All-oral combination of vinorelbine and capecitabine as first-line treatment in HER2/Neu-negative metastatic breast cancer

Management of Oligometastatic Breast Cancer: An Expert Committee's Opinion

Patients with oligometastatic breast cancer (BC) are candidates of choice for metastasis-directed therapy (MDT). This paper summarizes the opinions of an expert committee about the management of oligometastatic BC. The experts could complete the questionnaire from 13 September 2021, to 10 October 2021, followed by a discussion. The experts were physicians working in the Province of Quebec (Canada) and specialized in BC care, including surgical oncologists, medical oncologists, and radiation oncologists. The experts provided their opinions about the context of the disease and therapeutic approach, local and systemic therapies, and the prognosis of oligometastatic BC. In addition to the expert panel's opinions about the management of oligometastatic disease per se, the experts stated that a prospective data registry should be implemented to collect data about oligometastatic BC to improve knowledge about oligometastatic BC and implement data-driven MDT. These data could also allow for the design of treatment algorithms. In conclusion, this paper presents the expert panel's opinions about the management of oligometastatic BC and highlights the needs to be met to improve the care of this condition.

Oral vinorelbine and capecitabine as first-line therapy in metastatic breast cancer: a retrospective analysis

A retrospective analysis of 70 patients with triple-negative or hormone-resistant advanced breast carcinoma who had not previously received chemotherapy was carried out. Patients received oral vinorelbine 60 mg/m² on day 1 and 8, plus capecitabine 1000 mg/m² bid for 14 consecutive days every 3 weeks. Overall response rate was 53% with a 9% complete response rate. Stable disease was recorded in 27% of the cases. Median progression-free survival was 7.9 months and median overall survival was 29.2 months. Toxicity was generally mild and easily manageable. These data demonstrate that this combination is feasible, safe and active as first-line treatment of triple-negative fully hormone-resistant advanced breast carcinoma patients.

The adoption of metronomic chemotherapy in the treatment of breast cancer is an important step forward in the management of this disease. The fluoropyrimidine capecitabine and the vinca alkaloid vinorelbine have been shown to be at least as active. Our data confirm the activity and safety of this all-oral regimen as first-line metronomic therapy being response rate.

Long-term disease control and survival observed after stereotactic ablative body radiotherapy for oligometastatic breast cancer

PURPOSE

We examined the characteristics of breast cancer patients with oligometastases (OM) treated with stereotactic ablative body radiotherapy (SABR) to identify factors associated with local progression, distant metastasis progression, time to subsequent therapy, progression-free survival (PFS), and overall survival (OS).

METHODS

We retrospectively reviewed a single-institution database of patients treated with radiotherapy between 2008 and 2018 and identified 79 patients who received SABR to OM. Twenty-seven patients had genetic testing of metastatic tumors using an institutional targeted sequencing platform. Kaplan-Meier analysis, Cox regression, and competing risk models were used to compare clinical and genetic correlates with outcomes.

RESULTS

Median follow-up was 50 months (IQR: 29-66) with 67% of patients alive at the last follow-up. Of the 65% of patients who progressed, 82% progressed outside of the radiation field, 18% experienced local failure, and 80% had oligoprogression. Median OS was 86 months (IQR: 29-66), and PFS was 33 months (IQR: 10-38). Less than 5 years from diagnosis to SABR and triple-negative breast cancer (TNBC) were associated with worse OS. Advanced T stage, any prior chemotherapy, and TNBC were associated with worse PFS. Alterations in CEBPB, RB1, TBX3, PTEN, and CDK4 were associated with worse survival outcomes.

CONCLUSION

Long-term systemic disease control and survival can be achieved with SABR for oligometastatic breast cancer. Hormone receptor-positive patients with a long disease interval from initial diagnosis and limited systemic progression history may be ideal for SABR to all sites of disease.

A multidisciplinary expert opinion on CINV and RINV, unmet needs and practical real-life approaches

Introduction: A range of combination chemotherapy regimens are currently used in clinical practice. However, international antiemetic guidelines often only categorize the emetogenic potential of single agents rather than the emetogenicity of combination chemotherapy regimens. To manage the nausea and vomiting induced by antineoplastic combinations, guidelines suggest antiemetics that are appropriate for the component drug with the highest emetogenic potential. Furthermore, antiemetic guidelines generally do not consider the influence of other factors, including individual patient characteristics, on the emetic effects of cancer treatments. Similarly, the emetogenic potential of radiotherapy is stratified only according to the site of radiation, while other factors contributing to emetic risk are overlooked.Areas covered: An Expert Panel was convened to examine unresolved issues and summarize the current clinical research on managing nausea and vomiting associated with combination chemotherapy and radiotherapy.Expert opinion: The panel identified the incidence of nausea and vomiting induced by multi-drug combination therapies currently used to treat cancer at different anatomic sites and by radiotherapy in the presence of other risk factors. Based on these data and the clinical experience of panel members, several suggestions are made for a practical approach to prevent or manage nausea and vomiting due to chemotherapy regimens and radiation therapy.

Stereotactic Radiotherapy for Oligometastasis

Oligometastatic disease is defined as “a condition with a few metastases arising from tumors that have not acquired a potential for widespread metastases.” Its behavior suggests a transitional malignant state somewhere between localized and metastatic cancer. Treatment of oligometastatic disease is expected to achieve long-term local control and to improve survival. Historically, patients with oligometastases have often undergone surgical resection since it was anecdotally believed that surgical resection could result in progression-free or overall survival benefits. To date, no prospective randomized trials have demonstrated surgery-related survival benefits. Short courses of highly focused, extremely high-dose radiotherapies (e.g., stereotactic radiosurgery and stereotactic ablative body radiotherapy (SABR)) have frequently been used as alternatives to surgery for treatment of oligometastasis. A randomized study has demonstrated the overall survival benefits of stereotactic radiosurgery for solitary brain metastasis. Following the success of stereotactic radiosurgery, SABR has been widely accepted for treating extracranial metastases, considering its efficacy and minimum invasiveness. In this review, we discuss the history of and rationale for the local treatment of oligometastases and probe into the implementation of SABR for oligometastatic disease.

Metastatic and triple-negative breast cancer: challenges and treatment options

The major current conventional types of metastatic breast cancer (MBC) treatments include surgery, radiation, hormonal therapy, chemotherapy, or immunotherapy. Introducing biological drugs, targeted treatment and gene therapy can potentially reduce the mortality and improve the quality of life in patients with MBC. However, combination of several types of treatment is usually recommended. Triple negative breast cancer (TNBC) accounts for 10-20% of all cases of breast carcinoma and is characterized by the low expression of progesterone receptor (PR), estrogen receptor (ER), and human epidermal growth factor receptor 2 (HER2). Consequently, convenient treatments used for MBC that target these receptors are not effective for TNBC which therefore requires special treatment approaches. This review discusses the occurrence of MBC, the prognosis and predictive biomarkers of MBC, and focuses on the novel advanced tactics for treatment of MBC and TNBC. Nanotechnology-based combinatorial approach for the suppression of EGFR by siRNA and gifitinib is described.

Multifunctional targeting vinorelbine plus tetrandrine liposomes for treating brain glioma along with eliminating glioma stem cells

Malignant brain glioma is the most lethal and aggressive type of cancer. Surgery and radiotherapy cannot eliminate all glioma stem cells (GSCs) and blood–brain barrier (BBB) restricts the movement of antitumor drugs from blood to brain, thus leading to the poor prognosis with high recurrence rate. In the present study, the targeting conjugates of cholesterol polyethylene glycol polyethylenimine (CHOL-PEG₂₀₀₀-PEI) and D-a-tocopheryl polyethylene glycol 1000 succinate vapreotide (TPGS₁₀₀₀-VAP) were newly synthesized for transporting drugs across the BBB and targeting glioma cells and GSCs. The multifunctional targeting vinorelbine plus tetrandrine liposomes were constructed by modifying the targeting conjugates. The studies were undertaken on BBB model, glioma cells, GSCs, and glioma-bearing mice. In vitro results showed that multifunctional targeting drugs-loaded liposomes with suitable physicochemical property could enhance the transport drugs across the BBB, increase the intracellular uptake, inhibit glioma cells and GSCs, penetrate and destruct the GSCs spheroids, and induce apoptosis via activating related apoptotic proteins. In vivo results demonstrated that multifunctional targeting drugs-loaded liposomes could significantly accumulate into brain tumor location, show the specificity to tumor sites, and result in a robust overall antitumor efficacy in glioma-bearing mice. These data suggested that the multifunctional targeting vinorelbine plus tetrandrine liposomes could offer a promising strategy for treating brain glioma.

The expanding role of stereotactic body radiation therapy in oligometastatic solid tumors: What do we know and where are we going?

The spectrum hypothesis posits that there are distinct clinical states of metastatic progression. Early data suggest that aggressive treatment of more biologically indolent metastatic disease, characterized by metastases limited in number and destination organ, may offer an opportunity to alter the disease course, potentially allowing for longer survival, delay of systemic therapy, or even cure. The development of stereotactic body radiation therapy (SBRT) has opened new avenues for the treatment of oligometastatic disease. Early data support the use of SBRT for treating oligometastases in a number of organs, with promising rates of treated metastasis control and overall survival. Ongoing investigation is required to definitively establish benefit, determine the appropriate treatment regimen, refine patient selection, and incorporate SBRT with systemic therapies.

Vinorelbine With Capecitabine, an Evergreen Doublet for Advanced Breast Cancer: A Systematic Literature Review and Pooled-Analysis of Phase II-III Studies

Metastatic breast cancer (MBC) is treated with cytotoxic drugs or endocrine agents according to the site and extent of the disease, biology, previous treatments, and the patient's condition, comorbidities, and wishes. In MBC, vinorelbine (VRB) and capecitabine (X; VRB + X) are chemotherapy drugs that hold activity as first or later lines of therapy. We conducted a systematic literature review and meta-analysis to quantify the efficacy of the VRB + X combination in HER2-negative (HER2^-) MBC. We searched PubMed, EMBASE, SCOPUS, Web of Science, the Cochrane Library, and CINAHL for phase II/III clinical trials that assessed VRB + X for patients with HER2^- MBC. Pooled estimates of the overall response rate (RR), median progression-free survival (PFS), and overall survival (OS) were computed using random or fixed effects models. Twenty-seven studies were included in the analysis, encompassing a total of 1356 MBC patients. All were phase II (n = 21) or prospective/pilot (n = 5) trials, except for 1 that was a phase III controlled trial. The pooled estimate for the RR in first-line therapy (n = 16 trials) was 52.9% (95% confidence interval [CI], 46.5%-59.2%). For second-line trials, data were available in n = 9 studies and the overall RR was 41% (95% CI, 31.2%-51.6%). The pooled estimates for median PFS and OS in first-line therapy were 7.3 (95% CI, 6.2-8.3) and 22.3 (95% CI, 20-24.5) months, respectively. Vinorelbine + X, with the dose and schedules currently used in clinical practice, appears to be an effective and feasible chemotherapy for MBC, for first- and also for second-line therapy.

The role of surgery and ablative radiotherapy in oligometastatic breast cancer

The ability to deliver precise focused radiation, combined with improved surgical techniques, has led to multiple reports of long-term survivors in patients with oligometastatic breast cancer. The removal or ablation of known metastases, often present after systemic therapy regimens has the potential to be paradigm shifting rendering many patients without evidence of disease. However, the utility of these therapies has not been proven in phase III studies. Additionally, patient selection for metastasis-directed therapies is based on clinical criteria, with many patients not benefiting from these therapies. Refinements of radiation techniques are continuing, and discoveries are uncovering the biology of breast cancer in the oligometastatic state among patients. Integrated into ongoing studies, and those in development, they have the potential to alter standard management strategies in oligometastatic patients.

Prolonged complete response after treatment withdrawal in HER2-overexpressed, hormone receptor-negative breast cancer with liver metastases: the prospect of disappearance of an incurable disease

BACKGROUND

Metastatic breast cancer has consistently been viewed as a non-curable disease. Specific palliative treatments such as chemotherapy and hormone therapy have resulted in a mean overall survival of approximately 30 months. While cases of prolonged complete response have been reported with hormone or trastuzumab monotherapy, rendering metastatic breast cancer a chronic disease, any treatment withdrawal has ineluctably led to relapse. Prolonged remission without any anti-cancer treatment has never been reported to our knowledge.

CASE PRESENTATION

We report here the unique observation of the spontaneous evolution of two breast cancer patients with synchronous liver metastases who decided to stop trastuzumab after achieving complete response. They were Caucasian women with synchronous liver metastatic breast carcinoma. Both breast cancers reached skin and regional lymph nodes. There were several liver metastases in both patients. They received surgery, radiotherapy and chemotherapy combined with trastuzumab. They decided to stop their treatment, despite guidelines. After a follow-up longer than 20 months, they did not relapse clinically, radiologically, and biologically.

CONCLUSION

This findings question the belief of the unavoidability of recurrence of metastatic breast cancer, specifically in the liver. It opens up the unprecedented possibility of a cure-like state in exceptional and probably special cases.

Radical irradiation of extracranial oligometastases

Advances in radiotherapy planning and delivery have been used to treat patients with limited metastatic disease. With these techniques, high rates of treated metastasis control and low toxicity have been reported. Some patients have long disease-free intervals after radiotherapy similar to those seen after surgical resection. Ongoing studies will determine the benefit of these irradiation techniques to treat limited metastases, identify appropriate candidates, and assist in integrating these treatments into management strategies for specific diseases.