Chemotherapy treatment for older women with metastatic breast cancer: what is the evidence?

While the over-representation of the elderly in the breast cancer population is projected to dramatically increase within the next two decades, data on chemotherapy for elderly patients with metastatic breast carcinoma (MBC) remain very limited. The aim of the present study is to investigate whether elderly patients included in clinical studies for MBC are representative of the population seen during usual clinical practice. Firstly, a review of the literature was performed identifying 39 publications about chemotherapy for MBC focusing on elderly patients and we examined patient characteristics in each of these publications. Comparison of the age distribution of patients included in these studies with that of a large cohort of consecutive MBC patients aged 65years who received chemotherapy in our institution over the last ten years (n=573) indicated that trials tend to include relatively younger patients. Furthermore, criteria to assess external validity of the results are seldom reported. Possible ways to improve the applicability of results such as increasing the minimum age for inclusion and the use of CGA are proposed.

Quality of randomized controlled trials reporting in the treatment of sarcomas

PURPOSE

Randomized controlled trials (RCTs) represent the best evidence in oncology practice. The aim of this study was to assess the reporting quality of sarcoma RCTs and to identify significant predictors of quality.

PATIENTS AND METHODS

Two investigators searched MEDLINE for pediatric and adult bone and soft tissue sarcoma RCTs published between January 1988 and December 2008. The quality of each report was assessed by using a 15-point overall reporting quality score based on 15 items from the revised Consolidated Standards of Reporting Trials (CONSORT) statement (overall quality score [OQS] range, 0 to 15 points). Concealment of allocation, appropriate blinding, and analysis according to intention-to-treat principle were assessed separately because of their crucial methodologic importance by using a 3-point key methodologic index score (MIS; range, 0 to 3).

RESULTS

We retrieved 72 relevant RCTs that included 16,029 patients. The median OQS was 9.5. Allocation concealment, blinding, and analysis by intent to treat were reported only in 21 (29%), nine (12.5%), and 23 (32%) of the 72 RCTs, respectively. The median MIS was 1 with a minimum of 0 and a maximum of 2. On multivariate analysis, publication after 1996 and high impact factor remained independent and significant predictors of improved OQS. The sole variable associated with improved MIS was the publication of chemotherapy-only trials.

CONCLUSION

Although the overall quality of sarcoma RCTs reporting has improved over time, reporting of key methodologic issues remains poor. This may lead to biased interpretation of sarcoma trial results.

Separate and combined analysis of successive dependent outcomes after breast-conservation surgery: recurrence, metastases, second cancer and death

BACKGROUND

In the setting of recurrent events, research studies commonly count only the first occurrence of an outcome in a subject. However this approach does not correctly reflect the natural history of the disease. The objective is to jointly identify prognostic factors associated with locoregional recurrences (LRR), contralateral breast cancer, distant metastases (DM), other primary cancer than breast and breast cancer death and to evaluate the correlation between these events.

METHODS

Patients (n = 919) with a primary invasive breast cancer and treated in a cancer center in South-Western France with breast-conserving surgery from 1990 to 1994 and followed up to January 2006 were included. Several types of non-independent events could be observed for the same patient: a LRR, a contralateral breast cancer, DM, other primary cancer than breast and breast cancer death. Data were analyzed separately and together using a random-effects survival model.

RESULTS

LRR represent the most frequent type of first failure (14.6%). The risk of any event is higher for young women (less than 40 years old) and in the first 10 years of follow-up after the surgery. In the combined analysis histological tumor size, grade, number of positive nodes, progesterone receptor status and treatment combination are prognostic factors of any event. The results show a significant dependence between these events with a successively increasing risk of a new event after the first and second event. The risk of developing a new failure is greatly increased (RR = 4.25; 95%CI: 2.51-7.21) after developing a LRR, but also after developing DM (RR = 3.94; 95%CI: 2.23-6.96) as compared to patients who did not develop a first event.

CONCLUSION

We illustrated that the random effects survival model is a more satisfactory method to evaluate the natural history of a disease with multiple type of events.

Abstract P6-11-04: Capecitabine Therapy for Locally Advanced or Metastatic Breast Cancer: A Difference between Reported Clinical Trials and Routine Clinical Practice? Results from the ELIXIR Study in Routine Oncology Practice

Background: Capecitabine (X) monotherapy is an effective and well-tolerated treatment for locally advanced or metastatic breast cancer (LABC/MBC), showing consistently high activity in both the 1st-line setting andpretreated disease. The registered dose is 1250 mg/m2 bid, d1-14 q21d, but there is considerable variation in the administration of X (dose, line, monotherapy vs combination) in everyday practice. Patients and methods: ELIXIR is a French, multicenter, prospective, observational cohort study assessing the use of X in routine oncology practice in patients (pts) with LABC/MBC. The observation period is 24 months.

Results: Between Dec 05 and Jan 08, 668 pts were enrolled, of whom 655 were evaluable. The majority of pts (540; 82%) received X as monotherapy (1st line: n=201; 2nd line: n=205; ≥3rd line: n=134). The remaining 115 pts received X combined with chemotherapy (1st line: n=60; 2nd line: n=36; ≥3rd line: n=19), typically vinorelbine (n=66) or a taxane (n=42). Overall, 57 pts (9%) received X in combination with trastuzumab. Among pts receiving X monotherapy, only 21 % began therapy at the full registered dose, 60% of pts started at 75% of the registered dose and in 19% of pts, therapy was initiated at ≥50% of the registered dose. At the 12-month analysis, median progression-free survival (PFS) in the overall population was 8.0 months (95% CI 7.1-8.8), 61% of pts were still alive, and median overall survival had not been reached. Analysis of safety data among pts receiving X monotherapy revealed no major differences in tolerability according to treatment line, except for less grade 3 hand-foot syndrome (HFS) and grade 3/4 diarrhea in pts treated in later lines (Table).

Conclusion: ELIXIR is one of the largest prospective cohort studies of X in LABC/MBC. Tolerability in the 1st-line setting compares favorably with that of X 1000 or 1250 mg/m2 bid observed in the exclusively 1st-line GBG39 (MoniCa) and PELICAN trials, presumably reflecting the selection of a lower dose in most pts treated in ELIXIR. Despite the tailored dose, median PFS of 8.0 months is consistent with the median time to progression of 7.1-7.3 months reported in GBG39 and PELICAN. These data suggest that the efficacy of X seen in clinical trials can be reproduced in the real-life setting, despite widespread use of lower doses to improve tolerability. The wide array of variables in routine clinical practice makes interpretation of the data complex. Slight qualitative differences in the safety profile between treatment lines may be attributable to differences in starting dose and/or disease symptoms and require further investigation. Analysis of efficacy and safety results according to treatment line and starting dose is ongoing and 24-month results will be presented.

First-line chemotherapy for metastatic breast cancer in patients ≥75 years: a retrospective single-centre analysis

Data on chemotherapy for elderly patients with metastatic breast carcinoma (MBC) are limited. We performed a 7-year retrospective analysis of MBC patients at our institution receiving first-line chemotherapy aged ≥75 years. Of 117 patients, 103 received monotherapy (67 capecitabine, 29 vinorelbine, 5 docetaxel, 2 liposomal doxorubicin) and 14 received polychemotherapy (12 anthracycline-based, 2 vinorelbine-gemcitabine). Chemotherapy demonstrated acceptable tolerability. Median progression-free survival (PFS) and overall survival (OS) from initiation of chemotherapy were 6.2 months and 13.8 months, respectively. At 2 years, 25% of patients were alive; however, 25% died within 3 months of beginning chemotherapy. Independent prognostic factors for longer PFS were good performance status, absence of visceral disease and capecitabine treatment. Good performance status and lack of visceral disease were also significant for OS. These results suggest that palliative chemotherapy should not be systematically excluded in this setting, but should be carefully discussed as it appears to be feasible with apparent benefit in selected patients.

Impact of liposomal doxorubicin-based adjuvant chemotherapy on autonomy in women over 70 with hormone-receptor-negative breast carcinoma: A French Geriatric Oncology Group (GERICO) phase II multicentre trial

RATIONALE

Breast cancer is a disease of ageing. Functional independence in elderly patients, measured with the Katz activities of daily living (ADL) scale, predicts overall survival and the need for welfare support. Few prospective studies have examined the feasibility of adjuvant chemotherapy and its impact on autonomy in women over 70 years of age with high-risk breast cancer. This multicentre phase II trial was designed to assess the impact of adjuvant anthracycline-based chemotherapy on these patients' autonomy.

DESIGN AND METHODS

In a two-stage Fleming design, women aged ≥70 years with histologically proven hormone-receptor-negative early breast cancer and a significant risk of recurrence (pN+ or "high risk" pN0) received 4 cycles of nonpegylated liposomal doxorubicin 60 mg/m(2) and cyclophosphamide 600 mg/m(2) every 3 weeks postoperatively, on an outpatient basis. The primary endpoint was the change in the ADL score during chemotherapy. Secondary endpoints include comprehensive geriatric, quality-of-life and acceptability assessments, tolerability, and long-term outcome. The results for the primary endpoint and other scales at completion of adjuvant chemotherapy are reported here, while long-term follow-up is not yet complete.

RESULTS

Forty patients (median age 75 [70-82]) were enrolled between February 2006 and November 2007. Chemotherapy had no deleterious impact on ADL, cognition, mental status, or the frequency of comorbidities. In contrast, the number of patients at risk of malnutrition, based on the Mini Nutritional Assessment, more than doubled between baseline and the end of chemotherapy, rising from 15% to 38%. Quality-of-life deteriorated in terms of social and role functioning, likely owing to fatigue, loss of appetite, nausea and vomiting. Treatment acceptability was good. The main adverse effect was neutropenia, 15% of the patients experiencing febrile neutropenia. No cardiac toxicity or toxic deaths occurred.

CONCLUSION

This study demonstrates the feasibility of an adjuvant chemotherapy regimen combining nonpegylated liposomal doxorubicin and cyclophosphamide in fit elderly women <85 years with breast cancer. Although chemotherapy had an impact on social and role functioning, autonomy was not impaired and toxicity was acceptable. Special attention should be paid to nutritional status before and after treatment.

Is it useful to detect lymphovascular invasion in lymph node-positive patients with primary operable breast cancer?

BACKGROUND

Lymphovascular invasion (LVI) is a widely recognized prognostic factor in lymph node-negative breast cancers. However, there are only limited and controversial data about its prognostic significance in lymph node-positive patients.

METHODS

Among 931 patients operated on and monitored at the authors' institution for an invasive breast carcinoma between 1989 and 1992, all 374 lymph node-positive breast cancers entered the study (median follow-up, 126 months).

RESULTS

LVI was present in 46% of tumors and was associated with age < or = 40 years (P = .02), high histological grade (P = .01), and negative estrogen receptor status (P = .032), but not with tumor size, number of involved lymph nodes, or HER-2/neu status. LVI was an independent prognostic factor for distant metastases (P = .002). Furthermore, in HER-2/neu-negative/hormone receptor-positive (n = 287) tumors, the number of independent prognostic factors (LVI, age, histological grade, number of involved lymph nodes, and tumor size) was associated with a 5-years metastasis-free survival ranging from 100% if no factors (n = 25) to 89% +/- 2% if 1 or 2 factors (n = 186) and 67% +/- 6 if 3, 4, or 5 factors (n = 76) were present (P < .001).

CONCLUSIONS

LVI is an independent prognostic factor in lymph node-positive breast cancer and merits further prospective investigations as a decision tool in the adjuvant chemotherapy setting.

Variables with time-varying effects and the Cox model: some statistical concepts illustrated with a prognostic factor study in breast cancer

BACKGROUND

The Cox model relies on the proportional hazards (PH) assumption, implying that the factors investigated have a constant impact on the hazard - or risk - over time. We emphasize the importance of this assumption and the misleading conclusions that can be inferred if it is violated; this is particularly essential in the presence of long follow-ups.

METHODS

We illustrate our discussion by analyzing prognostic factors of metastases in 979 women treated for breast cancer with surgery. Age, tumour size and grade, lymph node involvement, peritumoral vascular invasion (PVI), status of hormone receptors (HRec), Her2, and Mib1 were considered.

RESULTS

Median follow-up was 14 years; 264 women developed metastases. The conventional Cox model suggested that all factors but HRec, Her2, and Mib1 status were strong prognostic factors of metastases. Additional tests indicated that the PH assumption was not satisfied for some variables of the model. Tumour grade had a significant time-varying effect, but although its effect diminished over time, it remained strong. Interestingly, while the conventional Cox model did not show any significant effect of the HRec status, tests provided strong evidence that this variable had a non-constant effect over time. Negative HRec status increased the risk of metastases early but became protective thereafter. This reversal of effect may explain non-significant hazard ratios provided by previous conventional Cox analyses in studies with long follow-ups.

CONCLUSIONS

Investigating time-varying effects should be an integral part of Cox survival analyses. Detecting and accounting for time-varying effects provide insights on some specific time patterns, and on valuable biological information that could be missed otherwise.

First-line capecitabine monotherapy for slowly progressing metastatic breast cancer: do we need aggressive treatment?

BACKGROUND

Primary treatment goals in less aggressive metastatic breast cancer (MBC) are prolonged survival, good quality of life and control of the disease and its symptoms. High activity, oral administration and no alopecia make capecitabine monotherapy attractive in slowly evolving disease.

METHODS

We retrospectively analysed 226 patients who had received single-agent capecitabine as 1st-line chemotherapy at our institution.

RESULTS

The median interval between breast cancer diagnosis and MBC was 52 months (range 0-479); 76% had received endocrine therapy for MBC, 58% had visceral involvement and 30% had 3 or more metastatic sites. The median starting dose was 1,000 mg/m(2) twice daily. Disease was improved in 56% of the patients (median duration: 13.2 months) and stabilised in 20%. Median time to treatment failure was 8.8 months (95% CI: 7.1-10.5); median overall survival from initiating capecitabine was 23.6 months (95% CI: 19.7-27.4). Prior adjuvant chemotherapy, endocrine therapy for MBC, visceral disease, hormone receptor status and initial capecitabine dose did not influence time to treatment failure. Among 161 patients <75 years, 90% received further chemotherapy.

CONCLUSION

Based on these findings, 1st-line capecitabine should be considered in slowly progressing disease, offering an active, well-tolerated oral treatment with minimal toxicity and no alopecia. More toxic treatments may be reserved for more aggressive disease.

D2-40 in breast cancer: should we detect more vascular emboli?

Peritumoral emboli assessed on hematoxylin-eosin-stained slides are taken into account for treatment of patients with operable breast cancer. We assessed whether immunostaining with D2-40 improves the prognostic significance of emboli in a group of tumors with a large immunohistochemical sampling and a long-term follow-up. Topography, number, and extension of hematoxylin-eosin and D2-40 emboli were compared in 94 node-negative breast cancers (median number of immunostained slides per tumor: 3). Metastasis-free survival of patients with or without hematoxylin-eosin and/or D2-40 emboli were evaluated (median follow-up of 178 months). Hematoxylin-eosin emboli were detected in 14 (15%) tumors and were located at distance from the tumor. D2-40 emboli were detected in 39 (41%) tumors and was often multiple (n=30), extensive (n=23), located within (n=13), close to (n=10) or at distance from the tumor (n=16). The 12 distant hematoxylin-eosin and D2-40 emboli were located in the same vessels (seven missed at the first hematoxylin-eosin examination and secondarily diagnosed by D2-40 staining). A difference in metastasis-free survival was found only between patients with no D2-40 emboli and those with distant D2-40 emboli (P=0.02). D2-40 emboli located within or close to the tumor had no prognostic value. Comparing the metastasis-free survival of patients with or without hematoxylin-eosin emboli, the prognostically unfavorable significance of hematoxylin-eosin emboli was improved when taking into account the seven patients with missed emboli at the first examination and secondarily diagnosed by D2-40 staining (P=0.006 vs 0.003). To conclude, D2-40 increases the diagnostic sensitivity of emboli in breast carcinoma and the high incidence of D2-40 emboli might be related to the number of immunostained slides per case. Nevertheless, only distant D2-40+ emboli had a prognostic impact. In practice, D2-40 might be useful to detect missed hematoxylin-eosin emboli especially in cases without any other prognostically unfavorable criterion.

Contribution of Mib1 to the SBR grade for prediction of metastatic recurrence in breast cancer

Abstract #3003

Background: The Scarff Bloom and Richardson (SBR) histologic grade, which assesses tumor differentiation, nuclear pleomorphism and tumor proliferation through a mitotic score, is known to be an independent prognostic factor in breast cancer. Ki-67 is a nuclear protein that is expressed by cells that are engaged in the cell cycle and may be a more accurate proliferation marker than the mitotic score used in SBR grade. The aim of our study was to look at the prognostic value of ki-67 (detected with Mib1 antibody) in breast cancer and if it could improve the prognostic value of SBR grade (SBR G).&#x2028; Materials and Methods: We analyzed ki-67 expression by immunohistochemistry using the Mib1 antibody on tissue microarrays comprising four 0.6mm diameter tissue cores of 1033 consecutive invasive ductal carcinomas (290 SBR G1, 470 SBR G2, 273 SBR G3) operated on between 1989 and 1993 (median follow-up: 167 months, 280 metastatic events). Using the median and 75th percentile values of Mib1 expression in the series (10 % and 20%, respectively) as cut offs, we defined a three tiered Mib1 score and used it to replace the mitotic score in the SBR G (Mib1 G). The prognostic values of Mib1 score alone, SBR G, Mib1 G and combined SBR/Mib1 G using the higher of the 2 grades to assign tumors to a risk category were assed by univariate analysis using the Log-rank test with the Kaplan Meier method.&#x2028; Results: 53/290 (18%) and 53/470 (11%) of SBR G1 and 2 tumors were reclassified in combined SBR/Mib1 G2 and G3, respectively. In the combined SBR/Mib1 G three groups of tumors could be individualized according to their metastatic risk.&#x2028; &#x2028; Patients with SBR G1/Mib1 G1 tumors had the lowest metastatic risk. Patients with SBR G1/Mib1 G2 tumors, SBR G2/Mib1 G1 tumors and SBR G2/Mib1 G2 tumors had an intermediate risk. Finally, patients with SBR G2/Mib1 G3 tumors, SBR G3/Mib1 G2 and SBR G3/Mib1 G3 tumors had the highest metastatic risk. Mib1 score, Mib1 G, SBR G, and combined SBR/Mib1 G were all strongly associated with Metastasis-free Interval (p=3.10-10, p=8.10-11, p=2.10-12 and p=4.10-13, respectively).&#x2028; Discussion: In the combined grade patient assignment to risk category (low, intermediate or high) is made on the higher of the two grades. Metastatic risk was more accurately estimated when SBR and Mib1 grades were combined compared to SBR G or Mib1 G separately. Mib1 may complement the prognostic information provided by histologic grade.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3003.

Genomic score predictive of metastatic evolution in breast cancer

Abstract #5069

Background: Despite of the existence of clinical and pathological prognostic factors, the metastatic evolution in breast cancer remains uncertain in a substantial proportion of cases. Previous studies have suggested that genome profiling could address this question. In this context we developed a genomic score to evaluate the total level of copy number aberrations in a given tumor, based on data from array-CGH analysis.&#x2028; Material and Methods:We performed array-CGH analysis in a series of 135 sporadic, operable breast cancers treated at our institution between 1989 and 1992 (more than 10 years follow-up). These cases included 45 invasive ductal carcinomas with metastatic evolution (M+) and 90 cases that did not relapse at 11 years (M- ). Cases were paired on patients age and initial axillary lymph node status (pN +/pN0), and were equally distributed between the two groups of evolution: 25 pN0/M+, 20 pN+/M+, 50 pN0/M- and 40 pN+/M-. Tumoral DNA was co-hybridized with pooled normal germline DNA from 20 individuals on a 4407 BAC-array (CIT-V6) provided by the CIT program and manufactured by Integragen. Gain, normal and loss status (GNL) were generated from the CapWeb pipeline developped by the bioinformatics plateforme from Institut Curie (Paris). Clinical, pathological and genomic data were retrieved through Annotator, the CIT cancer database and the analysis has been driven by using the R statistical software along with the CIT R packages.&#x2028; Results:The proposed score of genomic instability is based on two items: (i) the proportion of alteration and (ii) the number of altered genomic regions. By applying a set of appropriate thresholds on these two items we were able to define three highly different prognostic subgroups, 95 % (18/19), 74 % (65/88) and 25 % (7/28) 11 years metastatic-free survival respectively (p-value = 4.04e−10) while univariate analysis of histological parameters such as tumor size and SBR grade showed weaker associations (p-values of 0.006 and 0.065 respectively). The predictive properties of the genomic score have been assessed by cross-validation but also on other independent large data sets. A signature of genome instability inferred from genomic and gene expression profiles will also be proposed.&#x2028; Conclusion: Genomic profiling in breast carcinoma is a strong tool for prognostication in breast cancer. We developed a computational method to characterize genome instability of that predict clinical outcome in breast cancer and could be useful for more accurate therapeutic choice but also for identifying new therapeutical targets.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5069.

Neoadjuvant endocrine treatment. Long term outcome of a series of patients treated at the Institut Bergonié, Bordeaux

Abstract #5106

Background: Endocrine treatment (NET) is an attractive alternative to chemotherapy as neoadjuvant systemic therapy for women with hormone-responsive primary breast tumors. Randomized phase III trials comparing aromatase inhibitors and tamoxifen have demonstrated that NET has the potential to render suitable for breast conservation some tumours that were too large at initial presentation. However, long term outcome is largely unknown.&#x2028; The objective of this retrospective analysis was to evaluate in clinical practice the rate of breast-conserving surgery, rate of local relapse after breast-sparing treatment, and metastasis-free survival.&#x2028; Methods: We retrospectively analyzed all women ≤ 80 years treated between 1984 and 2003 in our institute with NET for a stage II-IIIA &gt; 30 mm estrogen [ER] and/or progesterone receptor [PR] positive, previously untreated, breast cancer. On diagnosis, all tumours were judged too large for breast-conserving treatment. Tumor response was based on clinical and radiological (mammogram and ultrasound) changes.&#x2028; Results: Characteristics of the 204 selected patients (pts) were: median age: 67.3 yrs (range 34-80) (non menopausal: 5.4%); median clinical tumor size: 4.5 (3.6-8.5) cm; median ultrasound tumor size: 2.7 (1.6-5.3) cm; 77.5% T2 and 22.5% T3; 7% invasive lobular carcinomas, 93% invasive ductal carcinomas; mSBR grade: 24% grade I, 54% grade II, 22% grade III; ER+/PR+: 58%, ER+/PR-: 33%, ER-/PR+: 9%. Most pts received tamoxifen : 178 cases (88%) vs aromatase inhibitor: 24 (12%) (other:1).&#x2028; Breast-conserving treatment could not be proposed in 96 cases (47%) because of insufficient tumour response (64 cases, 31%) or disease progression (19 cases, 9%). In 13 other cases, multifocality or diffuse microcalcifications were secondary revealed. Breast-conserving treatment could be proposed to 108 pts (53%) (58% for T2 vs 35% for T3, p=0.005). In this group, median duration of endocrine treatment before local treatment was 7.3 months (3.2-38). Patey was however performed in 7 pts because of patient choice (4 pts) or positive margins at lumpectomy (3 pts). Conserving treatment was finally performed in 101 pts (49%): lumpectomy followed by irradiation in 70 pts and exclusive irradiation in 31 pts because of contra-indication to surgery (13 pts), complete remission (13 pts) and/or patient willingness (7 pts).&#x2028; With a median follow-up of 14 years, 5-yrs and 10-yrs metastatic relapse free rate were 78% and 63%. For the subgroup of breast-conserving treatment, 5-yrs and 10-yrs local relapse free rate were 97% and 85%.&#x2028; Conclusions: NET is confirmed as being an effective neoadjuvant treatment to be discussed as an alternative to chemotherapy in cases of hormone-sensitive low-grade tumors. When endocrine therapy renders suitable breast-conserving treatment, local relapse rate is low.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5106.

[Male breast cancer: a review of 52 cases collected at the Institute Bergonié (Bordeaux, France) from 1980 to 2004]

OBJECTIVES

To analyze the characteristics and to establish prognosis factors for 52 men suffering from breast cancer from 1980 to 2004.

PATIENTS AND METHODS

Men treated for breast cancer (invasive or in situ). A retrospective study analyzed clinical and histological characteristics, and treatment procedures. The probability of survival or recurrence was calculated using the Kaplan-Meier method. Prognostic factors were studied using the Log Rank test.

RESULTS

The mean age of our patients was 63.5 years old. In 73.1% of cases, subaerolar tumors were the initial symptoms, the average size was 30.31 mm. Among patients, 17 (32.7%) had T1, 19 (36.5%) T2, two (3.8%) T3 and 14 (26.9%) T4. The most represented histological type was the infiltrative ductal carcinoma (84.6%). The spread rate to axillary lymph nodes was 63.6%. The hormone dependency of these tumors was proven in 84.6% of cases. Overall survival rate were about 69% at five years and 32% at 10 years. The spread to lymph node and to derm, the clinical stage were significant factors influencing disease free survival. None of these factors had any significance regarding overall survival.

DISCUSSION AND CONCLUSION

Male breast cancer is a rare disease (about 1% of breast cancer) with a poor prognosis (32% 10 years disease free survival). An early diagnosis and better knowledge of the disease would certainly lead to improvement of prognosis.

[Breast cancer in the elderly]

Breast cancer is the most commonly diagnosed cancer and leading cause of cancer mortality in women worldwide. The elderly comprise a large part of the breast cancer population, and there are important specific considerations for this population. Late diagnosis and substandard local and systemic therapies are frequent, which is only partially "compensated" by a more indolent tumour behaviour due to the increasing likelihood according to age of potentially hormone sensitive tumour status. Endocrine treatment remains a key component of systemic treatment in both advanced and early setting. However chemotherapy is a valid option, with interest strengthened by proven efficacy in adjuvant setting for aggressive phenotypes, better management of side effects and attempts to develop predictive index for toxicity. The recently reported laboratory studies on potential mechanisms for resistance to endocrine therapies that involve crosstalk between growth factor signalling pathways and hormonal receptors stimulate also new therapeutic approaches.

Administration of further chemotherapy (CT) after capecitabine as first-line chemotherapy (CT) for metastatic breast cancer (MBC)

1095

Background: Based on results of randomized trials of Xeloda (X) vs CMF or taxanes (T) as first-line CT for MBC, very favorable tolerability, and patients’ (pts) preference for oral therapy, front-line X is now often used in our institution, especially for slowly progressing disease. As other CT regimens, especially T, have demonstrated improved OS, we analyzed post-X CT in these pts. Methods: Analysis was restricted to pts who began X before Jan 05, all of whom have now discontinued because of progression or toxicity. Results: In 90 eligible pts, median TTF and OS from initiation of X are 9 [95% CI 7–11] and 26 [22–30] months, respectively. 75% of pts received second-line CT. Three subgroups can be analyzed: (A) 65 pts (median age 58y, range 34–84) received further CT (median 2 regimens, range 1–6) after stopping X, including T (85% of pts), anthracycline (a/c: 42%), vinorelbine (45%), or mitomycin C (20%). 24 pts received =2 regimens including a/c and T; 7 pts received neither T nor a/c (vinorelbine, n = 6; UFT, n = 1). Median OS from initiation of X was 30 months [95% CI 27–32]. 30 pts are alive after a 16-month median follow-up since X failure; they may receive another CT; (B) 3 pts are currently receiving endocrine therapy after X failure and may receive another CT later; (C) 22 pts (24%) (median age 77y, 19 =70y) died without receiving further CT. Median OS from initiation of X was 11 months (range 0.5–23). 4 of these pts (aged 57, 71, 74, and 84y) received endocrine therapy for 2–10 months. Ability to administer further CT varies with age: of pts <75y, 89% received subsequent CT (T: 75%), whereas 37% of pts =75y received second-line CT. Conclusions: TTF and OS indicate that capecitabine is very active as first-line CT for MBC. For a large majority of pts <75y, first-line X does not compromise administration of further CT including T.

No significant financial relationships to disclose.

Capecitabine (X) monotherapy as first-line chemotherapy (CT) for metastatic breast cancer (MBC): High efficacy regardless of prior therapy

1092

Background: X is one of the most active agents in pretreated MBC. Data on X monotherapy as first-line CT are limited, although a recent randomized phase III trial showed a survival benefit vs oral CMF (Stockler et al SABCS 2006). We retrospectively analyzed MBC pts receiving first-line X at our institution. Methods: Between 01/2002 and 09/2006, 167 pts received X (bid, days 1–14 q3w). Response classifications (improvement in disease [ID], stable disease [SD], or progressive disease [PD]) were as described by Hennessy et al (Ann Oncol 2005). Results: Median age was 68 years (range 34–91). Prior adjuvant therapy included CT in 47% and tamoxifen in 49% of pts. Median interval between initial surgery and MBC was 4.4 years (range 0–39). Before X, most pts (79%) had received endocrine therapy (ET) for MBC (median 2 lines, median duration 2.1 years). Median no. of metastatic sites was 2; bone and visceral metastases were each present in 60% of pts. The initial X dose was 1,500–2,500mg/d in 23%, 3,000mg/d in 47%, and 3,150–4,800mg/d in 29% of pts. ID was seen in 57% of pts (median duration 11.7 months [95% CI 3.8–28.6]). A further 20% had SD for =6 weeks. Median time to X failure (TTF) and OS were 9.0 [95% CI 7.1–11.0] and 25.8 months [95% CI 22.1–29.5], respectively. None of the following influenced TTF: age (<70/=70y), prior adjuvant CT (yes/no), prior ET for MBC (no/<12m/=12m), visceral disease (yes/no), initial dose (<3,000/3,000/>3,000mg). Toxicities were typical of X monotherapy. X was continued for =12 months in 46 pts without cumulative toxicity. Conclusions: X appears highly active as first-line CT for MBC pts, including those who had received ET for MBC and/or adjuvant CT. Long-term treatment is well tolerated. The safety profile is consistent with previous reports. High activity, oral administration, lack of alopecia, and low hematologic toxicity make X a very attractive first- line CT for slowly progressing disease and/or after ET failure.

No significant financial relationships to disclose.

Predictors of early relapse in postmenopausal women with hormone receptor-positive breast cancer in the BIG 1-98 trial

BACKGROUND

Aromatase inhibitors are considered standard adjuvant endocrine treatment of postmenopausal women with hormone receptor-positive breast cancer, but it remains uncertain whether aromatase inhibitors should be given upfront or sequentially with tamoxifen. Awaiting results from ongoing randomized trials, we examined prognostic factors of an early relapse among patients in the BIG 1-98 trial to aid in treatment choices.

PATIENTS AND METHODS

Analyses included all 7707 eligible patients treated on BIG 1-98. The median follow-up was 2 years, and the primary end point was breast cancer relapse. Cox proportional hazards regression was used to identify prognostic factors.

RESULTS

Two hundred and eighty-five patients (3.7%) had an early relapse (3.1% on letrozole, 4.4% on tamoxifen). Predictive factors for early relapse were node positivity (P < 0.001), absence of both receptors being positive (P < 0.001), high tumor grade (P < 0.001), HER-2 overexpression/amplification (P < 0.001), large tumor size (P = 0.001), treatment with tamoxifen (P = 0.002), and vascular invasion (P = 0.02). There were no significant interactions between treatment and the covariates, though letrozole appeared to provide a greater than average reduction in the risk of early relapse in patients with many involved lymph nodes, large tumors, and vascular invasion present.

CONCLUSION

Upfront letrozole resulted in significantly fewer early relapses than tamoxifen, even after adjusting for significant prognostic factors.

[Diagnosis and treatment of soft-tissue tumors]

The diagnostic and therapeutic management of patients with soft-tissue tumors would be similar to the approach used for bone tumors if it were not for one crucial factor: the absolute necessity to recognize a sarcoma. The predominant features are the size of the tumor and its superficial or deep localization. If the tumor is small and superficial, biopsy can be associated with immediate resection without risk of dissemination to the deep tissues: this is the biopsy-resection approach. If the tumor is deep or superficial but large sized, search for locoregional spread with MRI is necessary before undertaking any surgical procedure. MRI can help guide the biopsy and plan resection if the tumor is a sarcoma. A first biopsy is necessary to establish the histological diagnosis and elaborate the therapeutic strategy. Samples should be sent immediately to the pathology lab which should examine sterile fresh tissue. Experience has demonstrated that proper rules for diagnosis and treatment are not necessarily applied initially in approximately one-fourth of all subjects with a malignant soft-tissue tumor. Besides the medical problems caused by this situation, the patient loses a chance for cure. When the tumor is a sarcoma, surgery is the basis of treatment. Complementary radiation therapy may be necessary, particularly for high-grade tumors or if the surgical margin was insufficient. Systemic or locoregional chemotherapy can also be used for high-grade or non-resectable tumors.

[Bilateral ductal carcinoma in situ of the breast: independent events or bilateral disease?]

OBJECTIVES

In a retrospective study of bilateral Ductal Carcinoma In Situ (DCIS), cases were analysed to determine the relationship between the two events.

MATERIAL AND METHODS

From 1971 to 2001, among 812 patients with DCIS in Bergonie Institute, 78 suffering from bilateral DCIS and only19 were treated entirely in our institute. It was either synchronous DCIS or asynchronous (before 6 months). We realised a comparative study between, clinical and pathological characteristics of each DCIS.

RESULTS

In case of asynchronous DCIS, contra lateral DCIS occurred after a median 75-months period and until 22 years after the first event. We found at least for one histological subtype an agreement in 53% of cases. In 31% of cases, the grade was the same. For low plus intermediary grade versus high grade, the agreement was 53%. There was a subtype and grade agreement of 32% and a subtype or grade agreement in 63% of cases.

CONCLUSION

Histological agreement between the two lesions indicated the possible existence of in situ bilateral disease in these women. The local relapse rate was 20% and all of them were invasive. The risk of relapse in controlateral breast is high and patient needs a long follow up even in case of mastectomy.

Prognostic factors of early distant recurrence in hormone receptor-positive, postmenopausal breast cancer patients receiving adjuvant tamoxifen therapy

BACKGROUND

Current adjuvant hormone therapy in postmenopausal women with breast cancer is debatable between upfront aromatase inhibitors (AIs) and sequential treatment with tamoxifen. A major concern is the higher rate of early recurrences observed with sequential treatment. The authors conducted a retrospective analysis to identify risk factors of early recurrences in hormone receptor (HR)-positive, postmenopausal women within the first 3 years of adjuvant tamoxifen.

METHODS

Between 1986 and 2000, operable breast cancer patients who received exclusively adjuvant tamoxifen for at least 3 years were selected from the authors' institutional database. Age, histology, pathologic tumor size, modified Scarff-Bloom-Richardson (mSBR) grade, mitotic index, tumor necrosis, peritumoral vascular emboli (PVE), HR status, and the number of involved axillary lymph-node were considered as prognostic factors of recurrence.

RESULTS

Among 715 patients who met the inclusion criteria, a distant recurrence occurred in 38 patients (5.3%) within the first 3 years of tamoxifen therapy. Significant prognostic factors of early recurrence were mSBR, axillary lymph node involvement, tumor necrosis, mitotic index, PVE, and pathologic tumor size. Grade 1 and/or lymph node-negative tumors were excluded from the multivariate analysis (1 recurrence in 208 patients). In this model, mSBR grade 3 was the only significant predictive factor of early recurrence (hazard ratio, 3.72; P<.001).

CONCLUSIONS

In this study, a subset of patients was identified that was at low-risk of early recurrence (mSBR grade 1 and/or negative lymph node status). Women in that subset could be treated using sequential hormone therapy with tamoxifen and AIs. In women with mSBR grade 3 or lymph node-positive tumors, an upfront treatment with AIs seemed to be the current optimal strategy.

Celecoxib (Ce) + exemestane (Ex) versus placebo + Ex in post-menopausal (PM) metastatic breast cancer (MBC) patients (pts): A double-blind phase III GINECO study

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Background: in vitro and in vivo studies suggest that COX-2 inhibitors have proper antitumor effect and could enhance the activity of aromatase inhibitors (AI). Methods: PM first-line MBC pts without previous adjuvant AI were randomized to receive per os until progression either A: Ce (400 mg bid) + Ex (25mg/d) or B: placebo (1 tablet bid) + Ex (25mg/d). PFS was the main end-point. The trial was prematurely stopped (Dec 2004) with 157/342 pts enrolled (A: 74, B: 83 pts) after occurrence of Ce cardio-vascular toxicity in other trials. Results: patient (median age, A:61, B:63 yrs) characteristics were well balanced between A and B (%) : ER and/or PR positive (93, 94), HER2 positive (4, 5), adjuvant chemotherapy (45, 53) or tamoxifen (57, 61), ECOG PS 0–1 (90, 90), visceral (63, 53) or bone involvement (35, 41). Tolerance: compared to placebo (B), pts treated with Ce (A) experienced less gr 2–3 CTCAE: pain (A:52, B:63%), arthralgias (19, 28), asthenia (20, 30), Gr 1–3 insomnia (32, 47), but more hypersentivity reactions (7,0) and oedema (8, 2). Gastro-intestinal toxicity was not increased in A. One episode of paroxystic arythmia occurred in the Ce arm, without complication in a patient with known cardiopathy. Overall response rate was significantly higher in A (35 vs 20%, p=.034). Median PFS in intent-to-treat analysis was similar in A (9.8 months) and B (9.8), but tend to be superior in A (A:12.2, B:9,8, p=.09) in pts who were included at least 3 months before early trial stopping. In addition, PFS was significantly longer in pts treated with Ce +Ex (A: 8.4 months, B: 4.7, p=.019) in the subgroup of pts who developed MBC under Tam or within 12 months after Tam stopping (A: 26, B: 29 pts). Conclusion: The combination of celecoxib and exemestane is promising and should be further explored in MBC with adequate cardiac monitoring.

No significant financial relationships to disclose.

Intense paraneoplastic neutrophilic leukemoid reaction related to a G-CSF-secreting lung sarcoma

A white blood cell count more than 50 x 10(9)/l, not related to bone marrow involvement, is termed leukemoid reaction. We report on the first case of an undifferentiated sarcoma of the lung associated with an intense paraneoplastic neutrophilic leukemoid reaction related to the production of granulocyte colony-stimulating factor (G-CSF). A radiography and a computed tomography scan of the chest revealed a well-limited voluminous and heterogeneous low-density mass of the left lung. The patient died of multiorgan failure related to uncontrolled progressive tumor growth after admission and two cycles of chemotherapy. The patient's G-CSF serum concentration was dramatically elevated (6,538 pg/ml) compared to serum levels observed in normal controls and patients with elevated leukocytosis (31 and 387 pg/ml, respectively). The G-CSF concentration dramatically increased after the first cycle of chemotherapy and during the subsequent neutropenia, as a result of the tumor lyses as well as of disruption of the physiological negative feedback mechanism. Adjunction of the patient's serum to CD34+ cell cultures induced a 12.3-fold increase in CD15+ cells, demonstrating the serum's capacity to induce myeloid differentiation.

When will more useful predictive factors be ready for use?

Adjuvant chemotherapy is widely used, but its performance is not optimal. Two subgroups of patients do not get any benefit from adjuvant chemotherapy: the first one comprises patients who are already cured by locoregional treatment alone and the second one patients who do not profit from adjuvant chemotherapy because of resistance to the regimens employed. To improve the cost/benefit of this treatment strategy, we have two means: one is to improve the sensitivity of prognostic factors to be able to select a specific group with a good signature that does not need adjuvant treatment; the second is to identify predictive factors that may help us to select the optimal therapeutic strategy or the optimal regimen or drug for individual patients. New technologies of microarray revealed several genetic profiles. A large randomized trial (Microarray In Node-negative Disease may Avoid ChemoTherapy, MINDACT) will compare the information obtained with the genomic profiling and the classical clinico-pathologic index (St Gallen); the objective is to allow women not to be treated with adjuvant chemotherapy if their genomic signature is good. Another trial (EORTC 10994) is conducted in order to show that in cases of p53 mutated tumors, neoadjuvant chemotherapy with docetaxel is more efficient than an anthracycline-containing regimen. A supplementary study will evaluate gene profile predicting for p53 status. So, new genomic prognostic factors are still in development and seem very promising for optimizing the indications for adjuvant chemotherapy.

Subcutaneous interleukin-2, interferon alpha-2b and 5-fluorouracil in metastatic renal cell carcinoma as second-line treatment after failure of previous immunotherapy: a phase II trial

The association of interleukin-2 (IL-2), interferon alpha-2a (IFNalpha), 5-fluorouracil (5-FU) has been reported to induce response in metastatic renal cell carcinoma (MRCC). This study evaluated IL-2, IFNalpha and 5FU as second-line treatment after failure under immunotherapy. A total of 35 patients received IL-2, at 9 x 10(6) IU m(-2), once or t.i.d, 5 days a week, every other week. Interferon alpha was administered at 6 MUI, TIW along with IL-2 every week. 5-Fluorouracil was given at 750 mg m(-2) day(-1) on days 1-5 every 4 weeks. One cycle lasted 8 weeks. All patients were evaluable for response and toxicity. There were two objective responses (5.7%) and 14 stable diseases (40%). Survival was 14 months. In all, 17 patients experienced grade 3 toxicity. The predictive factor for progression to second-line immunotherapy was the results of first-line immunotherapy, and performance status, delay from primary tumour to metastases and response or stabilisation to chemo-immunotherapy for survival. IL-2, IFNalpha and 5-FU induce low objective response but stabilisation in patients with MRCC having failed with immunotherapy, and may be considered only in selected patients on performance status, stabilisation or response after first-line immunotherapy and interval from their primary tumour to metastases.

[Low grade pulmonary sarcoma preceding the discovery of a uterine primary]

INTRODUCTION

Low grade pulmonary sarcomas are very rare tumours. We report the case of a low grade sarcoma of the lung occurring two years prior to the finding of a uterine primary.

CASE REPORT

Complete surgical excision of a low grade pulmonary sarcoma was performed. The initial search for dissemination was negative. Two years later a follow-up scan discovered a uterine mass as well as a para-aortic shadow that proved to be the primary tumour (low grade uterine sarcoma) and a metastasis.

CONCLUSION

This is the second case of a pulmonary metastasis discovered before a primary low grade uterine sarcoma. The first was found during the investigation of a pulmonary sarcoma. The main differential diagnosis to consider is metastatic leiomyosarcoma. In both cases their finding justifies the search for a uterine primary by immunohistochemical examination for oestrogen and progesterone receptors as well as pelvic ultrasound or even magnetic resonance imaging.