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Tasoulis MK, Lee HB, Kuerer HM. Omission of Breast Surgery in Exceptional Responders. Clin Breast Cancer 2024; 24:310-318. [PMID: 38365541 DOI: 10.1016/j.clbc.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/22/2024] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
Breast cancer management has transformed significantly over the last decades, primarily through the integration of neoadjuvant systemic therapy (NST) and the evolving understanding of tumor biology, enabling more tailored treatment strategies. The aim of this review is to critically present the historical context and contemporary evidence surrounding the potential of omission of surgery post-NST, focusing on exceptional responders who have achieved a pathologic complete response (pCR). Identifying these exceptional responders before surgery remains a challenge, however standardized image-guided biopsy may allow optimized patient selection. The safety and feasibility of omitting breast and axillary surgeries in these exceptional responders are explored in ongoing clinical trials and the reported preliminary results appear promising. Moreover, understanding patient and physician perspectives regarding the potential elimination of surgery post-NST is integral. While some patients express a preference to omit or minimize surgery, the majority of healthcare providers are intrigued by the prospect of avoiding surgical interventions and endorse further research in this field.
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Affiliation(s)
- Marios-Konstantinos Tasoulis
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK; Division of Breast Cancer Research, The Institute of Cancer Research, London, UK.
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Henry Mark Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Hu Q, Hu Y, Ai H, Xia L, Liu R, Ai T. Pre-operative MRI in evaluating pathologic complete response to neoadjuvant chemotherapy in patients with breast cancer: a study focused on influencing factors of baseline clinical-pathological and imaging features. Front Oncol 2024; 14:1366613. [PMID: 38826784 PMCID: PMC11140022 DOI: 10.3389/fonc.2024.1366613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 05/03/2024] [Indexed: 06/04/2024] Open
Abstract
Purpose To investigate what pre-treatment clinical-pathological features and MRI characteristics influence the performance of breast MRI in assessing the pathologic complete response (pCR) of breast cancer patients to Neoadjuvant Chemotherapy (NAC). Methods A total of 225 patients with pathologically-confirmed breast cancer who underwent pre- and post-NAC breast MRI between January 2020 and April 2023 were retrospectively analyzed. All patients were categorized into radiologic complete response (rCR) and non-rCR groups based on pre-operative MRI. Univariable and multivariable logistic regression were used to identify independent clinicopathological and imaging features associated with imaging-pathological discordance. The performance of pre-operative MRI for predicting pCR to NAC was assessed according to the baseline characteristics of the clinicopathological data and pre-NAC MRI. In addition, the discrepancy between the pre-operative MRI and post-operative pathological findings was further analyzed by a case-control approach. Results Among 225 patients, 99 (44.0%) achieved pCR after NAC. MRI showed the overall sensitivity of 97.6%, specificity of 58.6%, accuracy of 80.4%, a positive predictive value (PPV) of 75.0%, and a negative predictive value (NPV) of 95.1% in identifying pCR. Of baseline features, presence of ductal carcinoma in situ (DCIS) (OR, 3.975 [95% CI: 1.448-10.908], p = 0.007), luminal B (OR, 5.076 [95% CI: 1.401-18.391], p = 0.013), HER2-enriched subtype (OR, 10.949 [95% CI: 3.262-36.747], p < 0.001), multifocal or multicentric lesions (OR, 2.467 [95% CI: 1.067-5.706], p = 0.035), segmental or regional distribution of NME (OR, 8.514 [95% CI: 1.049-69.098], p = 0.045) and rim enhancement of mass (OR, 4.261 [95% CI: 1.347-13.477], p = 0.014) were significantly associated with the discrepancy between MRI and pathology. Conclusion Presence of DCIS, luminal B or HER2-enriched subtype, multicentric or multifocal lesions, segmental or regional distribution of NME and rim enhancement of mass may lead to a decrease in diagnostic accuracy of MRI in patients of breast cancer treated with NAC.
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Affiliation(s)
- Qilan Hu
- Department of Radiology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yiqi Hu
- Department of Radiology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Huiyang Ai
- Department of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liming Xia
- Department of Radiology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Liu
- Department of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Ai
- Department of Radiology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
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Lavasani S, Healy E, Kansal K. Locoregional Treatment for Early-Stage Breast Cancer: Current Status and Future Perspectives. Curr Oncol 2023; 30:7520-7531. [PMID: 37623026 PMCID: PMC10453608 DOI: 10.3390/curroncol30080545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND The locoregional recurrence of breast cancer has been reduced due to the multidisciplinary approach of breast surgery, systemic therapy and radiation. Early detection and better surgical techniques contribute to an improvement in breast cancer outcomes. PURPOSE OF REVIEW The purpose of this review is to have an overview and summary of the current evidence behind the current approaches to the locoregional treatment of breast cancer and to discuss its future direction. SUMMARY With improved surgical techniques and the use of a more effective neoadjuvant systemic therapy, including checkpoint inhibitors and dual HER2-directed therapies that lead to a higher frequency of pathologic complete responses and advances in adjuvant radiation therapy, breast cancer patients are experiencing better locoregional control and reduced local and systemic recurrence. De-escalation in surgery has not only improved the quality of life in the majority of breast cancer patients, but also maintained the low risk of recurrence. There are ongoing clinical trials to optimize radiation therapy in breast cancer. More modern radiation technologies are evolving to improve the patient outcome and reduce radiation toxicities.
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Affiliation(s)
- Sayeh Lavasani
- Division of Hematology and Medical Oncology, UC Irvine, Orange, CA 92868, USA
| | - Erin Healy
- Department of Radiation Oncology, UC Irvine, Orange, CA 92868, USA
| | - Kari Kansal
- Division of Breast Surgery, UC Irvine, Orange, CA 92868, USA
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van Hemert AKE, van Duijnhoven FH, Vrancken-Peeters MJTFD. ASO Author Reflections: Biopsy Guided Pathological Response Assessment in Breast Cancer is Insufficient: Additional Pathology Findings of the MICRA Trial. Ann Surg Oncol 2023; 30:4690-4692. [PMID: 37202571 PMCID: PMC10319661 DOI: 10.1245/s10434-023-13546-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Annemiek K E van Hemert
- Departments of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Frederieke H van Duijnhoven
- Departments of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken-Peeters
- Departments of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
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van Hemert AKE, van Duijnhoven FH, van Loevezijn AA, Loo CE, Wiersma T, Groen EJ, Peeters MJTFDV. Biopsy-Guided Pathological Response Assessment in Breast Cancer is Insufficient: Additional Pathology Findings of the MICRA Trial. Ann Surg Oncol 2023; 30:4682-4689. [PMID: 37071235 PMCID: PMC10319687 DOI: 10.1245/s10434-023-13476-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/21/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Neoadjuvant systemic treatment (NST) leads to pathologic complete response (pCR) in 10-89% of breast cancer patients depending on subtype. The added value of surgery is uncertain in patients who reach pCR; however, current imaging and biopsy techniques aiming to predict pCR are not accurate enough. This study aims to quantify the residual disease remaining after NST in patients with a favorable response on MRI and residual disease missed with biopsies. METHODS In the MICRA trial, patients with a favorable response to NST on MRI underwent ultrasound-guided post-NST 14G biopsies followed by surgery. We analyzed pathology reports of the biopsies and the surgical specimens. Primary outcome was the extent of residual invasive disease among molecular subtypes, and secondary outcome was the extent of missed residual invasive disease. RESULTS We included 167 patients. Surgical specimen showed residual invasive disease in 69 (41%) patients. The median size of residual invasive disease was 18 mm (interquartile range [IQR] 12-30) in hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) patients, 8 mm (IQR 3-15) in HR+/HER2-positive (HER2+) patients, 4 mm (IQR 2-9) in HR-negative (HR-)/HER2+ patients, and 5 mm (IQR 2-11) in triple-negative (TN) patients. Residual invasive disease was missed in all subtypes varying from 4 to 7 mm. CONCLUSION Although the extent of residual invasive disease is small in TN and HER2+ subtypes, substantial residual invasive disease is left behind in all subtypes with 14G biopsies. This may hamper local control and limits adjuvant systemic treatment options. Therefore, surgical excision remains obligatory until accuracy of imaging and biopsy techniques improve.
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Affiliation(s)
- Annemiek K E van Hemert
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Claudette E Loo
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Terry Wiersma
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Emilie J Groen
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
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Backhaus P, Burg MC, Asmus I, Pixberg M, Büther F, Breyholz HJ, Yeh R, Weigel SB, Stichling P, Heindel W, Bobe S, Barth P, Tio J, Schäfers M. Initial Results of 68Ga-FAPI-46 PET/MRI to Assess Response to Neoadjuvant Chemotherapy in Breast Cancer. J Nucl Med 2023; 64:717-723. [PMID: 36396458 PMCID: PMC10152127 DOI: 10.2967/jnumed.122.264871] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/01/2022] [Accepted: 11/01/2022] [Indexed: 11/18/2022] Open
Abstract
Improving imaging-based response after neoadjuvant chemotherapy (NAC) in breast cancer assessment could obviate histologic confirmation of pathologic complete response (pCR) and facilitate deescalation of chemotherapy or surgery. Fibroblast activation protein inhibitor (FAPI) PET/MRI is a promising novel molecular imaging agent for the tumor microenvironment with intense uptake in breast cancer. We assessed the diagnostic performance of follow-up breast 68Ga-FAPI-46 (68Ga-FAPI) PET/MRI in classifying the response status of local breast cancer and lymph node metastases after completion of NAC and validated this approach immunohistochemically. Methods: In women who completed NAC for invasive breast cancer, follow-up 68Ga-FAPI PET/MRI and corresponding fibroblast activation protein (FAP) immunostainings were retrospectively analyzed. Metrics of 68Ga-FAPI uptake and FAP immunoreactivity in women with or without pCR were compared using the Mann-Whitney U test. Diagnostic performance to detect remnant invasive cancer was calculated for tracer uptake metrics using receiver-operating-characteristic curves and for masked readers' visual assessment categories of PET/MRI and MRI alone. Results: Thirteen women (mean age ± SD, 47 ± 9 y) were evaluated. Seven of the 13 achieved pCR in the breast and 6 in the axilla. FAP immunoreactivity was significantly associated with response status. The 68Ga-FAPI PET/MRI mean breast tumor-to-background ratio was 0.9 (range, 0.6-1.2) for pCR and 2.1 (range, 1.4-3.1) for no pCR (P = 0.001). Integrated PET/MRI could classify breast response correctly in all 13 women based on readers' visual assessment or tumor-to-background ratio. Evaluation of MRI alone resulted in at least 2 false-positives. For lymph nodes, PET/MRI readers had at least 2 false-negative classifications, whereas MRI alone resulted in 2 false-negatives and 1 false-positive. Conclusion: To our knowledge, this was the first analysis of 68Ga-FAPI PET/MRI for response assessment after NAC for breast cancer. The diagnostic performance of PET/MRI in a small study sample trended toward a gain over MRI alone, clearly supporting future prospective studies.
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Affiliation(s)
| | - Matthias C. Burg
- Clinic for Radiology, University Hospital Münster, Münster, Germany
| | - Inga Asmus
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Michaela Pixberg
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Florian Büther
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
| | - Hans-Jörg Breyholz
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Randy Yeh
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | | | | | - Walter Heindel
- Clinic for Radiology, University Hospital Münster, Münster, Germany
| | - Stefanie Bobe
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
- Gerhard-Domagk Institute for Pathology, University of Münster, Münster, Germany; and
| | - Peter Barth
- Gerhard-Domagk Institute for Pathology, University of Münster, Münster, Germany; and
| | - Joke Tio
- Department of Gynecology and Obstetrics, University Hospital Münster, Münster, Germany
| | - Michael Schäfers
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
- European Institute for Molecular Imaging, University of Münster, Münster, Germany
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van Hemert AKE, van Olmen JP, Boersma LJ, Maduro JH, Russell NS, Tol J, Engelhardt EG, Rutgers EJT, Vrancken Peeters MJTFD, van Duijnhoven FH. De-ESCAlating RadioTherapy in breast cancer patients with pathologic complete response to neoadjuvant systemic therapy: DESCARTES study. Breast Cancer Res Treat 2023; 199:81-89. [PMID: 36892723 DOI: 10.1007/s10549-023-06899-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/16/2023] [Indexed: 03/10/2023]
Abstract
PURPOSE Neoadjuvant systemic therapy (NST) is increasingly used in breast cancer patients and depending on subtype, 10-89% of patients will attain pathologic complete response (pCR). In patients with pCR, risk of local recurrence (LR) after breast conserving therapy is low. Although adjuvant radiotherapy after breast conserving surgery (BCS) reduces LR further in these patients, it may not contribute to overall survival. However, radiotherapy may cause early and late toxicity. The aim of this study is to show that omission of adjuvant radiotherapy in patients with a pCR after NST will result in acceptable low LR rates and good quality of life. METHODS The DESCARTES study is a prospective, multicenter, single arm study. Radiotherapy will be omitted in cT1-2N0 patients (all subtypes) who achieve a pCR of the breast and lymph nodes after NST followed by BCS plus sentinel node procedure. A pCR is defined as ypT0N0 (i.e. no residual tumor cells detected). Primary endpoint is the 5-year LR rate, which is expected to be 4% and deemed acceptable if less than 6%. In total, 595 patients are needed to achieve a power of 80% (one-side alpha of 0.05). Secondary outcomes include quality of life, Cancer Worry Scale, disease specific and overall survival. Projected accrual is five years. CONCLUSION This study bridges the knowledge gap regarding LR rates when adjuvant radiotherapy is omitted in cT1-2N0 patients achieving pCR after NST. If the results are positive, radiotherapy may be safely omitted in selected breast cancer patients with a pCR after NST. TRIAL REGISTRATION This study is registered at ClinicalTrials.gov on June 13th 2022 (NCT05416164). Protocol version 5.1 (15-03-2022).
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Affiliation(s)
- Annemiek K E van Hemert
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Josefien P van Olmen
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), Maastricht University Medical Centre+ - GROW School for Oncology and Reproduction, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Nicola S Russell
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Jolien Tol
- Department of Medical Oncology, Jeroen Bosch Ziekenhuis, Henri Dunantstraat 1, 5223 GZ, 'S-Hertogenbosch, The Netherlands
| | - Ellen G Engelhardt
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Emiel J Th Rutgers
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | | | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Portnow LH, Kochkodan-Self JM, Maduram A, Barrios M, Onken AM, Hong X, Mittendorf EA, Giess CS, Chikarmane SA. Multimodality Imaging Review of HER2-positive Breast Cancer and Response to Neoadjuvant Chemotherapy. Radiographics 2023; 43:e220103. [PMID: 36633970 DOI: 10.1148/rg.220103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Human epidermal growth factor receptor 2 (HER2/neu or ErbB2)-positive breast cancers comprise 15%-20% of all breast cancers. The most common manifestation of HER2-positive breast cancer at mammography or US is an irregular mass with spiculated margins that often contains calcifications; at MRI, HER2-positive breast cancer may appear as a mass or as nonmass enhancement. HER2-positive breast cancers are often of intermediate to high nuclear grade at histopathologic analysis, with increased risk of local recurrence and metastases and poorer overall prognosis. However, treatment with targeted monoclonal antibody therapies such as trastuzumab and pertuzumab provides better local-regional control and leads to improved survival outcome. With neoadjuvant treatments, including monoclonal antibodies, taxanes, and anthracyclines, women are now potentially able to undergo breast conservation therapy and sentinel lymph node biopsy versus mastectomy and axillary lymph node dissection. Thus, the radiologist's role in assessing the extent of local-regional disease and response to neoadjuvant treatment at imaging is important to inform surgical planning and adjuvant treatment. However, assessment of treatment response remains difficult, with the potential for different imaging modalities to result in underestimation or overestimation of disease to varying degrees when compared with surgical pathologic analysis. In particular, the presence of calcifications at mammography is especially difficult to correlate with the results of pathologic analysis after chemotherapy. Breast MRI findings remain the best predictor of pathologic response. The authors review the initial manifestations of HER2-positive tumors, the varied responses to neoadjuvant chemotherapy, and the challenges in assessing residual cancer burden through a multimodality imaging review with pathologic correlation. © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Leah H Portnow
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Jeanne M Kochkodan-Self
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Amy Maduram
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Mirelys Barrios
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Allison M Onken
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Xuefei Hong
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Elizabeth A Mittendorf
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Catherine S Giess
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Sona A Chikarmane
- From the Departments of Radiology (L.H.P., J.M.K.S., A.M., M.B., C.S.G., S.A.C.), Pathology (A.M.O., X.H.), and Surgery (E.A.M.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
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Nissan N, Bauer E. Editorial for "4D Machine Learning Radiomics for the Prediction of Breast Cancer Pathologic Complete Response to Neoadjuvant Chemotherapy in Dynamic Contrast-Enhanced MRI". J Magn Reson Imaging 2023; 57:111-112. [PMID: 35652378 DOI: 10.1002/jmri.28277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Noam Nissan
- Department of Radiology, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ethan Bauer
- Department of Radiology, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Liang Y, Guo W, Li C, Shen G, Tan H, Sun P, Chen Z, Huang H, Li Z, Li Z, Ren Y, Li G, Hu Y. Tumor-Targeted Polydopamine-Based Nanoparticles for Multimodal Mapping Following Photothermal Therapy of Metastatic Lymph Nodes. Int J Nanomedicine 2022; 17:4659-4675. [PMID: 36199474 PMCID: PMC9528963 DOI: 10.2147/ijn.s367975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/07/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Lymphadenectomy with lymph node (LN) mapping is essential for surgical removal of solid tumors. Existing agents do not provide accurate multimodal mapping and antitumor therapy for metastatic LNs; therefore, we fabricated a polydopamine (PDA) nanoparticle (NP)-based tumor-targeted LN mapping agent capable of multimodal mapping and guided photothermal therapy (PTT) for metastatic LNs. Materials and Methods PDA NPs modified with polyethylene glycol (PEG) were obtained by polymerization under alkaline conditions. The PEG-PDA NPs were loaded with the circular tripeptide Arg-Gly-Asp (cRGD) to achieve tumor-targeting capacity and with the fluorescent dye IR820 and magnetic resonance imaging (MRI) contrast Gd(NH2)2 for in situ detection. The resulting cRGD-PEG-PDA@IR820/Gd(NH2)2 (cRGD-PPIG) NPs were tested for their biosafety and metastatic LN mapping ability. They were drained specifically into LNs and selectively taken up by gastric MKN45 cells via αvβ3 integrin-mediated endocytosis. Results This phenomenon enabled MR/optical/near-infrared fluorescence multimodal metastatic LN mapping, guiding the creation of accurate and highly efficient PTT for gastric cancer metastatic LNs in mice. Conclusion In summary, we fabricated tumor-targeted cRGD-PPIG NPs with MR/optical/near-infrared fluorescence multimodal metastatic LN mapping capacity for surgery and efficient PTT guidance post-surgery.
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Affiliation(s)
- Yanrui Liang
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Weihong Guo
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Chuangji Li
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Guodong Shen
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Haoxian Tan
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, People’s Republic of China
| | - Peiwen Sun
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, People’s Republic of China
| | - Zhian Chen
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Huilin Huang
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Zhenhao Li
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Zhenyuan Li
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Yingxin Ren
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Guoxin Li
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Yanfeng Hu
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
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11
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Kuerer HM. Moving Forward with Omission of Breast Cancer Surgery Following Neoadjuvant Systemic Therapy. Ann Surg Oncol 2022; 29:7942-7944. [PMID: 36002702 DOI: 10.1245/s10434-022-12455-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/11/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Henry M Kuerer
- MD Anderson Cancer Network Breast Programs, Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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12
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Feng K, Jia Z, Liu G, Xing Z, Li J, Li J, Ren F, Wu J, Wang W, Wang J, Liu J, Wang X. A review of studies on omitting surgery after neoadjuvant chemotherapy in breast cancer. Am J Cancer Res 2022; 12:3512-3531. [PMID: 36119847 PMCID: PMC9442028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/03/2022] [Indexed: 06/15/2023] Open
Abstract
The advancement in systemic neoadjuvant therapy has significantly increased the pathological complete response (pCR) rate in breast cancer. As surgeries inevitably affect patients physically and psychologically and the accuracy of pCR prediction and diagnosis by minimal invasive biopsy is improving, the necessity of surgery in neoadjuvant chemotherapy (NAC) patients who achieve pCR is under debate. Thus, we conducted a literature review of studies on the selective omission of breast surgery after NAC for breast cancer patients. We summarized the existing predictive models and technologies to predict and diagnose pCR after NAC. Our research indicates that, for nearly half a century, the extent of surgery on both breast and axillary lymph nodes is decreasing, while more precise systematic treatments are increasing. NAC has advanced significantly and its pCR rates have improved, so surgery may be omitted in certain patients. However, accurately predicting pCR after NAC is still a challenge. We also described the design for a randomized clinical trial and the potential problems of omitting surgical treatment after NAC. In summary, the decrease in breast cancer surgery is an unavoidable trend, and more high-quality clinical trials need to be conducted.
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Affiliation(s)
- Kexin Feng
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Ziqi Jia
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Gang Liu
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Zeyu Xing
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Jiayi Li
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Jiaxin Li
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Fei Ren
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Jiang Wu
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Wenyan Wang
- Department of Breast Surgery, Beijing Tiantan Hospital, Capital Medical UniversityBeijing 100070, China
| | - Jie Wang
- Department of Ultrasound, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Jiaqi Liu
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
| | - Xiang Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing 100021, China
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13
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Tasoulis MK, Heil J, Kuerer HM. De-escalating Surgery Among Patients with HER2 + and Triple Negative Breast Cancer. CURRENT BREAST CANCER REPORTS 2022; 14:135-141. [PMID: 35915668 PMCID: PMC9328618 DOI: 10.1007/s12609-022-00453-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2022] [Indexed: 01/09/2023]
Abstract
Purpose of Review De-escalation of surgery has been central in the evolution of multidisciplinary management of breast cancer. Advances in oncology and increasing use of neoadjuvant chemotherapy (NACT) have opened opportunities for further surgical de-escalation especially for HER2 + and triple negative (TN) disease. The aim of this review is to discuss the recent data on de-escalation of surgery as well as the future directions. Recent Findings Patients with TN and HER2 + breast cancer with excellent response to NACT would be the ideal candidates for surgical de-escalation. Post-NACT image-guided biopsy, potentially combined with machine learning algorithms, may accurately identify patients achieving pathologic complete response that would be eligible for clinical trials assessing safety of omission of breast and axillary surgery. Summary Multidisciplinary research is required to further support results of preliminary studies. Current data point towards a future when even less or no surgery may be required for exceptional responders.
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Affiliation(s)
- Marios-Konstantinos Tasoulis
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- Division of Breast Cancer Research, The Institute of Cancer Research, Old Brompton Road, London, SW7 3RP UK
| | - Joerg Heil
- Department of Obstetrics and Gynecology, University Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Henry M. Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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14
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Browne R, McAnena P, O'Halloran N, Moloney BM, Crilly E, Kerin MJ, Lowery AJ. Preoperative Breast Magnetic Resonance Imaging as a Predictor of Response to Neoadjuvant Chemotherapy. Breast Cancer (Auckl) 2022; 16:11782234221103504. [PMID: 35769423 PMCID: PMC9234834 DOI: 10.1177/11782234221103504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/28/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: The ability to accurately predict pathologic complete response (pCR) after
neoadjuvant chemotherapy (NAC) in breast cancer would improve patient
selection for specific treatment strategies, would provide important
information for patients to aid in the treatment selection process, and
could potentially avoid the need for more extensive surgery. The diagnostic
performance of magnetic resonance imaging (MRI) in predicting pCR has
previously been studied, with mixed results. Magnetic resonance imaging
performance may also be influenced by tumour and patient factors. Methods: Eighty-seven breast cancer patients who underwent NAC were studied. Pre-NAC
and post-NAC MRI findings were compared with pathologic findings
postsurgical excision. The impact of patient and tumour characteristics on
MRI accuracy was evaluated. Results: The mean (SD) age of participants was 48.7 (10.3) years. The rate of pCR
based on post-NAC MRI was 19.5% overall (19/87). The sensitivity,
specificity, positive predictive value (PPV), negative predictive value, and
accuracy in predicting pCR were 52.9%, 77.1%, 36.0%, 87.1%, and 72.4%,
respectively. Positive predictive value was the highest in nonluminal versus
Luminal A disease (45.0% vs 25.0%, P < .001), with
higher rates of false positivity in nonluminal subtypes
(P = .002). Tumour grade, T category, and histological
subtype were all independent predictors of MRI accuracy regarding post-NAC
tumour size. Conclusion: Magnetic resonance imaging alone is insufficient to accurately predict pCR in
breast cancer patients post-NAC. Magnetic resonance imaging predictions of
pCR are more accurate in nonluminal subtypes. Tumour grade, T category, and
histological subtype should be considered when evaluating post-NAC tumour
sizes.
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Affiliation(s)
- Robert Browne
- Department of Surgery, University Hospital Galway, Galway, Ireland
| | - Peter McAnena
- Department of Surgery, University Hospital Galway, Galway, Ireland
| | - Niamh O'Halloran
- Department of Radiology, University Hospital Galway, Galway, Ireland
| | - Brian M Moloney
- Department of Radiology, University Hospital Galway, Galway, Ireland
| | - Emily Crilly
- Department of Surgery, University Hospital Galway, Galway, Ireland
| | - Michael J Kerin
- Department of Surgery, University Hospital Galway, Galway, Ireland.,Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
| | - Aoife J Lowery
- Department of Surgery, University Hospital Galway, Galway, Ireland.,Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
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15
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Ma SJ, Serra LM, Yu B, Farrugia MK, Iovoli AJ, Yu H, Yao S, Oladeru OT, Singh AK. Racial/Ethnic Differences and Trends in Pathologic Complete Response Following Neoadjuvant Chemotherapy for Breast Cancer. Cancers (Basel) 2022; 14:cancers14030534. [PMID: 35158802 PMCID: PMC8833599 DOI: 10.3390/cancers14030534] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Despite improving rates of pathologic complete response (pCR; the absence of invasive cancer at the time of surgery) among patients with breast cancer who underwent chemotherapy prior to surgery, racial and ethnic minority groups were under-represented in clinical trials. Our study used a large cancer registry database in the United States to evaluate the temporal trend of pCR and patterns of pCR and survival outcomes among diverse racial and ethnic groups. It suggested that although pCR rates improved over time for all groups, pCR rates and survival outcomes varied significantly. For instance, compared to non-Hispanic White women, Black women were less likely to have pCR for triple negative and hormone receptor (HR)-negative, human epidermal growth factor receptor 2 (HER2)-positive tumors, but more likely for HR-positive, HER2-negative tumors. Given such heterogeneous outcomes among various racial and ethnic minority groups, further investigations would be warranted to optimize outcomes among such underserved populations. Abstract The purpose of this study was to evaluate nationwide trends in pathologic complete response (pCR) and its racial variations for breast cancer. The National Cancer Database was queried for women from 2010 to 2017 with non-metastatic breast cancer who underwent neoadjuvant chemotherapy. The primary endpoints, pCR and overall survival, were evaluated using Cochran-Armitage test, logistic, and Cox regression multivariable analyses. A total of 104,161 women were analyzed. Overall, pCR improved from 2010 to 2017 (15.1% to 27.2%, trend p < 0.001). Compared to non-Hispanic White (NHW) women, Hispanic White (HW) women were more likely to have pCR for hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-positive tumors (adjusted odds ratio (aOR) 1.29, 95% confidence interval (CI) 1.08–1.53, p = 0.005). Black women were less likely to have pCR for HR-HER2+ tumors (aOR 0.81, 95% CI 0.73–0.89, p < 0.001) and triple negative (aOR 0.82, 95% CI 0.77–0.87, p < 0.001) tumors, but more likely for HR+HER2- tumors (aOR 1.13, 95% CI 1.03–1.24, p = 0.009). Among patients who achieved pCR, Asian or Pacific Islander (API) women were associated with better survival (adjusted hazards ratio (aHR) 0.52, 95% CI 0.33–0.82, p = 0.005) than NHW women. Despite positive trends in pCR rates, the likelihood of pCR and survival outcomes may be intricately dependent on racial/ethnic groups and tumor receptor subtypes.
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Affiliation(s)
- Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY 14203, USA; (S.J.M.); (M.K.F.); (A.J.I.)
| | - Lucas M. Serra
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, 955 Main Street, Buffalo, NY 14203, USA; (L.M.S.); (B.Y.)
| | - Brian Yu
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, 955 Main Street, Buffalo, NY 14203, USA; (L.M.S.); (B.Y.)
| | - Mark K. Farrugia
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY 14203, USA; (S.J.M.); (M.K.F.); (A.J.I.)
| | - Austin J. Iovoli
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY 14203, USA; (S.J.M.); (M.K.F.); (A.J.I.)
| | - Han Yu
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY 14203, USA;
| | - Song Yao
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY 14203, USA;
| | - Oluwadamilola T. Oladeru
- Department of Radiation Oncology, University of Florida, 2000 SW Archer Road, Gainesville, FL 32610, USA;
| | - Anurag K. Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY 14203, USA; (S.J.M.); (M.K.F.); (A.J.I.)
- Correspondence: ; Tel.: +1-716-845-1179
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16
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Prediction of pathologic complete response on MRI in patients with breast cancer receiving neoadjuvant chemotherapy according to molecular subtypes. Eur Radiol 2022; 32:4056-4066. [PMID: 34989844 DOI: 10.1007/s00330-021-08461-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/06/2021] [Accepted: 11/08/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study aimed to investigate the predictability of breast MRI for pathologic complete response (pCR) by molecular subtype in patients with breast cancer receiving neoadjuvant chemotherapy (NAC) and investigate the MRI findings that can mimic residual malignancy. METHODS A total of 506 patients with breast cancer who underwent MRI after NAC and underwent surgery between January and December 2018 were included. Two breast radiologists dichotomized the post-NAC MRI findings as radiologic complete response (rCR) and no-rCR. The diagnostic performance of MRI predicting pCR was evaluated. pCR was determined based on the final pathology reports. Tumors were divided according to hormone receptor (HR) and human epidermal growth factor receptor (HER) 2. Residual lesions on post-NAC MRI were divided into overt and subtle which classified as nodularity or delayed enhancement. Pearson's χ2 and Wilcoxon rank-sum tests were used for MRI findings causing false-negative pCR. RESULTS The overall pCR rate was 30.04%. The overall accuracy for predicting pCR using MRI was 76.68%. The accuracy was significantly different by subtypes (p < 0.001), as follows in descending order: HR - /HER2 - (85.63%), HR + /HER2 - (82.84%), HR + /HER2 + (69.37%), and HR - /HER2 + (62.38%). MRI in the HR - /HER2 + type showed the highest false-negative rate (18.81%) for predicting pCR. The subtle residual enhancement observed only in the delayed phase was associated with false-negative findings (76.2%, p = 0.016). CONCLUSIONS The diagnostic accuracy of MRI for predicting pCR differed by molecular subtypes. When the residual enhancement on MRI after NAC is subtle and seen only in the delayed phase, overinterpretation of residual tumors should be performed with caution. KEY POINTS • In patients with breast cancer after completion of neoadjuvant chemotherapy, the diagnostic accuracy of MRI for predicting pathologic complete response (pCR) differed according to molecular subtype. • When residual enhancement on MRI is subtle and seen only in the delayed phase, this finding could be associated with false-negative pCR results.
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17
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Hadar T, Koretz M, Nawass M, Allweis TM. Innovative Standards in Surgery of the Breast after Neoadjuvant Systemic Therapy. Breast Care (Basel) 2021; 16:590-597. [PMID: 35087362 PMCID: PMC8739938 DOI: 10.1159/000520051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/29/2021] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND The goal of neoadjuvant systemic therapy (NST) in breast cancer is to downstage tumors and downgrade treatment. Indications are constantly evolving. These changes raise practical questions for planning of surgery after NST. SUMMARY In this review we discuss current evolving aspects of surgery of the breast after NST. Breast-conserving surgery (BCS) eligibility increases after NST - both neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy. Adequate margin width in NST and upfront surgery are similar - "no tumor on ink" for invasive cancer. Oncoplastic breast surgery after NST is feasible - both for BCS and mastectomy with reconstruction. There is increasing interest in the possibility of omitting surgery in patients with a complete response to NAC. Several trials are being conducted in aim of achieving acceptable prediction of pathological complete response, by combination of imaging and percutaneous biopsy of the tumor bed, as well as assessing the safety of such an approach. KEY MESSAGES Surgery of the breast after NST should be determined not only according to biologic and anatomic parameters at diagnosis, but is dynamic, and must be tailored according to the response to therapy. The omission of surgery in exceptional responders after NAC is being explored.
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Affiliation(s)
- Tal Hadar
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Michael Koretz
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mahmood Nawass
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tanir M. Allweis
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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18
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Lim DW, Greene BD, Look Hong NJ. Relationship Between Breast and Axillary Pathologic Complete Response in Women Receiving Neoadjuvant Chemotherapy for Breast Cancer. Ann Surg Oncol 2021; 28:5495-5506. [PMID: 34374914 DOI: 10.1245/s10434-021-10519-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We aim to delineate the relationship between breast and axillary pathologic complete response (pCR) in patients receiving neoadjuvant chemotherapy for breast cancer. METHODS We performed a retrospective cohort study of patients with clinical T1-4N0-3M0 breast cancer receiving neoadjuvant chemotherapy followed by surgical therapy at Sunnybrook Health Sciences Centre in Toronto, Canada between 2014 and 2019. Clinicopathologic data were abstracted from the electronic medical record. Women were stratified into receptor subtypes as follows: hormone receptor positive (HR+)/human epidermal growth factor receptor 2 negative (HER2-), HR+/HER2+, HR-/HER2+ and HR-/HER2- (triple negative) and compared with Fisher's exact test. Our primary outcome was to assess the positive predictive value of breast pCR for determining axillary pCR, and vice versa. RESULTS There were 374 breast cancers, with 109 (29.1%) achieving breast pCR (ypT0/Tis). Amongst node-positive tumours achieving breast pCR, rates of associated axillary pCR (ypN0/0i+) were as follows: HR+/HER2- (2/6, 33.3%), HR+/HER2+ (12/13, 92.3%), HR-/HER2+ (15/17, 88.2%) and triple negative (15/17, 88.2%) (P = 0.02). Conversely, amongst node-positive tumours achieving axillary pCR, rates of associated breast pCR were: HR+/HER2- (2/10, 20.0%), HR+/HER2+ (12/23, 52.2%), HR-/HER2+ (15/24, 62.5%) and triple negative (15/26, 57.7%) (P = 0.1). CONCLUSIONS Breast pCR is a strong predictor of axillary pCR in women with HER2-positive and triple-negative breast cancers. Conversely, axillary pCR is a modest predictor of breast pCR for these subtypes. There is a poor relationship between breast and axillary pCR in women with hormone receptor-positive disease. These data may inform future de-escalation of surgery in women with HER2-positive and triple-negative disease.
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Affiliation(s)
- David W Lim
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. .,Department of Surgery, Women's College Hospital, Toronto, Ontario, Canada. .,Division of General Surgery, Department of Surgery, University Health Network, Toronto, Ontario, Canada.
| | - Brittany D Greene
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nicole J Look Hong
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Odette Cancer Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Surgical Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
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19
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De Luca A, Frusone F, Buzzacchino F, Amabile MI, Taffurelli M, Del Mastro L, Rutgers EJT, Sacchini V, Caruso F, Minelli M, Fortunato L. First Surgical National Consensus Conference of the Italian Breast Surgeons association (ANISC) on breast cancer management in neoadjuvant setting: Results and summary. Eur J Surg Oncol 2021; 47:1913-1919. [PMID: 33972142 DOI: 10.1016/j.ejso.2021.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/31/2022] Open
Abstract
RATIONALE On October 15th, 2020, the first Surgical National Consensus Conference on neoadjuvant chemotherapy (NACT) was promoted by the Italian Association of Breast Surgeons (ANISC). METHOD The Consensus Conference was entirely held online due to anti-Covid-19 restrictions and after an introductory four lectures held by national and international experts in the field, a total of nine questions were presented and a digital "real-time" voting system was obtained. A consensus was reached if 75% or more of all panelists agreed on a given question. RESULTS A total of 202 physicians, from 76 different Italian Breast Centers homogeneously distributed throughout the Italian country, participated to the Conference. Most participants were surgeons (75%). Consensus was reached for seven out of the nine considered topics, including management of margins and lymph nodes at surgery, and there was good correspondence between the 32 "Expert Panelists" and the "Participants" to the Conference. Consensus was not achieved regarding the indications to NACT for high-grade luminal-like breast tumors, and the need to perform an axillary lymph node dissection in case of micrometastases in the sentinel lymph node after NACT. CONCLUSIONS NACT is a topic of major interest among surgeons, and there is need to develop shared guidelines. While a Consensus was obtained for most issues presented at this Conference, controversies still exist regarding indications to NACT in luminal B-like tumors and management of lymph node micrometastases. There is need for clinical studies and analysis of large databases to improve our knowledge on this subject.
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Affiliation(s)
- Alessandro De Luca
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Federico Frusone
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Maria Ida Amabile
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy.
| | - Mario Taffurelli
- IRCCS Policlinico di Sant'Orsola, University of Bologna, Bologna, Italy
| | - Lucia Del Mastro
- IRCCS Ospedale Policlinico San Martino, Breast Unit, and Department of Internal Medicine and Medical Specialties (DIMI), Genova, Italy
| | - Emiel J T Rutgers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, 10065, USA
| | - Francesco Caruso
- Department of Oncological Surgery, Humanitas Catanese Center of Oncology, Catania, Italy
| | - Mauro Minelli
- Division of Medical Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Lucio Fortunato
- Breast Centre, San Giovanni-Addolorata Hospital, Rome, Italy.
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20
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Liefaard MC, Lips EH, Wesseling J, Hylton NM, Lou B, Mansi T, Pusztai L. The Way of the Future: Personalizing Treatment Plans Through Technology. Am Soc Clin Oncol Educ Book 2021; 41:1-12. [PMID: 33793316 DOI: 10.1200/edbk_320593] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Advances in tissue analysis methods, image analysis, high-throughput molecular profiling, and computational tools increasingly allow us to capture and quantify patient-to patient variations that impact cancer risk, prognosis, and treatment response. Statistical models that integrate patient-specific information from multiple sources (e.g., family history, demographics, germline variants, imaging features) can provide individualized cancer risk predictions that can guide screening and prevention strategies. The precision, quality, and standardization of diagnostic imaging are improving through computer-aided solutions, and multigene prognostic and predictive tests improved predictions of prognosis and treatment response in various cancer types. A common theme across many of these advances is that individually moderately informative variables are combined into more accurate multivariable prediction models. Advances in machine learning and the availability of large data sets fuel rapid progress in this field. Molecular dissection of the cancer genome has become a reality in the clinic, and molecular target profiling is now routinely used to select patients for various targeted therapies. These technology-driven increasingly more precise and quantitative estimates of benefit versus risk from a given intervention empower patients and physicians to tailor treatment strategies that match patient values and expectations.
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Affiliation(s)
- Marte C Liefaard
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nola M Hylton
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
| | - Bin Lou
- Digital Technology and Innovation, Siemens Healthineers, Princeton, NJ
| | - Tommaso Mansi
- Digital Technology and Innovation, Siemens Healthineers, Princeton, NJ
| | - Lajos Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven, CT
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