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

Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in cN0 Breast Cancer: Impact of HER2-Positive Status on Survival

Objective

High rates of negative sentinel lymph node biopsy (SLNB) in clinically node-negative (cN0) breast cancer (BC) after neoadjuvant chemotherapy (NAC) have been described. These results are associated with triple-negative (TNBC) and human epidermal growth factor receptor 2 (HER2+) subtypes achieving pathologic complete response (pCR). This study evaluates predictive variables and survival in order to assess the possible omission of SLNB after NAC.

Materials and Methods

Prospective study of women with cN0 BC treated with NAC and subsequent surgery, between April 2010 and May 2021. SLNB technique included, performing axillary lymphadenectomy in the absence of detection or SLNB-positivity. Multivariable logistic regression was used for analysis of NAC-response and SLNB-results in molecular subtypes: HR-/HER2+, TNBC, HR+/HER2- and HR+/HER2+. Kaplan-Meyer and log-rank were used for survival analysis.

Results

A total of 179 patients (50.5±10.1 years) were included. Of these, 39.7% achieved pCR (ypT0/Tis). HR-negative subtypes had higher pCR rates (HR-/HER2+: 59.4%; TNBC: 53.4%), with no cases of SLNB-positive. With residual disease, HR-/HER2+ and TNBC showed low rates of SLNB-positivity (6.7% and 10.3%) versus HR+ (HR+/HER2+: 20%; HR+/HER2-: 44%; p<0.001). Multivariable analysis identified independent predictors of SLNB-negativity (p<0.0001) to be: HR- [odds ratio (OR)=0.15; 95% confidence interval (CI): 0.06-0.37; p = 0.0001], HER2+ (OR=0.34; 95% CI: 0.14-0.81; p = 0.015) and high-grade Nottingham (OR=0.42; 95% CI: 0.18-0.99; p = 0.048). Disease-free survival showed worse outcomes with SLNB-positivity (p<0.0001), HR+/HER2- (p = 0.0277), larger tumor size (p = 0.002) and residual disease after NAC (p<0.0001).

Conclusion

Patient selection based on NAC response, molecular subtype, and survival outcomes is a priority for establishing individualized therapeutic strategies after NAC. Molecular subtypes with higher pCR rates and lower rates of SLNB-positivity could benefit from non-invasive strategies that include omission of SLNB.

Prediction of axillary lymph node pathological complete response to neoadjuvant therapy using nomogram and machine learning methods

Purpose

To determine the feasibility of predicting the rate of an axillary lymph node pathological complete response (apCR) using nomogram and machine learning methods.

Methods

A total of 247 patients with early breast cancer (eBC), who underwent neoadjuvant therapy (NAT) were included retrospectively. We compared pre- and post-NAT ultrasound information and calculated the maximum diameter change of the primary lesion (MDCPL): [(pre-NAT maximum diameter of primary lesion – post-NAT maximum diameter of preoperative primary lesion)/pre-NAT maximum diameter of primary lesion] and described the lymph node score (LNS) (1): unclear border (2), irregular morphology (3), absence of hilum (4), visible vascularity (5), cortical thickness, and (6) aspect ratio <2. Each description counted as 1 point. Logistic regression analyses were used to assess apCR independent predictors to create nomogram. The area under the curve (AUC) of the receiver operating characteristic curve as well as calibration curves were employed to assess the nomogram’s performance. In machine learning, data were trained and validated by random forest (RF) following Pycharm software and five-fold cross-validation analysis.

Results

The mean age of enrolled patients was 50.4 ± 10.2 years. MDCPL (odds ratio [OR], 1.013; 95% confidence interval [CI], 1.002–1.024; p=0.018), LNS changes (pre-NAT LNS – post-NAT LNS; OR, 2.790; 95% CI, 1.190–6.544; p=0.018), N stage (OR, 0.496; 95% CI, 0.269–0.915; p=0.025), and HER2 status (OR, 2.244; 95% CI, 1.147–4.392; p=0.018) were independent predictors of apCR. The AUCs of the nomogram were 0.74 (95% CI, 0.68–0.81) and 0.76 (95% CI, 0.63–0.90) for training and validation sets, respectively. In RF model, the maximum diameter of the primary lesion, axillary lymph node, and LNS in each cycle, estrogen receptor status, progesterone receptor status, HER2, Ki67, and T and N stages were included in the training set. The final validation set had an AUC value of 0.85 (95% CI, 0.74–0.87).

Conclusion

Both nomogram and machine learning methods can predict apCR well. Nomogram is simple and practical, and shows high operability. Machine learning makes better use of a patient’s clinicopathological information. These prediction models can assist surgeons in deciding on a reasonable strategy for axillary surgery.

Increased aldehyde dehydrogenase 1 (ALDH1) levels are associated with chemo-responsiveness in breast cancer patients treated with taxane-adriamycin-cyclophosphamide regimen

BACKGROUND

Increased plasma aldehyde dehydrogenase 1 (ALDH1) levels have been proposed to predict cancer chemoresistance. However, studies have reported inconsistent results, depending on the type of cancer cells used.

OBJECTIVE

This study aimed to investigate the correlation between plasma levels of ALDH1 and chemotherapy responses to the taxane-adriamycin-cyclophosphamide (TAC) regimen in breast cancer patients.

METHODS

Thirty breast cancer patients who underwent chemotherapy using the TAC regimen were included in this study. Blood sampling was performed before chemotherapy was initiated and after the first and third cycles of chemotherapy administration. After 3 cycles of chemotherapy, patients were categorized as non-responsive if the tumor size was reduced <30%, if the tumor size remained the same or increased, or if any new tumors were discovered. Patients were defined as responsive after 3 cycles of chemotherapy if the tumor mass disappeared, if the tumor size was reduced by at least 30% of the initial size and if no new tumors were found.

RESULTS

Among the 30 patients, only five were responsive to the TAC regimen. The clinical response to TAC was not correlated with the patient's age, cancer grading, or tumor stage. A change in the ALDH1 levels was observed after the third cycle of TAC administration, with significantly higher ALDH1 levels observed in responsive compared with non-responsive patients (p < 0.05).

CONCLUSION

The results of this study may indicate a role for ALDH1 in chemoresponsiveness, rather than chemoresistance, for the TAC regimen in breast cancer patients. Further research remains necessary to confirm this result.

Association between Skeletal Muscle Loss and the Response to Neoadjuvant Chemotherapy for Breast Cancer

Simple Summary

The loss of skeletal muscle mass is known to be associated with poor treatment outcome, treatment-related toxicity, and high mortality. The association between loss of skeletal muscle mass and the response to treatment is not well-defined yet. In this study, we evaluated the impact of loss of skeletal muscle mass on responsiveness to neoadjuvant chemotherapy in breast cancer. The prediction of response to neoadjuvant chemotherapy could be helpful to guide the treatment direction.

Abstract

There are no means to predict patient response to neoadjuvant chemotherapy (NAC); the impact of skeletal muscle loss on the response to NAC remains undefined. We investigated the association between response to chemotherapy and skeletal muscle loss in breast cancer patients. Patients diagnosed with invasive breast cancer who were treated with NAC, surgery, and radiotherapy were analyzed. We quantified skeletal muscle loss using pre-NAC and post-NAC computed tomography scans. The response to treatment was determined using the Response Evaluation Criteria in Solid Tumors. We included 246 patients in this study (median follow-up, 28.85 months). The median age was 48 years old (interquartile range 42–54) and 115 patients were less than 48 years old (46.7%). Patients showing a complete or partial response were categorized into the responder group (208 patients); the rest were categorized into the non-responder group (38 patients). The skeletal muscle mass cut-off value was determined using a receiver operating characteristic curve; it showed areas under the curve of 0.732 and 0.885 for the pre-NAC and post-NAC skeletal muscle index (p < 0.001 for both), respectively. Skeletal muscle loss and cancer stage were significantly associated with poor response to NAC in locally advanced breast cancer patients. Accurately measuring muscle loss to guide treatment and delaying muscle loss through various interventions would help enhance the response to NAC and improve clinical outcomes.

BIK and GRP78 protein expression as possible markers of response to preoperative chemotherapy and survival in breast cancer

OBJECTIVE

BIK and GRP78 have shown differential expression profiles in breast cancer (BC) tissue, in addition to its important participation in the pathophysiology of cancer. The purpose of this study was to evaluate the association of BIK and GRP78 protein expression with clinical and pathologic response to preoperative chemotherapy, recurrence, disease-free survival (DFS) and overall survival (OS), in patients with BC.

MATERIAL AND METHODS

Fifty-three patients who received preoperative chemotherapy where included in an observational, analytical and retrospective study to assess the BIK and GRP78 protein expression by immunohistochemistry in microarrays of BC tissue obtained before treatment. Associations between BIK and GRP78 expression with clinicopathological characteristics, clinical and pathologic response to preoperative chemotherapy, and recurrence were analyzed using Chi-square or Fisher's exact test. OS and postoperative DFS were assessed at 5-year follow-up by Kaplan-Meir curves, and the difference according to BIK and GRP78 expression was evaluated using the log-rank test. Bivariate analysis was performed using Cox risk proportion model. A p value < 0.05 was considered to be statistically significant.

RESULTS

BIK and GRP78 staining revealed positive expression in 37 (71.2%) and 35 patients (72.9%) respectively. Association between pathological complete response (pCR) and positive expression of BIK (p = 0.046), as well as between clinical complete response (cCR) and negative expression of GRP78 was observed (p = 0.048). Patients with expression of GRP78 had lower DFS (HR = 3.46; 95% CI 1.01-11.80; p = 0.047) and shorter OS (HR = 3.49; 95% CI 1.04 a 11.72; p = 0.043).

CONCLUSION

When finding association of GRP78 and BIK protein expression with the response (clinical and pathologic respectively) to preoperative chemotherapy, and GRP78 with DFS and OS, in patients with BC, our results suggest a potential prognostic value of both proteins; however, a larger sample size is required to confirm this.

Survival Analysis of Patients with Inflammatory Breast Cancer in Relation to Clinical and Histopathological Characteristics

Purpose

To evaluate the survival of patients with inflammatory breast cancer (IBC) and to correlate these survival rates with the histopathological parameters found in the resection specimen of the tumor.

Patients and Methods

This retrospective study was based on 27 patients that had been diagnosed and had undergone surgery in the 2nd General and Oncological Surgery Clinic of the County Emergency Hospital in Timisoara, Romania. Data about the patient group were collected from archived patient files over a period of eight years starting from January 2008. The collected data regarded age, tumor size and histopathological type and immunohistochemistry (IHC), presence or absence of tumor embolus in lymphatic or blood vessels and the presence or absence of distant metastases at the time of diagnosis. We evaluated the impact of tumor characteristics on the patients’ outcome.

Results

The 12-month survival rates postsurgery were significantly increased if tumors were <5 cm compared to those >5 cm (p=0.046), if nodal status was N0 vs N1–2 (p=0.039), as well as in cases where distant metastases were absent, compared to patients with distant metastases (p=0.001, α=0.001) and positive-hormone receptors (p=0.043). Survival was influenced neither by histopathological type (p=0.357) nor by the presence of tumor embolus in the resection specimen (p=0.250) and HER2 status (p=0.763). Survival at 12 months after surgery was equal between those with stage IIIB noninflammatory breast cancer (NIBC) and IBC. At 24 months after surgery, IBC cases presented a significantly lower probability of survival.

Conclusion

The prognosis of patients with IBC is reserved compared to NIBC, increased tumor size, positive lymph node, hormone receptors negative cases and distant metastases drastically decreasing survival rates.

Prognostic assessment of breast carcinoma submitted to neoadjuvant chemotherapy with pathological non-complete response

Background

Breast cancer with pathological non-complete response (non-pCR) after neoadjuvant chemotherapy (NAC) has a worse prognosis. Despite Neo-Bioscore has been validated as an independent prognostic model for breast cancer submitted to NAC, non-pCR carcinoma was not assessed in this setting.

Methods

This is a retrospective trial that included women with localized breast cancer who underwent NAC and had non-pCR carcinoma in surgical specimen between 01/01/2013 to 12/31/2015 with a three-year follow-up. Survival analysis was performed by Kaplan-Meier estimator and hazard ratio (HR) set by log-rank test for the primary and secondary endpoints, respectively Disease-Free Survival (DFS) and Overall Survival (OS). According to Neo-Bioscore, the proposed prognostic model named Clustered Neo-Bioscore was classified into low (0–3), low-intermediate (4–5), high-intermediate (6) and high (7) risk. The prognostic accuracy for recurrence risk was assessed by time-dependent receiver operating characteristic (time-ROC) methodology. Multivariate Cox regression assessed the menopausal status, histological grade, Ki-67, estrogen receptor, HER2, tumor subtype, pathological and clinical stages. Confidence interval at 95% (CI95%) and statistical significance at set 2-sided p-value less than 0.05 were adopted.

Results

Among the 310 women enrolled, 267 patients (86.2%) had non-pCR carcinoma presenting size T3/T4 (63.3%), node-positive axilla (74.9%), stage III (62.9%), Ki-67 ≥ 20% (71.9%) and non-luminal A (78.3%). Non-pCR carcinoma presented worse DFS-3y (HR = 3.88, CI95% = 1.18–11.95) but not OS-3y (HR = 2.73, CI95% = 0.66–11.40). Clustered Neo-Bioscore discerned the recurrence risk for non-pCR carcinoma: low (DFS-3y = 0.86; baseline), low-intermediate (DFS-3y = 0.70; HR = 2.61), high-intermediate (DFS-3y = 0.13, HR = 14.05), and high (DFS-3y = not achieved; HR = 22.19). The prognostic accuracy was similar between Clustered Neo-Bioscore and Neo-Bioscore (0.76 vs 0.78, p > 0.05). Triple-negative subtype (HR = 3.6, CI95% = 1.19–10.92) and pathological stages II (HR = 5.35, CI95% = 1.19–24.01) and III (HR = 6.56, CI95% = 1.29–33.32) were prognoses for low-intermediate risk, whereas pathological stage III (HR = 13.0, CI95% = 1.60–106.10) was prognosis for low risk.

Conclusions

Clustered Neo-Bioscore represents a novel prognostic model of non-pCR carcinoma undergoing NAC with a more simplified and appropriate score pattern in the assessment of prognostic factors.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5812-0) contains supplementary material, which is available to authorized users.

Post-neoadjuvant treatment and the management of residual disease in breast cancer: state of the art and perspectives

Achieving a pathologic complete response after neoadjuvant treatment is associated with improved prognosis in breast cancer. The CREATE-X trial demonstrated a significant survival improvement with capecitabine in patients with residual invasive disease after neoadjuvant chemotherapy, and the KATHERINE trial showed a significant benefit of trastuzumab-emtansine (TDM1) in human epidermal growth factor receptor 2 (HER2)-positive patients who did not achieve a pathologic complete response after neoadjuvant treatment, creating interesting alternatives of post-neoadjuvant treatments for high-risk patients. New agents are arising as therapeutic options for metastatic breast cancer such as the cyclin-dependent kinase inhibitors and the immune-checkpoint inhibitors, but none has been incorporated into the post-neoadjuvant setting so far. Evolving techniques such as next-generation sequencing and gene expression profiles have improved our knowledge regarding the biology of residual disease, and also on the mechanisms involved in treatment resistance. The present manuscript reviews the current available strategies, the ongoing trials, the potential biomarker-guided approaches and the perspectives for the post-neoadjuvant treatment and the management of residual disease after neoadjuvant treatment in breast cancer.

RNA Sequencing Uncovers Molecular Mechanisms Underlying Pathological Complete Response to Chemotherapy in Patients with Operable Breast Cancer

Background

This study aimed to identify key genes contributing to pathological complete response (pCR) to chemotherapy by mRNA sequencing (RNA-seq).

Material/Methods

RNA was extracted from the frozen biopsy tissue of patients with pathological complete response and patients with non-pathological complete response. Sequencing was performed on the HiSeq2000 platform. Differentially expressed genes (DEGs) were identified between the pCR group and non-pCR (NpCR) group. Pathway enrichment analysis of DEGs was performed. A protein-protein interaction network was constructed, then module analysis was performed to identify a subnetwork. Finally, transcription factors were predicted.

Results

A total of 673 DEGs were identified, including 419 upregulated ones and 254 downregulated ones. The PPI network constructed consisted of 276 proteins forming 471 PPI pairs, and a subnetwork containing 18 protein nodes was obtained. Pathway enrichment analysis revealed that PLCB4 and ADCY6 were enriched in pathways renin secretion, gastric acid secretion, gap junction, inflammatory mediator regulation of TRP channels, retrograde endocannabinoid signaling, melanogenesis, cGMP-PKG signaling pathway, calcium signaling pathway, chemokine signaling pathway, cAMP signaling pathway, and rap1 signaling pathway. CNR1 was enriched in the neuroactive ligand-receptor interaction pathway, retrograde endocannabinoid signaling pathway, and rap1 signaling pathway. The transcription factor-gene network consists of 15 transcription factors and 16 targeted genes, of which 5 were downregulated and 10 were upregulated.

Conclusions

We found key genes that may contribute to pCR to chemotherapy, such as PLCB4, ADCY6, and CNR1, as well as some transcription factors.

Clinical tumor stage is the most important predictor of pathological complete response rate after neoadjuvant chemotherapy in breast cancer patients

BACKGROUND

Pathological complete response (pCR) is the ultimate response in breast cancer patients treated with neoadjuvant chemotherapy (NCT). It might be a surrogate outcome for disease-free survival (DFS) and overall survival (OS). We studied the effect of clinical tumor stage (cT-stage) on tumor pCR and the effect of pCR per cT-stage on 5-year OS and DFS.

METHODS

Using the Netherlands Cancer Registry, all primary invasive breast cancer patients treated with NCT from 2005 until 2008 were identified. Univariable logistic regression analysis was performed to evaluate the effect of cT-stage on pCR, stepwise logistic regression analysis to correct for potential confounders and Kaplan-Meier survival analyses to calculate OS and DFS after five years.

RESULTS

In 2366 patients, overall pCR rate was 21%. For cT1, cT2, cT3, and cT4, pCR rates were 31, 22, 18, and 17%, respectively. Lower cT-stage (cT1-2 vs cT3-4) was a significant independent predictor of higher pCR rate (p < 0.001, OR 3.15). Furthermore, positive HER2 status (p < 0.001, OR 2.30), negative estrogen receptor status (p = 0.062, OR 1.69), and negative progesterone receptor status (p = 0.008, OR 2.27) were independent predictors of pCR. OS and DFS were up to 20% higher in patients with cT2-4 tumors with pCR versus patients without pCR. DFS was also higher for cT1 tumors with pCR.

CONCLUSIONS

The most important predictor of pCR in breast cancer patients is cT-stage: lower cT-stages have significantly higher pCR rates than higher cT-stages. Patients with cT2-4 tumors achieving pCR have higher OS and DFS compared to patients not achieving pCR.

A Novel System for Estimating Residual Disease and Pathologic Response to Neoadjuvant Treatment of Prostate Cancer

BACKGROUND

Pathologic variables that characterize response of prostate carcinoma to current neoadjuvant therapy have not been characterized in detail. This study reports (i) the histological features of prostate cancer treated with abiraterone and enzalutamide and inter-pathologist variance in identifying these features, and (ii) the effect of the novel androgen deprivation agents on residual cancer volume.

METHODS

We reviewed sections of prostatectomies from 37 patients treated with neoadjuvant agents and 22 untreated patients, tabulated the frequency of nine features of cancer (intact cancer glands, isolated cancer cells, poorly formed glands, cribriform architecture, clear spaces, intraductal carcinoma, solid sheets of cancer cells, prominent nucleoli, and previously described ABC grouping) and two features of benign glands (prominent basal cells and coalescent corpora amylacea). We used several methods, including a novel metric (visual grid system), to estimate residual tumor volume.

RESULTS

The most highly reproducible features were ABC grouping (κ = 0.56-0.7), presence of intraductal carcinoma (κ = 0.34-0.72), cribriform architecture (κ = 0.42-0.68), solid sheets of tumor cells (κ = 0.44-0.56), and coalescent corpora amylacea (κ = 0.4-0.54). Among poorly reproducible features were prominent nucleoli (κ = 0.03-0.11), clear spaces (κ = 0.05-0.07), and poorly formed cancer glands (κ = 0.02-0.1). Determination of tumor mass was excellent regardless of the method used-maximum tumor size (κ = 0.9-0.94), tumor area (κ = 0.94-0.96), and grid-based tumor cellularity (κ = 0.9).

CONCLUSIONS

We propose using a set of parameters including maximum tumor size, tumor area/volume, cellularity, volume, and ABC grouping for evaluating radical prostatectomies post-neoadjuvant therapy. Prostate 76:1285-1292, 2016. © 2016 Wiley Periodicals, Inc.

Early Evaluation of Relative Changes in Tumor Stiffness by Shear Wave Elastography Predicts the Response to Neoadjuvant Chemotherapy in Patients With Breast Cancer

OBJECTIVES

Neoadjuvant chemotherapy plays an important role in comprehensive therapy for breast cancer, but response prediction is imperfect. Shear wave elastography (SWE) is a novel technique that can quantitatively evaluate tissue stiffness. In this study, we sought to investigate the application value of SWE for early prediction of the response to neoadjuvant chemotherapy in patients with breast cancer.

METHODS

We prospectively evaluated tumor stiffness in 62 patients with breast cancer using SWE, which was performed at baseline and after the second cycle of neoadjuvant chemotherapy. After chemotherapy, all of the patients underwent surgery. We investigated the correlations between the relative changes in tumor stiffness (Δ stiffness) after 2 cycles of chemotherapy and the pathologic response to the therapy.

RESULTS

Compared with baseline values, tumor stiffness after 2 cycles of neoadjuvant chemotherapy was significantly decreased in responders (P < .001) but not in nonresponders (P = .172). The Δstiffness was significantly higher in responders (-42.194%) than in nonresponders (-23.593%; P = .001). As determined at either the baseline or after the second cycle of chemotherapy, tumor stiffness was significantly lower in responders than in nonresponders (P = .033 and .009, respectively). The Δ stiffness threshold for distinguishing between responders and nonresponders was -36.1% (72.92% sensitivity and 85.71% specificity). Furthermore, correlating Δ stiffness with clinical and pathologic characteristics, we found that estrogen and progesterone receptor expression showed statistically significant correlations with Δ stiffness (estrogen receptor, P = .008; progesterone receptor, P = .023).

CONCLUSIONS

Early evaluation of relative changes in tumor stiffness using SWE could effectively predict the response to neoadjuvant chemotherapy in patients with breast cancer and might indicate better therapeutic strategies on a timelier basis.

Safety, tolerability, and pharmacokinetics of single and multiple doses of intravenous cixutumumab (IMC-A12), an inhibitor of the insulin-like growth factor-I receptor, administered weekly or every 2 weeks in patients with advanced solid tumors

BACKGROUND

Type 1 insulin-like growth factor receptor (IGF-IR) signaling is often dysregulated in cancer. Cixutumumab, a fully human IgG1 monoclonal antibody, blocks IGF-IR and inhibits downstream signaling. The current study determined the recommended dose, safety, and pharmacokinetic (PK) profile of weekly or every-2-week dosing of cixutumumab.

PATIENTS AND METHODS

Two open-label, multicenter phase I studies evaluated weekly (3-15 mg/kg) or every-2-weeks (6-15 mg/kg) dosing of cixutumumab in patients with advanced solid tumors. Serial blood samples for PK were collected up to 168-336 h (day 8-15) following the first administration of cixutumumab. Efficacy was evaluated as best overall tumor response.

RESULTS

A total of 24 and 16 patients were enrolled in the weekly and every-2-week dosing studies, respectively. Treatment-emergent adverse events (≥10%) included hyperglycemia, fatigue, anemia, nausea, and vomiting. Severe adverse events (AE) were infrequent; one serious AE (grade 3 electrocardiogram QT prolongation) was deemed possibly cixutumumab-related (10 mg/kg every-2-weeks). One death occurred due to disease progression (6 mg/kg weekly cohort). Maximum serum concentrations increased with dose. A maximum tolerated dose was not identified; pre-determined target serum minimum concentrations (60 μg/mL) were achieved with ≥6 mg/kg weekly and ≥10 mg/kg every-2-week dosing. Cixutumumab terminal elimination half-life is approximately a week (individual range, t1/2 = 4.58-9.33 days based upon 10 mg/kg every 2 weeks). Overall, stable disease was achieved in 25% of all patients.

CONCLUSIONS

Cixutumumab was associated with favorable safety and PK profiles. A dosing regimen of 10 mg/kg every 2 weeks was recommended for subsequent disease-focused clinical trials.

Histologic parameters predictive of disease outcome in women with advanced stage ovarian carcinoma treated with neoadjuvant chemotherapy

The use of neoadjuvant chemotherapy followed by tumor reduction surgery, also called interval debulking surgery (IDS), is considered an alternative therapeutic regimen for selected patients with advanced stage epithelial ovarian cancer (EOC). Although minimal residual disease has been proven to be a prognostic factor in traditional cytoreduction for advanced stage EOC, predictive factors after IDS still remain unexplored. The aim of this study was to determine the prognostic value of post-neoadjuvant histologic changes with clinical outcome. Three pathologists evaluated 67 cases for the following parameters: fibrosis, necrosis, residual tumor, and inflammation. The Cohen's kappa statistic was used to measure agreement among pathologists. Univariate and multivariate Cox proportional hazards models were used to determine the association between histologic parameters and recurrence-free survival (RFS) and overall survival (OS). There was substantial to almost perfect agreement among the three pathologists in all four histologic parameters (k ranged from 0.65 to 0.97). Fibrosis was associated with longer RFS (P = 0.0257) with a median of 20 months for tumors with fibrosis (3+) versus 12 months for tumors with fibrosis (1+, 2+) and longer OS (P = 0.0249) with a median of 51 months for tumors with fibrosis (3+) versus 32 months for tumors with fibrosis (1+, 2+). Our results revealed that patients with tumors exhibiting fibrosis (1+, 2+), as well as necrosis (0, 1+), had significant shorter RFS and OS (P = 0.059 and P = 0.0234, respectively). We suggest that the assessment of fibrosis and necrosis should be implemented in pathologic evaluation and prospectively validated in future studies.

A systematic evaluation of multi-gene predictors for the pathological response of breast cancer patients to chemotherapy

Previous studies have reported conflicting assessments of the ability of cell line-derived multi-gene predictors (MGPs) to forecast patient clinical outcomes in cancer patients, thereby warranting an investigation into their suitability for this task. Here, 42 breast cancer cell lines were evaluated by chemoresponse tests after treatment with either TFAC or FEC, two widely used standard combination chemotherapies for breast cancer. We used two different training cell line sets and two independent prediction methods, superPC and COXEN, to develop cell line-based MGPs, which were then validated in five patient cohorts treated with these chemotherapies. This evaluation yielded high prediction performances by these MGPs, regardless of the training set, chemotherapy, or prediction method. The MGPs were also able to predict patient clinical outcomes for the subgroup of estrogen receptor (ER)-negative patients, which has proven difficult in the past. These results demonstrated a potential of using an in vitro-based chemoresponse data as a model system in creating MGPs for stratifying patients’ therapeutic responses. Clinical utility and applications of these MGPs will need to be carefully examined with relevant clinical outcome measurements and constraints in practical use.

Patient and tumor characteristics associated with breast cancer recurrence after complete pathological response to neoadjuvant chemotherapy

Breast cancer patients whose tumors achieve a pathological complete response (pCR) with neoadjuvant chemotherapy have a prognosis which is better than that predicted for the stage of their disease. However, within this subgroup of patients, recurrences have been observed. We sought to examine factors associated with recurrence in a population of breast cancer patients who achieved a pCR with neoadjuvant chemotherapy. A retrospective chart review was conducted of all patients with unilateral breast cancer treated with neoadjuvant chemotherapy from January 1, 2000 to December 31, 2010 at one comprehensive cancer center. A pCR was defined as no residual invasive cancer in the breast in the surgical specimen following neoadjuvant therapy. Recurrence was defined as visceral or bony reappearance of cancer after completion of all therapy. Of 818 patients who completed neoadjuvant chemotherapy, 144 (17.6 %) had pCR; six with bilateral breast cancer were excluded from further analysis. The mean time to follow-up was 47.2 months. Among the 138 patients with unilateral breast cancer, there were 14 recurrences (10.1 %). Using a binary multiple logistic regression model, examining types of chemotherapy and surgery, race, lymph node assessment, and lymph node status, breast cancer side, triple-negative status, and radiation receipt, only African-American patients (OR: 5.827, 95 % CI: 1.280-26.525; p = 0.023) were more likely to develop distant recurrence. The mean time to recurrence was 31.9 months. In our study, race was the only independent predictor of recurrence after achieving pCR with neoadjuvant chemotherapy. The reasons for this observation require further study.

Stage-to-stage comparison of neoadjuvant chemotherapy versus adjuvant chemotherapy in pathological lymph node positive breast cancer patients

OBJECTIVE

The purpose of this study was to investigate the prognostic implications of post-neoadjuvant chemotherapy on the survival outcomes of breast cancer patients with persistent positive axillary lymph nodes by performing a stage-to-stage comparison between neoadjuvant chemotherapy and initial surgery.

METHODS

Retrospective analysis was performed on 813 breast cancer patients with positive axillary lymph node after surgery, who were treated between 2001 and 2006. Of these, 269 patients received neoadjuvant chemotherapy, and 544 patients were treated with surgery followed by adjuvant chemotherapy. The median follow-up time was 5.9 years.

RESULTS

The 5-year disease-free survival rates for patients in the neoadjuvant chemotherapy and adjuvant chemotherapy groups were 73 and 88%, respectively (P<0.001). The 5- and 9-year disease-free survival rates for ypStage II (82 and 76%) were significantly worse than those for pStage II (93 and 80%, P=0.002), and the rates for ypStage III (64 and 50%) were worse than those for pStage III (74 and 66%, P=0.04). The disease-free survival of ypStage II was similar to that of pStage III (P=0.16). Similar results were seen when comparing distant metastasis-free survival rates. Using multivariate analyses, grade, age, hormonal receptor status, final pathological stage and neoadjuvant chemotherapy itself were found to be independent negative prognostic factors for disease-free survival.

CONCLUSIONS

Stage-to-stage comparison of pathologically node-positive patients revealed that the survival outcome at each ypStage after neoadjuvant chemotherapy was worse than that for the comparable pStage. These data may help to formulate more accurate prognoses for patients with residual positive nodes after neoadjuvant chemotherapy.

Pathologic changes in breast cancer after anti-estrogen therapy

Breast cancer patients do not commonly receive anti-estrogens prior to surgical excision. We reviewed a cohort of patients who received preoperative anti-estrogen therapy after baseline biopsy and then had a repeat biopsy after several weeks on treatment. Patients with estrogen receptor positive tumors received anastrozole and fulvestrant in combination with gefitinib. Core needle biopsies were performed at day 1 and 21, and tumors were completely excised if operable at day 112. All patients were postmenopausal. Following treatment, tumors had degenerative changes including smudged nuclei, decreased nuclear size, intranuclear vacuoles, vacuolated cytoplasm, and increased cellular discohesion. In addition, increased tubule formation and intracytoplasmic lumina were seen in 6/9 cases (66.7%) and decreased mitotic rate was demonstrated in 7/9 cases (77.8%). These findings indicate increased differentiation of the tumor cells in response to anti-estrogen therapy and that may correlate with clinical response.

Primary chemo-radiotherapy in the treatment of locally advanced and inflammatory breast cancer

BACKGROUND

The best management of large, diffuse or inflammatory breast cancers is uncertain and the place of radiotherapy and/or surgery is not clearly defined.

METHODS

A cohort of 123 patients with non-metastatic locally advanced or inflammatory breast cancer 3 cm or more in diameter or T4, was treated between 1989 and 2006. All patients received primary chemotherapy followed by radiotherapy, 40 Gy in 15 fractions with 10 Gy boost. Patients with ER positive tumours received Tamoxifen. Assessment was carried out 8 weeks post-treatment and surgery was reserved for residual or recurrent disease.

RESULTS

For each stage there were T2/3: 63, T4b: 31 and T4d: 29 patients. 80 had complete clinical response (65%) but 18 patients were never free of inoperable local disease. 25 patients had residual operable disease at assessment and 12 patients who initially had a complete response developed operable local recurrence (LR). 37 Patients (30%) had surgery at a mean of 15 months post diagnosis. At 5 years, overall survival (OS) of the two surgical groups was not significantly different from those 68 patients who had complete remission without surgery, p=0.218, HR 1.46 (0.80-2.55). Surgery as an independent variable to predict survival was not significant on a Cox proportional hazards model (p=0.97). LR in the surgical groups was 13.5% vs 17.5% in the non-surgical patients. The median OS was 64.5 months and disease-free survival (DFS) was 52.5 months. 5-Year OS was 54% and DFS survival 43%.

CONCLUSION

In patients with a complete or partial response to chemo-radiotherapy for locally advanced or inflammatory breast cancer, reserving surgery for those with residual or recurrent local disease did not appear to compromise survival. This finding would support examination of this treatment strategy by a randomised controlled trial.

Estrogen receptor-α directly regulates sensitivity to paclitaxel in neoadjuvant chemotherapy for breast cancer

Neoadjuvant chemotherapy (NAC) has become the standard treatment for advanced breast cancer. Several prognostic markers, including estrogen receptor-α (ERα), are used to predict the response to NAC. However, the molecular significance of ERα expression in the efficacy of chemotherapy is not yet fully understood. To examine this issue, we first evaluated ERα transcriptional activity in breast cancer cells derived from pre-NAC specimens using estrogen response element-green fluorescent protein (ERE-GFP) as a reporter gene, and found that, in the cases for which ERα activities determined by GFP expression were not detected or low, pCR (pathological complete response) could be achieved even though ERα protein was expressed. Next, we examined the effects of alterations in ERα expression levels on sensitivity to paclitaxel, a key drug in NAC, by stable expression of ERα in ER-negative SKBR3 cells and by siRNA-mediated down-regulation of ERα in ER-positive MCF-7 cells, and showed that ERα expression and sensitivity to paclitaxel showed an inverse correlation. We also established paclitaxel-resistant MCF-7 cell clones and found that they have higher estrogen-induced ER activity than parent cells. Paclitaxel is a microtubule-stabilizing agent, while HDAC6 (histone deacetylase 6), which we previously identified as an estrogen-regulated gene, enhances cell motility by destabilizing microtubules via deacetylation of α-tubulin. Finally, we demonstrate herein that ERα knockdown in MCF-7 cells prevents deacetylation of α-tubulin, thereby increasing sensitivity to paclitaxel. Taken together, these results suggest that ERα expression directly regulates sensitivity to paclitaxel in NAC for breast cancer via the effect on microtubule stability.

Response rate to neoadjuvant chemotherapy measured on imaging predicts early recurrence and death in breast cancer patients with lymph node involvements

BACKGROUND

The use of neoadjuvant chemotherapy for breast cancer is effective as postoperative adjuvant therapy, permits more lumpectomies, and can be used to study breast cancer biology. Although pathological response is the strongest prognostic factor, response rates vary according to various parameters, such as dissociation between breast and axillary node responses.

PURPOSE

To clarify the correlation of response rates between breast tumors and metastasized lymph nodes and to identify the clinical significance; response rates measured on imaging were evaluated among breast cancer patients with axillary lymph node involvement.

MATERIAL AND METHODS

Subjects consisted of 98 patients diagnosed with node-positive breast cancer who received chemotherapy before surgery. The response to the therapy was evaluated by changes in the largest dimensions of the breast mass and of regional lymph nodes measured on a multidetector row helical CT before and after chemotherapy. The percent reduction was calculated as a response rate. The correlation between response rate and patient outcome was analyzed retrospectively.

RESULTS

Breast tumor response rates correlated statistically well with those of lymph nodes (p < 0.001). Disease-free cases had a greater tumor and/or nodal response rates than recurrence cases (p = 0.021, p < 0.001, respectively), regardless of tumor size, histological grade and HER2 amplification. Cancer-associated death was observed more frequently in cases with lower response rates compared to surviving cases (p = 0.007, p = 0.021, respectively). The prognostic difference was found most strongly in nodal response rates (p = 0.001).

CONCLUSION

The present series evaluated the therapeutic effect of NAC on breast tumors and metastasized lymph nodes, and a significant correlation with patient outcome was observed. Evaluating the response rate measured by imaging could be used as a surrogate marker for prognosis before assessment of the pathological response which is ordinarily obtained after surgery.

[Predictive factors of response to anthracyclines neoadjuvant chemotherapy in breast cancer]

OBJECTIVES

Anthracyclines chemotherapy remains primordial and impossible to circumvent in the treatment of breast cancer, in the adjuvant, metastatic and neoadjuvant setting. But some breast invasive tumors are resistant to anthracyclines. The neoadjuvant model is ideal to test the chemosensibility by selecting the well-responder patients and identifying the predictive factors of this response.

PATIENTS AND METHODS

We report a retrospective study of 126 patients treated at our institute during 2 years (January 2003-December 2004) for a breast cancer with primary chemotherapy. All the patients received anthracyclines according to protocol AC60 (doxorubicine plus cyclophosphamide).

RESULTS

The clinical objective response rate (RO) was 67 % with a complete clinical response (RC) of 11 %. We found a pathological complete response (pCR) in seven patients (5,6 %) of the 126 cases. The statistical study identifies only two clinical factors as predictive of RC and pCR: tumoral size T2-T3 and clinical nodal status N0-N1, while the SBR grading and the hormonal receptors were not correlated.

DISCUSSION AND CONCLUSION

Some clinical and histological factors are recognized as predictive for the benefit of anthracyclines neoadjuvant chemotherapy, and correlated to the pCR; we discuss our results through those of the literature, by exposing the current data.

Triple negative phenotype and N-ratio are important for prognosis in patients with stage IIIB non-inflammatory breast carcinoma

BACKGROUND AND OBJECTIVES

The aim is to evaluate novel prognostic factors such as triple negative (TN) phenotype and ratio between positive nodes and total dissected lymph nodes (N-ratio) in stage IIIB breast carcinoma patients.

METHODS

In this retrospective study, primary endpoints were local recurrence (LR), distant recurrence (DR), and overall survival (OS). Univariate and multivariate prognostic factor analyses were carried out using Cox and Kaplan-Meier methods in the data of 185 patients.

RESULTS

The median observation time was 36 (range 16-86) months. Pathological tumor size (continuous [cont.], P = 0.002; Hazard ratio [HR], 1.2; 95% confidence interval [CI], 1.1-1.3) and N-ratio (cont., P < 0.0001; HR, 1.02; CI, 1.01-1.03) were strongly associated with LR. Tumor phenotype (triple vs. non-triple, P = 0.002; HR, 2.6; CI, 1.4-4.7), N-ratio (cont., P = 0.01; HR, 1.02; CI, 1.01-1.03) and pathological tumor size (cont., P = 0.003; HR, 1.2; CI, 1.1-1.3) for DR, and also tumor phenotype (triple vs. non-triple, P < 0.0001; HR, 3.7; CI, 1.8-7.5), N-ratio (cont., P = 0.03; HR, 1.02; CI, 1.01-1.03) and pathological tumor size (cont., P = 0.006; HR, 1.3; CI, 1.2-1.4) for OS were the most important prognostic factors.

CONCLUSIONS

N-Ratio and TN phenotype were the most important prognostic factors for stage IIIB breast carcinoma patients.

Neoadjuvant chemotherapy for locally advanced breast cancer

Preoperative systemic therapy is the standard of care in locally advanced breast cancer. In this setting, the intent of preoperative systemic therapy is to expand surgical options and to improve survival. Locally advanced and inflammatory breast cancer have different biological features, but they share the use of preoperative (primary, neoadjuvant) systemic therapy as the initial treatment of choice. The management of these patients necessitates involvement of a multidisciplinary team from the onset and during therapy. The eradication of invasive cancer from the breast and axillary lymph nodes, pathologic complete response, is a predictor of outcome associated with improved disease-free and overall survival. However, conventional chemotherapy regimens result in pathologic complete response in only a minority of patients. The management of patients with residual invasive disease after preoperative therapy is a common clinical problem for which additional research is necessary. The differential expression of genes and pathways in locally advanced and inflammatory breast cancer allows for the exploitation of targeted therapy, and early trials have shown exciting target and tumor effects. Much work remains, and future trials combining targeted and conventional therapies based on molecular subtypes and/or specific targets are needed if we hope to improve survival for patients with locally advanced breast cancer.

Neoadjuvant chemotherapy for locally advanced breast cancer: a single center experience

Neoadjuvant chemotherapy (NAC) is one of the treatment options for patients with locally advanced breast cancer (LABC). Preoperative chemotherapy potentially may reduce the extent of the surgery and offers the opportunity to assess the chemosensitivity of the tumor in vivo. Herein, we evaluated the results of NAC in Turkish LABC patients. We retrospectively analyzed 73 LABC patients. Anthracycline/taxane-based chemotherapy regimens were administered. Patients were stratified according to age, menopausal status, type of surgery, response to the treatment, histopathological properties, and survival. After 3-6 cycles of chemotherapy, patients were re-staged radiologically and surgery was performed in operable patients. Adjuvant chemotherapy was administered as needed. The median age was 45 (29-93) at the time of diagnosis. Sixteen percentage of patients were younger than 35 years of age and 45.2% were premenopausal. Median follow-up time was 20.2 months. Sixty-seven out of 73 patients responded to therapy (89%). Breast conserving surgery was possible in the 15% of the patients. In histopathological analysis, lymph node invasion was detected in 85%. The estrogen (ER) and progesterone (PR) receptor were positive in 78.1% and c-erb-B2 was positive in 17.5% of patients. The median disease-free survival (DFS) was 44 months (SE: 9; %95 CI: 27.1-60.8), overall survival (OS) was not reached at the time of analysis. Three-year DFS and OS were 58% and 91.9%, respectively. In a multivariate Cox regression analyses; no demographic or pathologic prognostic parameter predicted overall survival. In recent years, NAC in breast cancer has become a viable treatment option for patients with LABC. NAC is not commonly applied in Turkey. The response rate to NAC in Turkish breast cancer patients is encouragingly high. Broader efforts should be made to evaluate breast cancer patients preoperatively at tumor boards for proper treatment sequence.

Response to therapy in breast cancer

Increasing numbers of patients with newly diagnosed breast cancer receive primary systemic therapy followed by surgery. Histopathology provides an accurate assessment of treatment efficacy on the basis of the extent of residual tumor and regressive changes within tumor tissue. However, only approximately 20% of breast cancer patients achieve a pathologic complete response, a fact that necessitates methods for monitoring therapeutic effectiveness early during therapy. (18)F-FDG PET and (18)F-FDG PET/CT provide essential information regarding a response to primary chemotherapy. Patients with low tumor metabolic activity on pretreatment (18)F-FDG PET are not likely to achieve a histopathologic response. The degree of changes in (18)F-FDG uptake after the initiation of therapy is correlated with the histopathologic response after the completion of therapy. Thus, tumor metabolic changes assessed early during therapy predict therapeutic effectiveness in individual patients. Early identification of ineffective therapy also might be helpful in patients with metastatic breast cancer because many palliative treatment options are available. Changes in metabolic activity generally occur earlier than changes in tumor size, which is the current standard for the assessment of a response. Although treatment stratification based on a metabolic response is an exciting potential application of PET, specific PET response assessment criteria still need to be developed and validated on the basis of patient outcomes before changes in treatment regimens can be implemented. There is increasing clinical evidence for metastatic breast cancer and other tumors that (18)F-FDG PET/CT is the most accurate imaging procedure for assessment of the response at the end of treatment when both CT information and tumor metabolic activity are considered. Importantly, in the setting of primary chemotherapy, neither PET/CT nor conventional imaging procedures can assess the extent of residual breast cancer as accurately as histopathology. Observation of changes in tumor blood flow or tumor cell proliferation is an additional encouraging approach for predicting a response. Ultimately, the prediction of therapeutic effectiveness by PET and PET/CT could help to individualize treatment and to avoid ineffective chemotherapies, with their associated toxicities.

Timing of sentinel lymph node biopsy in patients receiving neoadjuvant chemotherapy for breast cancer

OBJECTIVE

To address optimal timing of sentinel lymph node biopsy (SLNB) in breast cancer patients undergoing neoadjuvant treatment.

METHODS

The study population included 117 patients with locally advanced cancer with clinically negative nodes treated with primary chemotherapy. Group 1 underwent SLNB and completion axillary lymph node dissection (ALND) in conjunction with lumpectomy/mastectomy, after neoadjuvant treatment (n = 31). Group 2 underwent SLNB followed by neoadjuvant therapy and subsequently surgery and completion of ALNDs (n = 58). Group 3 was treated using the same sequence as group 2, however, completion ALND was performed only for patients with positive sentinel lymph nodes (SLNs) (n = 28).

RESULTS

SLN identification was lowest in group 1 compared to groups 2 and 3 (87% and 98.8% respectively; P = <0.05). The highest false negative rate was in group 1 (15.8% compared with 0% in group 2).

CONCLUSION

Neoadjuvant treatment lowers the SLN identification rate, possibly due to fibrosis within the axilla, and increases the false negative rate due to downstaging. SLN biopsy prior to chemotherapy could give a more accurate evaluation of axillary status, unaffected by any previous therapeutic intervention.

Prognosis of women with pT4b breast cancer: the significance of this category in the TNM system

AIMS

The T4b/pT4b category of the TNM System for breast cancer is discussed controversially. For a more detailed analysis, we explored the prognosis of patients with breast cancer strictly fulfilling the criteria for T4b/pT4b tumors according to the TNM System.

METHODS

Retrospectively analysed data from patients with pT4b breast tumors diagnosed between January 1994 and December 2004 were collected. Reclassification was undertaken according to the TNM System criteria establishing a study group including only "correctly" classified T4b/pT4b tumors. A control group with pT1-3 carcinomas was used for analysing the prognostic value of criteria for T4b/pT4b tumors.

RESULTS

Eighty-six patients with pT4b carcinomas were found. After reclassification, 65 remained as pT4b fulfilling the strict criteria. The study group showed a 60% three-year Disease Specific Survival (DSS). Age (p<0.01) and regional lymph node status (p<0.01) were significantly related to prognosis. Compared to the control group, the DSS in the study group of patients with a tumor size >2 cm to 5 cm was significantly worse (three-year survival: 82% vs. 51%, p<0.01). For tumors >5 cm, the DSS was not significantly different between both groups (three-year survival: 68% vs. 72%, p=0.7).

CONCLUSIONS

The criteria for T4b/pT4b breast cancer are associated with a poorer prognosis in patients with a tumor size >2 cm to 5 cm. For tumors >5 cm, prognosis is independent of T4b/pT4b criteria. These findings do not justify the demanded deletion of the T4b/pT4b category. The missing uniformity in applying the correct criteria of T4b/pT4b tumors queries the practicability of this category.

The relevance of circulating epithelial tumor cells (CETC) for therapy monitoring during neoadjuvant (primary systemic) chemotherapy in breast cancer

BACKGROUND

Having demonstrated in a previous report that the response of circulating epithelial tumor cells (CETC) during the first cycles of primary (neoadjuvant) chemotherapy perfectly reflects the response of the tumor, in the present study the changes in cell numbers during subsequent cycles and their possible impact on the therapy's outcome were examined.

PATIENTS AND METHODS

In 58 breast cancer patients CETC were quantified during therapy with either EC (epirubicin/ cyclophosphamid) or dose intensified E (epirubicin) followed by taxane, with or without trastuzumab, and subsequent CMF (cyclophosphamid/methorexate/ fluorouracil).

RESULTS

CETC numbers declined more than 10-fold (good response) in 65% (her2/neu-negative) and 55% (her2/neu-positive) of patients during EC, and in 60% during dose intensified E, respectively, followed by an increase of CETC in all patients. CETC remained increased, decreasing only when adding CMF. A good initial response correlated with estrogen-receptor negativity, a poor response with early distant relapse (P < 0,0001, hazard ratio = 11.91).

CONCLUSION

Response of CETC already during the first cycles of neoadjuvant treatment predicts the final response of the tumor. Hitherto unknown effects of the release of tumor cells during therapy further our understanding of tumor-blood interaction and may improve access of agents like antibodies to cells. The impact on the further course of disease remains to be evaluated.

Histopathology of breast carcinoma following neoadjuvant systemic therapy: a common association between letrozole therapy and central scarring

AIMS

Neoadjuvant systemic therapy of large and locally advanced breast cancers may, through shrinkage, enable breast conservation surgery. Letrozole, an aromatase inhibitor, is used frequently in the treatment of oestrogen receptor-positive breast cancer. The aim was to examine the response patterns in a letrozole-treated group compared with a chemotherapy-treated group.

MATERIALS AND METHODS

Fifty patients with primary breast cancer were treated with 3 months of chemotherapy and 53 with 3 months of neoadjuvant letrozole. Excised tumours were compared with preoperative core biopsy specimens. Volume calculations before and after therapy were used to calculate clinical response in the letrozole group.

RESULTS

Response patterns were significantly different between the two therapies (P < 0.0005). Chemotherapy produced more complete pathological responses (P = 0.008) and a scattered cell pattern was also seen more frequently (P = 0.035). Letrozole produced substantially more central scars - 31 cases as opposed to two cases in the chemotherapy group (P = 0.0001) - and there was a statistically significant correlation with central scarring and clinical tumour volume reduction (P = 0.034).

CONCLUSIONS

There are significantly different histological responses between cancers treated with chemotherapy and endocrine therapy, particularly central scarring. This has not been documented previously and may be an important factor in down-sizing tumours with letrozole, enabling subsequent conservation surgery.

Selective Mastectomy in the Management of Locally Advanced Breast Cancer

PURPOSE

To evaluate local control for patients with locally advanced noninflammatory breast cancer (LABC) managed by selective mastectomy.

METHODS AND MATERIALS

Between 1979 and 1996, 176 patients with LABC were prospectively managed by chemotherapy (CT)-irradiation (RT)-CT without routine mastectomy. All surviving patients were followed for a minimum of 5 years.

RESULTS

A total of 132 patients (75%) had a T4 tumor and 22 (12.5%) supraclavicular nodal disease. The clinical complete response rate was 91% (160/176), which included 13 patients who underwent mastectomy and 2 an iridium wire implant. The first site of failure was local for 43 patients (breast +/- axilla for 38); 27 of these patients underwent salvage mastectomy and 11 did not for an overall mastectomy rate of 23% (40/176). If all 176 patients had undergone routine mastectomy (136 extra mastectomies), 11 additional patients may have avoided an unsalvageable first local relapse. The others would have either have not had a local relapse or would have suffered local relapse after distant disease. No tumor or treatment related factor was found to predict local disease at death. Median disease-free and overall survival for all patients was 26 and 52 months, respectively.

CONCLUSIONS

Selective mastectomy in LABC may not jeopardize local control or survival.

Weekly cisplatin, epirubicin, and paclitaxel with granulocyte colony-stimulating factor support vs triweekly epirubicin and paclitaxel in locally advanced breast cancer: final analysis of a sicog phase III study

The present study aimed at evaluating whether a weekly cisplatin, epirubicin, and paclitaxel (PET) regimen could increase the pathological complete response (pCR) rate in comparison with a tri-weekly epirubicin and paclitaxel administration in locally advanced breast cancer (LABC) patients. Patients with stage IIIB disease were randomised to receive either 12 weekly cycles of cisplatin 30 mg m⁻², epirubicin 50 mg m⁻², and paclitaxel 120 mg m⁻² (PET) plus granulocyte-colony stimulating factor support, or four cycles of epirubicin 90 mg m⁻²+paclitaxel 175 mg m⁻² (ET) every 3 weeks. Overall, 200 patients (PET/ET=100/100) were included in this study. A pCR in both breast and axilla occurred in 16 (16%) PET patients and in six (6%) ET patients (P=0.02). The higher activity of PET was evident only in ER negative (27.5 vs 5.4%; P=0.026), and in HER/neu positive (31 vs 5%; P=0.037) tumours. The two arms yielded similar pCR rate in ER positive (PET/ET=7.5/7.1%) and HER/neu negative (PET/ET=10/6%) patients. At a 39 months median follow-up, 70 patients showed a progression or relapses (PET, 32 vs ET, 38). Anaemia, mucositis, peripheral neuropathy, and gastrointestinal toxicity were substantially more frequent in the PET arm. The PET weekly regimen is superior to ET in terms of pCR rate in LABC patients with ER negative and/or HER2 positive tumours Mature data in terms of disease-free and overall survival are needed to ascertain whether this approach could improve the prognosis of these subsets of LABC patients.

Prognostic significance of residual breast disease and axillary node involvement for patients who had primary induction chemotherapy for advanced breast cancer

BACKGROUND

We performed this study to determine the prognostic significance of clinical tumor size, pathologic measurement of residual tumor, and number of positive axillary nodes in the surgical specimen relative to overall survival for patients who underwent primary induction chemotherapy for advanced breast cancer.

METHODS

Data, collected prospectively between 1997 and 2002, included clinical tumor-node-metastasis stage, age at diagnosis, hormone receptor status, type of preoperative chemotherapy, histological type, surgical procedure, pathologic measurement in centimeters of residual breast tumor, and the number of positive axillary nodes in the surgical specimen. Univariable correlates of residual breast disease were assessed by using the chi2 test. Recursive partitioning analysis was used to determine the prognostic significance of clinical tumor size, residual tumor size, and pathologic node involvement relative to overall survival. Survival was estimated by using the method of Kaplan and Meier and compared by using the log-rank test. A P value of <.05 was considered significant.

RESULTS

Data were available for 85 patients with advanced breast cancer. Although univariable analysis identified increasing age, clinically involved axillary nodes, and a higher clinical tumor-node-metastasis stage as predictors of an increased risk of residual disease, recursive partitioning analysis identified more than three involved axillary nodes in the surgical specimen, with or without any measurable residual breast disease, as the most significant predictor of decreased survival (P<.001).

CONCLUSIONS

Pathologic axillary node involvement was the most significant predictor of decreased survival for patients who had undergone primary induction chemotherapy for advanced breast cancer.

Size of residual lymph node metastasis after neoadjuvant chemotherapy in locally advanced breast cancer patients is prognostic

BACKGROUND

The prognostic significance of micrometastasis after neoadjuvant chemotherapy for locally advanced breast cancer is unknown. We examined the residual lymph node metastasis size in patients after treatment with neoadjuvant chemotherapy to determine the relevance of metastasis size on outcome.

METHODS

Stage II/III breast cancer patients treated with neoadjuvant chemotherapy at our institution from 1991 to 2002 were included. We examined the relationship of postneoadjuvant chemotherapy lymph node metastasis size and number with distant disease-free survival (DDFS) and overall survival (OS).

RESULTS

In 122 patients with a median follow-up of 5.4 years, we found not only that patients with an increasing number of residual positive nodes had progressively worse DDFS and OS (P < .0001 for both) compared with patients with negative nodes, but also that the size of the largest lymph node metastasis was associated with worse DDFS and OS (P < .0001 for both) in both univariate and multivariate analysis. Compared with negative nodes, even lymph node micrometastasis (<2 mm) was associated with worsened DDFS and OS (adjusted P = .02 and P = .005, respectively).

CONCLUSIONS

Residual micrometastatic disease in the axillary lymph nodes after neoadjuvant chemotherapy is predictive of worse prognosis than negative nodes. In this study, the lymph node metastasis size and the number of involved lymph nodes were independent powerful predictors of DDFS and OS.

Breast conservation treatment in women with locally advanced breast cancer - experience from a single centre

INTRODUCTION

In absence of randomized evidence to support safety of conservative surgery (BCT) in locally advanced breast cancer (LABC), we analyzed a cohort of 664 women with LABC treated during January 1998 to December 2002 at Tata Memorial Hospital, Mumbai, India.

MATERIALS AND METHODS

All were treated with a multimodality regimen comprising of neoadjuvant chemotherapy (NACT) followed by surgery (modified radical mastectomy or BCT) and adjuvant radiotherapy and hormone therapy. The outcome was evaluated to assess safety of BCT.

RESULTS

71% (469/664) women responded to NACT (22% clinical CR and 49% PR) and 28.3% (188/664) underwent BCT. Positive lumpectomy margins were reported in 8.5%, with gross presence of tumor at the margins in 2.3% requiring a revision surgery. At a median follow-up of 30months, local relapse rate was 8% after BCT and 10.7% after mastectomy. The 3-year local DFS was better post-conservation than after mastectomy (87% vs 78%, P=0.02). The disease-free survival (DFS) was also superior after BCT, 72% vs 52% (P<0.001) at 3years and 62% vs 37% (P<0.001) at 5years respectively. On multivariate analysis, presence of lymphatic vascular emboli (LVE) was the major significant predictor of local recurrence (P<0.001, HR 2.52, 95% CI 1.52-4.18). DFS was better after BCT [(P<0.001, HR 2.0 (95% CI 1.38-2.91)]; shorter DFS was noted in LVE positive (HR 1.54, P=0.007) and larger residual disease after NACT (HR 1.13, P=0.001).

CONCLUSION

BCT is technically feasible and safe post neo-adjuvant chemotherapy in women with LABC with no detriment in outcome.

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.