Chemotherapy with estrogenic recruitment and surgery in locally advanced breast cancer: clinical and cytokinetic results

A Randomized Trial of Chemotherapy with or without Estrogenic Recruitment in Locally Advanced Breast Cancer

The present phase III trial was carried out to verify whether a kinetic recruitment induced by low doses of diethylstilbes-trol (DES) could increase the killing efficacy of chemotherapy in patients with locally advanced breast cancer. One-hundred and seventeen untreated patients with locally advanced breast cancer (stage IIIA/IIIB) were randomized to receive 3 courses of primary chemotherapy consisting of cyclophosphamide (600 mg/m2 i.v.), doxorubicin (50 mg/m2 i.v.) and fluorouracil (600 mg/m2 i.v.) (CAF) on day 1, or DES-CAF (DES, 1 mg orally days 1-3, CAF on day 4). The courses were repeated every 3 weeks. The patients who achieved an objective response were submitted to mastectomy followed by 3 courses of CAF alternated with 3 courses of CMF (cyclophosphamide, 600 mg/m2 i.v.; methotrexate, 40 mg/m2 i.v.; fluorouracil, 600 mg/m2 i.v.), with or without DES. The two treatment arms were well balanced in terms of clinical and pathologic features. There was no significant difference in response rates to induction chemotherapy between the two treatment arms (objective response rate, 63.3% for CAF and 56.1% for DES-CAF). Median overall survival was 49 and 47 months and median progression-free survival was 24 and 21 months for CAF and DES-CAF patients, respectively. Toxicity was not significantly different in the two groups, with the exception of leukopenia: DES chemotherapy was significantly more myelotoxic than the standard treatment, which resulted in a significant reduction in the actual dose intensity. In spite of the attractive experimental evidence, we conclude that so far there is no clinical advantage in the combination of estrogen and chemotherapy. Further research is needed to investigate different schedules of chemotherapy and hor-mones, or to test the possibility of combining various mitogens.

Neoadjuvant Moderately High-Dose Chemotherapy with rh-G-CSF in Locally Advanced Breast Carcinoma

Aims and Background

The poor results of local treatment for locally advanced breast carcinoma (LABC) justify the use of chemotherapy as primary treatment. Retrospective studies have shown a positive correlation between dose and response rate in advanced breast cancer. G-CSF has shown efficacy in achieving optimal dose intensity and ameliorating chemotherapy-induced myelosuppression. The aim of the present study was to assess the efficacy of a moderately high-dose chemotherapy regimen in terms of response rate, disease-free and overall survival and to assess the role of G-CSF in induced neutropenia.

Methods

Inclusion criteria were the following: age <65 years, WHO performance status <2, histologically proven breast carcinoma, adequate hematologic, renal and hepatic function, stage IIIA or IIIB disease, and no metastatic disease. No prior chemotherapy or radiotherapy was allowed. Three cycles of the following chemotherapy were used preoperatively: epirubicin (100 mg/m2 on day 1), cyclophosphamide (400 mg/m2 for 3 consecutive days) and rh-G-CSF (5 μg/kg/die from day 4 to day 12 every 14 days). After mastectomy or quadrantectomy plus radiotherapy, all patients were treated with 4 courses of adjuvant chemotherapy according to the CMF 1-8 schedule (methotrexate, 40 mg/m2; cyclophosphamide, 600 mg/m2; fluorouracil, 600 mg/m2; all on days 1 and 8, with recycle every 4 weeks).

Results

From May 1992 to June 1996, 57 patients with histologically proven LABC were preoperatively treated. Forty-four patients were premenopausal and 13 postmenopausal; the median age was 45 years (range, 29-64). Thirty-five patients had stage IIIA and 22 patients stage IIIB disease (7 with inflammatory disease). Forty-seven patients underwent radical mastectomy and 10 conservative surgery. A clinical response was noted in 93% (95% confidence interval, 83-98%) of patients (12% complete responses and 81% partial responses); 2 pathological complete remissions (3.5%) were obtained. No toxic deaths were observed. All patients had a follow-up of at least 42 months. The overall 5-year survival rate was 76% (standard error - SE), 6%) and the 5-year disease-free survival rate was 68% (SE, 6.3%).

Conclusions

The 14-day regimen was well tolerated and effective in LABC patients, although not superior to standard-dose chemotherapy. To improve results the use of new drugs in controlled clinical trials seems warranted.

Value of estrogenic recruitment before chemotherapy: first randomized trial in primary breast cancer

PURPOSE

Several preclinical studies showed that short-term pretreatment of breast cancer cells with estrogens can increase the antitumor efficacy of different cytotoxic drugs. Some early clinical studies in patients with advanced breast cancer did seem to support these findings. Therefore, the efficacy of estrogenic recruitment followed by chemotherapy was compared with that of chemotherapy alone in a randomized phase III study in women with lymph node-positive primary breast cancer.

PATIENTS AND METHODS

Three hundred twenty-eight patients with stage II/IIIA breast cancer who were younger than 66 years of age were randomly allocated to chemotherapy with fluorouracil, doxorubicin, and cyclophosphamide (FAC) or FAC plus pretreatment with ethinyl estradiol (EE(2)). FAC (500, 50, and 500 mg/m(2), respectively) was administered intravenously once every 4 weeks for four cycles. EE(2) (0.5 mg) was administered orally, both 24 hours and immediately preceding FAC chemotherapy.

RESULTS

Patient and tumor characteristics and chemotherapy dosages were comparable in both treatment groups. Of 318 assessable patients, with a median follow-up of 6.8 years, 177 patients had a relapse and 127 died. No significant differences were observed between the two treatment groups with respect to relapse-free, local recurrence-free, and overall survival according to univariate and multivariate analyses adjusted for age, menopausal status, tumor size, grade, number of positive nodes, and steroid-receptor status. The power for the detection of an increase of 50% in the median relapse-free survival was 80%.

CONCLUSION

Estrogenic recruitment of breast cancer cells before FAC chemotherapy did not influence the efficacy of adjuvant chemotherapy in stage II/IIIA breast cancer patients after a follow-up of 6.8 years.

Breast cancer and in vitro fertilization. About 32 cases

Because of the increased risk of breast cancer for infertile nulliparous women, the suspected promoter role of estradiol in mammary carcinogenesis and the high frequency of ovulation inducer treatments, it was interesting to focus on the risk of breast cancer after such a treatment. We reviewed 32 cases during a retrospective survey in Assisted Reproductive Techniques (ART) centers in France. Because of the small sample size and the few cases published so far, no statistical study could be made. However, many observations may have gone unnoticed or were not published. Two hypotheses can be proposed: (1) the facilitating role of stimulation on potential infra-clinical or un-diagnosed cancers; (2) the initiation of new cancers. Consequently, we propose to establish a register for the follow-up of treated women to monitor the advent of new cancers and to increase the follow-up of patients with other associated risk factors.

Chemotherapy with or without estrogenic recruitment in metastatic breast cancer. A randomized trial of the Gruppo Oncologico Nord Ovest (GONO)

BACKGROUND

This phase III study was carried out to verify whether a kinetic recruitment induced with low doses of diethylstilbestrol (DES) could increase the antitumor activity of chemotherapy in patients with advanced breast cancer.

PATIENTS AND METHODS

Two hundred fifty-eight women with metastatic breast cancer were randomized to receive chemotherapy consisting of cyclophosphamide 600 mg/sqm i.v., epidoxorubicin 60 mg/sqm i.v. and fluorouracil 600 mg/ sqm i.v. (CEF) on day 1 or DES-CEF (diethylstilbestrol 1 mg orally days 1-3 CEF on day 4) every 21 days. Patients were treated until progression or, if responsive, for a maximum of 10 courses.

RESULTS

There were no significant differences between the two treatment arms in response rates (51.3% to CEF and 49.6% for DES-CEF); median progression-free survival (9.4 months for CEF and 11 months for DES-CEF group) or median overall survival (17.3 and 20 months for CEF and DES-CEF arms, respectively). Non-hematological toxicities were superimposable in the two arms, while DES-chemotherapy was more myelotoxic.

CONCLUSIONS

This trial confirms that chemotherapy preceded by estrogenic recruitment is still in an experimental phase and that, at present, it has no role in clinical practice. Further research is needed to test the possibility of combining different mitogens in the light of new information about breast cancer cell growth.

A pilot evaluation of alternating preoperative chemotherapy in the management of patients with locoregionally advanced breast carcinoma

BACKGROUND

This prospective trial was conducted to evaluate the outcome of patients treated with preoperative and post operative chemotherapy, mastectomy, and irradiation for locoregionally advanced breast carcinoma.

METHODS

Between June 1986 and September 1990, 71 patients received 2 cycles of doxorubicin that alternated with 2 cycles of cyclophosphamide, methotrexate, and 5-fluorouracil prior to mastectomy; irradiation was administered when the tumor was not amenable to surgical resection. Additional chemotherapy and tamoxifen, in hormone receptor-positive tumors, was used after mastectomy. Post-operative irradiation was given on a selective basis for patients at high risk for locoregional disease recurrence.

RESULTS

Although 5 patients (7%) had disease progression, clinical partial or complete tumor response to preoperative chemotherapy was noted in 46 patients (65%). Sixty-eight patients (96%) underwent mastectomy. With a median follow-up of 52 months, the relapse-free and overall survival rates at 5 years were 42% and 57% respectively. Locoregional tumor recurrence occurred in 14 patients (20%), and 28 patients (39%) developed metastatic disease. Menopausal status, clinical presentation (noninflammatory vs. inflammatory), and American Joint Committee on Cancer clinical stage were independent covariates associated with patient outcome.

CONCLUSIONS

Preoperative alternating chemotherapy, with the selective use of irradiation, resulted in significant locoregional disease regression and the successful integration of mastectomy into the therapeutic strategy. Locoregional tumor control and relapse-free and overall survival estimates for the approach described herein compared favorably with other comtemporary reports for this condition.

Inflammatory breast cancer

Multimodal therapy with induction chemotherapy has improved significantly local disease control and overall survival in patients with IBC. This is now considered standard therapy for patients with this disease. Although survival has been improved, well over 50% of these patients will succumb to this disease. Ongoing and future investigations may better define the optimal approach for local control, the optimal duration of maintenance chemotherapy, and the possible role of biologic response modifiers and growth factors in further improving the outcome for patients with this disease.

Assessment of response to therapy of primary breast cancer by mammography and physical examination

BACKGROUND

Accurate assessment of response to treatment is necessary to treat appropriately primary breast cancers that are not surgically removed. This retrospective study was undertaken to compare the effectiveness of physical examination (PE) and mammography to assess response of primary breast cancer to medical therapy in women who were ineligible for initial surgical treatment.

METHODS

Thirteen women with 14 breast carcinomas were evaluated for interval changes. Except for 1 patient who had two follow-up studies, the other 12 each had a single follow-up study including PE and mammography; changes therefore were assessed in 15 instances. Response to treatment also was judged by mastectomy results in two instances, changes in metastatic disease by other imaging procedures in five, and changes in primary tumor by computed tomography in two breasts.

RESULTS

In 11 of 15 assessments of posttherapy changes, PE and mammography results were similar concerning treatment response. Of four discordant follow-ups, the tumors were found to be stable by PE, whereas they were found to be increasing by mammography in two. In both of these cases, progression of disease outside the breast was identified by other imaging studies, consistent with the mammographic findings. In another case, disease appeared to regress by PE but was unchanged by mammography; disease extent in mastectomy specimens was consistent with that found mammographically and more extensive than that suggested by physical examination. In the fourth case, superficial healing of a fungating tumor was obvious by clinical examination but could not be appreciated by mammography. The detectability of changes was not related to type of treatment.

CONCLUSIONS

Physical examination and mammography are both useful in the serial evaluation of breast cancers. Although usually complimentary, disease progression, when it occurs, may be detected by only one of these methods.

Multidisciplinary management of advanced primary and metastatic breast cancer

Combined modality therapy has become the treatment of choice for patients with primary breast cancer, including those with locally advanced breast cancer. Primary or induction chemotherapy, followed by surgery or radiation therapy or both, and adjuvant systemic therapy is a generally accepted strategy. Most tumors respond with a more than 50% decrease in tumor size, and approximately 70% of patients experience down-staging through primary chemotherapy. Breast conservation is possible for many patients with locally advanced breast cancer, and almost all patients initially are rendered disease free. Primary chemotherapy should be the initial choice of treatment for patients with locally advanced tumors, but it is unclear what the optimal sequence of subsequent therapies should be, or whether one or two local treatment modalities are necessary. The most dramatic example of the efficacy of these regimens was demonstrated in patients with inflammatory breast cancer. Previously a universally fatal condition, the natural history of this disease has been changed dramatically by the introduction of these combined modality therapies. Five-year survival rates of 35-60% commonly are reported, and it is likely that about one third of patients with this highly aggressive form of disease will survive beyond 10 years without recurrence. Combined modality therapy that includes primary chemotherapy provides appropriate local control, the possibility of breast conservation therapy, and, probably, an increased survival rate, at least for some subsets of patients with locally advanced breast cancer. The use of similar treatment strategies for early breast cancer is currently under evaluation. Hormone therapy and combination chemotherapy represent the main treatment approaches to metastatic breast cancer. Radiotherapy is also a useful palliative tool, especially for control of painful bone metastases and central nervous system involvement. Patient and tumor characteristics help in the optimal selection of systemic therapy. Palliative therapy for symptomatic control and prolongation of life also preserves a good quality of life. Dose-intensive chemotherapy is being evaluated as a treatment to increase complete response rates and cause remission consolidation. Clinical trials on several new and effective cytotoxic agents, as well as new hormonal compounds, are being completed and are showing encouraging preliminary results.(ABSTRACT TRUNCATED AT 400 WORDS)

Management of locally advanced breast cancer

The management of locally advanced breast cancer with single modality therapy has been associated with a high rate of systemic failure. A multimodality treatment strategy that includes induction cytotoxic chemotherapy, surgery, radiation therapy, and, possibly, hormonal ablation therapy is the current preferred management approach. As our knowledge and understanding of the mechanisms involved in mitogenic signal transduction improve, it is likely that less toxic, more efficacious agents will emerge.

Tumour kinetics, response to chemotherapy and survival in primary ovarian cancer

The analysis of thymidine labelling index (TLI) in relation to clinico-pathological variables and survival was carried out in 111 ovarian cancer patients. The significance of TLI in predicting response to aggressive first line chemotherapy regimens was examined. The overall median TLI value of 1.8% was used as a cut-off to discriminate slowly from highly proliferating cancers. 94 patients entered into two consecutive randomised trials, and were treated with six courses of cisplatin-based chemotherapy with or without doxorubicin. A significantly higher objective response of 60% was reported in the subset of patients with TLI > 1.8% as compared to 35% in patients with TLI < or = 1.8% (P = 0.03). In addition, patients achieving complete response had tumours with median TLI of 3.8% as compared to 2.4% for partial responders, 1.5% for patients with stable disease and 1.7% for those with progressive disease. A significant increase in tumour kinetics was observed in advanced cancers (P = 0.001), more undifferentiated tumours (P = 0.02) and postsurgical residual disease greater than 2 cm (P = 0.04). In univariate analysis, TLI failed to influence significantly clinical outcome: 26 versus 32 months median survival time for patients with high and low tumour TLI, respectively. In the Cox's regression model, the only independent prognostic variables were performance status and amount of residual disease after primary surgery (P = 0.000).

Relationship of variations in tumor cell kinetics induced by primary chemotherapy to tumor regression and prognosis in locally advanced breast cancer

The relationship of changes in 3H-thymidine labelling index (TLI) induced by primary chemotherapy to tumor response and relapse rate in 36 patients with previously untreated locally advanced breast cancer (LABC) was analyzed. All patients received primary chemotherapy (3 cycles FAC), followed by mastectomy and subsequent adjuvant chemotherapy (3 FAC alternated with 3 CMF). Tumor TLI was evaluated immediately prior to primary chemotherapy and at the time of mastectomy. Median pretreatment TLI was used to discriminate between tumors with a high or low proliferative rate. Clinical objective response to primary chemotherapy was 83% in patients with high TLI and 56% for those with low pretreatment TLI (p = 0.06). Primary chemotherapy induced a > or = 50% reduction of the proliferative rate in 83% and 39% of the tumors with high and low pretreatment TLI, respectively (p = 0.006). Patients were classified into 4 groups according to TLI values both before and after primary chemotherapy: patients who remained in the high TLI group after primary FAC had the highest response rate (100%) and the lowest 2-year relapse rate (20%). These data suggest that: a) improved response to aggressive cytotoxic treatment occurs in tumors with high TLI at diagnosis; b) there is a significant correlation between TLI changes induced by primary chemotherapy and pretreatment proliferative activity; c) patients who remain in the high TLI group after primary chemotherapy are more likely to benefit from subsequent adjuvant systemic therapy.

The Centre H. Becquerel studies in inflammatory non metastatic breast cancer. Combined modality approach in 178 patients

One hundred and seventy-eight patients with non metastatic inflammatory breast cancer (IBC) have been treated at the Centre H. Becquerel. Median follow up is 67 months (6-178). Every patient received neoadjuvant chemotherapy (mean number of cycles = 4; range: 2-8), followed by a loco regional treatment (radiotherapy = XRT or modified radical mastectomy = S), followed by adjuvant chemotherapy. During this period, the types of chemotherapy and locoregional treatment have been the following: Study I: 64 patients treated with CMF or AVCF and XRT; Study II: 83 patients, treated with either AVCF, FAC or VAC followed by S (n = 38) or XRT (n = 22) in case of complete or partial response, or followed by XRT (23) in case of initial supraclavicular lymph node involvement or lack of response after chemotherapy; Study III: 31 patients treated with FEC-HD + Estrogenic recruitment followed by S and XRT after adjuvant chemotherapy, except seven patients who received XRT (refusal of surgery). Although objective response rates (= 56.2, 73.5 and 93.5% for study I, II and III respectively) are statistically better in the 3rd study, this does not translate in dramatically different disease free survival (median = 16.7, 19 and 22.2 months respectively for study I, II and III) or overall survival (median = 25, 45.7 and 32.6 months respectively for study I, II and III). Analysis of subset of patients without supra clavicular lymph node involvement where neoadjuvant chemotherapy obtained at least a 50% response reveals a median disease free survival and median overall survival of respectively 38.3 and 60.1 months for patients who underwent S vs 19 and 38.3 months for those who received XRT (P = 0.15). These studies suggest that surgery has no deleterious effect on outcome of IBC. Advantage on disease free survival or overall survival from intensive chemotherapy in IBC remains to be proven with appropriate randomised trials.

Oncogenes, breast cancer, and chemoprevention

Perturbations of oncogenes in breast carcinoma include amplifications of the HER-2/neu and PRAD1 genes, as well as p53 mutations. Some of these lesions frequently appear in early cancers such as ductal carcinoma in situ and are stable as the tumors become invasive and metastasize. Thus these findings suggest that oncogene mutations may define a point of origin for a given breast cancer, and are fixed lesions during tumor progression. Such germline abnormalities may occur at the BRCA1, H-RAS VNTR, and p53 loci. The rational use of genetics may be to identify women at high risk for the development of breast cancer so that they may be enrolled in future chemoprevention trials.

Arrest in late G2 or prophase of cell cycle induced by 4,4-(1,2-ethanediyl) bis (1-isobutoxycarbonyloxymethyl 2, 6-piperazinedione) (MST-16) in cultured L1210 cells

The effects of MST-16, a new antitumor agent derived from bis (2, 6-dioxopiperazine), on cell growth, cell-cycle progression and DNA synthesis, alone and in combination with other antitumor agents, were investigated in murine leukemia L1210 cells in vitro. The drug showed dose-dependent inhibition of cell growth, and this effect was cell-cycle phase-specific. Flow cytometric analysis indicated that the drug could retard-arrest the cells in late G2 phase or prophase and that it did not affect the progression from G1 to G2 phase. In the presence of MST-16, the change in 3H-thymidine incorporation was proportional to the retardation-arrest of the cells, suggesting that MST-16 has no direct action on DNA synthesis itself. MST-16 could continuously retard the cells which were arrested by etoposide (VP-16); and vincristine (VCR) could block the progression of the cells arrested by MST-16, but not vice versa. The addition of MST-16 followed by VCR was more effective than simultaneous addition of the 2 drugs on inhibition of cell growth. These results will be useful in designing a reasonable regimen of MST-16 chemotherapy for malignancies.

Changes in cell kinetics induced by primary chemotherapy in breast cancer

Changes in the 3H-thymidine labelling index (3H-TdR LI) of primary tumor induced by cytoreductive chemotherapy were evaluated in 26 patients with locally advanced breast cancer subjected to mastectomy after different systemic therapies. A significant reduction of 3H-TdR LI by primary chemotherapy was observed in 11 cases. Changes in cell kinetics were related to the pretreatment proliferative activity: significant increases were observed in 70% of tumors with a very low 3H-TdR LI (less than 25%) and significant decreases in 100% of tumors with a very high 3H-TdR LI (greater than 7.0%). There was no correlation between pretreatment 3H-TdR LI and the objective clinical response, which was conversely related to posttreatment cell kinetics. The 2-year progression rate was lower for patients whose residual tumors after treatment had remained (2/7) or become (1/8) slowly proliferating than for patients whose tumors had remained (5/7) or become (4/4) rapidly proliferating.

Selection of therapy for stage III breast cancer

Locally advanced breast cancer is a heterogenous group including both operable and inoperable lesions. Local surgery or radiation alone produces poor survival rates, indicating micrometastases at diagnosis. Systemic chemotherapy as part of multimodality regimens has increased the length and rate of disease-free survival.

In vitro sensitivity testing of human breast cancer cells to hormones and chemotherapeutic agents

The sensitivities of human breast cancer cells to hormones and chemotherapeutic agents were measured using a new in vitro assay. Tumor cells from individual patients were cultured on collagen-coated dishes in medium containing the patient's serum. The rationale for use of the patient's serum is that the components of this serum interact with the cells and therapeutic agents in vivo. Cells were incubated for the length of the assay in the presence or absence of estrogen (E2) with or without tamoxifen (TAM) or in the presence or absence of cortisol (F). At 1 day after cell seeding, cells were exposed to a chemotherapeutic agent, Adriamycin, melphalan, or 5-fluorouracil, for 24 h. After a 48-h recovery period, [3H]-thymidine ([3H]-TdR) was added to the cultures for 24 h. Depending on the concentration, E2 generally stimulated or inhibited incorporation of [3H]-TdR into the DNA of cells from estrogen-receptor (ER)-positive tumors. TAM eliminated the effects of E2. F generally stimulated or inhibited incorporation in cells with no correlation to ER status. Stimulation of [3H]-TdR incorporation by hormones increased cell sensitivity to Adriamycin. In contrast, hormone inhibition of [3H]-TdR incorporation decreased cell responsiveness to this drug. This rapid assay, which can measure the sensitivities of breast carcinoma cells to hormones and drugs and identify effective combinations of therapeutic agents, should lead to a rational selection of treatment for the individual patient.

Actions of medroxyprogesterone acetate on the efficacy of cytotoxic drugs: studies with human breast cancer cells in culture

Human breast cancer cells (MCF-7) showed increased responses to methotrexate and vincristine after a 48-hr pre-treatment with medroxyprogesterone acetate. The effect of the hormone, which was detectable at concentrations of between 10 and 100 nM, was independent of its growth-inhibitory action. These findings confirm a previous clinical study and have important implications with regard to the management of advanced breast cancer.