Relationship of clinical and pathologic response to neoadjuvant chemotherapy and outcome of locally advanced breast cancer

Histopathologic and Metabolic Criteria for Assessment of Treatment Response in Breast Cancer

Increasing use of neoadjuvant chemotherapy in locally advanced breast cancer necessitates methods for evaluation of therapeutic response. Histopathology provides accurate assessment of treatment efficacy but only approximately 20% of breast cancer patients achieve complete pathologic response after neoadjuvant chemotherapy. Therefore, methods that predict therapeutic effectiveness could help individualize treatment and avoid ineffective chemotherapies. Metabolic imaging using positron emission tomography (PET) and F-18 fluorodeoxyglucose (FDG) seems to provide early response assessment in vivo. Change in FDG uptake after chemotherapy initiation correlates with histopathologic response after completion. PET response assessment criteria and imaging protocols need to be developed and validated. This article compares complementary approaches for assessment of treatment response, namely histologic features of the tumor on the microscopic level versus in vivo metabolic changes on a macroscopic level.

Quantification of the response of circulating epithelial cells to neodadjuvant treatment for breast cancer: a new tool for therapy monitoring

INTRODUCTION

In adjuvant treatment for breast cancer there is no tool available with which to measure the efficacy of the therapy. In contrast, in neoadjuvant therapy reduction in tumour size is used as an indicator of the sensitivity of tumour cells to the agents applied. If circulating epithelial (tumour) cells can be shown to react to therapy in the same way as the primary tumour, then this response may be exploited to monitor the effect of therapy in the adjuvant setting.

METHOD

We used MAINTRAC analysis to monitor the reduction in circulating epithelial cells during the first three to four cycles of neoadjuvant therapy in 30 breast cancer patients.

RESULTS

MAINTRAC analysis revealed a patient-specific response. Comparison of this response with the decline in size of the primary tumour showed that the reduction in number of circulating epithelial cells accurately predicted final tumour reduction at surgery if the entire neoadjuvant regimen consisted of chemotherapy. However, the response of the circulating tumour cells was unable to predict the response to additional antibody therapy.

CONCLUSION

The response of circulating epithelial cells faithfully reflects the response of the whole tumour to adjuvant therapy, indicating that these cells may be considered part of the tumour and can be used for therapy monitoring.

Lymphatic mapping and sentinel lymphadenectomy prior to neoadjuvant chemotherapy in patients with large breast cancers

BACKGROUND

Lymphatic mapping and sentinel lymphadenectomy (LM/SL) accurately evaluates the axilla in patients with small breast cancers. LM/SL in patients with large breast cancers is controversial. We examined the accuracy of LM/SL prior to neoadjuvant chemotherapy in patients with large (>3.5 cm) breast cancers.

METHODS

Patients with large breast cancers underwent LM/SL prior to neoadjuvant chemotherapy using 99m-technetium radiocolloid and isosulfan-blue dye technique.

RESULTS

Twenty-one patients with large (median 5.0 cm) breast cancers underwent LM/SL prior to neoadjuvant chemotherapy. Twelve patients had a tumor-free sentinel node (SN) and received doxorubicin-based chemotherapy; 9 patients had disease in the SN and received doxorubicin followed by a taxane. No patient progressed while receiving neoadjuvant chemotherapy, nor has there been an axillary recurrence (median 36 months).

CONCLUSIONS

LM/SL performed prior to neoadjuvant chemotherapy in patients with large breast cancers is an accurate method of axillary staging. Axillary staging prior to neoadjuvant chemotherapy may have prognostic and therapeutic implications.

Breast Conservation After Neoadjuvant Chemotherapy

BACKGROUND

Tumor downstaging by preoperative neoadjuvant chemotherapy in patients with locally advanced breast tumors allows breast conservation in women who were previously candidates for mastectomy. Nevertheless, lumpectomy success in such cases cannot be fully achieved. The aim of this study was to create a quantitative tool for preoperative evaluation of the success of breast conservation in such patients.

METHODS

The study population included 100 consecutive patients with stage II and III breast cancer who were designated for lumpectomy and 19 patients who were designated for mastectomy. All patients received neoadjuvant therapy. Breast-conserving surgery was offered in accordance with clinical and esthetic criteria. Demographic details and clinical, imaging, and pathologic information were collected from medical files. A decision protocol for classifying patients to lumpectomy or mastectomy was built by using the Classification and Regression Trees procedure based on preoperative characteristics.

RESULTS

Three factors were found to be the main predictors for successful breast conservation: absence of diffuse microcalcifications as seen in the pretreatment mammogram, a postchemotherapy tumor size of < 25 mm, and the existence of a circumscribed lesion on mammography.

CONCLUSIONS

The use of these criteria as a basis for decision on the type of surgery may decrease the performance of unnecessary procedures.

Good clinical response of breast cancers to neoadjuvant chemoendocrine therapy is associated with improved overall survival

BACKGROUND

We present extended follow-up from a prospective randomised trial evaluating the role of neoadjuvant chemoendocrine therapy in the treatment of operable breast cancer.

PATIENTS AND METHODS

309 women were randomised to primary surgery followed by eight cycles of adjuvant mitoxantrone, methotrexate with tamoxifen (2MT) or 2MT with mitomycin-C (3MT) versus the same regimen for four cycles before followed by four cycles after surgery. For this analysis the median follow-up of patients was 112 months.

RESULTS

After 10 years follow-up there is still no statistically significant difference in disease-free survival (DFS) (71% versus 71%) or overall survival (OS) (63% versus 70%) when comparing adjuvant versus neoadjuvant treatment, respectively. Of 144 evaluable patients in the neoadjuvant arm, 74 achieved a good clinical response and 70 patients achieved a poor clinical response. Good responders had a superior DFS (80% versus 64%, P=0.01) and OS (77% versus 63%, P=0.03) compared to poor responders.

CONCLUSIONS

At 10 years, neoadjuvant and adjuvant treatment continue to have equivalent OS and DFS. Good clinical response to neoadjuvant chemotherapy is associated with superior DFS and OS. This supports the use of clinical response of primary breast cancer to neoadjuvant therapy as a surrogate marker of survival benefit.

Neoadjuvant Chemotherapy for Locally Advanced Breast Cancer Results in Alterations in Preoperative Tumor Marker Status

Neoadjuvant therapy followed by breast-conserving surgery has become an acceptable option for patients with locally advanced breast cancer. Although a distinct survival benefit has not been demonstrated using this approach, several questions have been raised following such therapy including its effects on receptor status and tumor markers. The current study retrospectively reviews estrogen receptor (ER), progesterone receptor (PR), and HER2-neu status in 55 consecutive patients treated by neoadjuvant chemotherapy. Preoperative and postoperative tumor markers were available for 43 of the 55 patients (78%). The pathologic complete tumor response rate (pCR) for this group was 19 per cent (8/43). Of those patients who did not achieve a pCR (n = 35), a change in tumor markers was seen in 25.7 per cent (9/35) of patients. When compared to a control group not undergoing neoadjuvant therapy, a significantly higher percent change in marker expression was noted in the neoadjuvant group (25.7% vs 5.9%, P = 0.046). ER, PR, and HER2-neu status remain important prognostic indicators for breast cancer. Tumor markers are useful in planning adjuvant therapy regimens. In this review, nearly 19 per cent of patients achieved a pCR. In patients not achieving a pCR, one in four patients had at least one change in tumor marker status. This study demonstrates the importance of establishing receptor and marker status prior to neoadjuvant therapy, as many patients will achieve a pCR and make tumor analysis impossible. Postoperative marker studies should be performed given the possibility of a change in status. The clinical relevance of this data will require further long-term follow-up. Until such data becomes available, caution should be considered when basing adjuvant therapy regimens on preoperative tumor marker studies alone.

Effective Local Control and Long-Term Survival in Patients with T4 Locally Advanced Breast Cancer Treated with Breast Conservation Therapy

BACKGROUND

The presence of skin involvement has been accepted as a relative contraindication to breast preservation because it is believed to be associated with an increased local failure rate. This study was conducted to assess the outcome of a carefully selected group of patients who presented with breast cancer involving the skin and who had breast conservation therapy (BCT) following neoadjuvant chemotherapy.

METHODS

Between 1987 and 1999, 33 patients with stage IIIB or IIIC breast cancer completed treatment consisting of four cycles of neoadjuvant chemotherapy, lumpectomy, radiation therapy, and consolidative chemotherapy. Clinicopathologic factors were analyzed and patients were followed for locoregional and distant recurrence.

RESULTS

Initial median tumor size was 7 cm. All patients had skin involvement, defined as erythema, skin edema, direct skin invasion, ulceration, or peau d'orange. Following chemotherapy, median pathologic tumor size was 2 cm. Complete resolution of skin changes occurred in 29 patients (88%). At median follow-up time of 91 months in surviving patients, 26 patients (79%) were alive without evidence of disease. The 5-year, disease-free survival rate was 70%, and the 5-year overall survival rate was 78%. The actuarial ipsilateral breast cancer recurrence rate was 6% at 5 years.

CONCLUSIONS

Patients who present with T4 breast cancer who experience tumor shrinkage and resolution of skin changes with neoadjuvant chemotherapy represent a select group of patients who can have BCT. These patients have favorable rates of long-term local control and survival. Mastectomy is not mandatory for all patients with breast cancer who present with skin involvement.

Preoperative Chemotherapy and Endocrine Therapy in Patients with Breast Cancer

This review focuses on the aims, results, advantages, and possible disadvantages of preoperative chemotherapy and endocrine therapy. We present the recent improvements in terms of pathologic response rates that have resulted from new combinations of drugs. The change of established prognostic factors during neoadjuvant treatment, the need for new markers, and the consequences in terms of clinical decision-making are demonstrated. We discuss the risk of local relapse after breast-conserving surgery, which was made feasible by preoperative chemotherapy. A short overview of current neoadjuvant cytostatic, endocrine, and immunotherapy trials is provided. Future opportunities for tailoring therapy to each individual patient based on early information from the primary tumor are discussed. Important considerations and results of recent endocrine trials that analyzed possible tamoxifen-resistance in subgroups are reported. New opportunities exist to evaluate the efficacy of new cancer drugs more rapidly in the neoadjuvant setting than in the metastatic and adjuvant setting. This approach offers the possibility of monitoring prognostic markers in the primary tumor before, during, and after treatment with specific chemotherapeutic agents. With respect to recent findings of gene-array techniques, it is likely that the advances in this technology will lead to improved prognostic statements. It will show the influence of therapy on gene expression profiles in the course of treatment and might enable us to identify chemoresistance of specific tumors rather early. This could potentially lead to a new direction of cancer therapy.

Pathologic Changes in Breast Cancer Following Neoadjuvant Chemotherapy: Implications for the Assessment of Response

Neoadjuvant chemotherapy (also known as preoperative or primary chemotherapy) is the treatment of choice for patients with locally advanced breast cancer. One of the main advantages of neoadjuvant chemotherapy is that it allows for assessment of pathologic response to treatment. Clinical and radiologic evaluations of response to neoadjuvant chemotherapy are based on change in tumor size, and the correlation with pathologic response is often inaccurate. Pathologic evaluation of tumor size remains the gold standard for evaluation of residual tumor after chemotherapy. Chemotherapy-induced histomorphologic change is commonly observed in posttreatment resection specimens and can contribute to the less-than-perfect correlation between the clinical assessment of tumor size and the pathologic measurement. Therefore, accurate histologic mapping to the macroscopic and radiologic appearance of the tumor bed is necessary. Cytopathologic changes are also common in residual cancer cells after neoadjuvant chemotherapy and have uncertain clinical relevance. There is a role for the development of new histologic approaches to augment the pathologic and clinical assessment and provide information on the differential response, particularly for tumors in which less than pathologic complete response is achieved.

Measuring response to chemotherapy in locally advanced breast cancer: methodological considerations

In this review the findings of response monitoring studies in breast cancer, using [(18)F]2-fluoro-2-deoxy-D-glucose (FDG) and positron emission tomography (PET), are summarised. These studies indicate that there is a strong relationship between response and decrease in FDG signal even at an early stage of therapy. The review concentrates on methodological aspects of monitoring response with FDG: timing of serial scans, approach to region of interest definition, method of quantification and pitfalls of FDG. It is argued that, for clinical applications, there is now a need to standardise methodology. This would be necessary to establish firm cut-off values for discriminating responders from non-responders, which in turn would provide a means for providing optimal treatment for as many patients as possible.

Nuclear factor-κB as a predictor of treatment response in breast cancer

PURPOSE OF REVIEW

To examine the links of nuclear factor-kappa B (NF-kappa B) to treatment-induced signaling in breast cancer and to propose further studies to elucidate the role of NF-kappa B in breast cancer response to chemotherapy and radiation.

RECENT FINDINGS

The authors' group and others have investigated the clinical relevance of ubiquitously expressed NF-kappa B in breast cancer. Possibly through its effects on apoptosis, NF-kappa B has been implicated in tumor resistance to chemotherapy and radiation in many types of tumors. Furthermore, both in vitro and in vivo studies have shown that targeted inhibition of NF-kappa B can sensitize tumor cells to chemotherapy and radiation.

SUMMARY

The molecular mechanisms involved in chemotherapy-induced and radiation-induced cell death in breast cancer are not fully known, nor are the mechanisms of treatment resistance. NF-kappa B is a transcription factor for a number of genes involved in tumor progression and resistance to systemic therapies and is a major regulator of the apoptotic pathway. Gaining further insights into molecular factors such as NF-kappa B as biomarkers for treatment response may help clinicians predict treatment outcome and lead to the development of targeted therapeutics.

Sentinel node biopsy prior to neoadjuvant chemotherapy

BACKGROUND

Several studies have explored sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy, but false negative rates and the loss of pretreatment nodal staging are limitations. Sentinel lymph node biopsy prior to induction chemotherapy may address both.

METHODS

Sentinel lymph node biopsy was performed in clinically node negative patients prior to initiating chemotherapy. Standard level I/II axillary lymph node dissection (ALND) was performed at the time of surgery in those patients who had metastases in the sentinel lymph node (SLN).

RESULTS

Twenty-five patients had 26 SLNB prior to the initiation of chemotherapy. The SLN was identified in all cases (100%). Twelve patients (48%) were found to be node negative and did not require axillary node dissection after chemotherapy. Of the patients who were SLN positive and underwent completion ALND, residual nodal disease was identified in 60%. There were no surgical complications or delay of chemotherapy.

CONCLUSIONS

Sentinel lymph node biopsy prior to neoadjuvant chemotherapy can avoid the morbidity of ALND without compromising the accuracy of axillary staging. It allows for identification of node positive patients subsequently rendered disease free in the regional nodes, which can assist in planning additional chemotherapy or radiation.

Neoadjuvant therapy before radical prostatectomy in high-risk localized prostate cancer: defining appropriate endpoints

High-risk localized prostate cancer remains a vexing problem for clinicians. Definitive local treatments such as surgery and radiation therapy cure only a minority of these patients. As a result, efforts are being made to reduce the risk of recurrence by using chemotherapy and new agents before, during or after definitive local therapy. Neoadjuvant androgen deprivation therapy has yielded disappointing results when combined with surgery. Chemotherapy in the management of localized disease is evolving, and preliminary studies are just now being completed. Although these agents have established activity and acceptable toxicity in the hormone-refractory setting, more extensive use of them in patients with androgen-dependent disease will require data from randomized studies to determine overall efficacy. New molecular-targeted therapies are promising and hold the greatest hope that outcomes in early disease may be improved with early use of systemic therapy. The neoadjuvant surgical model also has promise in assessing the activity of new drugs, because it provides a means to determine molecular effects of specific agents, along with standard pathologic and clinical parameters of efficacy.

Breast cancer response to neoadjuvant chemotherapy: predictive markers and relation with outcome

The aim of this study was to provide a better insight into breast cancer response to chemotherapy. Chemotherapy improves outcome in breast cancer patients. The effect of cytotoxic treatment cannot be predicted for individual patients. Therefore, the identification of tumour characteristics associated with tumour response and outcome is of great clinical interest. We studied 97 patients, who received anthracycline-based neoadjuvant chemotherapy. Tumour samples were taken prior to and after chemotherapy. We quantified the response to chemotherapy clinically and pathologically and determined histological and molecular tumour characteristics. We assessed changes in the expression of Bcl-2, ER, P53 HER2 and Ki-67. Association with response and outcome was tested for all parameters. The experimental results showed 15 clinical (17%) and three (3%) pathological complete remissions. There were 18 (20%) clinical vs 29 (33%) pathological nonresponders. The expression of most markers was similar before and after chemotherapy. Only Ki-67 was significantly decreased after chemotherapy. Factors correlated with response were: large tumour size, ER negativity, high Ki-67 count and positive P53 status. Tumour response and marker expression did not predict disease-free or overall survival. In conclusion, clinical and pathological response assessments are poorly associated. Proliferation decreases significantly after chemotherapy. ER negativity and a high proliferation index are associated with better response. HER2 status does not predict response, and outcome is not related to tumour response.