OT3-02-02: Yoga Compared to Exercise as a Therapeutic Intervention during (Neo)adjuvant Chemotherapy in Women with Stage I-III Breast Cancer

Background: Psychological and physical distress is high in breast cancer patients receiving neoadjuvant or adjuvant chemotherapy. The ***patients'ability to cope with this distress has an impact on treatment variables, i.e. deliverable chemotherapy dose, tolerabilty of side effects, and finaly treatment completion rate. Exercise intervention studies have shown physiological and psychological benefits when undertaken during cancer treatment. There is also evidence that mind/body interventions such as yoga are useful to manage treatment-related symptoms and anxiety in breast cancer patients. Considering the specific theoretical background of mind/body interventions this ongoing trial aims to elucidate the different effects of yoga and conventional exercise on physical and psychological factors in breast cancer patients undergoing neoadjuvant or adjuvant chemotherapy. Trial design: Longitudinal data collection within an open, prospective, randomized trial using standardized questionnaires about inner correspondence and peacefulness with practices (ICPH), health-related quality of life (EORTC QLC C-30), fatigue (Cancer Fatigue Scale, CFS-D), mindfulness (Freiburg Mindfulness Inventory, FMI), spiritual/religious attitudes and disease coping (SpREUK), and life satisfaction (Brief Multidimensional Life Satisfaction Scale, BMLSS). Patients with newly diagnosed stage I-III breast cancer undergoing neoadjuvant or adjuvant chemotherapy are randomly assigned to receive yoga or conventional exercise on a 1:1 ratio. The yoga intervention consists of a weekly 60-minute Iyengar-Yoga group-session together with individual home-based, selfcontained 20-minute sessions twice a week. The conventional exercise intervention consists of a weekly 60-minute physiotherapy exercise session together with individual home-based, selfcontained 20-minute sessions twice a week. Data assessments via questionnaires are done at baseline, right after the 12-week intervention period and 2 months after the end of intervention. Statistical analysis includes analysis of variance with all collected parameters and analysis of correlation between ICPH and above parameters. For statistical power 1-β=0.8 and twosided probability of error a=0.05 the target accrual is 120 patients. Patient accrual within two breast care units started in April 2011 with 12 patients being on study to date (2011, June 21). Planned period of accrual is 20 months.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT3-02-02.

Effect of cyclooxygenase inhibition on CXCR3 ligand secretion in breast cancer

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Background: In murine cancer models, the two IFN-γ inducible chemokines CXCL9 and CXCL10, those bind to the common receptor CXCR3, recruit NK cells and tumor-suppressive lymphocytes into the tumor site and impair tumor growth and metastatic spread. In human breast cancer (BC), we and others have shown that high levels of CXCL9 mRNA correlate with favorable prognosis and the number of infiltrating lymphocytes. Raising the intratumoral level of CXCR3 ligands might therefore be a feasible way to enhance the infiltration by tumor-suppressive immune cells and to improve immune intervention in breast cancer. Inhibition of cyclooxygenases (COX) has been shown to inhibit tumor growth and metastases formation in a lymphocytic and IFN-γ dependent manner. We therefore tested whether COX inhibition induces CXCR3 ligand secretion from breast cancer cells.

Methods: Human MCF-7 and MDA-MB 231 BC cells were stimulated with IFN-γ with or without prostaglandin E2 (PGE2) or COX inhibitors (indomethacin, aspirin, celecoxib). CXCL9 and CXCL10 release was measured by ELISA. COX-1 and COX-2 expression was measured in 45 BC samples and correlated with intratumoral CXCR3 ligand concentration.

Results: Prostaglandin E2 inhibits CXCL10 and CXCL9 release from breast cancer cells. Aspirin and indomethacin enhance the INF-γ mediated secretion of these CXCR3 ligands by inhibition of endogenous cyclooxygenases. Celecoxib has this effect only at low concentrations, at higher concentrations is shows PGE2 agonistic effects. In human breast cancer samples, COX-2 overexpression inversely correlates with CXCR3 ligand concentration, which shows that the mechanism of PGE2 induced CXCL9/CXCL10 suppression might also be relevant in vivo.

Conclusions: Suppressing endogenous PGE2 by cyclooxygenase inhibition increases CXCL9 and CXCL10 release from breast cancer cells and is therefore a feasible way to enhance the infiltration of breast tumors by tumor-suppressive lymphocytes. However, our results show that unselective COX inhibitors might be more suitable than the COX-2 specific celecoxib. Clinical trials are now warranted to clarify the mechanisms and therapeutic efficacy of COX inhibition in breast cancer.

Breast cancer after hormone replacement therapy--does prognosis differ in perimenopausal and postmenopausal women?

Hormone replacement therapy (HRT) has been associated with higher incidence of breast cancer in postmenopausal women, but it is unclear if breast cancers developing after HRT use have different prognosis. 1053 women with hormone receptor positive non-metastasized breast cancer were analyzed in a retrospective trial, stratifying by HRT use before diagnosis. Postmenopausal HRT users had significantly more early tumor stages (p<0.001). HRT in postmenopausal patients was associated with longer time to progression (TTP) (HR 0.81, 95%CI 0.55-1.19, p=0.28) and overall survival (OS) (HR 0.68, 95%CI 0.45-1.02, p=0.059). Perimenopausal HRT users showed shorter TTP and OS (HR 1.99, 95%CI 0.57-6.91, p=0.28 and HR 4.59, 95%CI 0.91-23.25, p=0.06 respectively). Higher BMI was significantly associated with poorer prognosis in perimenopausal women only (TTP: HR=1.16; OS: HR=1.31). In this retrospective analysis postmenopausal HRT users seemed to have a better breast cancer prognosis. For perimenopausal HRT users however, a trend towards worse prognosis was found.

Circulating biomarker tissue kallikrein-related peptidase KLK5 impacts ovarian cancer patients' survival

BACKGROUND

Effective cancer biomarkers for early detection, prognosis, or therapy response prediction are urgently needed in ovarian cancer. Kallikrein-related peptidases, including KLK5, have been reported to play an important role in the course of the disease.

PATIENTS AND METHODS

KLK5 antigen content was determined by enzyme-linked immunosorbent assay in ovarian cancer patients' [FIGO (International Federation of Gynecology and Obstetrics) stages I-IV, n = 52] serum as well as ascitic fluid and compared with KLK5 content in serum of patients with benign ovarian tumors (n = 45).

RESULTS

KLK5 antigen content was significantly elevated in the serum of ovarian cancer patients compared with the serum of patients with benign ovarian tumors. Forty-two of 52 ovarian cancer serum samples, 42 of 43 benign ovarian tumor serum samples, and all 41 ascitic fluid samples were KLK5 positive. Elevated KLK5 antigen in serum and ascitic fluid of ovarian cancer patients was a prognostic factor for progression-free survival.

CONCLUSIONS

Our data support the finding that ovarian cancer patients release significant amounts of KLK5 into serum and ascitic fluid but KLK5 antigen is low in serum of patients with benign ovarian tumors. Increased serum and ascitic fluid KLK5 levels are associated with poor patient outcome, thus underlining the importance of KLK5 as a biomarker for early detection as well as for disease management in ovarian cancer.

Abstract P1-01-22: Use of Freehand SPECT for 3D Navigated Radio-Guided Axillary Sentinel Lymph Node Biopsy and Quality Assurance in Breast Cancer Surgery

Background: The sentinel lymph node (SLN) concept in breast cancer is an integral standard of care. However, several practical issues have been raised preventing proper identification of the sentinel node in certain clinical scenarios. Moreover, the criteria for definition of sentinel node have recently been questioned, including the value of dynamic information or the value of preoperative lymphoscintigraphy. The problems behind some of these questions rely on the impracticability to incorporate the preoperative imaging information into the operative procedure of sentinel lymph node biopsy (SLNB).

Methods: For the freehand SPECT (fhSPECT, SurgicEye Germany) acquisition a gamma probe system and an infrared optical tracking system were combined in one system including a data processing unit in order to acquire the readouts of the probe and the position synchronously, process the readings into a 3D image and display them for the user. To date, 20 patients with invasive breast cancer undergoing SLNB were recruited and scanned intraoperatively using fhSPECT before excision of SLNs. The localization of SLNs with fhSPECT was compared to the position of SLNs detected using gamma probe and blue dye. FhSPECT was further used to prove the excision of the SLN postoperatively. Preoperative planar scintigraphy was used as a reference.

Results: Preoperatively, 38 SLNs were mapped with conventional scintigraphy. In the pre-excision scan (performed in 19 of 20 patients) fhSPECT managed to map all but 3 SLNs in the identical position as compared to node location at planar scintigrams (34/37). Only in 1 patient fhSPECT did not find any SLN in the pre-excision scan. Gamma probe failed to detect any SLNs in 2 patients and mapped in total 30 of 38 nodes. 28 SLNs were resected and confirmed to be radioactive ex-vivo. fhSPECT detected 11 SLNs in 11 patients after primary SLN excision. In 4 cases additionally detected nodes were resected and confirmed to be radioactive, while in 7 cases harvesting of the additionally detected node was discarded as higher uptake SLNs had been removed already. In the remaining 9 patients no residual radioactivity was found in the axilla. Pre-excision fhSPECT acquisitions took approx. 3.1min (SD, 1.1min) while post-excision scans took 3.2min (SD, 0.9min). The surgical procedure was extended by 12min (6min before incision and 6min after excision of SLNs).

Discussion: Intraoperative 3D imaging with fhSPECT for lymphatic mapping in breast cancer patients is feasible. Identification of the SLN can be repeated at any time during surgery to guide proper and precise resection of the sentinel node(s). For quality assurance the system can digitally document that all SLNs have been successfully removed. The freehand SPECT provides also new options concerning the above stated controversies in the principal sentinel lymph node concept. Controlled studies using 3D intraoperative imaging could help to clarify many of the discussed issues, including the role of lymphatic uptake on selecting the nodes for surgical resection. Also, the option to transfer dynamic information from preoperative imaging into the OR or the possibility to skip preoperative imaging bears additional advantages over the standard procedure.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-22.

Abstract P3-11-06: Tumor Characteristics and Prognostic Factors in Nodal Positive Early Stage Breast Cancer of Obese Patients — Sub Analysis of the German ADEBAR Study

Background:

Obesity is often associated with an increased risk of dying from breast cancer and poor outcomes of therapy. There are several possible explanations for this phenomenon.

The aim of this analysis was to examine the correlation and potential causality between overweight, obesity and breast cancer. Tumor size, tumor histology, tumor grading and tumor localisation, number of positive lymph nodes, patients age, menopausal status, hormone receptor and HER-2 status are relevant characteristics in prognosis and treatment of breast cancer and at the same time potentially strongly associated with the body mass index.

Patients and Methods:

The ADEBAR study is a german multicenter phase III trial (n=1502). Study-goal was to evaluate whether breast cancer (BC) pts with &gt; 3 axillarylymph node metastases benefit from a sequential anthracycline-docetaxel regimen (E90C-D: 4 cycles epirubicin [E] 90 mg/m2 plus cyclophosphamide [C] 600 mg/m2 q21 days followed by 4 cycles docetaxel [D] 100mg/m2 q21 days) compared to dose-intensive anthracycline-containing polychemotherapy (FE120C: 6 cycles E 60 mg/m2 d 1+8, 5-FU 500mg/m2 d 1+8 and C 75 mg/m2 d 1-14, q4 weeks). For our evaluation at hand Adebar-Patients were grouped according the WHO global database on body mass index (BMI) into normal range (18,50 - 24,99 kg/sqm) and obese (≤30,00 kg/sqm) high risk patients. Results:

There is a strong correlation between body mass index, age and menopausal status at clinical diagnosis of breast cancer. Obese patients (n=300) at diagnosis in median are 55 years old (range 27-71 year) and already postmenopausal (52%, n=209). This analysis shows no connection of tumor localisation (unilateral left or right and bilateral breast cancer) and BMI.The tumor size at clinical diagnosis was strongly associated to the patient's weight (&lt;0.0001). Breast tumors in obese patients have shown a size &gt;3cm in 61 % (n=184) and a size &gt;5cm in 16% (n=47). In normal weight and obese patients there was no sign for a significant difference in the number of positive lymph nodes (p=0.0440), tumor histology (p=0.8028) and grading (p=0.7353). Breast Cancer positivity for ER and PR hormone receptors (ER p=0.7364, PR p=0.4405) and the expression of HER-2 at the tumor surface (p=0.1560) were not significant associated to obesity in study patients. Conclusion:

Our sub analysis between normal weight and obese patients shows a highly significant coherence between body mass index and tumor size in patients with early stage node positive breast cancer.This finding is in line with current publications which show that overweight and obese woman have often been diagnosed at a more advanced stage of disease and the treatment in this patients being less effective as a consequence. Weight reduction and tumor prevention in this high risk collective might be an additional approach on breast cancer therapy.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-11-06.

Impact of expression differences of kallikrein-related peptidases and of uPA and PAI-1 between primary tumor and omentum metastasis in advanced ovarian cancer

BACKGROUND

Primary tumor levels of serine proteases of the kallikrein-related peptidases (KLK) family as well as urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1 impact disease course in ovarian cancer. The changes in levels of these factors from primary tumor to omentum metastasis ('level differentials') could thus be associated with metastastic processes.

PATIENTS AND METHODS

Protein levels of seven tissue KLK (KLK5-8, 10, 11, 13), uPA, and PAI-1 were determined in extracts of primary tumor tissue and corresponding omentum metastasis of 54 ovarian cancer patients.

RESULTS

Higher level differentials of KLK5-8, 10-11, and uPA were associated with residual tumor >10 mm. Residual tumor and larger level differentials of KLK5-7, 10, and uPA were associated with disease progression in the whole cohort. Remarkably, level differentials of KLK5-8 and 10-11 strongly impacted disease progression even in patients with residual tumor mass ≤10 mm; hence, the observed impact of level differentials in KLK5-7 and 10 on disease progression was not simply attributable to their association with surgical success.

CONCLUSION

Since they impact both surgical outcome and survival in advanced ovarian cancer, measurement of level differentials could support clinical decisions on surgical and systemic therapy or help in patient selection for novel targeted therapies.