Predictive factors of adjuvant therapy-related amenorrhea for patients with breast cancer

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Background: Reproductive age breast cancer patients often experience therapy-related amenorrhea so preserving fertility after treatment is a major concern. Anti-mullerian hormone (AMH) values have been reported useful in predicting menopause for infertility treatment patients, but published information is limited regarding breast cancer patients. If amenorrhea can be predicted before treatment, breast cancer patients hoping to have children in the future can consider this information in choosing treatment. Our aim was to predict patient fertility using AMH values.

Methods: Forty breast cancer patients, 25-45 years of age (median, 35.5), who received adjuvant chemotherapy (CT) or endocrine therapy (ET), had AMH values retrospectively assayed from frozen serum before and after treatment. AMH values were then analyzed in relation to clinicopathological factors using logistic analysis. Of 19 adjuvant CT patients whose AMH values could be assayed, Cox’s proportional hazard model indicated a correlation in terms of amenorrhea and time to menses resumption between clinicolpathological factors and AMH values.

Results: The mean pretreatment AMH value for all 40 patients was 21.4pM (range, 3-78) and a correlation was demonstrated with patient age, but not breast cancer intrinsic subtype or stage. AMH values decreased to the lower limit after treatment for all CT patients regardless of age, but there was a difference in degree depending on patient age for ET patients. Of the 19 CT patients, the mean AMH value was 25.6pM (3-78). These patients all underwent a regimen of anthracycline with 11 (58%) also receiving a regimen of taxiane. After starting CT, 17 patients (89%) experienced amenorrhea, but 11 (59%) resumed menstruation within one year of finishing CT and 15 (78%) resumed within two years. There were no significant differences among CT patients in age, pretreatment AMH value, intrinsic subtype or stage, but patients receiving taxiane demonstrated a noteworthy trend.

Conclusions: Although we were unable to predict menopause directly using AMH values given the small number of patients in this study, we could estimate the risk of menopause as being either low or high for CT patients based on age and type of regimen.

What factors affect the place of end-of-life care for patients with metastatic breast cancer?

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Background: Despite the early detection and treatment, advanced breast cancer is still impossible to cure. Palliative care has become the standard of care at the time of end-of-life (EOL). However, there are limited data about the degree of access to such care and the factors that affect the choice of place to die. The purpose of this study is to identify factors that affect the place of EOL care in patients with metastatic breast cancer in Japan.

Methods: Our study included breast cancer patients who were diagnosed with recurrence or metastatic diseases between 2004 and 2010 at the National Cancer Center Hospital and received EOL care. The following data were obtained: treatments, place of EOL care, and social background such as age, whether patients had young children, whether patients had elderly family members who needed nursing care, whether patients had jobs at the time of recurrence, and where they lived in.

Results: Overall, 124 patients met our inclusion criteria. Among them, only 13% of patients received EOL care at home and 43.5% of patients at hospices, while 43.5% of patients died in acute care beds. Patients who had jobs at the time of recurrence were significantly more likely to receive EOL care in acute care beds (odds ratio 2.46; 95% CI 1.04−5.83). Other social backgrounds were not significantly related to the place of EOL care.

Conclusions: A sizable proportion of patients, especially patients who had jobs at the time of recurrence, received acute care at the EOL and did not have access to palliative care at home or hospices. Familial backgrounds were not the determinant to choose the place of EOL.

Compliance with Good Clinical Practice in oncology registration trials in Japan

BACKGROUND

This study aimed to examine the quality in oncology registration trials for new drug application (NDA) or supplemental new drug application (sNDA) as extensions of the indications for use in Japan based on Good Clinical Practice (GCP) audit findings.

MATERIALS AND METHODS

We collected audit reports of on-site GCP inspections for registration trials in 383 NDAs or sNDAs that were reviewed by the Pharmaceuticals and Medical Devices Agency between the fiscal years 2004 and 2009.

RESULTS

Among the 40 audits for oncology drug applications, the frequencies at which one or more deficiencies ascribed to institution, investigator, sponsor, and institutional review board were found to be 15 (37.5%), 13 (32.5%), 21 (52.5%), and 10 (25.0%), respectively. The exclusion of patients from the review objective due to serious violations of GCP in 40 audits for oncology drug applications was observed in 2 (5.0%) cases, whereas that in the remaining 343 audits for other drug applications was observed in 40 (11.7%) cases.

CONCLUSION

The overall compliance of GCP in oncology registration trials was moderately better than that in registration trials for other diseases, although there was no statistically significant difference between them.

FcγR2A and 3A polymorphisms predict clinical outcome of trastuzumab in both neoadjuvant and metastatic settings in patients with HER2-positive breast cancer

BACKGROUND

Antibody-dependent-mediated cytotoxicity (ADCC) is one of the modes of action for trastuzumab. Recent data have suggested that fragment C γ receptor (FcγR) polymorphisms have an effect on ADCC. This prospective phase II trial aimed to evaluate whether these polymorphisms are associated with clinical efficacies in patients who received trastuzumab.

PATIENTS AND METHODS

Patients in a neoadjuvant (N) setting received Adriamycin and cyclophosphamide followed by weekly paclitaxel/trastuzumab. Patients in a metastatic (M) setting received single trastuzumab until progression. In total, 384 distinct single nucleotide polymorphisms of different FcγR, HER2, and fucosyltransferase loci were assessed.

RESULTS

Fifteen operable and 35 metastatic HER2-positive breast cancer patients were enrolled in each of the N and M settings, respectively. The FcγR2A-131 H/H genotype was significantly correlated with the pathologically documented response (pathological response) (P = 0.015) and the objective response (P = 0.043). The FcγR3A-158 V/V genotype was not correlated with the pathological response, but exhibited a tendency to be correlated with the objective response. Patients with the FcγR2A-131 H/H genotype had significantly longer progression-free survival in the M setting (P = 0.034).

CONCLUSION

The FcγR2A-131 H/H polymorphism predicted the pathological response to trastuzumab-based neoadjuvant chemotherapy in early-stage breast cancer, and the objective response to trastuzumab in metastatic breast cancer.

Predictors of recurrence in breast cancer patients with a pathologic complete response after neoadjuvant chemotherapy

Background:

Although a pathologic complete response (pCR) after neoadjuvant chemotherapy is associated with favourable outcomes, a small proportion of patients with pCR have recurrence. This study was designed to identify factors predictive of recurrence in patients with pCR.

Methods:

A total of 449 breast cancer patients received neoadjuvant chemotherapy, and 88 evaluable patients had a pCR, defined as no evidence of invasive carcinoma in the breast at surgery. The clinical stage was II in 61 patients (69%), III in 27 (31%). All patients received taxanes and 92% received anthracyclines. Among 43 patients with HER2-positive tumours, 27 received trastuzumab. Cox regression analyses were performed to identify predictors of recurrence.

Results:

Median follow-up was 46.0 months. There were 12 recurrences, including 8 distant metastases. The rate of locoregional recurrence was 10.4% after breast-conserving surgery, as compared with 2.5% after mastectomy. Multivariate analysis revealed that axillary metastases (hazard ratio (HR), 13.6; P<0.0001) and HER2-positive disease (HR, 5.0; P<0.019) were significant predictors of recurrence. Five of six patients with both factors had recurrence. Inclusion of trastuzumab was not an independent predictor among patients with HER2-positive breast cancer.

Conclusion:

Our study results suggest that HER2 status and axillary metastases are independent predictors of recurrence in patients with pCR.

Lawsonia intracellularis and virulent Rhodococcus equi infection in a thoroughbred colt

A 26-month-old thoroughbred colt with a 4-month history of continuous diarrhoea and weight loss was subject to necropsy examination. The small intestinal mucosa was thickened and this change particularly affected the terminal ileum. Microscopical examination revealed multifocal epithelial hyperplasia, with multifocal granulomas and marked lymphocytic infiltration of the lamina propria. Numerous gram-negative argyrophilic curved bacilli were observed within the cytoplasm of affected enterocytes. Macrophages and epithelioid cells forming the granulomas had abundant, lightly eosinophilic, foamy cytoplasm, with occasional large, clear vacuoles containing gram-positive coccobacilli. Immunohistochemical studies suggested that the argyrophilic bacilli were Lawsonia intracellularis and the gram-positive coccobacilli were Rhodococcus equi. L. intracellularis-specific DNA fragments were amplified from the affected ileocaecal mucosa by polymerase chain reaction. Virulent R. equi (VapA positive) was isolated in pure culture from the liver and mesenteric lymph nodes. These results suggested that the two intracytoplasmic organisms had induced multifocal proliferative and granulomatous enteritis accompanied by severe and extensive lymphocytic infiltration.

Prediction of progressive disease using tumor markers in metastatic breast cancer patients without target lesions in first-line chemotherapy

BACKGROUND

The aim of this study was to develop a prediction model of progressive disease (PD) in breast cancer patients without measurable disease in first-line chemotherapy.

METHODS

We developed a model to predict PD using carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 15-3 in metastatic breast cancer patients who were enrolled in a phase III trial. The model was determined using the area under the receiver operating characteristic curve (AUC) calculated by the bootstrap method as internal validation. We verified the model for those who received first-line chemotherapy in a clinical setting as external validation. We categorized patients without measurable disease into PD and non-PD groups and compared the time to progression (TTP).

RESULTS

The model consisted of percent changes in CEA and CA 15-3 levels from second to third chemotherapy course and baseline abnormality of them. The AUC after external validation was 0.90. Patients without measurable disease were categorized into PD (N = 10) and non-PD groups (N = 53) by the model. The difference in TTP between the two groups was statistically significant (hazard ratio, 0.437; P = 0.021).

CONCLUSION

The model may be useful to determine PD in metastatic breast cancer patients without measurable disease.

Gene-Set Enrichment Analysis (GSEA) of Microarray Data in Patients with HER2-Positive Breast Cancer Treated with Preoperative Chemotherapy Including Trastuzumab

Background: Identification of molecular predictors of response is important in the aspect of personalization of treatment, especially in the era of molecular targeted drugs. Genome-wide analysis such as microarray may be useful in exploring genes related to mechanism of action or resistance to trastuzumab-based treatment.Patients and Methods: 17 HER2-negative and 13 HER2-positve patients with primary breast cancer were enrolled onto this prospective study. HER2 status was determined by HercepTest (3+) or (2+) with gene amplification. The patients were prospectively treated with preoperative chemotherapy (4 cycles of 5FU/epirubicin/cyclophosphamide 500/100/500 mg/m2, q3w, followed by 12 cycles of weekly paclitaxel 80mg/m2. All HER2-positve patients were administered trastuzumab 2mg/kg weekly with paclitaxel. Gene expressions were measured using Affimetrix GeneChip Human Genome U133 Plus 2.0 array in mRNA samples extracted from pretreatment core-needle biopsy specimens. GSEA (www.broad.mit.edu/gsea/msigdb/) were performed to explore gene sets differentially expressed between tumors that achieved pathological complete response (pCR) and those did not (non-pCR). 386 gene sets corresponding to human chromosome and 1454 gene sets named by gene ontology term were examined.Results: The 5 gene sets significantly differentiated HER2-positive and HER2-negative tumors with nominal p-value of &lt;.03 and false-discovery rate (FDR) q-value of &lt;.25 included 3 gene sets located in 17q chromosome including 17q11, indicating the validity of the microarray experiment and GSEA in a relatively small study. Six HER2-positive tumors achieved pCR. We identified 22 and 112 gene sets with nominal p-value of &lt;0.01 and &lt;0.05 that differentiated pCR and non-pCR in HER2-positive tumors, respectively. The top 22 gene sets included gene sets related to regulation of phosphorylation, receptor complex, cell proliferation, cytoplasmic vesicle, regulation of apoptosis and immune response. Other significant gene sets were those related to cell adhesion, signal transduction, cell proliferation and protein homodimerization. We could not identify gene sets which was differentiately expressed in tumors with pCR and non-pCR with FDR q-value of &lt;.25 probablely because of the sample size.Conclusion: Although the results are still exploratory, GSEA seems to be helpful in narrowing down the gene sets from wide range of pathways in molecular network even in a small study if the selected gene sets are biologicaly robust.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1167.

Prediction of the benefit of trastuzumab (T)-based therapy by the change of gene expression of peripheral blood mononuclear cells (PBMC)

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Background: Identification of molecular predictors of response is important in the aspect of personalization of treatment, especially in the era of molecular targeted drugs. Antibody-dependent cell-mediated cytotoxicity (ADCC) is suggested as one of the main mechanism of action of T. Moreover, PBMC specimens can securely be obtained with minimal invasion. We therefore hypothesized that gene expression changes induced by T of PBMC may be useful for prediction of response of T. Methods: 36 HER2-positive metastatic breast cancer (BC) patients were enrolled in this prospective biomarker study. The patients were treated with single-agent T (q1w) for chemotherapy-naïve, hormone refractory metastatic disease. The clinical response was measured after 8 cycles of single-agent T. PBMC were collected prior to and 1-week after the first administration of T. Gene expressions of PBMC were measured using Affimetrix GeneChip Human Genome U133 Plus 2.0 array. Change of gene expressions before and after T was correlated with clinical response using Wilcoxon rank sum test. A multi-gene predictor of response to T was generated using the highly ranked genes. The performance of the predictor was then assessed in patients prospectively treated with neoadjuvant chemotherapy (NAC): HER2- positive BC patients recieved NAC containing T. PBMC were collected prior to NAC and 1-week after the first administration of T. Results: 34 patients were evaluable for clinical outcome. 15 and 19 patients were classified as responders and non- responders, respectively. The top 4 genes differentially regulated by T between responders and non-responders were selected for development of a predictor by leave-one-out cross validation. The 4-gene predictor correctly predicted the pathological complete response (pCR) in 5 out of 5 patients who achieved pCR and residual disease (RD) in 10 out of 12 patients with RD (error rate 12 %) in HER2-positive breast BC patients treated with NAC containing T. However, it was not associated with pathological response in 19 HER2- negative patients treated with NAC without T (error rate 39 %). Conclusions: Change in PBMC gene expression after single dosage of T may be useful as a predictor of response to T-based therapy.

No significant financial relationships to disclose.

Correlation of FcγR IIa-H131R and IIIa-V158F polymorphisms and clinical outcome of trastuzumab in both neoadjuvant and metastatic setting in patients with HER-2 positive breast cancer

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Background: The antibody dependent cell mediated cytotoxicity (ADCC) affects an efficacy of Immunoglobulin G1 antibody, including trastuzumab which is a humanized anti-HER-2 monoclonal antibody, through fragment C receptor (FcγR) polymorphisms. One report suggested that allotype of two kinds of FcγR single nucleotide polymorphisms (SNPs) are associated with clinical outcome of patients (pts) with metastatic breast cancer (BC) who received combination trastuzumab with taxane. Ethnic difference was reported in frequency of these SNPs between Western and Asian pts. The objective of this prospective study was to evaluate whether these SNPs are associated with pathological complete response (pCR) in neoadjuvant (N) setting with pts who received trastuzumab based chemotherapy, and objective response (OR) in metastatic (M) setting in pts who received single trastuzumab. Methods: Eligible criteria include HER-2 positive BC, chemotherapy-naïve, measurable disease, PS 0–2 and adequate organ functions. Pts in N setting received standard FEC (5-fluorouracil/epirubicin/cyclophosphamide q3w for 4cycles followed by weekly paclitaxel/trastuzumab for 12 weeks. Pts in M setting received single trastuzumab q1w until progression. 384 SNPs of different FcγR loci were assessed from genomic DNA extracted from peripheral blood by GOLDEGATE beads array (illumina Co.). Results: Nineteen operable and 36 metastatic HER-2 positive BC pts have been enrolled in each N and M setting, respectively. pCR in N setting was 26.3%, and OR in M setting was 22.2%. The frequencies of FcγRIIa131 genotypes were H/H 43%, H/R 49%, R/R 8%, and that of FcγRIIIa158 were V/V 43%, V/F 47%, F/F 10%, respectively. 131H/H genotype was significantly correlated with pCR (p = 0.0034) and OR (p = 0.037). 158V/V genotype had a tendency to be correlated with pCR (p = 0.067) and was significantly correlated with OR (p = 0.037). The median PFS was 8.9 months for pts with 131H/H and 3.8 months for R carriers (H/R or R/R). Conclusions: Our data for the first time suggest that these two SNPs predict pCR to trastuzumab based chemotherapy in N setting, and OR to single trastuzumab in M setting.

No significant financial relationships to disclose.

Secondary platinum therapy in patients with uterine cervical cancer previously treated with platinum chemotherapy

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Background: Second-line chemotherapy after the front-line platinum based regimens including concurrent chemoradiation (CCRT) has not been established for patients with advanced or recurrent cervical cancer. Platinum based regimens are often selected, but the predictive and prognostic factors of secondary platinum therapy are unclear. We therefore evaluated the relative influence of platinum free interval ( PFI ) between the completion of front-line regimen and the institution of second-line regimen. Methods: This retrospective review was undertaken of 65 patients who received ≥ 2 platinum-based regimens and were assessable for secondary response in National Cancer Center Hospital between 1996 and 2008. We analyzed independent predictive factors associated with secondary response by logistic regression model and prognostic factors associated with subsequent survival by Cox regression model. Results: The median age was 54 years old (range, 28 to 73). The median follow-up of subsequent survival was 11.0 months (1.1 to 66.6). The median PFI was 11.1 months (0.7 to 77.6). Overall secondary response rate was 40%, while response rate for 36 patients after CCRT was 36%. The response increases in frequency with longer PFI ( Table ). Univariate and multivariate analyses using logistic regression model showed PFI for ≥ 9 months (odds ratio [OR] = 0.28; P =.04), PS 0 (OR = 0.19; P =.006) and maximum tumor diameter ≥ 30 mm (OR = 0.23; P =.02) were independent predictive factors of secondary response. Univariate and multivariate analyses using Cox regression model revealed PFI for ≥ 9 months (hazard ratio [HR] = 0.44; P =.005), PS 0 (HR = 0.30; P =.000) and histology of squamous cell carcinoma (HR = 2.20; P =.02) were independent prognostic factors of subsequent survival. Conclusions: Our exploratory study demonstrates that platinum free interval has both predictive and prognostic value for secondary platinum-based treatment for patients with advanced or recurrent cervical cancer.

[Table: see text]

[Table: see text]

Evaluation of tumor-infiltrating lymphocytes (TIL) and tumor cell apoptosis as predictive markers for response to neoadjuvant chemotherapy in triple-negative breast cancer

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Background: Triple-negative breast cancer (TNBC) lacks the expression of estrogen receptor (ER), progesterone receptor (PgR) and HER-2. Pathological complete response (pCR) of TNBC to neoadjuvant chemotherapy (NAC) is correlated with excellent clinical outcome. We examined the value of histological parameters including tumor-infiltrating lymphocytes (TIL) and tumor cell apoptosis as surrogate markers for pCR in TNBC. Methods: Of 474 patients who received NAC and subsequent surgical therapy to stage II-III invasive breast carcinoma between 1999 and 2007, 102 (22%) had TNBC, and 92 core needle biopsy (CNB) specimens before NAC were available. We first immunohistochemically confirmed TNBC and basal-like subtype by current criteria for ER, PgR, and HER-2, cytokeratin (CK) 5/6, CK14, EGFR, and p53. All cases were TNBC, and 54 tumors (59%) were basal-like subtype defined as expression of at least one of CK5/6, CK14 and EGFR in >1% of cancer cells. Totally, 26 tumors (28%) showed pCR. Thirteen histopathological parameters were examined, and their correlation with pCR rate was tested. These parameters were also examined in resected tumor specimens from 21 non-pCR cases. Results: The pCR rate was significantly higher in the patients with tumors with TIL (24 of 68, 35%) than in those without (2 of 24, 8%, p = 0.01), and higher in tumors with high-score apoptosis (9 of 19, 47%) than in those with low-score apoptosis (17 of 73, 23%, p = 0.04). Tumors showing medullary features and p53-negative tended to show pCR more frequently (38% and 35%) than those with non-medullary features and with p53-positive (25% and 24%), but the differences were not significant. Of 21 non-pCR cases, TIL was consistently negative before and after NAC in 8, but TIL emerged after NAC in 13. The pCR rate did not differ significantly between the basal-like type (31%) and non-basal-like type (24%). Conclusions: TIL and the level of tumor cell apoptosis appeared predictive markers for response to NAC in TNBC. Patients’ host factors correlated with immune response appears play a substantial role in the response to NAC in TNBC.

No significant financial relationships to disclose.

Irinotecan plus carboplatin for patients with carcinoma of unknown primary site

Carcinoma of unknown primary site (CUP) is rarely encountered in clinical practice and optimal chemotherapy has not yet been established. This phase II study was conducted to evaluate the efficacy and toxicity of combined irinotecan+carboplatin therapy in chemotherapy-naive patients with CUP. Irinotecan was administered at 60 mg m(-2) as a 90-min intravenous infusion on days 1, 8 and 15. Carboplatin was administered at an area-under-the curve of 5 mg ml(-1) min as a 60-min intravenous infusion on day 1. This cycle was repeated every 28 days for up to six cycles. Forty-five patients were enrolled in the study. An intent-to-treat analysis revealed an objective response rate to the treatment of 41.9% (95% confidence interval, 27.0-57.9%). The median time to progression was 4.8 months and the median survival was 12.2 months. The 1- and 2-year survival rates were 44 and 27%, respectively. The most frequent grade 3 or more severe adverse events were leukopaenia (21%), neutropaenia (33%), anaemia (25%) and thrombocytopaenia (20%). Thus, the combination of irinotecan plus carboplatin was found to be active in patients with CUP. Therefore, the regimen may be one of the potentially available chemotherapeutic options for community standard of care in patients with a good performance status.