduce CTC &lt; 5 after one cycle of first line CT in a homogeneously bevacizumab-treated cohort of MBC patients did not differ from previous series. As second lines of chemotherapy do not improve the poor prognosis of this group of patients according to the SWOG 500 study results (Smerage et al, JCO 2014), trials of novel therapeutic agents should be considered at the time of progression.

Citation Format: Jean-Yves Pierga, Isabelle Vaucher, Maya Gutierrez, Olivier Tredan, Séverine Guiu, Gilles Romieu, Anthony Goncalves, Marc Debled, Christelle Levy, Jean-Marc Ferrero, Christelle Jouannaud, Elisabeth Luporsi, Marie-Ange Mouret-Reynier, Florence Dalenc, Bernard Asselain, Jerome Lemonnier, Francois-Clement Bidard. Circulating tumor cells (CTC) and endothelial cells (CEC) changes in HER2 negative metastatic breast cancer (MBC) patients treated with first line weekly paclitaxel and bevacizumab: Preliminary results of a prospective cohort from the French Breast Cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-01-12.

Abstract P4-18-03: IBCSG BIG 1-98 study: The long-term follow-up experience

Background

Industry-sponsored clinical trials often have duration of patient follow-up that is defined according to regulatory requirements. However, in diseases such as endocrine-responsive, early breast cancer, recurrences occur after protocol follow-up, and monitoring of long-term toxicity is important. It is challenging to continue patient follow-up after industry sponsorship ends. Transferring responsibility for additional follow-up to the participating academic centers is required. One such example is the long-term follow-up (LTFU) of patients in the Breast International Group (BIG) 1-98 Trial. We present the procedures and current status of the BIG 1-98 LTFU protocol.

Methods

In 2010, the BIG 1-98 trial embarked on a new LTFU protocol to gather data on patient outcomes for an additional five years after study completion (2011-2015). Industry sponsorship ceased at the end of 2010. The LTFU study is designed as an observational, non-interventional study to continue the collection of simplified and updated data on survival, disease status, and long-term adverse events from centers participating in the 4-arm option. The International Breast Cancer Study Group (IBCSG) is sponsoring BIG 1-98 LTFU, and per case reimbursement is available.

Results

The potential BIG 1-98 LTFU cohort consists of the 148 academic medical centers that participated in the 4-arm option with a maximum of 6843 patients enrolled to the parent study. In May 2014, approximately 3 years after initiation of the LTFU protocol, 96 centers had agreed to participate, of which 67 sites had activated the protocol and submitted LTFU data; 31 additional centers were not participating, and the status of 21 centers was unknown.

Participation StatusNumber of CentersPatients Enrolled in BIG 1-98Closed317Not Participating28643No response/Unknown21850Yes, participating965333 Activated674215Not Activated291118Totals1486843

Because the original BIG 1-98 informed consent indicated life-long follow-up, only three countries required patient re-consent in order to participate. At least one LTFU data submission has occurred for 73% of patients participating in the LTFU (May 2014).

Conclusion

Long-term follow-up for a large-scale clinical trial is feasible, but challenging. The methods used for BIG 1-98 LTFU will be described and the status will be updated at the meeting.

Citation Format: Anita Giobbie-Hurder, Beat Thürlimann, Bent Ejlertsen, Patrick Neven, Robert E Coleman, Ian Smith, Andrew M Wardley, István Láng, Marco Colleoni, Marc Debled, John F Forbes, Karen N Price, Meredith M Regan, Manuela Rabaglio, Aron Goldhirsch, Alan S Coates, Richard D Gelber. IBCSG BIG 1-98 study: The long-term follow-up experience [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-18-03.

Guidelines for time-to-event end point definitions in breast cancer trials: results of the DATECAN initiative (Definition for the Assessment of Time-to-event Endpoints in CANcer trials)†

BACKGROUND

Using surrogate end points for overall survival, such as disease-free survival, is increasingly common in randomized controlled trials. However, the definitions of several of these time-to-event (TTE) end points are imprecisely which limits interpretation and cross-trial comparisons. The estimation of treatment effects may be directly affected by the definitions of end points. The DATECAN initiative (Definition for the Assessment of Time-to-event Endpoints in CANcer trials) aims to provide recommendations for definitions of TTE end points. We report guidelines for randomized cancer clinical trials (RCTs) in breast cancer.

PATIENTS AND METHODS

A literature review was carried out to identify TTE end points (primary or secondary) reported in publications of randomized trials or guidelines. An international multidisciplinary panel of experts proposed recommendations for the definitions of these end points based on a validated consensus method that formalize the degree of agreement among experts.

RESULTS

Recommended guidelines for the definitions of TTE end points commonly used in RCTs for breast cancer are provided for non-metastatic and metastatic settings.

CONCLUSION

The use of standardized definitions should facilitate comparisons of trial results and improve the quality of trial design and reporting. These guidelines could be of particular interest to those involved in the design, conducting, reporting, or assessment of RCT.

Accumulation of an endogenous tryptophan-derived metabolite in colorectal and breast cancers

Tumor immune escape mechanisms are being regarded as suitable targets for tumor therapy. Among these, tryptophan catabolism plays a central role in creating an immunosuppressive environment, leading to tolerance to potentially immunogenic tumor antigens. Tryptophan catabolism is initiated by either indoleamine 2,3-dioxygenase (IDO-1/-2) or tryptophan 2,3-dioxygenase 2 (TDO2), resulting in biostatic tryptophan starvation and l-kynurenine production, which participates in shaping the dynamic relationship of the host's immune system with tumor cells. Current immunotherapy strategies include blockade of IDO-1/-2 or TDO2, to restore efficient antitumor responses. Patients who might benefit from this approach are currently identified based on expression analyses of IDO-1/-2 or TDO2 in tumor tissue and/or enzymatic activity assessed by kynurenine/tryptophan ratios in the serum. We developed a monoclonal antibody targeting l-kynurenine as an in situ biomarker of IDO-1/-2 or TDO2 activity. Using Tissue Micro Array technology and immunostaining, colorectal and breast cancer patients were phenotyped based on l-kynurenine production. In colorectal cancer l-kynurenine was not unequivocally associated with IDO-1 expression, suggesting that the mere expression of tryptophan catabolic enzymes is not sufficiently informative for optimal immunotherapy.

Surgery following neoadjuvant chemotherapy for HER2-positive locally advanced breast cancer. Time to reconsider the standard attitude

BACKGROUND

While the addition of targeted therapy to neoadjuvant chemotherapy (NACT) dramatically increases the rate of pathological complete response in HER2-positive breast cancer, no reduction in the rate of mastectomy has been observed in randomised studies.

METHODS

A retrospective single centre analysis of all patients treated with anti HER2-based NACT for T2-4 breast cancer, focusing on patients treated with mastectomy.

RESULTS

Among 165 patients treated between June 2005 and July 2012, surgery was performed immediately post-NACT in 152 cases (92%). Breast-conserving surgery could be performed for 108 of the patients (71%), with a 4-year local relapse-free survival of 97%. A mastectomy was performed in two cases following patients' wishes and in 37 cases based on pre-NACT findings (n = 18) or post-NACT outcomes (n = 19). For 21 out of the 37 cases, a good pathological response was observed, and multidisciplinary reanalysis suggests that breast-conserving surgery outright may have been sufficient for 12 patients. Finally, a salvage mastectomy based on post-lumpectomy pathological results was decided in five cases (11%). The 4-year metastasis-free survival was 84% for all patients operated on after NACT (n = 152).

CONCLUSIONS

Given the good efficacy of anti HER2-based NACT, breast-conserving surgery should be standard practice for most patients. Total mastectomy on the other hand should be restricted to a few patients, mainly those with positive margins on the lumpectomy specimen.

Neoadjuvant endocrine treatment in breast cancer: analysis of daily practice in large cancer center to facilitate decision making

BACKGROUND

To examine outcomes of neoadjuvant endocrine therapy in daily practice to inform decision making.

METHODS

We retrospectively selected 204 patients who received neoadjuvant endocrine therapy with T2 (≥30 mm) or T3 tumors, examining subsequent breast-sparing surgery and long-term outcomes.

RESULTS

Neoadjuvant endocrine therapy was administered for 7.3 months (median) and breast-sparing surgery was achievable in 53% of patients. Smaller initial tumor size and modified version of the Scarff-Bloom and Richardson grades 1 to 2 were associated with breast-sparing surgery. Disease progression during treatment was 6.9%; actuarial risk of local relapse was 3% at 5 years and 15% at 10 years. Five- and 10-year metastasis relapse-free survival was 78% and 63%, respectively. Grade 3, negative progesterone receptors, and absence or slow response to neoadjuvant therapy were associated prognostic factors.

CONCLUSION

These daily practice data provide important information about feasibility, efficacy, and long-term results of neoadjuvant endocrine therapy and can be used to inform patients for decision making between mastectomy and endocrine induction therapy.

Bone mineral density and circulating biomarkers in the BIG 1-98 trial comparing adjuvant letrozole, tamoxifen and their sequences

The purpose of the study is to determine the effects of the BIG 1-98 treatments on bone mineral density. BIG 1-98 compared 5-year adjuvant hormone therapy in postmenopausal women allocated to four groups: tamoxifen (T); letrozole (L); 2-years T, 3-years L (TL); and 2-years L, 3-years T (LT). Bone mineral density T-score was measured prospectively annually by dual energy X-ray absorption in 424 patients enrolled in a sub-study after 3 (n = 150), 4 (n = 200), and 5 years (n = 74) from randomization, and 1 year after treatment cessation. Prevalence of osteoporosis and the association of C-telopeptide, osteocalcin, and bone alkaline phosphatase with T-scores were assessed. At 3 years, T had the highest and TL the lowest T-score. All arms except for LT showed a decline up to 5 years, with TL exhibiting the greatest. At 5 years, there were significant differences on lumbar T-score only between T and TL, whereas for femur T-score, differences were significant for T versus L or TL, and L versus LT. The 5-year prevalence of spine and femur osteoporosis was the highest on TL (14.5 %, 7.1 %) then L (4.3 %, 5.1 %), LT (4.2 %, 1.4 %) and T (4 %, 0). C-telopeptide and osteocalcin were significantly associated with T-scores. While adjuvant L increases bone mineral density loss compared with T, the sequence LT has an acceptable bone safety profile. C-telopeptide and osteocalcin are useful markers of bone density that may be used to monitor bone health during treatment. The sequence LT may be a valid treatment option in patients with low and intermediate risk of recurrence.

Abstract P3-14-13: eIF4E/4EBP1 axis and response to neoadjuvant trastuzumab-based treatment in HER2+ breast cancer – Results of a multicentre French retrospective cohort

Background

Despite a growing number of studies exploring the underlying mechanisms, resistance to trastuzumab (TTZ) in HER2+ breast cancer (BC) remains elusive and an important issue in clinical practice. Among the proposed mechanisms, involvement of the PI3K/Akt/mTOR pathway is one of the best characterized. In a previous preclinical and clinical study (n = 54) (Bergé Y et al, SABCS 2009 and [1]), we have shown a significant correlation between eIF4E (a downstream effector of the PI3K/Akt/mTOR pathway) expression level as determined by immunohistochemistry (IHC) on initial tumor biopsy and pathological complete response (pCR) in patients with HER2+ BC treated with a neoadjuvant TTZ-containing regimen. The aim of this study was to validate these findings on an independent and larger cohort of HER2+ BC treated in neoadjuvant setting.

Method

In this multicenter (n = 9) study, 274 patients (pts) with HER2+ BC treated were included. All pts received neoadjuvant chemotherapy regimen containing TTZ, consisting mostly of 3-4 cycles of FEC (5FU, Epirubicin, Cyclophosphamid) followed by 3-4 cycles of TTZ–Docetaxel (n = 116). 74 pts received 6 cycles of TTZ–Docetaxel, 18 received 6 cycles of TTZ–Docetaxel-Cyclophosphamid, 12 received 6 cycles of TTZ–Docetaxel-carbolpatine, and the remaining 54 pts received other regimens. Pathological response was assessed according to Sataloff and Chevallier criteria. Unstained slides from the initial tumor biopsy were centrally collected for biomarkers analysis. Expression levels of eIF4E, p-4EBP1 and pS6 were determined by IHC. An immunoreactive score (IRS) combining the percentage of stained tumor cells and staining intensity was assessed by two pathologists.

Results

Median age at diagnosis was 50 years [range 22–84]. Most pts presented with T2 (52.6%), N1 (53.9%) stage, with a median tumor size of 40mm [range 0-150mm] as determined on clinical examination. Tumors were mainly invasive ductal of no special type (93.8%), of histological grade III (50%) and II (45%), ER+ (54.4%). Breast conserving surgery with free margins was achieved in 50.9% of pts. pCR (breast Sataloff TA) was observed in 53% of pts, and in 47.6% when considering both breast and lymph node response. Out of the 274 pts, 257 had sufficient tumor on the initial biopsy for biomarker analysis. Preliminary results showed a median eIF4E IRS of 6 [range 1-12], with 52.1% of cases displaying a low eIF4E expression level (IRS£6). The agreement for inter-observer assessment of eIF4E status was good (k = 0.618, 95% CI [0.523-0.713]). Scoring of p-4EBP1 and pS6 are ongoing and correlations of pCR with eIF4E/4EBP1 axis will be presented.

Conclusion

In this large multicentre retrospective study, the rate of pCR obtained in neoadjuvant setting of HER2+ BC is similar to those described in the literature. Thorough tumor collection allows biomarkers analysis, which has been specifically focused on downstream effectors of the PI3K/Akt/mTOR pathway.

Reference[1] Zindy P, Bergé Y, Allal B et al. Formation of the eIF4F translation-initiation complex determines sensitivity to anticancer drugs targeting the EGFR and HER2 receptors. Cancer Res. 2011;71(12):4068-73.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-13.

Abstract P1-15-01: A randomized phase II study evaluating anastrozole and fulvestrant in postmenopausal patients treated for large operable or locally-advanced hormone-receptor-positive breast cancer: First results

Background: Neoadjuvant endocrine therapy improves surgical outcomes for postmenopausal women with hormone-receptor-positive (HR+) breast cancer. We performed a prospective trial aiming to assess the response rate of an aromatase inhibitor (anastrozole) or an antiestrogen (fulvestrant) and to better understand the mechanisms of sensitivity or resistance to therapy. Translational research was carried out on DNA and mRNA from samples taken from the tumor at baseline and surgery.

Patients and methods: 120 post-menopausal patients (pts) from 3 centers were enrolled in this multicenter randomized phase II study between Jan 2008 to Aug 2012. They were randomly assigned to receive either neoadjuvant anastrozole (arm A: 1 mg/day) or fulvestrant (arm B: 500 mg with a loading dose during the first month then q4W) for 6 months. The primary endpoint was objective response rate (ORR) determined by clinical palpation based on RECIST criteria at 6 months. Secondary endpoints include ORR by ultrasound and mammography, toxicity, rate of breast-conserving surgery (BCS), pathological response using the Sataloff classification, and disease-free and overall survivals (DFS, OS). Follow-up is planned for 5 years.

Results: 118 pts were evaluable for toxicity. 108 pts were evaluable for response (arm A: 56, Arm B: 52). Baseline characteristics in arm A vs. arm B were well balanced: median age (69 vs. 71yrs), median clinical size (45 vs. 50 mm), histologic grades I-II (56 pts, 91.8% vs. 52 pts, 88.2%), grade III (3 pts, 4.9% vs. 5 pts, 8.5%), and HER2-positivity (4 pts, 6.6% vs. 3 pts, 5.1%).

The most common Grade 1-2 treatment-related toxicities were hot flushes (21.7% and 17.2% in arms A and B respectively), asthenia (10.0% vs. 29.3%) and musculoskeletal symptoms (38.3% vs. 20.7%). Grade 3 Toxicity was reported for one pt (joint pain) in arm A and 3 pts (hot flushes) in arm B. No treatment-related serious adverse events were reported.

ORR was 58.9% (95%CI[45-72]) in arm A and 53.8% (95%CI[39-68]) in arm B; 33 pts in arm A underwent BCS (58.9%) vs. 26 (50%) in arm B. 1 pt in arm A and 3 pts in arm B did not undergo surgery.

TA and TB pathological responses were observed in 24 pts (42.9%) in arm A and 13 pts (25.0%) in arm B. Ki67 values were analyzed before treatment and at surgery in 39 cases (arm A) and 34 cases (arm B). We observed a decrease of Ki67 in 76.9% of pts in arm A and 73.5% in arm B.

Genomic analysis showing the appearance of acquired changes after treatment will be reported in another presentation.

Conclusions: Both anastrozole and fulvestrant seem to be effective neoadjuvant endocrine therapies and may offer an attractive option with low toxicity profile for HR+ post-menopausal women. Both treatments have similar efficacy in terms of both clinical impact and Ki67 decrease.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-15-01.

Abstract P6-06-07: 5-year disease free-survival results of aggressively-treated breast cancer during pregnancy: Results from a French multicenter study

Background: Breast cancer (BC) during pregnancy (BCP) is a rare situation that requires multi-disciplinary management. The objectives of this study were to assess the tumor characteristics, clinical course and outcome of such patients (pts).

Methods: French hospitals were invited to collect retrospective clinical, treatment and follow-up data of BCP managed between 2000 and 2006. Pts with histologically confirmed M0, invasive BC and pregnant at diagnosis were included. Pts whose pregnancy was interrupted were not eligible. Survival times were calculated from the date of diagnosis.

Results: 100 BCP pts were identified. Median age was 32 years (24-42). Median gestational age at diagnosis was 25 weeks (3-38). 84% and 13% had palpable breast axillary mass respectively. Clinical stages were 1T0, 21T1, 39T2, 28T3, 6 T4A-C, 2 T4D, 3 TX, 56 N0, 39 N1, 5 NX. Histological analysis identified 85 ductal carcinomas, 4 lobular, 11 others. The histopathological grades was G1 in 4,3%, G2 in 29%, and G3 in 66,7%. Tumor subtype was luminal A in 3%, luminal B in 37% (24HER2-, 13HER2+), luminal undetermined in 6%, triple-negative in 45,9%, Her2 + in 21,3%, and not classified in 2% (HR -, HER 2 unknown). Median time interval between first observation and biopsy was 31 days (0-337), respectively 40 days (0-337) and 15 days (0-172) when the first observation was made by patients or physicians. Median time interval between pathologic diagnosis and treatment was 18 days (0-295). Treatment was initiated after pregnancy for 42 pts, with median time of 18 days after delivery. 97 pts received chemotherapy with a median number of 6 cycles (4-11), 92 with anthracyclin, 44 with taxanes. 53 chemotherapy were administered in neo adjuvant setting among which 25 during pregnancy), and 44 in adjuvant setting (23 during pregnancy). 98 pts underwent surgery (34 during pregnancy), with 57 conservations and 41 mastectomies, 93 pts received radiotherapy and 43 hormone therapy after pregnancy. 10 pts received Trastuzumab. The mean gestational age at delivery was 35 weeks (22-45). All children were alive, with a median weight of 2735 g at birth (550-3740). The 5-year Overall Survival rate is 83% (95%CI 74-89), while Disease Free Survival is 53% (95%CI 43-63). First recurrence site was metastasis in 28, locoregional in 13, controlateral in 9 and other cancers in 2.

Conclusion: Biopsy and treatment intervals remain long among this population. In this large series BCP, there is an excess of triple-negative breast cancer. The 5-year OS rate is higher than previously reported but with DFS is lower. BCP remains an aggressive entity despite adapted treatment. Multivariate analysis will be presented. A comparison of this BCP population to matched controls is ongoing.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-07.

Triple-negative breast cancers: associations between imaging and pathological findings for triple-negative tumors compared with hormone receptor-positive/human epidermal growth factor receptor-2-negative breast cancers

BACKGROUND

Triple-negative (TN) breast cancers have high malignancy potential and are often characterized by early systemic relapse. Early detection is vital, but there are few comprehensive imaging reports. Here we describe mammography, ultrasound, and magnetic resonance imaging (MRI) findings of TN breast cancers, investigate the specific features of this subtype, and compare the characteristics of TN breast cancers with those of hormone receptor (HR)-positive/human epidermal growth factor receptor (HER)-2-negative breast cancers.

MATERIALS AND METHODS

From July 2009 to June 2011, mammography and ultrasound findings of 210 patients with pathologically confirmed TN (n = 105) and HR-positive/HER-2-negative breast cancers (n = 105) were retrospectively reviewed from our institutional database. Ultrasound vascularity was notified in 88 cases and elasticity scores were notified in 49 cases overall. Thirty-five patients underwent MRI (22 TN and 13 HR-positive/HER-2-negative). Mammograms, ultrasound, and MRI were reviewed according to the Breast Imaging-Reporting and Data System (BI-RADS) lexicon and classification.

RESULTS

TN breast cancers were more likely to show round, oval, or lobulated masses with indistinct margins on mammography than HR-positive/HER-2-negative breast cancers. On ultrasound, TN tumors were more likely than HR-positive/HER-2-negative breast cancers to show circumscribed or microlobulated margins and no posterior acoustic features or posterior enhancement-positive. On MRI, TN cancers exhibited suspicious aspects more often than HR-positive/HER-2-negative cancers, often with rim enhancement-positiveHER-2 (84.6% of masses were classified BI-RADS 5).

CONCLUSION

This study is the first to describe findings on mammography, ultrasound, and MRI for TN breast cancers with a matched HR-positive/HER-2-negative control group. Several distinctive morphological features of these aggressive tumors are identified that can be used for earlier diagnosis and treatment, and ultimately to improve outcomes.

6 months versus 12 months of adjuvant trastuzumab for patients with HER2-positive early breast cancer (PHARE): a randomised phase 3 trial

BACKGROUND

Since 2005, 12 months of adjuvant trastuzumab has been the standard treatment for patients with HER2-positive early-stage breast cancer. However, the optimum duration of treatment has been debated. We did a non-inferiority trial of a shorter exposure of 6 months versus the standard 12 months of trastuzumab for patients with early breast cancer.

METHODS

We did an open-label, randomised, phase 3 trial in 156 centres in France. Patients with HER2-positive early breast cancer who had received at least four cycles of chemotherapy, had breast-axillary surgery, and had received up to 6 months of trastuzumab (administered by intravenous infusions over 30-90 min every 3 weeks; initial loading dose 8 mg/kg; 6 mg/kg thereafter) before randomisation were eligible. Patients were randomly assigned via central randomisation procedure with web-based software to continue trastuzumab for another 6 months (12 months total duration; control group) or to discontinue trastuzumab at 6 months (6 months total duration; experimental group). Randomisation was stratified by concomitant or sequential administration of trastuzumab with chemotherapy, oestrogen-receptor status, and centre using a minimisation algorithm. The primary endpoint was disease-free survival, with a prespecified non-inferiority margin of 1·15. Analyses were done in the intention-to-treat population. This study is registered at ClinicalTrials.gov, number NCT00381901.

FINDINGS

1691 patients were randomly assigned to receive 12 months of trastuzumab and 1693 to receive 6 months of trastuzumab; 1690 patients in each group were included in the intention-to-treat analyses. After a median follow-up of 42·5 months (IQR 30·1-51·6), 175 disease-free survival events were noted in the 12-month group and 219 in the 6-month group. 2-year disease-free survival was 93·8% (95% CI 92·6-94·9) in the 12-month group and 91·1% (89·7-92·4) in the 6-month group (hazard ratio 1·28, 95% CI 1·05-1·56; p=0·29). 119 (93%) of the 128 cardiac events (clinical or based on assessment of left ventricular ejection fraction) occurred while patients were receiving trastuzumab. Significantly more patients in the 12-month group experienced a cardiac event than did those in the 6-month group (96 [5·7%] of 1690 patients vs 32 [1·9%] of 1690 patients, p<0·0001).

INTERPRETATION

After 3·5 years follow-up, we failed to show that 6 months of treatment with trastuzumab was non-inferior to 12 months of trastuzumab. Despite the higher rates of cardiac events, 12 months of adjuvant trastuzmab should remain the standard of care.

FUNDING

French National Cancer Institute.

Comprehensive analysis of PTEN status in breast carcinomas

PTEN plays a well-established role in the negative regulation of the PI3K pathway, which is frequently activated in several cancer types, including breast cancer. A nuclear function in the maintenance of chromosomal stability has been proposed for PTEN but is yet to be clearly defined. In order to improve understanding of the role of PTEN in mammary tumorigenesis in terms of a possible gene dosage effect, its PI3K pathway function and its association with p53, we undertook comprehensive analysis of PTEN status in 135 sporadic invasive ductal carcinomas. Four PTEN status groups were defined; complete loss (19/135, 14%), reduced copy number (19/135, 14%), normal (86/135, 64%) and complex (11/135, 8%). Whereas the PTEN complete loss status was significantly associated with estrogen receptor (ER) negativity (p=0.006) and in particular the basal-like phenotype (p<0.0001), a reduced PTEN copy number was not associated with hormone receptor status or a particular breast cancer subtype. Overall, PI3K pathway alteration was suggested to be involved in 59% (79/134) of tumors as assessed by human epidermal growth factor receptor 2 overexpression, PIK3CA mutation or a complete loss of PTEN. A complex PTEN status was identified in a tumor subgroup which displayed a specific, complex DNA profile at the PTEN locus with a strikingly similar highly rearranged pan-genomic profile. All of these tumors had relapsed and were associated with a poorer prognosis in the context of node negative disease (p=1.4 × 10(-13) ) thus may represent a tumor subgroup with a common molecular alteration which could be targeted to improve clinical outcome.

Abstract PD05-04: Targeted resequencing in oncogenetics: developing a new approach for molecular diagnostics

Introduction: Next-generation sequencing (NGS) appears to be an accurate tool adapted for molecular oncogenetics. In contrast to certain somatic mutations, a lack of germline mutation hotspots in genes involved in cancer predisposition syndromes, especially hereditary breast and ovarian cancer (HBOC), force the molecular biologist to screen the entire coding sequence.

Material & methods: In order to screen a panel of genes predominantly involved in HBOC & Cowden disease in a molecular diagnostic setting, we captured 408 exons (and their surrounding intronic sequences) of 25 genes using the SureSelect oligonucleotide library capture (Agilent technologies). The bioinformatics resources Earray (Agilent technologies), Ensembl human genome v62 and UCSC repeat masker were used to create the capture design. This gave us 2899 unique 120-mers oligonucleotide probes which were duplicated 19 to 38 times depending on the GC content or the size of the targeted regions. Germline DNA of 190 patients (40 with previously identified mutations and 150 without previous molecular genetic analysis) was sequenced using a MiSeq bench top next-generation sequencer (Illumina) and in parallel was analyzed using our current screening method (EMMA, Enhanced Mismatch Mutation Analysis, similar to high resolution melting). Samples were prepared according the manufacturer's recommendations (Agilent technologies).

Results: All previously identified mutations along with 33 mutations in previously unscreened patients were detected. In addition, more than five hundred variants described as polymorphisms were identified. NGS seems to be more sensitive than our current screening method due to its detection and identification of homozygous variants. In order to limit the interpretation time, we restricted sequence analysis to the exon, −50 bp (including the acceptor splice site of the upstream intron) and +50 bp (including the donor splice site of the downstream intron). We have validated NGS as a technique adapted for germline mutation screening in oncogenetics. From the beginning of 2013, all germline DNA samples will be screened by NGS for oncogenetic molecular diagnostics. Sample preparation, technical organization, bioinformatics workflow and comprehensive results will be presented.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD05-04.

An array CGH based genomic instability index (G2I) is predictive of clinical outcome in breast cancer and reveals a subset of tumors without lymph node involvement but with poor prognosis

Background

Despite entering complete remission after primary treatment, a substantial proportion of patients with early stage breast cancer will develop metastases. Prediction of such an outcome remains challenging despite the clinical use of several prognostic parameters. Several reports indicate that genomic instability, as reflected in specific chromosomal aneuploidies and variations in DNA content, influences clinical outcome but no precise definition of this parameter has yet been clearly established.

Methods

To explore the prognostic value of genomic alterations present in primary tumors, we performed a comparative genomic hybridization study on BAC arrays with a panel of breast carcinomas from 45 patients with metastatic relapse and 95 others, matched for age and axillary node involvement, without any recurrence after at least 11 years of follow-up. Array-CGH data was used to establish a two-parameter index representative of the global level of aneusomy by chromosomal arm, and of the number of breakpoints throughout the genome.

Results

Application of appropriate thresholds allowed us to distinguish three classes of tumors highly associated with metastatic relapse. This index used with the same thresholds on a published set of tumors confirms its prognostic significance with a hazard ratio of 3.24 [95CI: 1.76-5.96] p = 6.7x10^-5 for the bad prognostic group with respect to the intermediate group. The high prognostic value of this genomic index is related to its ability to individualize a specific group of breast cancers, mainly luminal type and axillary node negative, showing very high genetic instability and poor outcome. Indirect transcriptomic validation was obtained on independent data sets.

Conclusion

Accurate evaluation of genetic instability in breast cancers by a genomic instability index (G2I) helps individualizing specific tumors with previously unexpected very poor prognosis.

An European Organisation for Research and Treatment of Cancer phase I study of lapatinib and docetaxel as neoadjuvant treatment for human epidermal growth factor receptor 2 (HER2) positive locally-advanced/inflammatory or large operable breast cancer

BACKGROUND

Lapatinib is an effective anti-HER2 therapy in advanced breast cancer and docetaxel is one of the most active agents in breast cancer. Combining these agents in pre-treated patients with metastatic disease had previously proved challenging, so the primary objective of this study aimed to determine the maximum tolerated dose (MTD) in treatment-naive patients, by identifying acute dose-limiting toxicities (DLT) during cycle 1 in the first part of a phases 1-2 neoadjuvant European Organisation for Research and Treatment of Cancer (EORTC) trial.

PATIENTS AND METHODS

Patients with large operable or locally-advanced HER2 positive breast cancer were treated with continuous lapatinib, and docetaxel every 21days for 4 cycles. Dose levels (DLs) were: 1000/75, 1250/75, 1000/85, 1250/85, 1000/100 and 1250/100 (mg/day)/(mg/m(2)).

RESULTS

Twenty-one patients were included. Two DLTs occurred at dose level 5 (1000/100); one grade 4 neutropenia ≥ 7days and one febrile neutropenia. A further 3 patients were therefore treated at the same dose with prophylactic granulocyte-colony stimulating factor (G-CSF), and 3 patients at dose level 6. No further DLTs were observed.

CONCLUSIONS

Our recommended dose for phase II is lapatinib 1000mg/day and docetaxel 100mg/m(2) with G-CSF in HER2 positive non-metastatic breast cancer. The dose of lapatinib should have been 1250mg/day but we were mindful of the high rate of treatment discontinuation in GeparQuinto with lapatinib 1250mg/day combined with docetaxel. No grade 3-4 diarrhoea was observed. Pharmacodynamics analysis suggests that concomitant medications altering P-glycoprotein activity (in addition to lapatinib) can modify toxicity, including non-haematological toxicities. This needs verification in larger trials, where it may contribute to understanding the sources of variability in clinical toxicity and treatment discontinuation.

Radiofrequency ablation as a substitute for surgery in elderly patients with nonresected breast cancer: pilot study with long-term outcomes

PURPOSE

To determine the efficacy and tolerance of ultrasonography (US)-guided percutaneous radiofrequency (RF) ablation with endocrine therapy in elderly patients with breast cancer who decline or are not candidates for surgery.

MATERIALS AND METHODS

Internal ethics committee approval was obtained, and patients gave informed written consent. Women older than 70 years with breast carcinoma, who had undergone neoadjuvant endocrine therapy within the past 6 months, underwent US-guided RF ablation while under local anesthesia and sedation. Only tumors measuring 3 cm or smaller and situated at least 1 cm from the skin, nipple, and chest wall were selected. Multitine electrodes were used. Endocrine therapy was continued for a total of 5 years, and breast irradiation was not performed. Clinical follow-up included US, mammography, and dynamic contrast material-enhanced (DCE) magnetic resonance (MR) imaging every 2 months for 6 months and then every 6 months until 5 years. Primary end points were RF ablation efficacy at 1 year on the basis of DCE MR imaging follow-up and procedural tolerance. The secondary end point was delayed local efficacy at the end of endocrine therapy (5 years) on the basis of DCE MR imaging follow-up.

RESULTS

Twenty-one women were treated from December 2004 to April 2010 (median age, 79 years; age range, 70-88 years). Efficacy was demonstrated at 1 year, with only one patient presenting with a local relapse. No general complications were noted. Skin burn occurred in four patients, with spontaneous healing after a maximum of 2 months. Ten patients were followed up for 5 years, with three additional patients presenting with cancer recurrence outside the ablation zone at 30, 48, and 60 months-including two with lobular carcinoma. Four patients died during the full follow-up, two of breast cancer-related causes and two of unrelated causes.

CONCLUSION

RF ablation in elderly patients with nonresected breast cancer is well tolerated and efficient at 1-year follow-up. The technique is not recommended for lobular carcinoma.

ASTER 70s: Benefit of adjuvant chemotherapy for estrogen receptor-positive HER2-negative breast cancer in women over 70 according to genomic grade—A French GERICO/UCBG UNICANCER multicenter phase III trial

TPS667

Background: The benefit of adjuvant chemotherapy (CT) is highly controversial for elderly breast cancer (BC) women presenting with an oestrogen receptor-positive (ER+) HER2-negative (HER2-) phenotype. Conversely to hormonal treatment (HT) that remains the cornerstone of adjuvant treatment for such luminal tumours, CT may severely decompensate comorbidities and alter quality of life in elderly patients. As disappointing as it is in drug development, elderly have been constantly excluded from trials evaluating new modern prognosis classifiers. This prospective multicentre trial funded by a French national grant (PHRC 2011) is the first phase III trial to investigate the impact on overall survival (OS) of adjuvant CT in elderly ER+ HER2- BC patients selected with a modern prognosis classifier and taking into account competing risks for mortality (EudraCT 2011-004744-22). Methods: Following surgery, 2,000 women 70+ with ER+ HER2- BC (any pT/pN), will have a genomic grade (GG, derived from frozen MapQuantDx™, Ipsogen) centrally assessed on formalin-fixed paraffin-embedded samples. Only those with a high GG (estimation~700) will be randomized between HT alone vs CT followed by HT. CT regimen is left to the choice of investigators amongst 3 regimen of same duration [4 q3w cycles, docetaxel+cyclophosphamide, doxorubicin or non pegylated liposomal doxorubicin (Myocet)+cyclophosphamide, all with G-CSF], as well as HT (aromatase inhibitor±tamoxifen). Those with low GG or not included for other reasons (estimation~1,300) will be followed as an observational parallel cohort with HT alone. Sample size is based on 4-year OS as primary endpoint (87.5 vs 80%), bilateral α=0.05, β=0.20 and HR= 0.60. Secondary endpoints include assessment of competing risks for mortality, cost-effectiveness and Q-TWiST analysis, geriatric items (e.g. Lee’s 4-year mortality score and G8 screening tool), acceptability, quality of life (QLQ-C30 and specific elderly scale ELD15), and translational research on ageing/prognostic biomarkers and pharmacogenetic. The trial has been just opened to inclusion in February 2012.

Impact of adjuvant trastuzumab-based chemotherapy in T1ab node-negative HER2 overexpressing breast carcinomas

601

Background: HER2 overexpression has been recognized as a pejorative prognostic factor in node negative T1ab (T1abN0) breast tumors. Randomized clinical trials have shown benefit of adjuvant trastuzumab-based chemotherapy (ATBC) for node-positive and/or greater than 1 cm (T1c or more) HER2+ breast carcinomas. There are no prospective efficacy data of ATBC in T1abN0 HER2+ tumors. Methods: We retrospectively evaluated 276 cases of T1ab node-negative HER2+ breast tumors in 8 French Comprehensive Cancer Centers. We assessed clinical, therapeutic features and outcome. We estimated the probability of disease-free survival (DFS), analyzed associations of ATBC, patient and tumor characteristics with DFS and prognosis factors using the log-rank test, multivariate analysis with logistic regression and Cox’s proportional hazards model. Results: Out of the 276 T1abN0 cases, 129 (47%) received ATBC (ATBC+) and 123 (45%) were not treated by either trastuzumab or chemotherapy (ATBC-). Of these 252 ATBC+ or ATBC- patients, decision of ATBC was associated with date of diagnosis (before or after ASCO 2005 Annual Meeting when interim results from three trastuzumab adjuvant trials were reported) and with poor prognosis features: negative hormone receptors (HR-) status, Elston-Ellis high grade, tumor size > 5 mm and age. With a median follow-up of 44 months 16 recurrences were observed (13 in the ATBC- group, 2 in the ATBC+ and 1 with adjuvant chemotherapy alone). Nine recurrences were distant metastases. A survival benefit in ATBC+ was observed with a 99% 40-months DFS versus 93% for ATBC- (logrank p-test = 0.018). In an exploratory analysis, two factors were significantly associated with worst prognosis for ATBC- that were not observed for ATBC+ : HR- status (98% 40-months DFS for ATBC+ patients versus 84% for ATBC- patients; logrank p-test = 0.0003) and presence of lymphovascular invasion (100% 40-months DFS for ATBC+ versus 73% in ATBC- cases; logrank p-test = 0.003). Conclusions: In our seriesATBC is associated with a significant reduction of risk of recurrence of T1abN0 HER2+ tumors. A clear DFS benefit of ATBC was observed in HR- tumors and/or in presence of lymphovascular invasion.

Randomized phase II trial of everolimus in combination with tamoxifen in patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer with prior exposure to aromatase inhibitors: a GINECO study

PURPOSE

Cross-talk between signal transduction pathways likely contributes to hormone resistance in metastatic breast cancer (mBC). Everolimus, an oral inhibitor of the mammalian target of rapamycin, has restored sensitivity in endocrine-resistance models and shown anticancer activity in early-phase mBC clinical trials. This analysis evaluated efficacy and safety of everolimus in combination with tamoxifen in patients with mBC resistant to aromatase inhibitors (AIs).

PATIENTS AND METHODS

This open-label, phase II study randomly assigned postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative, AI-resistant mBC to tamoxifen 20 mg/d plus everolimus 10 mg/d (n = 54) or tamoxifen 20 mg/d alone (n = 57). Randomization was stratified by primary and secondary hormone resistance. Primary end point was clinical benefit rate (CBR), defined as the percentage of all patients with a complete or partial response or stable disease at 6 months. No formal statistical comparison between groups was planned.

RESULTS

The 6-month CBR was 61% (95% CI, 47 to 74) with tamoxifen plus everolimus and 42% (95% CI, 29 to 56) with tamoxifen alone. Time to progression (TTP) increased from 4.5 months with tamoxifen alone to 8.6 months with tamoxifen plus everolimus, corresponding to a 46% reduction in risk of progression with the combination (hazard ratio [HR], 0.54; 95% CI, 0.36 to 0.81). Risk of death was reduced by 55% with tamoxifen plus everolimus versus tamoxifen alone (HR, 0.45; 95% CI, 0.24 to 0.81). The main toxicities associated with tamoxifen plus everolimus were fatigue (72% v 53% with tamoxifen alone), stomatitis (56% v 7%), rash (44% v 7%), anorexia (43% v 18%), and diarrhea (39% v 11%).

CONCLUSION

This study suggests that tamoxifen plus everolimus increased CBR, TTP, and overall survival compared with tamoxifen alone in postmenopausal women with AI-resistant mBC.

Complete response to exemestane in a patient with a desmoid tumor

Desmoid tumors are rare mesenchymal neoplasms without metastatic potential. Despite the benign nature of this condition, some patients develop disease progression despite all locoregional options for care. Aggressive forms of desmoid tumors may induce morbidity that can lead to physical impairment and mortality that is occasionally observed as a result of local infiltrative growth and tissue invasion, in particular with abdominal disease. Few therapeutic options are available for patients with recurrent/unresectable desmoid tumors. Several studies have suggested the potential benefit of antiestrogens such as tamoxifen in this setting. Here we report the first description of the efficacy of an aromatase inhibitor in a patient with a desmoid tumor.

Capecitabine monotherapy: review of studies in first-line HER-2-negative metastatic breast cancer

The goals of treatment for metastatic breast cancer (MBC) are to prolong overall survival (OS) while maximizing quality of life, palliating symptoms, and delaying tumor progression. For many years, anthracyclines and taxanes have been the mainstay of treatment for MBC, but these agents are now commonly administered earlier in the course of the disease. A recent meta-analysis revealed adverse effects on OS and overall response rates in patients with MBC receiving first-line anthracycline-based chemotherapy following relapse on adjuvant chemotherapy. Noncrossresistant cytotoxic agents and combinations that combine high clinical activity and acceptable tolerability while being convenient for patients are therefore needed for the first-line treatment of MBC patients. Capecitabine has substantial antitumor activity in the first-line treatment of patients with MBC in prospective, randomized, phase II/III clinical trials as monotherapy and in combination with biologic and novel agents. First-line capecitabine monotherapy has a favorable safety profile, lacking myelosuppression and alopecia, and does not compromise the administration of further lines of chemotherapy. Capecitabine is suitable for long-term administration without the cumulative toxicity that can limit the prolonged use of other chemotherapy agents. Here, we review the available data on capecitabine as a single agent for first-line treatment of patients with human epidermal growth factor receptor 2-negative MBC.

CYP2D6 genotype and tamoxifen response in postmenopausal women with endocrine-responsive breast cancer: the breast international group 1-98 trial

BACKGROUND

Adjuvant tamoxifen therapy is effective for postmenopausal women with endocrine-responsive breast cancer. Cytochrome P450 2D6 (CYP2D6) enzyme metabolizes tamoxifen to clinically active metabolites, and CYP2D6 polymorphisms may adversely affect tamoxifen efficacy. In this study, we investigated the clinical relevance of CYP2D6 polymorphisms.

METHODS

We obtained tumor tissues and isolated DNA from 4861 of 8010 postmenopausal women with hormone receptor-positive breast cancer who enrolled in the randomized, phase III double-blind Breast International Group (BIG) 1-98 trial between March 1998 and May 2003 and received tamoxifen and/or letrozole treatment. Extracted DNA was used for genotyping nine CYP2D6 single-nucleotide polymorphisms using polymerase chain reaction-based methods. Genotype combinations were used to categorize CYP2D6 metabolism phenotypes as poor, intermediate, and extensive metabolizers (PM, IM, and EM, respectively; n = 4393 patients). Associations of CYP2D6 metabolism phenotypes with breast cancer-free interval (referred to as recurrence) and treatment-induced hot flushes according to randomized endocrine treatment and previous chemotherapy were assessed. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). All statistical tests were two-sided.

RESULTS

No association between CYP2D6 metabolism phenotypes and breast cancer-free interval was observed among patients who received tamoxifen monotherapy without previous chemotherapy (P = .35). PM or IM phenotype had a non-statistically significantly reduced risk of breast cancer recurrence compared with EM phenotype (PM or IM vs EM, HR of recurrence = 0.86, 95% CI = 0.60 to 1.24). CYP2D6 metabolism phenotype was associated with tamoxifen-induced hot flushes (P = .020). Both PM and IM phenotypes had an increased risk of tamoxifen-induced hot flushes compared with EM phenotype (PM vs EM, HR of hot flushes = 1.24, 95% CI = 0.96 to 1.59; IM vs EM, HR of hot flushes = 1.23, 95% CI = 1.05 to 1.43).

CONCLUSIONS

CYP2D6 phenotypes of reduced enzyme activity were not associated with worse disease control but were associated with increased hot flushes, contrary to the hypothesis. The results of this study do not support using the presence or absence of hot flushes or the pharmacogenetic testing of CYP2D6 to determine whether to treat postmenopausal breast cancer patients with tamoxifen.

Radiological features of triple-negative breast cancers (73 cases)

OBJECTIVES

Triple-negative breast cancers generally occur in young women and they have the potential to be aggressive. It is important for this subtype of tumour to be detected early. We studied the appearance of 73 tumours on mammography, sonography and MRI in order to determine what specific features they showed on imaging.

PATIENTS AND METHODS

From July 2009 to December 2010, we retrospectively reviewed mammogram and sonogram images of 73 triple-negative cancers. Colour Doppler had been used to depict vascularisation in 34 cases and elastography score calculated in 17 cases. Sixteen patients had undergone MRI. The radiological description of these different modalities draws on the BI-RADS lexicon and categorisation.

RESULTS

On mammography, triple-negative cancers often presented as a round mass (59.3%) or an oval or lobulated mass (65%), with circumscribed (15%), microlobulated (12.5%), indistinct (55%) or occasionally spiculated margins (15%). On sonography, the vast majority of these cancers appeared as masses (92.8%) with occasional posterior acoustic attenuation (22.6%). MRI showed more suspicious images than the standard examinations, notably rim-enhancement (eight out of 12 masses).

CONCLUSION

. Radiological images appear as lobulated masses more readily, while on sonography posterior enhancement is shown more often than attenuation, and MRI finds rim-enhancement.

The inflammatory breast: management, decision-making algorithms, therapeutic principles

Inflammatory syndrome is one of the rare emergency breast situations. Its etiology is benign, infectious in most cases. The clinical examination is often self-evident and suggests the diagnosis. But alone it is insufficient, and diagnostic tests are necessary to guide therapy. As essential as it is, mammography's limitations reinforce the benefit of ultrasonography, which in all cases reveals an abscess and has greater sensitivity for detecting a malignant tumor. If the etiology is benign, clinical signs will disappear with medical treatment, with no need for further investigation. While it is legitimate to initiate a trial treatment, it must not delay oncologic management, because of the severity of inflammatory cancer.

Chemotherapy in patients with desmoid tumors: a study from the French Sarcoma Group (FSG)

BACKGROUND

Data regarding the role of chemotherapy (CT) in patients with recurrent and/or unresectable desmoid tumors (DTs) are scarce.

PATIENTS AND METHODS

Records of patients with DT who were treated with CT in centers from the French Sarcoma Group were reviewed.

RESULTS

Sixty-two patients entered the study. The two most common locations were extremities (35.5%) and internal trunk (32.5%). Twelve patients (19.5%) were diagnosed with Gardner syndrome. Thirty-seven patients (54.7%) received previously one or more lines of systemic therapies (nonsteroidal anti-inflammatory drugs: 43.5%, antiestrogens: 43.5% and imatinib: 30.5%). Combination CT was delivered in 44 cases (71%) and single agent in 18 patients (29%), respectively. Thirteen patients (21%) received an anthracycline-containing regimen. The most frequent nonanthracycline regimen was the methotrexate-vinblastine combination (n=27). Complete response, partial response, stable disease and progressive disease were observed in 1 (1.6%), 12 (19.4%), 37 (59.6%) and 12 (19.4%) patients, respectively. The response rate was higher with anthracycline-containing regimens: 54% versus 12%, P=0.0011. Median progression-free survival (PFS) was 40.8 months. The sole factor associated with improved PFS was the nonlimb location: 12.1 months (95% confidence interval 5.6-18.7) versus not reached, P=0.03.

CONCLUSIONS

CT has significant activity in DT. Anthracycline-containing regimens appear to be associated with a higher response rate.

PD10-04: Exploration of the Relationship between Loss of PTEN and BRCA1 Expression in Triple Negative Breast Carcinoma

Based on the mechanism of action of PARP inhibitors, BRCAness breast and ovarian cancers could be defined as the optimal group of tumours to target with such drugs. As the BRCAness phenotype is not fully defined at present, a surrogate phenotype of triple negative breast cancer (TNBC) has been proposed. Results of recent clinical trials involving PARP inhibitors in the context of TNBC do not demonstrate a significant improvement in overall survival or progression free survival, partly due to the inaccurate selection of certain tumours. Data from cell culture studies suggests that loss of PTEN expression could be a marker of PARP inhibitor sensitivity.

Materials and Methods: A retrospective study of 160 TNBC resected at Institut Bergonie between 1989 and 2010 was undertaken. Inclusion criteria were: ER & PR immunohistochemcial (IHC) negativity (&lt;10% tumour cells positive), non-amplification of HER2 (IHC score 0, 1, or 2 with negative FISH analysis) and an invasive ductal carcinoma resected before chemotherapy. For some familial cases, germline BRCA1 mutation screening had been performed in a diagnostic setting and was accompanied by genetic counselling. PTEN IHC, point mutation and gross rearrangement screening, along with BRCA1 expression and promoter methylation analysis (through real-time PCR and bisulfite treatment, respectively) and 53BP1 IHC were undertaken on this series of TNBC.

Results: Twenty percent of sporadic and familial TNBC demonstrated reduced BRCA1 expression with a greater than 7 fold reduction in expression. Almost half of tumours demonstrated a complete loss of PTEN expression as assessed by IHC, with a deleterious PTEN point mutation identified in 5% of cases. Although a slight correlation is observed between the complete loss of PTEN and a reduction in BRCA1 expression, a complete overlap of these two alterations was not observed; tumours with reduced BRCA1 expression do not always demonstrate complete negativity on PTEN IHC and certain tumours displaying complete negativity on PTEN IHC do not show a reduction in BRCA1 expression. Full immunohistochemical characterization of the tumour series (ER, PR, HER2, AR, CK5/6 & EGFR) together with the results of PTEN, BRCA1 and 53BP1 analyses will be presented. Conclusion

These results suggest that at present, loss of PTEN expression is not a suitable surrogate marker for tumours with reduced BRCA1 expression. This should be borne in mind for ancillary studies of clinical trials involving PARP inhibitors in the treatment of breast tumours and further investigation is warranted.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD10-04.

Phase III randomized equivalence trial of early breast cancer treatments with or without axillary clearance in post-menopausal patients results after 5 years of follow-up

BACKGROUND

Axillary lymph node clearance (ALNC) improves locoregional control and provides prognostic information for early breast cancer treatment, but effects on survival are controversial. This multicentre, randomized pragmatic equivalence trial compares outcomes for post-menopausal early invasive breast cancer patients after locoregional treatment with ALNC and adjuvant therapies to outcomes after locoregional treatment without ALNC and adjuvant therapies.

METHODS

From 1995-2005, women aged ≥ 50 years with early breast cancer (tumor ≤ 10 mm) and clinically-negative axillary nodes were randomized to receive treatment with ALNC (Ax) or without (no-Ax). Adjuvant therapies were prescribed according to hormonal receptor status and individual histological results. The primary endpoint was overall survival (OS); secondary endpoints were event-free survival (EFS) and functional outcomes. The trial was terminated due to lack of equivalence and low accrual after first interim analyses.

TRIAL REGISTRATION

NCT00210236.

RESULTS

Of 625 patients, 297 no-Ax and 310 Ax patients were maintained for final per-protocol analyses. OS and EFS at five years were not equivalent (Ax vs. no-Ax: 98% vs. 94% and 96% vs. 90% respectively). Recurrence was higher for no-Ax, particularly in the first five years after surgery. Axillary nodes were positive for 14% Ax patients but only 2% no-Ax patients experienced axillary node recurrence. Functional impairments were greater after ALNC.

CONCLUSION

Our results fail to demonstrate equivalence of outcomes when ALNC is omitted from post-menopausal early breast cancer patient treatment. However the low locoregional recurrence rates warrant further examination over a longer duration, in particular to consider whether these would impact on survival.