Postsurgical drainage and the risk of breast cancer recurrence in Chinese breast cancer patients

e22234

Background: Clinical investigations suggest that while primary breast cancer surgical removal favorably modifiers the natural history of breast cancer. Postoperative drainage, a surgery-derived discharge after breast cancer surgery, reflecting some biological features of surgical stimulation, was assessed and explored its relationship with breast cancer recurrence in this study. Methods: A total of 1445 women undergoing surgery between Jan 1, 2000 and Dec31, 2002 in Cancer Hospital of Fudan University, Shanghai, China was retrospectively studied. Survival curves were performed with Kaplan-Meier method and the predictive value of postsurgical drainage was estimated using proportional Cox regression model. Conclusions: The larger drainage volume POD 1 is a useful marker, suggesting a greater stimulation to surgical treatment compared to the lower ones. Awareness of the relationship between early surgery-stimulated effects and harmful wound healing response might help to explore new strategies to block or deplete these harmful effects, resulting in improving patients' survival.

No significant financial relationships to disclose.

Population pharmacokinetic (PK)/pharmacodynamic (PD) modeling and simulations for exposure‐;tumor response relationships: Motesanib in a phase II thyroid cancer (TC) trial

e14528

Background: Motesanib is a highly selective, oral inhibitor of VEGF receptors 1, 2, and 3; PDGFR; and Kit that is being investigated for its antitumor activity. In a phase 2 monotherapy study, a response rate of 14% (per RECIST) was observed in patients (pts) with differentiated thyroid cancer (DTC; NEJM 359:31–42, 2008) compared with 1% in pts with medullary TC (MTC; Endocr Soc Ann Meeting 2007, abstract OR39–3). We evaluated the relationship between motesanib PK and tumor response, investigated whether differences in PK between MTC and DTC pts contributed to the observed difference in response, and simulated tumor response with different dose regimens in pts with TC. Methods: Data from the phase 2 TC trial were used for PK/PD modeling. The study enrolled 93 DTC and 91 MTC pts who received motesanib 125 mg once daily (QD). Motesanib concentrations were fitted to a 2- compartment population PK model. Estimates of pts’ PK parameters were used to calculate concentration and steady-state area under the curve values for motesanib, which were used as the exposure measures in population PK/PD modeling (ie, longitudinal exposure-tumor response modeling of drug effect on tumor growth dynamics). Monte Carlo simulations were used to evaluate the potential effect of doses other than 125 mg QD (75 mg and 100 mg QD) on tumor response in TC pts. Results: Clearance in MTC pts was 40% faster than in DTC pts (74 vs 44 L/h). The fit was significantly improved (P<0.001) when exposure instead of dose was used in the model. The exposure-tumor response model that incorporated the difference in exposure described change in tumor size well in both MTC and DTC populations. Clinical trial simulations using the preliminary model based on week 24 data predicted that DTC pts would achieve 19.7%, 15.7%, and 11.3% reductions in tumor size at week 24 following doses of 125 mg QD, 100 mg QD, and 75 mg QD, respectively. The actual change in median tumor size at week 24 following 125-mg QD dosing in DTC pts included in the PK/PD analysis was 17.9%. Conclusions: The use of 125 mg QD motesanib in DTC pts was supported by PK/PD modeling and Monte Carlo simulations. Differences in PK may explain the difference in tumor response observed in MTC and DTC patient populations.

[Table: see text]

PhaseI/II clinical trial of dose escalation using daily on-line cone beam CT guided radiotherapy combined with active breath control after transcatheter arterial chemoembolization for hepatocellular carcinoma

e15654

Background: The radiation dose is the key factor to improve survival of patients with hepatocellular carcinoma (HCC). The optimal way to increase radiation dose is to reduce uncertainties of target mainly due to respiratory motion and setup error in radiotherapy. Our previous study demonstrated that lipiodol can be a reliable surrogate of direct tumor targeting in Kv- cone beam CT(CBCT) for patients with good lipiodol embolization. Relying on lipiodol,the daily on-line CBCT guidance with ABC is feasible. By reducing geometric position uncertainty, as well as liver movement, the technique of ABC combined with on-line CBCT guidance can permit CTV(clinical target volume)-PTV(planning target volume) margin reduction and dose escalation. The purpose of the study is to apply the new technique for clinical application and investigate the dose escalation, toxicities and response of liver tumors with the technique combined with chemoembolization(TACE). Methods: 20 HCC patients with Child-Pugh A liver function score were treated by daily on-line CBCT guided radiotherapy relying on lipiodol combined with ABC after TACE. After current doses of 45Gy/ 9 fractions,3 fractions/weeks were delivered,the scheduled dose escalation ranged from 5 to 20Gy. Each mean liver dose not reached 23G y, V30 ( the percentage of normal liver volume with radiation dose≥30 Gy) less than 28%. Results: The planned dose escalation was finished in all subgroups. None of these patients developed Grade 2 or greater liver toxicity except two patients developed Grade 2 gastrointestinal complications and one had grade 1 acute liver toxicity.The overall immediate tumor response rate was 76.3%. 1-year overall survival rate was 80.5%. Conclusions: The technique of daily on-line CBCT guided radiotherapy combined with ABC after TACE is a safe and effective treatment which can reduce CTV-PTV margin significantly and increase target precision greatly. With the technique combined with TACE, the total irradiation dose above 65Gy is feasible in daily fraction of 5Gy.

No significant financial relationships to disclose.

Simulation of survival with first- and second-line non-small cell lung cancer (NSCLC) therapy using a public domain drug-disease modeling framework

8087

Background: Modeling and simulation approaches are advocated to support drug development decisions. In this study, we evaluated the ability of a drug-disease model recently developed by scientists at the FDA using data from pivotal studies in NSCLC (Wang et al. http://www.fda.gov/ohrms/dockets/ac/08/briefing/2008–4351b1–00-index.htm ) to simulate survival and tumor response for approved therapies in NSCLC. Methods: The modeling framework comprises a longitudinal tumor size model and a survival model relating change in tumor size at first visit (week 8) and patient characteristics (tumor size and ECOG performance status at baseline) to survival time. The tumor size and survival models were used to simulate change in tumor size at first visit and expected survival in the carboplatin/paclitaxel (CP) arm of the E4599 study (first-line NSCLC, N Eng J Med. 2006;355:2542–2550) and in the erlotinib arm in the BR.21 study (second-line NSCLC, N Eng J Med. 2005;353:123–132). The predictive distributions (95% prediction interval [PI]) of survival times were derived from multiple replicates (500) of 400 CP patients and 500 erlotinib patients with similar characteristics to patients in the original studies. Results: There was a high level of concordance between the results of the simulation and the observed results in the two arms, indicating that the modeling framework successfully predicted survival and tumor response. Expected median survival was 9.8 (95% PI, 8.2–11.8) months (vs 10.3 months observed) for the CP arm and 6.8 (95% PI, 5.3–8.9) months (vs 6.7 months observed) for the erlotinib arm. The median change in relative tumor size from baseline at week 8 predicted by the model was 12.1% for the CP arm and 9.5% for the erlotinib arm. Conclusions: The modeling framework can be used to perform simulations of survival of approved treatments. These results suggest that the model could be used to simulate survival for investigational treatments based on tumor shrinkage data observed in early clinical studies (e.g. phase II) to support end-of-phase II decisions and the design of phase III studies.

[Table: see text]

Demographic features and prognostic profiles of breast cancer patients presenting with nipple discharge in Chinese population

e22204

Background: Breast cancer patients with nipple discharge (ND) may constitute a distinct clinical entity compared to those without ND, which has not been well elucidated in previous reports. We sought to analyze the demographic features and prognostic profiles of breast cancer patients presenting with nipple discharge in Chinese population. Methods: A total of 3234 patients, categorized as ND (2.47%) and non-nipple discharge (NND; 97.53%) according to different initial signs, were retrospectively analyzed. Survival curves were performed with Kaplan-Meier method and annual recurrence hazard was estimated by hazard function. Results: ND group tended to have smaller tumors and less axillary lymph node (ALN) involvement than NND group (P < 0.05). In the univariate analysis, we found significantly different recurrence-free survivals (RFS) between subgroups (P = 0.0182), with the rate of 77.78% for ND group and 72.46% for the other at the 11th year respectively. In Cox proportional hazards regression analysis, we found that tumor size (P < 0.001), ALN status (P < 0.001) were independent prognostic factors for RFS. To further evaluate whether prognostic effect of ND status remained unabated over time, the test for lack of proportionality was performed. However, it was statistically significant (global test, P = 0.039), which hinted at a demand for the employment of Cox non-proportional hazards regression in this analysis. In time dependent Cox model, ND status (P = 0.0495) as well as ERBB2 status (P = 0.017), tumor size (P < 0.001), ALN status (P < 0.001) were independent prognostic factors when ND and ERBB2 status were taken as time-varying covariates. Annual hazard rates for recurrence remained lower on ND group until approximately 4.5 years after surgery, while the situation was just the opposite thereafter. Conclusions: Our findings suggested that demographic features and prognostic profiles were quite different between breast cancers presenting with and without ND in Chinese population, which may indirectly uncover distinct biological behaviors and potentially enlighten novel therapeutic approaches for patients with different initial signs.

No significant financial relationships to disclose.

A modeling framework to simulate motesanib efficacy in thyroid cancer

e14553

Background: Motesanib is a highly selective, oral inhibitor of VEGF receptors 1, 2, and 3; PDGFR, and Kit with antiangiogenic and direct antitumor activity. A modeling framework that simulates clinical endpoints, including objective response rate (ORR; per RECIST) and progression-free survival (PFS), was developed to support clinical development of motesanib. This study evaluated the framework using results from a trial of motesanib in thyroid cancer (TC). Methods: Models for tumor growth inhibition (J Clin Oncol 24[18S]:abstract 6025, 2006) with drug effect driven by area under the curve (AUC) (as predicted by a population pharmacokinetic model), overall survival, and probability and duration of dose reductions were developed based on data from 93 differentiated TC (DTC) and 91 medullary TC patients who received motesanib monotherapy (125 mg once daily [QD]) in a phase 2 study (Horm Res 68[suppl 3]:28–9, 2007; NEJM 359:31–42, 2008). The full simulation framework was assessed in predicting dose intensity (starting dose of 125 mg QD), tumor size over time, ORR, and PFS. Dose-response simulations were performed in DTC patients. Results: Survival times followed a Weibull distribution with ECOG performance status, baseline tumor size, and change in tumor size from baseline at week 7 as predictors. The probability of dose reductions was dependent on time and AUC. Time to event Weibull models predicted the duration of dose reductions and dose interruptions. The models correctly predicted median daily exposure intensities up to week 24. The predicted ORR in DTC patients was 15.0% (95% prediction interval [PI], 7.5%-23.7%) compared with the observed ORR of 14.0%. Predicted median PFS was 40 weeks (95% PI, 32–49 wk) compared with the observed median PFS of 40 weeks. Dose- response simulations confirmed the appropriateness of 125-mg QD dosing in DTC: the modeling framework predicted no clinically relevant improvement in PFS would be obtained by dose intensification. Conclusions: This modeling framework (dose reduction/tumor growth inhibition/survival) will be an important tool to simulate clinical response and support clinical development decisions. Further evaluation of the model using additional datasets will be required.

[Table: see text]

CD1a expression defines an interleukin-12 producing population of human dendritic cells

Human and murine dendritic cell (DC) subsets are often defined by phenotypic features that predict their functional characteristics. In humans and mice, DC have been shown to have the ability to polarize naive CD4 T cells to a T helper type 1 (Th1) or Th2 phenotype. However, human myeloid DC generated from monocytes (monocyte-derived DC) have often been regarded as a homogeneous population, both phenotypically and functionally. Monocytes give rise to subpopulations of DC in vitro that can be separated on the basis of their expression of CD1a, a well-described DC subset marker. Importantly, we show that the CD1a(+) DC subset produces significant quantities of interleukin-12p70 (IL-12p70) upon stimulation and, similar to the murine CD8 alpha(+) DC subset, can polarize naive CD4(+) T cells to a Th1 phenotype. In contrast, CD1a(-) DC, similar to murine CD8 alpha(-) DC, do not produce significant amounts of IL-12p70 upon stimulation or polarize T cells to a Th1 phenotype. Like monocyte-derived DC, CD1a(+) and CD1a(-) DC subsets obtained from CD34(+) haematopoietic progenitors under distinct culture conditions were found to have these same features, suggesting that CD1a expression is a marker for myeloid DC that are a major source of IL-12 and Th1 CD4(+) T cell polarization in man.

Combustion smoke exposure induces up-regulated expression of vascular endothelial growth factor, aquaporin 4, nitric oxide synthases and vascular permeability in the retina of adult rats

Retinal cells respond to various experimental stimuli including hypoxia, yet it remains to be investigated whether they react to smoke inhalation. We show here that retinal cells in rats, notably the ganglion cells, Müller cells, astrocytes and blood vessels responded vigorously to a smoke challenge. The major changes included up-regulated expression of vascular endothelial growth factor (VEGF), aquaporin 4 (AQP4) and nitric oxide synthase (NOS). VEGF expression was localized in the ganglion cells, Müller cells, astrocytes and associated blood vessels. AQP4 was markedly enhanced in both astrocytes and Müller cells. Increase in vascular permeability after smoke exposure was evidenced by extravasation of serum derived rhodamine isothiocyanate which was internalized by Müller cells and ganglion cells. The tracer leakage was attenuated by aminoguanidine and N(G)-nitro-L-arginine methyl ester (L-NAME) treatment which suppressed retinal tissue NOS and nitric oxide (NO) levels concomitantly. It is suggested that VEGF, AQP4 and NO are involved in increased vascular permeability following acute smoke exposure in which hypoxia was ultimately implicated as shown by blood gases analysis. NOS inhibitors effectively reduced the vascular leakage and hence may ameliorate possible retinal edema in smoke inhalation.

Rapid method for simultaneous determination of flavonoid, saponins and polyacetylenes in folium ginseng and radix ginseng by pressurized liquid extraction and high-performance liquid chromatography coupled with diode array detection and mass spectrometry

A rapid pressurized liquid extraction (PLE) and high-performance liquid chromatography coupled with diode array detection and mass spectrometry (HPLC-DAD-MS) method for the simultaneous determination of one flavonoid (panasenoside), nine saponins (ginsenoside Rg1, Re, Rf, Rg2, Rb1, Rc, Rb2, Rb3 and Rd) and two polyacetylenes (panaxydol and panaxynol) in folium ginseng and radix ginseng was developed. A Prevail C(18) rocket column (33 mm x 7 mm, 3.0 microm) and gradient elution were used during the analysis. Flavonoid was quantified at 355 nm, and saponins and polyacetylenes were determined at 203 nm. The chromatographic peaks of 12 investigated compounds in samples were unambiguously identified by compared their UV spectra and/or MS data with the related reference compounds. All calibration curves showed good linearity (r>0.999) within the test ranges. The intra- and inter-day variations for 12 analytes were less than 1.17% and 2.17%, respectively. The developed method was successfully applied to determine the investigated compounds in 10 samples of radix ginseng and folium ginseng, respectively. The result showed that PLE combined with rocket column HPLC analysis could provide a rapid method for analysis of compounds in traditional Chinese medicines (TCMs), which is helpful to comprehensive evaluation of quality of radix ginseng and folium ginseng.

Luminal group may give more benefit for invasive micropapillary carcinoma component breast cancer patients: experience from Cancer Hospital Fudan University

Abstract #6152

Objective: Comparative studies on clinical features and outcomes of very rare invasive micropapillary carcinoma of breast cancer of 4 subtypes by immunohistochemistry staining.&#x2028; Methods: From Aug 2005 to Mar 2008, a total of 52 breast cancer patients(BCPs) with an invasive micropapillary component (IMPC) among 1951 Chinese BCPs with complete of clinicopathologic data in our institution were enrolled into a retrospective analysis. We characterized all these 52 patients and analyzed using various parameters.&#x2028; Results: The 52 cases of breast carcinoma with an IMPC all occurred in women. Mean age was 51 years (range from 26-82). All of these patients had breast masses; one also had metastasis to the supraclavicular lymph node at the time of diagnosis., mean tumor size was 2.83cm(T2), 23.08%(12/52) was pure invasive micropapillary carcinoma, and lymph node positive percentage was 75.59 %( 36/51).Fifty one patients received surgery, while one of them lost the chance of surgery. Forty of them received the modified mastectomy while one was performed lumpectomy due to old age. One was performed LAND alone and four were performed lumpectomy and sentinel lymph node biopsy.&#x2028; By using IHC staining, when we regard HER2/neu 0 and +as negative. The Luminal A group, Luminal B, trip-negative, HER2+ /ER- were 76.92% (40/52), 11.54 %( 6/52), 7.69 %( 4/52), 3.85 %( 2/52), respectively. Compared to the database of 2005 breast cancer carcinoma in our institution, there was more Luminal A group patients than the whole group (P=0.01, chi-square test.), more Luminal B (P=0.028, Fisher exact possibility test), less trip-negative group (P=0.001, chi-square test). The positive lymph node among the Luminal A group, Luminal B, trip-negative, HER2+ /ER- were 65%,80%, 100%, 100%, respectively, while the lymphvascular invasion were 55%,33.33%,50%,50%,respectively, Mulifocality in Luminal A was 25% , 16.67% in Luminal B , while 50% in both trip-negative and HER2+/ER-.&#x2028; Twenty-one of them received both anthracyclines and Taxane, while 27 only received anthracyclines, Four patients only were received only AIs due to old age. All the luminal group patients received endrocine therapy after chemo. After nearly 14 months (2∼34 months) follow up, thirty-six women were disease free, one had local recurrence, and 1 had lung metastasis, while 1 had ovary carcinoma when the diagnosis of breast malignant, one patient lost following up due to mental disorder. Among the luminal B, one had metastasis when diagnosis, others were disease free. One woman of the trip-negative died of non-breast cancer disease,the HER2+/ER- group was no recurrence or metastasis.&#x2028; Discussion: The prelimary results showed that more luminal group in the IMPC may get benefit from the endocrine therapy. However the number of these cases is small and follow-up time is not very long, further studies are necessary to explain these rare and unique pattern of invasive carcinoma.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6152.

Seroma formation after breast cancer surgery and its risk factors

Abstract #4085

Background:. Seroma formation is one of the most common complications after breast cancer surgery including modified radical mastectomy and breast conservative surgery. Our study aims to investigate the risk factors of postoperative seroma in Chinese breast cancer patients.&#x2028; Methods: Clinical data of 158 women who underwent surgerical therapy for breast cancer in our hospital were collected prospectively and all patients were followed up. The risk factors for seroma occurrence were compared between the seroma group and control group using X 2 test or t test, as well as the logistic regression was used as multivariate analysis.&#x2028; Results: Univariate analysis showed that the average age of the seroma group was significantly higher than those without seroma formation(58.71vs51.00, P=0.0019), but the total serum protein and albumin content were lower (68.47g/L vs 72.53g/L, P=0.009 and 40.75g/L vs 42.52g/L,P=0.020, respectively). In seroma group, the drainage volume of the first three days, the total and daily drainage volume were all higher (all p values less than 0.01), as well as drainage duration and hospital stay were longer(8.3d vs 14.4d, P=0.000 and 11.5d vs 23.7d, P=0.000, respectively). Logistic regression showed that older patients (OR=1.080, 95%CI 1.016∼1.148, P=0.013), lower total serum protein content(OR=0.814, 95%CI 0.705∼0.940, P=0.005)and higher drainage volume in d1(OR=1.009, 95%CI 1.001∼1.016, P=0.022) and d3 (OR=1.017, 95%CI 1.005∼1.029, P=0.005) were all independent risk factors for subcutaneous seroma. The daily average drainage curve showed a gradually decreasing trend with a highest collections in the first three days. The seroma group had significantly higher average daily drainage volume( P=0.034) and longer duration (P=0.000).&#x2028; Conclusion:The risk factors of seroma formation after breast cancer surgery are complicated. However in order to prevent its occurrence effectively, the factors including age, nutrition status and daily drainage volume should be taken into consideration.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4085.

Clinicopathological features of the triple-negative tumors in Chinese breast cancer patients

Abstract #6080

Background: Triple negative breast cancers are defined by a lack of expression of estrogen, progesterone, and Her-2 receptors. A number of studies suggested that the triple-negative phenotype could contribute to an aggressive behavior and a poor prognosis. However, similar data is still not available for Chinese populations. We sought to analyze the clinicopathological features of this subgroup in our hospital in order to get characteristics for Chinese breast cancer.&#x2028; Methods: We performed a retrospective study of 2028 female unilateral breast cancer patients undergoing surgery in our hospital from February 1991 to December 2003. ER, PR and Her-2 status were assessed using immunohistochemical staining. Survival curves were performed with Kaplan-Meier method and annual recurrence hazard was estimated by hazard function.&#x2028; Results: According to different combinations of hormone receptor (HR) and Her-2 status, 2028 patients were categorized into the three subgroups as follows: Her-2+ (32.25%), HR+/Her-2- (48.92%) and triple-negative (18.83%). Triple-negative tumors were larger (greater than 2 cm in diameter) than HR+/Her-2- tumors, but smaller than Her-2+ tumors (70.03%, 66.15% and 76.15% respectively, P &lt; 0.001). In addition, 21.99% of patients whose tumors were triple-negative had four or more axillary nodes involved compared with 27.37% of patients with Her-2+ tumors and 22.78% with HR+/Her-2- tumors (P = 0.004). There were statistical differences in the distribution of TP53 mutation and Cathepsin-D status (P &lt; 0.001 for both). In the univariate analysis, we found a statistical significance for recurrence-free survival (RFS) among the three subgroups (P = 0.0036), with the rate of 72.89% for Her-2+ tumors, 78.26% for HR+/Her-2- tumors and 75.61% for triple-negative tumors at the 11th year respectively. When it came to the time of hazard peaks, discrepancies existed in different subgroups. Triple-negative patients showed an early major recurrence surge peaking at the 2.5th year after surgery, followed by a gradual decline until year 6.5 and then a modest increase. As to HR+/Her-2- patients, the hazard plot exhibited a wide initial plateau-like wave covering at least 4 years and a subsequent rise. The hazard rate for Her-2+ patients displayed a tapering sharp at the 1st year and a second rise. Furthermore, the first peak of triple-negative tumors was higher than that of HR+/Her-2- patients, but lower than that of Her-2+ ones.&#x2028; Conclusions: The recurrence pattern for triple-negative tumors was intermediate between Her-2+ and HR+/Her-2- counterparts.Our findings suggested that biological characteristics and prognosis of Chinese triple-negative breast cancer might be more favorable and somewhat different from those in Western populations.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6080.

Time distributions and prognosis factors of breast cancer recurrence in different sites after operation

Abstract #2080

Objective Our study aims to analyze the breast caner patients with different sites of recurrence, and to have knowledge of the regular patterns and influence factors of metastastic breast cancer.&#x2028; Methods We performed a retrospective study of 210 female breast cancer patients who were continuously followed up in our hospital from January 2005 to May 2007 and had complete data of metastasis. The clinical and biological characteristics were compared between the patients with organ metastases (lung, liver, brain) and non-viscera metastases (lymph node, bone).&#x2028; Results Cox regression analysis-hazard function showed that patients with elder age (RR=0.927 95%CI 0.877∼0.981, P=0.008) and HER-2 negative(RR=0.253 95%CI 0.076∼0.836, P=0.024)tended to develop non-viscera metastases, while patients with larger tumors (RR=3.832 95%CI 1.073∼13.687, P=0.039) tended to develop organ metastasesp.&#x2028; &#x2028; When stratified by the prognostic factors, the annual risk hazard curve of the patients with high risk of recurrence had double peaks at the second year and the ninth years after mastectomy respectively, and it was significantly higher than those of the patients with middle and low risk.[figure1]Annual risk hazard curves of both local relapse and metastasis also showed a double-peaked pattern. The curves for lymph node, bone, lung and liver metastasis showed a similar pattern, but all the peaks of curve emerged later than that of the local relapse.&#x2028; &#x2028; Conclusion Patients with different clinical and biological characteristics may develop recurrence in different sites. There are certain regular patterns of time distribution for different metastasis sites after mastectomy. The local recurrence may be the foreboding for the metastasis and we should pay attention to the local relapse signs especially in the patients with high risk.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2080.

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