A prognostic model to predict outcome of patients failing to achieve pathological complete response after anthracycline-containing neoadjuvant chemotherapy for breast cancer

Survival Outcomes of Breast-Conserving Surgery Versus Mastectomy in Locally Advanced Breast Cancer Following Neoadjuvant Chemotherapy: A Meta-Analysis

BACKGROUND

Mastectomy (MT) and breast conservation surgery (BCS) are two common surgical options for the treatment of locally advanced breast cancer (LABC). Neoadjuvant chemotherapy (NACT) is frequently administered before surgery to shrink tumors and improve surgical outcomes. However, there is a lack of consensus on the optimal surgical approach after NACT and its impact on survival outcomes.

OBJECTIVE

This meta-analysis aims to compare the survival outcomes between MT and BCS in patients treated with NACT.

METHOD

A PRISMA selection was used to identify studies across electronic database such as PubMed, and Cochrane Library from inception until 11th July, 2023. A total of 10 comparative studies involving a total of 5018 patients were included. Among them, 2898 patients underwent MT while 2120 underwent BCS after receiving NACT. The outcomes assessed were the 5-year overall survival (OS) and 5-year disease-free survival (DFS). The data from the included studies were pooled, and odds ratios (OR) with 95% confidence intervals (CI) were calculated to evaluate the differences between MT and BCS in terms of survival outcomes. Prospero: CRD42024496831.

RESULT

The meta-analysis revealed that patients who underwent MT after NACT had a higher 5-year OS compared to those who underwent BCS (OR 2.68, 95% CI [2.19-3.28; p < 0.00001]). Additionally, the 5-year DFS was significantly better for patients who underwent MT (OR 3.11, 95% CI [1.80-5.38; p < 0.0001]).

CONCLUSION

MT after NACT may be associated with better 5-year OS and DFS compared to BCS.

Oncologic safety of breast conservation following NACT in women with locally advanced breast cancer

Introduction

Breast conservation surgery (BCS) is the accepted standard of treatment for early breast cancer, with evidence from randomized controlled and population-based studies. The oncological outcome of BCS in locally advanced breast cancer (LABC) is mainly available from retrospective series with a small sample size and a shorter follow-up duration.

Methods

A retrospective observational study of 411 non-metastatic LABC patients who received neoadjuvant chemotherapy (NACT) followed by surgery from 2011 to 2016. We retrieved the data from a prospectively maintained database and electronic medical records. Survival data were analyzed by Kaplan-Meier curves and Cox regression using Statistical Package for the Social Sciences 25 and STATA 14.

Results

146/411 (35.5%) women had BCS with a margin positivity rate of 3.42%. With a median follow-up of 64 months (IQR 61, 66), the local relapse rate was 8.9% in BCS and 8.3% after mastectomy. The estimated 5-year locoregional recurrence-free survival (LRFS), recurrence-free survival (RFS), distant disease-free survival (DDFS) and overall survival (OS) rates of BCS were 86.9%, 63.9%, 71% and 79.3%, and 90.1%, 57.9%, 58.3% and 71.5% in the mastectomy group. On univariate analysis, BCS showed superior survival outcomes compared to mastectomy (unadjusted HR (95% CI) for RFS: 0.70 (0.50-1), DDFS: 0.57 (0.39-0.84), OS: 0.58 (0.36-0.93)). After adjusting for age, cT stage, cN stage, poorer chemotherapy response (ypT0/is, N0) and radiotherapy, BCS and mastectomy groups were found comparable in terms of LRFS (HR: 1.1, 0.53-2.3), DDFS (HR: 0.67, 0.45-1.01), RFS (HR: 0.80, 0.55-1.17) and OS (HR: 0.69, 0.41-1.14).

Conclusion

BCS is technically feasible in LABC patients. LABC patients who respond well to NACT can be offered BCS without compromising survival outcomes.

Prognostic role of high cathepsin D expression in breast cancer: a systematic review and meta-analysis

Background:

High cathepsin D has been associated with poor prognosis in breast cancer; however, the results of many studies are controversial. Here, we assessed the association between high cathepsin D levels and worse breast cancer prognosis by conducting a meta-analysis.

Methods:

A comprehensive search strategy was used to search relevant literature in PUBMED and EMBASE by September 2018. The meta-analysis was performed in Review Manager 5.3 using hazard ratios (HRs) with 95% confidence intervals (CIs).

Results:

A total of 15,355 breast cancer patients from 26 eligible studies were included in this meta-analysis. Significant associations between elevated high cathepsin D and poor overall survival (OS) (HR = 1.61, 95% CI: 1.35–1.92, p < 0.0001) and disease-free survival (DFS) (HR = 1.52, 95% CI: 1.31–2.18, p < 0.001) were observed. In the subgroup analysis for DFS, high cathepsin D was significantly associated with poor prognosis in node-positive patients (HR = 1.38, 95% CI: 1.25–1.71, p < 0.00001), node-negative patients (HR = 1.78, 95% CI: 1.39–2.27, p < 0.0001), early stage patients (HR = 1.73, 95% CI: 1.34–2.23, p < 0.0001), and treated with chemotherapy patients (HR = 1.60, 95% CI: 1.21–2.12, p < 0.001). Interestingly, patients treated with tamoxifen had a low risk of relapse when their cathepsin D levels were high (HR = 0.71, 95% CI: 0.52–0.98, p = 0.04) and a high risk of relapse when their cathepsin D levels were low (HR = 1.50, 95% CI: 1.22–1.85, p = 0.0001).

Conclusions:

Our meta-analysis suggests that high expression levels of cathepsin D are associated with a poor prognosis in breast cancer. Based on our subgroup analysis, we believe that cathepsin D can act as a marker for poor breast cancer prognosis and also as a therapeutic target for breast cancer.

The prognostic value of cyclin D1 expression in the survival of cancer patients: A meta-analysis

BACKGROUND

The relationship between the expression of cyclin D1 and cancer prognosis and outcomes in different malignancies has not been fully elucidated.

AIMS

In the presented meta-analysis, we assessed the association between the expression level of cyclin D1 with overall survival (OS) in several cancers.

METHODS

Eligible studies were identified using PubMed, EMBase, Scopus, Web of Sciences and Cochrane Library databases. For the prognostic meta-analysis, study-specific hazard ratios (HRs) of tissue cyclin D1 for survival were obtained. Finally we pooled data derived from one hundred and eight studies comprising 19,224 patients with 10 different cancer types.

RESULTS

In the pooled analysis, high expression of cyclin D1 was significantly related to a poor OS with a pooled HR of 1.11 (95% CI: 1.02-1.20, P = 0.015; random-effects). Sub-group analysis revealed that high expression of cyclin D1 was related to worse OS of head and neck cancers (HR = 2.08, 95% CI: 1.75-2.47; P < 0.001), but not in breast (HR = 1.033, 95% CI: 0.873-1.223, P = 0.702), gastrointestinal (HR = 1.025, 95% CI:0.824-1.275; P = 0.825), bladder (HR = 0.937, CI: 0.844-1.041; P = 0.225) and in lung cancer patients (HR = 1.092, CI: 0.819-1.455; P = 0.549).

CONCLUSION

Further large, prospective, and well-designed trials are warranted to elucidate the precise clinical importance of cyclin D1 overexpression in the prognosis of cancer patients receiving different treatment regimens.

Risk factors of locoregional relapse in locally advanced breast cancer treated with neoadjuvant chemotherapy following mastectomy and radiotherapy

We seek to investigate the prognostic factors that could possibly increase the locoregional recurrence of breast cancer patients who do not achieve pathological complete response after neoadjuvant chemotherapy, and to build a prognostic nomogram to predict patients' outcome. The retrospective analysis included 510 patients who had received neoadjuvant chemotherapy followed by surgery and radiotherapy. 62 locoregional events occurred after a median 61 months of follow-up. The five-year cumulative incidence of local recurrence and regional recurrence were 8.63% and 4.31%, respectively. Multivariate analysis revealed that positivity for ≥ 4 lymph nodes and Ki-67 index ≥ 14% were independent factors. According to our prognostic model, the 5-year locoregional free survival rates in the low, intermediate, and high-risk groups were 95.5%, 89.1%, and 67.1%, respectively (p < 0.001). Annual recurrence curves indicated that the relapse peak after mastectomy emerged in the first 1 year. Positivity for ≥ 4 lymph nodes and Ki-67 index ≥ 14% were independent factors for locoregional recurrence. This prognostic model has considerable clinical value in predicting locoregional recurrence, which could help clinicians to design appropriate locoregional treatment specifically and to perform surveillance individually.

Targeting protein quality control pathways in breast cancer

The efficient production, folding, and secretion of proteins is critical for cancer cell survival. However, cancer cells thrive under stress conditions that damage proteins, so many cancer cells overexpress molecular chaperones that facilitate protein folding and target misfolded proteins for degradation via the ubiquitin-proteasome or autophagy pathway. Stress response pathway induction is also important for cancer cell survival. Indeed, validated targets for anti-cancer treatments include molecular chaperones, components of the unfolded protein response, the ubiquitin-proteasome system, and autophagy. We will focus on links between breast cancer and these processes, as well as the development of drug resistance, relapse, and treatment.

High expression of cyclin D1 is associated to high proliferation rate and increased risk of mortality in women with ER-positive but not in ER-negative breast cancers

Purpose

Cyclin D1 has a central role in cell cycle control and is an important component of estrogen regulation of cell cycle progression. We have previously shown that high cyclin D expression is related to aggressive features of ER-positive but not ER-negative breast cancer. The aims of the present study were to validate this differential ER-related effect and furthermore explore the relationship between cyclin D overexpression and CCND1 gene amplification status in a node-negative breast cancer case–control study.

Methods

Immunohistochemical nuclear expression of cyclin D1 (n = 364) and amplification of the gene CCND1 by fluorescent in situ hybridization (n = 255) was performed on tissue microarray sections from patients with T1-2N0M0 breast cancer. Patients given adjuvant chemotherapy were excluded. The primary event was defined as breast cancer death. Breast cancer-specific survival was analyzed in univariate and multivariable models using conditional logistic regression.

Results

Expression of cyclin D1 above the median (61.7%) in ER breast cancer was associated with an increased risk for breast cancer death (OR 3.2 95% CI 1.5–6.8) also when adjusted for tumor size and grade (OR 3.1). No significant prognostic impact of cyclin D1 expression was found among ER-negative cases. Cyclin D1 overexpression was significantly associated to high expression of the proliferation markers cyclins A (ρ 0.19, p = 0.006) and B (ρ 0.18, p = 0.003) in ER-positive tumors, but not in ER-negative cases. There was a significant association between CCND1 amplification and cyclin D1 expression (p = 0.003), but CCND1 amplification was not statistically significantly prognostic (HR 1.4, 95% CI 0.4–4.4).

Conclusion

We confirmed our previous observation that high cyclin D1 expression is associated to high proliferation and a threefold higher risk of death from breast cancer in ER-positive breast cancer.

Prognostic values of Ki-67 in neoadjuvant setting for breast cancer: a systematic review and meta-analysis

AIM

To assess the prognostic values of Ki-67 in neoadjuvant setting for breast cancer patients.

METHODS

PubMed and EMBASE were searched. Revman software was used to conduct random-effect model meta-analysis.

RESULTS

49 studies (14,076 patients) were included. High Ki-67 before and after neoadjuvant chemotherapy were associated with worse overall survival (OS; before: hazard ratio [HR]: 2.29; 95% CI: 1.42-3.69; after: HR: 2.24; 95% CI: 1.82-2.75) and disease-free survival (DFS; before: HR: 1.54; 95% CI: 1.23-1.95; after: HR: 2.08; 95% CI: 1.83-2.37). Low/no reduction or increase might be associated with worse DFS (HR: 2.13; 95% CI: 1.51-3.02) and OS.

CONCLUSION

Ki-67 before and after neoadjuvant chemotherapy, as well as the change could predict the prognosis for breast cancer patients.

Local Recurrence after Breast-Conserving Surgery and Mastectomy Following Neoadjuvant Chemotherapy for Locally Advanced Breast Cancer - a Meta-Analysis

BACKGROUND

Breast-conserving surgery (BCS) in patients with large tumors shrunk by neoadjuvant chemotherapy (NCT) remains controversial. We conducted a meta-analysis to evaluate the local recurrence rates in locally advanced breast cancer (LABC) patients receiving NCT comparing BCS with mastectomy.

METHODS

Pubmed, Web of Knowledge, and Ovid's database were searched for studies concerning treatment for LABC from January 2000 to June 2015. A meta-analysis was performed to compare the recurrence rates of patients receiving BCS versus mastectomy following NCT.

RESULTS

8 trials with a total of 3,215 patients were analyzed. The prevalence of local recurrence was 9.2% in the BCS group versus 8.3% in the mastectomy group without significant difference (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.28-1.48; p = 0.66). The 5-year local recurrence-free survival (LRFS) rate was lower in the mastectomy group than in the BCS group, but no significant difference was found between the 2 groups (OR 1.11, 95% CI 0.61-1.99; p = 0.74).

CONCLUSION

BCS after NCT is safe in terms of local recurrence and LRFS in LABC women. Shrinking tumors with NCT provides the opportunity to apply BCS with no detriment to outcome.

Molecular essence and endocrine responsiveness of estrogen receptor-negative, progesterone receptor-positive, and HER2-negative breast cancer

BACKGROUND

The clinical significance of progesterone receptor (PgR) expression in estrogen receptor-negative (ER-) breast cancer is controversial. Herein, we systemically investigate the clinicopathologic features, molecular essence, and endocrine responsiveness of ER-/PgR+/HER2- phenotype.

METHODS

Four study cohorts were included. The first and second cohorts were from the Surveillance, Epidemiology, and End Results database (n = 67,932) and Fudan University Shanghai Cancer Center (n = 2,338), respectively, for clinicopathologic and survival analysis. The third and fourth cohorts were from two independent publicly available microarray datasets including 837 operable cases and 483 cases undergoing neoadjuvant chemotherapy, respectively, for clinicopathologic and gene-expression analysis. Characterized genes defining subgroups within the ER-/PgR+/HER2- phenotype were determined and further validated.

RESULTS

Clinicopathologic features and survival outcomes of the ER-/PgR+ phenotype fell in between the ER+/PgR+ and ER-/PgR- phenotypes, but were more similar to ER-/PgR-. Among the ER-/PgR+ phenotype, 30% (95% confidence interval [CI] 17-42%, pooled by a fixed-effects method) were luminal-like and 59% (95% CI 45-72%, pooled by a fixed-effects method) were basal-like. We further refined the characterized genes for subtypes within the ER-/PgR+ phenotype and developed an immunohistochemistry-based method that could determine the molecular essence of ER-/PgR+ using three markers, TFF1, CK5, and EGFR. Either PAM50-defined or immunohistochemistry-defined basal-like ER-/PgR+ cases have a lower endocrine therapy sensitivity score compared with luminal-like ER-/PgR+ cases (P <0.0001 by Mann-Whitney test for each study set and P <0.0001 for pooled standardized mean difference in meta-analysis). Immunohistochemistry-defined basal-like ER-/PgR+ cases might not benefit from adjuvant endocrine therapy (log-rank P = 0.61 for sufficient versus insufficient endocrine therapy).

CONCLUSIONS

The majority of ER-/PgR+/HER2- phenotype breast cancers are basal-like and associated with a lower endocrine therapy sensitivity score. Additional studies are needed to validate these findings.

Macroscopic handling and reporting of breast cancer specimens pre- and post-neoadjuvant chemotherapy treatment: review of pathological issues and suggested approaches

Neoadjuvant chemotherapy (NACT) is used increasingly in the treatment of invasive breast cancer and presents challenges for the pathologist in the handling and interpretation of tissues. Potential issues include pathological identification and localization of the residual tumour site; how best to assess pathological response (given the diversity of scoring systems described); the timing and assessment of axillary node biopsy; and the value of retesting any residual tumour for dissonance between core biopsy and post-treatment residual cancer cells for biomarker expression such as oestrogen and progesterone receptors and human epidermal growth factor receptor 2 (HER2). The role of the pathologist is critical in modern NACT approaches to breast cancer and is likely to remain challenging as novel agents and newer biomarkers become available. In this manuscript we review these issues and describe some practical approaches to handling and reporting these samples in the routine histopathology laboratory.

Blood mRNA expression profiling predicts survival in patients treated with tremelimumab

PURPOSE

Tremelimumab (ticilimumab, Pfizer), is a monoclonal antibody (mAb) targeting cytotoxic T lymphocyte-associated antigen-4 (CTLA-4). Ipilimumab (Yervoy, BMS), another anti-CTLA-4 antibody, is approved by the U.S. Federal Drug Administration (FDA). Biomarkers are needed to identify the subset of patients who will achieve tumor control with CTLA-4 blockade.

EXPERIMENTAL DESIGN

Pretreatment peripheral blood samples from 218 patients with melanoma who were refractory to prior therapy and receiving tremelimumab in a multicenter phase II study were measured for 169 mRNA transcripts using reverse transcription polymerase chain reaction (RT-PCR). A two-class latent model yielded a risk score based on four genes that were highly predictive of survival (P < 0.001). This signature was validated in an independent population of 260 treatment-naïve patients with melanoma enrolled in a multicenter phase III study of tremelimumab.

RESULTS

Median follow-up was 297 days for the training population and 386 days for the test population. Expression levels of the 169 genes were closely correlated across the two populations (r = 0.9939). A four-gene model, including cathepsin D (CTSD), phopholipase A2 group VII (PLA2G7), thioredoxin reductase 1 (TXNRD1), and interleukin 1 receptor-associated kinase 3 (IRAK3), predicted survival in the test population (P = 0.001 by log-rank test). This four-gene model added to the predictive value of clinical predictors (P < 0.0001).

CONCLUSIONS

Expression levels of CTSD, PLA2G7, TXNRD1, and IRAK3 in peripheral blood are predictive of survival in patients with melanoma treated with tremelimumab. Blood mRNA signatures should be further explored to define patient subsets likely to benefit from immunotherapy.

A prognostic model for triple-negative breast cancer patients based on node status, cathepsin-D and Ki-67 index

Objective

The aim of this study was to evaluate clinicopathologic factors that could possibly affect the outcome of patients with triple negative breast cancer and subsequently build a prognostic model to predict patients’ outcome.

Methods

We retrospectively analyzed clinicopathologic characteristics and outcome of 504 patients diagnosed with triple-negative invasive ductal breast cancer. 185 patients enrolled between 2000 and 2002 were designated to the training set. The variables that had statistically significant correlation with prognosis were combined to build a model. The prognostic value of the model was further validated in the separate validation set containing 319 patients enrolled between 2003 and 2006.

Results

The median follow-up duration was 66 months. 174 patients experienced recurrence, and 111 patients died. Positivity for ≥4 lymph nodes, Cathepsin-D positivity, and Ki-67 index ≥20% were independent factors for DFS, while the lymph nodes status and Ki-67 index were the prognostic factors for OS. The prognostic model was established based on the sum of all three factors, where positivity for ≥4 lymph nodes, Cathepsin-D and Ki-67 index ≥20% would individually contribute 1 point to the risk score. The patients in the validation set were assigned to a low-risk group (0 and 1 point) and a high-risk group (2 and 3 points). The external validation analysis also demonstrated that our prognostic model provided the independent high predictive accuracy of recurrence.

Conclusion

This model has a considerable clinical value in predicting recurrence, and will help clinicians to design an appropriate level of adjuvant treatment and schedule adequate appointments of surveillance visits.

Prognostic and predictive value of Phospho-p44/42 and pAKT in HER2-positive locally advanced breast cancer patients treated with anthracycline-based neoadjuvant chemotherapy

BACKGROUND

To evaluate the predictive and prognostic value of various molecular factors associated with the Ras/MAPK and PI3K/Akt signaling pathways in HER2-positive locally advanced breast cancer patients treated with anthracycline-based neoadjuvant chemotherapy (NAC).

METHODS

A total of 113 patients were recruited in this retrospective study. Core needle biopsies and excision samples were assessed through immunohistochemistry for various biomarkers, including IGF-1R, Phospho-p44/42, Ki67, pAKT, PTEN, p27, and cyclinD1. The changes in these biomarkers after NAC and their predictive and prognostic values were investigated.

RESULTS

Significant decreases in Ki67, Phospho-p44/42, and pAKT expression were observed after treatment (30.7% vs. 18.1%, 36.4% vs. 18.9%, and 35.1% vs. 16.4%, respectively). The decreases in Phospho-p44/42, pAKT, and Ki67 expression were strongly associated with the response to anthracycline treatment (P = 0.027, P = 0.031, and P = 0.008, respectively). In a multivariate survival analysis, Phospho-p44/42 expression after neoadjuvant chemotherapy and lymph node status were significant independent prognostic factors of both relapse-free survival and overall survival.

CONCLUSIONS

Reductions in Ki-67, Phospho-p44/42, and pAKT expression are related to the clinical response to anthracycline-based NAC in HER2-positive breast cancer patients. High pAKT expression prior to NAC had a better clinical response. Phospho-p44/42 expression and lymph node status after NAC could be useful for determining relapse-free survival and overall survival.

Oncologic safety of breast-conserving surgery compared to mastectomy in patients receiving neoadjuvant chemotherapy for locally advanced breast cancer

BACKGROUND

Breast-conserving surgery (BCS) in patients with large tumors shrunk by neoadjuvant chemotherapy (NCT) remains controversial. We investigated oncologic outcomes of BCS in patients receiving NCT to treat locally advanced breast cancer (LABC).

METHODS

We reviewed 1,994 patients who underwent surgery with/without NCT. Patients were categorized into three groups according to treatment methods: initial BCS, BCS after NCT (NCT-BCS), and mastectomy after NCT (NCT-MX). Their characteristics and outcomes were analyzed.

RESULTS

The NCT-BCS group had earlier stage cancer, more hormone receptor-negative and triple-negative breast cancers (TNBC) than the NCT-MX group. However, outcomes did not differ statistically between the two groups. BCS patients receiving NCT were younger, and had more advanced, hormone receptor-negative, HER2-positive, and TNBC breast cancers than BCS patients without NCT. Patients with pathological complete remission (pCR) in the NCT-BCS group had better survival outcomes than non-pCR patients and the initial BCS group. By multivariate analysis in patients receiving NCT, final stage and TNBC were associated with poor overall survival (stage III: P = 0.008; TNBC: P = 0.01), however surgery type was not (P = 0.20).

CONCLUSIONS

BCS after NCT is a safe option for LABC that responded well to NCT. Shrinking tumors with NCT allows more opportunities to apply BCS without compromising outcomes.

Effect of large tumor size on cancer-specific mortality in node-negative breast cancer

OBJECTIVE

To examine the relationship between large tumor size and breast cancer-specific mortality (BCSM), especially in a subset of patients with negative lymph nodes (LNs).

PATIENTS AND METHODS

We used the Surveillance, Epidemiology and End Results registry to identify 107,705 female patients diagnosed from January 1, 1990, through December 31, 2003, as having invasive breast cancer and treated with surgery and LN dissection. Relevant issues unclear in the database were studied in an additional 335 patients with locally advanced disease treated with neoadjuvant chemotherapy.

RESULTS

In the multivariable analysis, a significant interaction was found between tumor size and LN involvement (P<.001). In LN-negative diseases, the relationship between tumor size and BCSM was piecewise. Using 21- to 30-mm tumors as the reference, the hazard ratio (HR) of BCSM increased with increasing tumor size until a peak at 41 to 50 mm (HR, 1.49; P<.001), after which increasing tumor size was unexpectedly related to decreasing hazard, with a nadir at 61 to 80 mm (HR, 1.06; P=.70). The 61- to 80-mm tumors exhibited a significantly lower BCSM compared with the 41- to 50-mm (P=.02) and greater than 80-mm (P=.03) subgroups. This pattern remained after stratification by estrogen receptor status but was not observed in patients with LN-positive disease. Further analysis indicated that the survival advantage of 61- to 80-mm tumors in LN-negative disease might result from its low risk of distant metastasis.

CONCLUSION

A relatively larger tumor size without LN involvement may be a surrogate for biologically indolent disease of distant metastasis. Our findings, if validated in other large databases, may provide better understanding of breast cancer biology.