1
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Pujari L, Suresh A, Chowdhury Z, Pradhan S, Tripathi M, Gupta A, Singh P, Giridhar P, Kapoor AR, Shinghal A, Sansar B, Mv M. Outcomes of De Novo Oligometastatic Breast Cancer Treated With Surgery of Primary and Metastasis Directed Radiotherapy. Am J Clin Oncol 2024:00000421-990000000-00212. [PMID: 38963014 DOI: 10.1097/coc.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES With sensitive imaging for breast cancer, the question arises whether present-day oncologists treat dOMBC with palliative systemic therapy (ST), which, a few years earlier, would have been treated with curative intent. We retrospectively analyzed outcomes of dOMBC treated with curative intent using a combination of surgery, metastasis-directed radiotherapy (RT), and adjuvant/neoadjuvant ST and have also explored the possible role of total lesional glycolysis of metastases and p53 immunohistochemistry in predicting outcomes. METHODS Data were collected from a prospectively maintained database using electronic medical records and Radiation Oncology Information System. In the study, dOMBC was defined as up to 3 metastatic sites, all amenable to treatment with ablative RT and primary and axillary disease amenable to curative surgery. Patients were treated with surgery, ST, and RT. RESULTS Patients underwent either breast conservation surgery or modified radical mastectomy. Patients were treated with 6 to 8 cycles of chemotherapy in the neoadjuvant and/or adjuvant setting. Hormone receptor-positive patients received either tamoxifen or aromatase inhibitors. Trastuzumab was offered to Her-2-neu receptor-positive patients. RT included locoregional RT and metastases-directed ablative body RT. The median progression-free survival was 39 months (95% CI: -28.7 to 50.1 mo). Two and 3 year estimated disease-free survival (DFS) was 79% and 60.5%, respectively. The median overall survival was not reached. The estimated 3-year overall survival was 87.3%. Total lesional glycolysis of metastases score and p53 status did not affect DFS. CONCLUSION Combination treatment of surgery, metastases-directed ablative RT, and ST may provide prolonged DFS in dOMBC.
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Affiliation(s)
| | | | | | | | | | - Anuj Gupta
- Department of Medical Oncology, Mahamana Pandit Madanmohan Malaviya Cancer Centre/Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, UP, India
| | | | | | | | | | - Bipinesh Sansar
- Department of Medical Oncology, Mahamana Pandit Madanmohan Malaviya Cancer Centre/Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, UP, India
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2
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Yue J, Wang J, Chen W, Yin X, Du H, Wei Y. Palliative surgery versus non-surgery of the solitary metastatic lesion in De novo metastatic breast cancer: A SEER based study. Medicine (Baltimore) 2024; 103:e38651. [PMID: 38905366 PMCID: PMC11191955 DOI: 10.1097/md.0000000000038651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/30/2024] [Indexed: 06/23/2024] Open
Abstract
This study aimed to evaluate whether palliative surgery for metastatic lesion could provide a survival benefit in metastatic breast cancer (MBC) patients with solitary metastasis. De novo MBC patients with solitary distant lesions were enrolled utilizing the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was conducted to form matched pairs of the surgery group and the non-surgery group. The breast cancer-specific survival (BCSS) and overall survival (OS) outcomes between the 2 groups were compared in the following 3 sample models: the entire cohort of MBC (7665 cases); subgroups of patients with different isolated metastatic organs; and subgroups of patients with different molecular subtypes for each isolated metastatic organ. Compared with the Non-surgery group, the surgery group showed better BCSS and OS before PSM (HR = 0.88, 95% CI = 0.79-0.99, P = .04 and HR = 0.85, 95% CI = 0.76-0.95, P = .006, respectively). After PSM, palliative surgery still provided an OS benefit in patients with brain metastasis and lung metastasis (HR = 0.59, 95% CI = 0.37-0.95, P = .01 and HR = 0.64, 95% CI = 0.45-0.90, P = .02, respectively). Likewise, a better BCSS benefit was also found in the subset of patients with brain metastasis (HR = 0.61, 95% CI = 0.38-1.00, P = .01). Further stratification analysis indicated that patients with the luminal A subtype with brain metastasis have a better BCSS (HR = 0.36, 95% CI = 0.16-0.79, P = .04) and OS (HR = 0.37, 95% CI = 0.18-0.75, P = .03) after undergoing palliative surgery than nonsurgical treatment. Our study originality showed that palliative surgery for metastatic lesion could improve survival prognosis in patients with special single-organ metastasis and specific molecular subtypes. More clinical studies are needed to determine whether palliative surgery should be performed in MBC patients.
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Affiliation(s)
- Jian Yue
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Breast Surgery, Gaozhou People’s Hospital, Gaozhou, China
| | - Jing Wang
- Department of Head, Neck and Breast Surgery, Anhui Provincial Cancer Hospital, Hefei, China
- Department of Head, Neck and Breast Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wei Chen
- Youyang Hospital, A Branch of The First Affiliated Hospital of Chongqing Medical University, Youyang, China
| | - Xuedong Yin
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huimin Du
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuxian Wei
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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3
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Dyer P, Xie J, Tran PK, Byrne K. Survival outcomes for women with a solitary extracranial metastasis from breast cancer. Breast 2024; 75:103730. [PMID: 38640551 PMCID: PMC11035361 DOI: 10.1016/j.breast.2024.103730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Aggressive metastasis directed treatment of extracranial oligometastatic breast cancer with the aim of increasing disease-free survival has emerged as a new potential treatment paradigm, however there is currently a lack of data to assist in identifying the subset of patients who will potentially benefit most. This single-institute retrospective cohort study aimed to evaluate survival outcomes for patients with a solitary extracranial metastasis from breast cancer and to assess for significant prognostic factors. METHODS AND MATERIALS Medical records of 70 female breast cancer patients with a solitary extracranial metastasis actively managed at the Peter MacCallum Cancer Centre (PMCC) Melbourne Campus between 2000 and 2019 were reviewed. Kaplan-Meier curves were used to estimate overall survival (OS), local progression free survival (LPFS) and distant progression free survival (DPFS). RESULTS Median follow-up period was 9.4 years. The study included 40 hormone receptor positive/HER2 negative (HR+HER2-), 14 hormone receptor positive/HER2 positive (HR+HER2+), 3 hormone receptor negative/HER2 positive (HR-HER2+), 9 triple negative (TNBC) and 4 unclassified breast cancer patients. 5-year OS rate for all patients was 46%, LPFS rate was 56% and DPFS was 20%. Tumour receptor group had a statistically significant association with OS and DPFS rates. TNBC patients had significantly poorer OS and DPFS rates in comparison to HR+HER2-patients. CONCLUSION Among patients with a solitary extracranial metastasis from breast cancer, TNBC was associated with the poorest OS and DPFS rates. Identification of other significant prognostic factors for oligometastatic breast cancer patients may inform guidelines for metastasis directed treatments.
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Affiliation(s)
- Patrick Dyer
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.
| | - Jing Xie
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Phillip K Tran
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Keelan Byrne
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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4
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Aydos U, Ateş SG, Kurukahvecioğlu O, Akdemir ÜÖ, Uyar Göçün P, Atay LÖ. Relationship Between Metabolic Activity, Cellularity, Histopathological Features of Primary Tumors and Distant Metastatic Potential in Breast Cancer. Mol Imaging Radionucl Ther 2023; 32:195-205. [PMID: 37870280 PMCID: PMC10600550 DOI: 10.4274/mirt.galenos.2022.60024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/18/2022] [Indexed: 10/24/2023] Open
Abstract
Objectives The aim of this study was to evaluate the relationship between the types of distant metastatic spread, histopathological features, and imaging features of primary tumor on positron emission tomography/magnetic resonance imaging (PET/MRI) for primary staging in newly diagnosed breast invasive ductal carcinoma (IDC) patients. Methods Data from 289 female patients were retrospectively evaluated. Maximum standardized uptake value, metabolic tumor volume (MTV), total lesion glycolysis (TLG), and minimum apparent diffusion coefficient (ADCmin) values of primary tumors were obtained from PET/MRI. The patients were grouped as non-metastatic, oligometastatic (1-5 metastatic lesions) and multimetastatic (>5 metastatic lesions) disease according to the number of distant metastases, and divided into two groups as isolated bone metastasis (IBM) and mixed/soft tissue metastasis (M-SM) groups according to the sites of metastatic spread. Results Metabolic parameters had higher values and ADCmin had lower values in the multimetastatic and oligometastatic groups than in the non-metastatic group. MTV was the only parameter that showed significant difference between the multimetastatic and oligometastatic groups. MTV and TLG were significantly higher in the M-SM group than in the IBM group. 18F-fluorodeoxyglucose PET parameters had significantly higher values in grade 3, hormone receptor negative, human epidermal growth factor receptor 2 positive, triple negative, and highly proliferative (Ki-67 ≥14%) tumors. The prediction models that included imaging parameters to predict the presence of distant metastasis had higher discriminatory powers than the prediction models that included only histopathological parameters. Conclusion Primary tumors with higher metabolic-glycolytic activity and higher cellularity were more aggressive and had higher metastatic potential in breast IDC. Compared with histopathological parameters alone, the combination of imaging parameters and histopathological features of primary tumors may help to better understand tumor biology and behavior.
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Affiliation(s)
- Uğuray Aydos
- Gazi University Faculty of Medicine, Department of Nuclear Medicine, Ankara, Türkiye
| | - Seda Gülbahar Ateş
- University of Health Sciences Türkiye, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Clinic of Nuclear Medicine, Ankara, Türkiye
| | | | - Ümit Özgür Akdemir
- Gazi University Faculty of Medicine, Department of Nuclear Medicine, Ankara, Türkiye
| | - Pınar Uyar Göçün
- Gazi University Faculty of Medicine, Department of Medical Pathology, Ankara, Türkiye
| | - Lütfiye Özlem Atay
- Gazi University Faculty of Medicine, Department of Nuclear Medicine, Ankara, Türkiye
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5
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Mahoney MT, Kubinak N, Masi A, Lok C, Eanelli TR. Mind the Gap: Recurrence of Oligometastatic Breast Invasive Ductal Carcinoma in the Sternal Gap of Two Tangential Photon Fields of Bilateral Whole Breast Irradiation a Decade Later. Cureus 2023; 15:e46601. [PMID: 37933375 PMCID: PMC10625834 DOI: 10.7759/cureus.46601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/08/2023] Open
Abstract
Despite bilateral breast cancer being a rare clinical entity compared to unilateral breast cancer, both share a treatment paradigm of breast-conserving therapy for limited disease and metastasis direct therapy for oligometastatic disease. We present a case of left breast invasive ductal carcinoma in the setting of original bilateral breast cancer, now with oligometastatic recurrence to the soft tissue of the sternum, notably in an area not previously irradiated, over a decade later.
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Affiliation(s)
- Mary T Mahoney
- Department of Radiation Oncology, Transitional Year Residency Program, Garnet Health, Middletown, USA
| | - Noelle Kubinak
- Department of Radiation Oncology, Touro College of Osteopathic Medicine, Middletown, USA
| | - Athena Masi
- Department of Radiation Oncology, Touro College of Osteopathic Medicine, Middletown, USA
| | - Christopher Lok
- Department of Radiation Oncology, Garnet Health, Middletown, USA
| | - Thomas R Eanelli
- Department of Radiation Oncology, Garnet Health, Middletown, USA
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6
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Rodríguez Pérez A, Felip Font E, Chicas-Sett R, Montero-Luis Á, de Paz Arias L, González-Del-Alba A, López-Campos F, López López C, Hernando Requejo O, Conde-Moreno AJ, Arranz Arija JÁ, de Castro Carpeño J. Unravelling oligometastatic disease from the perspective of radiation and medical oncology. Part I: non-small cell lung cancer and breast cancer. Clin Transl Oncol 2023; 25:882-896. [PMID: 36525231 DOI: 10.1007/s12094-022-03011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022]
Abstract
Oligometastatic disease (OMD) defines a cancer status that is intermediate between localized and widely spread metastatic disease, and can be treated with curative intent. While diagnostic imaging tools have considerably improved in recent years, unidentified micrometastases can still evade current detection techniques, allowing the disease to progress. The various OMD scenarios are mainly defined by the number of metastases, the biological and molecular tumour profiles, and the timing of the development of metastases. Increasing knowledge has contributed to the earlier and improved detection of OMD, underlining the importance of early disease control. In view of increasing OMD detection rates in current real-world clinical practice and the lack of standardized evidence-based guidelines to treat this cancer status, a board of experts from the Spanish Societies of Radiation Oncology (SEOR) and Medical Oncology (SEOM) organized a series of sessions to update the current state-of-the-art on OMD from a multidisciplinary perspective, and to discuss how results from clinical studies might translate into promising treatment options. This expert review series summarizes what is known and what it is pending clarification in the context of OMD in the scenarios of non-small cell lung cancer and breast cancer (Part I), and prostate cancer and colorectal cancer (Part II), aiming to offer specialists a pragmatic framework to help improve patient management.
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Affiliation(s)
- Aurora Rodríguez Pérez
- Radiation Oncology Department, Hospital Ruber Internacional, C. de La Masó, 38, 28034, Madrid, Spain.
| | - Enriqueta Felip Font
- Medical Oncology Department, Hospital Universitario del Vall d'Hebron, Barcelona, Spain
| | | | - Ángel Montero-Luis
- Radiation Oncology Department, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - Laura de Paz Arias
- Medical Oncology Department, Complejo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | | | | | - Carlos López López
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
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7
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Merloni F, Palleschi M, Gianni C, Casadei C, Curcio A, Romeo A, Rocchi M, Cima S, Sirico M, Sarti S, Cecconetto L, Mariotti M, Di Menna G, De Giorgi U. Locoregional treatment of de novo stage IV breast cancer in the era of modern oncology. Front Oncol 2023; 13:1083297. [PMID: 36793604 PMCID: PMC9923000 DOI: 10.3389/fonc.2023.1083297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/09/2023] [Indexed: 01/31/2023] Open
Abstract
Approximately 6% of metastatic breast cancers arise de novo. While systemic therapy (ST) remains the treatment backbone as for patients with metachronous metastases, locoregional treatment (LRT) of the primary tumor remains a controversial method. The removal of the primary has an established role for palliative purposes, but it is unclear if it could also determine a survival benefit. Retrospective evidence and pre-clinical studies seem to support the removal of the primary as an effective approach to improve survival. On the other hand, most randomized evidence suggests avoiding LRT. Both retrospective and prospective studies suffer several limitations, ranging from selection bias and outdated ST to a small sample of patients. In this review we discuss available data and try to identify subgroups of patients which could benefit the most from LRT of the primary, to facilitate clinical practice decisions, and to hypothesize future studies design on this topic.
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Affiliation(s)
- Filippo Merloni
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Michela Palleschi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Caterina Gianni
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Chiara Casadei
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Annalisa Curcio
- Breast Surgery Unit, Pierantoni-Morgagni Hospital Forlì and Santa Maria delle Croci Hospital Ravenna, Forli, Italy
| | - Antonino Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Maddalena Rocchi
- Breast Surgery Unit, Pierantoni-Morgagni Hospital Forlì and Santa Maria delle Croci Hospital Ravenna, Forli, Italy
| | - Simona Cima
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Marianna Sirico
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Samanta Sarti
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Lorenzo Cecconetto
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Marita Mariotti
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Giandomenico Di Menna
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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8
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Surgery in the Setting of Metastatic Breast Cancer. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00476-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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9
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Peron V, Miyasaki Piovesana M, Martins Medeiros E, André Di Ricco B, Teixeira Liutti V. Oligometastatic breast cancer to parotid gland with complete response. Breast Dis 2023; 42:67-71. [PMID: 36911926 DOI: 10.3233/bd-210049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Breast cancer metastatic to parotid gland is a very rare condition which tend to confer poor prognosis and challenging approaches. Oligometastatic breast cancer is usually defined as advanced breast cancer with less or equal than 5 metastatic lesions. We report a case of oligometastatic HER-2 breast cancer to parotid gland and lymph nodes which presented with left hemifacial swelling with erythema and enlargement of cervical and axillary lymph nodes. After 6 cycles of Docetaxel plus Trastuzumab the patient had complete response that was complemented with posterior surgical removal of primary tumor followed by radiotherapy directed to plastron, left supraclavicular and cervical drainage. The patient is still on Trastuzumab therapy and is free of disease in the last two years. We discuss the presentation and approach of a patient with metastatic breast cancer to parotid gland in the oligometastatic scenario.
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Affiliation(s)
- Veruska Peron
- Department of Medical Oncology, Hospital do Câncer de Londrina, Londrina, Brazil
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10
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Merloni F, Palleschi M, Casadei C, Romeo A, Curcio A, Casadei R, Stella F, Ercolani G, Gianni C, Sirico M, Cima S, Sarti S, Cecconetto L, Di Menna G, De Giorgi U. Oligometastatic breast cancer and metastasis-directed treatment: an aggressive multimodal approach to reach the cure. Ther Adv Med Oncol 2023; 15:17588359231161412. [PMID: 36950272 PMCID: PMC10026139 DOI: 10.1177/17588359231161412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 02/16/2023] [Indexed: 03/20/2023] Open
Abstract
Metastatic breast cancer (BC) is considered an incurable disease and is usually treated with palliative intent. However, about 50% of metastatic BCs present with only a few metastatic lesions and are characterized by longer overall survival. These patients, defined as oligometastatic, could benefit from a multimodal approach, which combines systemic therapy with metastasis-directed treatment (stereotactic ablative therapy or surgery). The current definition of oligometastatic seems incomplete since it is based only on imaging findings and does not include biological features, and the majority of relevant data supporting this strategy comes from retrospective or non-randomized studies. However, the chance of reaching long-term complete remission or even a cure has led to the development of randomized trials investigating the impact of combined treatment in oligometastatic BC (OMBC). The SABR-COMET trial, the first randomized study to include BC patients, showed promising results from a combination of stereotactic ablative radiotherapy and systemic therapy. Considering the randomized trial's results, multidisciplinary teams should be set up to select OMBC patients who could achieve long-term survival with aggressive multimodal treatment.
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Affiliation(s)
| | - Michela Palleschi
- Department of Medical Oncology, IRCCS Istituto
Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola,
Italy
| | - Chiara Casadei
- Department of Medical Oncology, IRCCS Istituto
Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola,
Italy
| | - Antonino Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo per
lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Annalisa Curcio
- Breast Surgery Unit, Pierantoni-Morgagni
Hospital Forlì and Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Roberto Casadei
- Orthopedic Unit, Morgagni-Pierantoni Hospital,
Ausl Romagna, Forlì, Italy
| | - Franco Stella
- Division of Thoracic Surgery, Department of
Experimental, Diagnostic and Specialty Medicine—DIMES of the Alma Mater
Studiorum, University of Bologna, Forlì, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical
Sciences-DIMEC, Alma Mater Studiorum – University of Bologna, Bologna,
Italy
- General and Oncology Surgery,
Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Caterina Gianni
- Department of Medical Oncology, IRCCS Istituto
Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola,
Italy
| | - Marianna Sirico
- Department of Medical Oncology, IRCCS Istituto
Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola,
Italy
| | - Simona Cima
- Radiotherapy Unit, IRCCS Istituto Romagnolo
per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Samanta Sarti
- Department of Medical Oncology, IRCCS Istituto
Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola,
Italy
| | - Lorenzo Cecconetto
- Department of Medical Oncology, IRCCS Istituto
Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola,
Italy
| | - Giandomenico Di Menna
- Department of Medical Oncology, IRCCS Istituto
Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola,
Italy
| | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto
Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola,
Italy
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11
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Aristei C, Bölükbaşı Y, Kaidar-Person O, Pfeffer R, Arenas M, Boersma LJ, Ciabattoni A, Coles CE, Franco P, Krengli M, Leonardi MC, Marazzi F, Masiello V, Meattini I, Montero A, Offersen B, Trigo ML, Bourgier C, Genovesi D, Kouloulias V, Morganti AG, Meduri B, Pasinetti N, Pedretti S, Perrucci E, Rivera S, Tombolini V, Vidali C, Valentini V, Poortmans P. Ways to improve breast cancer patients' management and clinical outcome: The 2020 Assisi Think Tank Meeting. Crit Rev Oncol Hematol 2022; 177:103774. [PMID: 35917884 DOI: 10.1016/j.critrevonc.2022.103774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 10/16/2022] Open
Abstract
We report on the third Assisi Think Tank Meeting (ATTM) on breast cancer, a brainstorming project which involved European radiation and clinical oncologists who were dedicated to breast cancer research and treatment. Held on February 2020, the ATTM aimed at identifying key clinical questions in current clinical practice and "grey" areas requiring research to improve management and outcomes. Before the meeting, three key topics were selected: 1) managing patients with frailty due to either age and/or multi-morbidity; 2) stereotactic radiation therapy and systemic therapy in the management of oligometastatic disease; 3) contralateral breast tumour prevention in BCRA-mutated patients. Clinical practice in these areas was investigated by means of an online questionnaire. In the lapse period between the survey and the meeting, the working groups reviewed data, on-going studies and the clinical challenges which were then discussed in-depth and subjected to intense brainstorming during the meeting; research protocols were also proposed. Methodology, outcome of discussions, conclusions and study proposals are summarized in the present paper. In conclusion, this report presents an in-depth analysis of the state of the art, grey areas and controversies in breast cancer radiation therapy and discusses how to confront them in the absence of evidence-based data to guide clinical decision-making.
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Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy.
| | - Yasemin Bölükbaşı
- Radiation Oncology Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Orit Kaidar-Person
- Breast Radiation Unit, Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Raphael Pfeffer
- Oncology Institute, Assuta Medical Center, Tel Aviv and Ben Gurion University Medical School, Israel
| | - Meritxell Arenas
- Universitat Rovira I Virgili, Radiation Oncology Department, Hospital Universitari Sant Hoan de Reus, IISPV, Spain
| | - Liesbeth J Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Antonella Ciabattoni
- Department of Radiation Oncology, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | | | - Pierfrancesco Franco
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | - Marco Krengli
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | | | - Fabio Marazzi
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - Valeria Masiello
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Angel Montero
- Department of Radiation Oncology, University Hospital HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Birgitte Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Maria Lurdes Trigo
- Service of Brachytherapy, Department of Image and Radioncology, Instituto Português Oncologia Porto Francisco Gentil E.P.E., Portugal
| | - Céline Bourgier
- Radiation Oncology, ICM-Val d'Aurelle, Univ Montpellier, Montpellier, France
| | - Domenico Genovesi
- Radiation Oncology, Ospedale Clinicizzato Chieti and University "G. d'Annunzio", Chieti, Italy
| | - Vassilis Kouloulias
- 2(nd) Department of Radiology, Radiotherapy Unit, Medical School, National and Kapodistrian University of Athens, Greece
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna; DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy
| | - Nadia Pasinetti
- Radiation Oncology Service, ASST Valcamonica Esine and Brescia University, Brescia, Italy
| | - Sara Pedretti
- Istituto del Radio "O.Alberti" - Spedali Civili Hospital and Brescia University, Brescia
| | | | - Sofia Rivera
- Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Vincenzo Tombolini
- Radiation Oncology, Department of Radiological, Oncological and Pathological Science, University "La Sapienza", Roma, Italy
| | - Cristiana Vidali
- former Senior Assistant Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Vincenzo Valentini
- Division of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
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12
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MRI-guided Radiotherapy (MRgRT) for treatment of Oligometastases: Review of clinical applications and challenges. Int J Radiat Oncol Biol Phys 2022; 114:950-967. [PMID: 35901978 DOI: 10.1016/j.ijrobp.2022.07.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Early clinical results on the application of magnetic resonance imaging (MRI) coupled with a linear accelerator to deliver MR-guided radiation therapy (MRgRT) have demonstrated feasibility for safe delivery of stereotactic body radiotherapy (SBRT) in treatment of oligometastatic disease. Here we set out to review the clinical evidence and challenges associated with MRgRT in this setting. METHODS AND MATERIALS We performed a systematic review of the literature pertaining to clinical experiences and trials on the use of MRgRT primarily for the treatment of oligometastatic cancers. We reviewed the opportunities and challenges associated with the use of MRgRT. RESULTS Benefits of MRgRT pertaining to superior soft-tissue contrast, real-time imaging and gating, and online adaptive radiotherapy facilitate safe and effective dose escalation to oligometastatic tumors while simultaneously sparing surrounding healthy tissues. Challenges concerning further need for clinical evidence and technical considerations related to planning, delivery, quality assurance (QA) of hypofractionated doses, and safety in the MRI environment must be considered. CONCLUSIONS The promising early indications of safety and effectiveness of MRgRT for SBRT-based treatment of oligometastatic disease in multiple treatment locations should lead to further clinical evidence to demonstrate the benefit of this technology.
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13
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Ueno T. Surgical Management of Metastatic Breast Cancer: A Mini Review. Front Oncol 2022; 12:910544. [PMID: 35600412 PMCID: PMC9114738 DOI: 10.3389/fonc.2022.910544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/13/2022] [Indexed: 12/17/2022] Open
Abstract
Breast cancer with distant metastases is a systemic disease. While systemic therapies are the main treatment strategy, locoregional therapy for metastatic breast cancer (MBC) is generally palliative only. However, recent progress in systemic and local therapies has improved the prognosis of patients with MBC and some may expect long-term survival. More vigorous local therapies for MBC may, therefore, be clinically justified in selected patients. A number of clinical trials and studies have investigated the clinical significance of surgical therapy for primary tumors and distant metastases in patients with MBC. Four prospective randomized trials and multiple retrospective studies have investigated the benefit of surgical resection of primary lesions in patients with MBC, with conflicting results. There have been a number of case-control studies examining the impact of surgical resection of distant metastases, but the benefit of this approach in terms of survival is controversial because selection bias is unavoidable in retrospective studies. The present review discusses the state of the literature relating to local management of the primary breast cancer through surgical resection and surgical management of distant metastatic lesions including pulmonary and liver metastases with future perspectives.
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Affiliation(s)
- Takayuki Ueno
- Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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14
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Oligometastasis in breast cancer—current status and treatment options from a radiation oncology perspective. Strahlenther Onkol 2022; 198:601-611. [PMID: 35527272 PMCID: PMC9217902 DOI: 10.1007/s00066-022-01938-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/24/2022] [Indexed: 12/16/2022]
Abstract
AbstractEvidence from a few small randomized trials and retrospective cohorts mostly including various tumor entities indicates a prolongation of disease free survival (DFS) and overall survival (OS) from local ablative therapies in oligometastatic disease (OMD). However, it is still unclear which patients benefit most from this approach. We give an overview of the several aspects of stereotactic body radiotherapy (SBRT) in extracranial OMD in breast cancer from a radiation oncology perspective. A PubMed search referring to this was conducted. An attempt was made to relate the therapeutic efficacy of SBRT to various prognostic factors. Data from approximately 500 breast cancer patients treated with SBRT for OMD in mostly in small cohort studies have been published, consistently indicating high local tumor control rates and favorable progression-free (PFS) and overall survival (OS). Predictors for a good prognosis after SBRT are favorable biological subtype (hormone receptor positive, HER2 negative), solitary metastasis, bone-only metastasis, and long metastasis-free interval. However, definitive proof that SBRT in OMD breast cancer prolongs DFS or OS is lacking, since, with the exception of one small randomized trial (n = 22 in the SBRT arm), none of the cohort studies had an adequate control group. Further studies are needed to prove the benefit of SBRT in OMD breast cancer and to define adequate selection criteria. Currently, the use of local ablative SBRT should always be discussed in a multidisciplinary tumor board.
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15
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Botticelli A, Fabbri A, Roberto M, Alesini D, Cirillo A, D'Auria G, Krasniqi E, Marrucci E, Muratore M, Pantano F, Pizzuti L, Portarena I, Rossi R, Scagnoli S, Marchetti P. The Role of the CDK4/6 Inhibitor Ribociclib in Locally Advanced and Oligometastatic Hormone Receptor Positive, Her2 Negative, Advanced Breast Cancer: Case Series and Review of the Literature. Front Oncol 2022; 12:797157. [PMID: 35223478 PMCID: PMC8864134 DOI: 10.3389/fonc.2022.797157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
The recent addition of cyclin-dependent kinase 4 (CDK4) and CDK6 inhibitors to endocrine therapy has remarkably improved the outcome of patients affected with hormone receptor positive (HR+), human epidermal grow factor receptor 2 negative (HER2 -) advanced breast cancer (ABC). Ribociclib showed to be effective across most subgroups, regardless of the number and the site of metastasis. Up to 10% of patients with ABC, reported an oligometastatic condition, recently defined as a slow-volume metastatic disease with limited number and size of metastatic lesions (up to 5 and not necessarily in the same organ), potentially amenable for local treatment, aimed at achieving a complete remission status. Despite the wide use of CDK4/6 inhibitors in HR+, HER2-, ABC treatment, data regarding both locally advanced, inoperable disease and oligometastatic conditions are still poor. We reported a review and case series of HR+, HER2-, ABC patients treated with ribociclib as first-line therapy, for a locally advanced and oligometastatic conditions, reporting an impressive response and good safety profile.
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Affiliation(s)
- Andrea Botticelli
- Medical Oncology Unit B, Policlinico Umberto I, Rome, Italy.,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Oncology Unit, Sant'Andrea Hospital, Rome, Italy
| | - Agnese Fabbri
- Medical Oncology Unit, Belcolle Hospital, Viterbo, Italy
| | - Michela Roberto
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Oncology Unit, Sant'Andrea Hospital, Rome, Italy.,Medical Oncology Unit A, Policlinico Umberto I, Rome, Italy
| | - Daniele Alesini
- UOSD Centro Oncologico S. Spirito e Nuovo Regina Margherita (SS-NRM), Ospedale Santo Spirito in Sassia, Rome, Italy
| | - Alessio Cirillo
- Medical Oncology Unit B, Policlinico Umberto I, Rome, Italy.,Department of Radiological, Oncological and Anatomo-Pathological Science, "Sapienza" University of Rome, Rome, Italy
| | - Giuliana D'Auria
- Department of Medical Oncology, Sandro Pertini Hospital, Rome, Italy
| | - Eriseld Krasniqi
- Division of Medical Oncology 2, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | | | - Margherita Muratore
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Francesco Pantano
- Department of Oncology, University Campus Biomedico of Rome, Rome, Italy
| | - Laura Pizzuti
- Division of Medical Oncology 2, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Ilaria Portarena
- Medical Oncology Unit, Internal Medicine Department, Tor Vergata Clinical Center University Hospital, Rome, Italy
| | - Rosalina Rossi
- Medical Oncology, San Giovanni Addolorata Hospital, Rome, Italy
| | - Simone Scagnoli
- Medical Oncology Unit B, Policlinico Umberto I, Rome, Italy.,Department of Medical and Surgical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Paolo Marchetti
- Medical Oncology Unit B, Policlinico Umberto I, Rome, Italy.,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Oncology Unit, Sant'Andrea Hospital, Rome, Italy
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16
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Ariani R, Hwang L, Maliglig AM, Ragab O, Ye JC. Temporality and Patterns of Metastatic Recurrence in Node-Positive Breast Cancer Following Trimodality Therapy: Opportunity for Improved Oligometastases Detection and Salvage Local Therapy. Am J Clin Oncol 2022; 45:88-94. [PMID: 34991105 DOI: 10.1097/coc.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES There is evidence that detection and treatment of oligometastases (≤5 lesions) may improve survival in breast cancer patients. However, there are no current national guidelines for screening of early, asymptomatic metastases. This study examined the patterns and timing of recurrence with respect to survival in node-positive breast cancer (NPBC) patients at higher risk for developing metastases. METHODS A single-institution retrospective review of NPBC patients treated with trimodality therapy was performed to collect patient and disease characteristics, recurrence location, method of detection, and survival outcome. Univariate and multivariate analyses were done to identify factors associated with recurrence. RESULTS Ninety-four NPBC patients treated at a safety-net hospital between 2008 and 2019 were identified. Twenty-one developed recurrence and were divided into oligometastatic (OM) (n=10) or diffusely metastatic (DM) (n=11) subgroups. Median recurrence-free survival in OM and DM was 18 and 36 months, respectively. Median overall survival (OS) for OM was not reached. Median OS for DM was 57 months. Four patients with OM progressed to diffuse disease in a median period of 17 months; median survival thereafter was 57 months. All patients with recurrence had distant metastases on initial detection, with the most common site being bone (14). Recurrence was most frequently detected by computed tomography (CT) (13), with the majority of disease located within the thorax region. CONCLUSIONS All NPBC patients had distant metastasis at time of recurrence. Patients with OM had shorter interval to recurrence yet longer OS compared with DM. This study highlights improved surveillance imaging for timely detection of OM breast cancer that may yet be amenable to aggressive local salvage therapy to prevent progression to diffuse disease.
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Affiliation(s)
| | | | - Ana M Maliglig
- Radiology, Keck School of Medicine of University of Southern California, Los Angeles, CA
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17
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Gogia A, Deo S, Sharma D, Mathur S. Oligometastatic breast cancer: An institutional analysis. Indian J Cancer 2022; 59:257-262. [DOI: 10.4103/ijc.ijc_169_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Zhou D, Jiang K, Hong R, Lu Q, Xia W, Li M, Zheng C, Zheng Q, Xu F, Wang S. Distribution Characteristics and Prognostic Value of Immune Infiltration in Oligometastatic Breast Cancer. Front Oncol 2021; 11:747012. [PMID: 34858823 PMCID: PMC8632540 DOI: 10.3389/fonc.2021.747012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/26/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND To assess the distribution characteristics and the prognostic value of immune infiltration in female oligometastatic breast cancer patients. METHODS We retrospectively analyzed the clinicopathological data of oligometastatic breast cancer (OMBC) patients diagnosed between June 2000 and January 2020. Immune markers were quantified by immunohistochemistry on FFPE tissues in paired normal breast tissues, primary breast cancers and oligometastatic lesions. Survival analyses were performed using the Kaplan-Meier curves and Cox-proportional hazards model. RESULTS A total of 95 female OMBC patients visited Sun Yat-sen University Cancer Center between June 2000 and January 2020, and 33 of them had matched normal breast tissues, primary cancers and oligometastatic lesions and were reviewed in immune infiltration analysis. CD8 of primary tumors had a higher expression than that in matched normal tissues. The expressions of CD8 and FOXP3 were higher in the primary sites than that in the oligometastatic lesions. CD3, CD4 and CD8 were significantly lower in the intratumoral regions than that in the peritumoral regions both in primary and oligometastatic lesions. Notably, the high percentage of CD3 in the intratumoral oligometastatic lesions predicted the longer PFS and OS, and higher CD4 in the same lesions also predicted a better OS. There was obviously positive correlation between CD4/CD3 and Ki-67 in primary cancers and negative correlation between CD4/CD3 and ER in oligometastatic sites. CONCLUSION We explored immune distribution and evolution in time and space in OMBC to provide new understandings for biological behaviors of this disease and further divided patients in different prognosis.
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Affiliation(s)
- Danyang Zhou
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Kuikui Jiang
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ruoxi Hong
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Qianyi Lu
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wen Xia
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Mei Li
- Department of Pathology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Chengyou Zheng
- Department of Pathology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Qiufan Zheng
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Fei Xu
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shusen Wang
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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19
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Zengel B, Kilic M, Tasli F, Simsek C, Karatas M, Ozdemir O, Cavdar D, Durusoy R, Bas KK, Uslu A. Breast cancer patients with isolated bone metastases and oligometastatic bone disease show different survival outcomes. Sci Rep 2021; 11:20175. [PMID: 34635748 PMCID: PMC8505657 DOI: 10.1038/s41598-021-99726-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/24/2021] [Indexed: 12/20/2022] Open
Abstract
In this study, we planned to investigate the clinical course of patients with breast cancer with oligometastatic bone disease (OMBD). The patients were grouped according to the characteristics and the sites of metastases. Group I included 928 patients without metastasis. Group II, the OMBD group, included 68 patients. Group III, the widespread metastasis group, comprised 185 patients with multiple bone metastases and/or solid organ metastases. The mean overall survival of the groups was 16.7 ± 0.3 years in group 1, and 7.8 ± 0.8 and 5.9 ± 0.4 years in groups 2 and 3, respectively (p < 0.001 for the comparison of all three groups together; p < 0.001 for group 1 vs. 2 and 3) and (p = 0.037 for group 2 vs. group 3). In the subgroup survival analysis of patients in group 2 (OMBD), the mean and median survival was 5.5 ± 0.8 and 4.0 ± 0.8 years vs. 9.2 ± 0.98 and 9.0 ± 1.05 years in patients with more than one bone metastasis and single bone metastasis, respectively (p = 0.019). OMBD seems to be a different disease than breast cancer with isolated bone metastases. The high risk of developing OMBD, especially following locoregional recurrence, increases the importance of locoregional therapy in large T and N stage tumors.
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Affiliation(s)
- Baha Zengel
- Department of General Surgery, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey.
| | - Mustafa Kilic
- Department of General Surgery, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey
| | - Funda Tasli
- Department of Pathology, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey
| | - Cenk Simsek
- Department of General Surgery, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey
| | - Murat Karatas
- Department of General Surgery, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey
| | - Ozlem Ozdemir
- Department of Medical Oncology, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey
| | - Demet Cavdar
- Department of Pathology, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey
| | - Raika Durusoy
- Department of Public Health, Medical Faculty, Ege University, Izmir, Turkey
| | - Kadir Koray Bas
- Department of General Surgery, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey
| | - Adam Uslu
- Department of General Surgery, Izmir Bozyaka Health Practice and Research Center, University of Health Sciences Turkey, Izmir, Turkey
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20
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Investigation of the Definition of De Novo Oligometastatic Nasopharyngeal Carcinoma: A Retrospective Study. JOURNAL OF ONCOLOGY 2021; 2021:9977455. [PMID: 34567120 PMCID: PMC8460388 DOI: 10.1155/2021/9977455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/24/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
Background The prognosis of metastatic nasopharyngeal carcinoma (mNPC) is highly heterogeneous. As a special stage of distant metastasis of mNPC, quite a few oligometastatic NPC (omNPC) patients can still achieve a long-term survival after treatment. However, there is no uniform standard for the definition of omNPC until now. Methods We retrospectively analyzed the survival data of 191 patients with de novo mNPC at the Affiliated Cancer Hospital and Institute of Guangzhou Medical University between 2010 and 2017 and specifically analyzed the clinical outcomes associated with the number of metastatic organs/lesions and tried to find a cohort with relatively better prognosis to define as omNPC. Results The median overall survival (OS) of the entire group of patients was 21.5 months (95% CI 15.0–28.0), and the 1-year, 2-year, and 3-year OS rates were 72.2%, 46.1%, and 34.3%, respectively. Multiple-organ metastases (P < 0.001) and >5 metastatic lesions (P < 0.001) were adverse influencing factors of prognosis, and the number of metastatic lesions (P < 0.001) was the independent factor influencing the prognosis of de novo mNPC. The overall survival (OS) and progression-free survival (PFS) of patients with ≤5 metastatic lesions were significantly better than those of patients with >5 metastatic lesions. Conclusion Patients with ≤5 metastatic lesions presented a better survival, and this criterion may be a definition standard for the de novo omNPC.
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21
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Barberi V, Pietragalla A, Franceschini G, Marazzi F, Paris I, Cognetti F, Masetti R, Scambia G, Fabi A. Oligometastatic Breast Cancer: How to Manage It? J Pers Med 2021; 11:532. [PMID: 34207648 PMCID: PMC8227505 DOI: 10.3390/jpm11060532] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 12/14/2022] Open
Abstract
Breast cancer (BC) is the most frequent cancer among women and represents the second leading cause of cancer-specific death. A subset of patients with metastatic breast cancer (MBC) presents limited disease, termed 'oligometastatic' breast cancer (OMBC). The oligometastatic disease can be managed with different treatment strategies to achieve long-term remission and eventually cure. Several approaches are possible to cure the oligometastatic disease: locoregional treatments of the primary tumor and of all the metastatic sites, such as surgery and radiotherapy; systemic treatment, including target-therapy or immunotherapy, according to the biological status of the primary tumor and/or of the metastases; or the combination of these approaches. Encouraging results involve local ablative options, but these trials are limited by being retrospective and affected by selection bias. Systemic therapy, e.g., the use of CDK4/6 inhibitors for hormone receptor-positive (HR+)/HER-2 negative BC, leads to an increase of progression-free survival (PFS) and overall survival (OS) in all the subgroups, with favorable toxicity. Regardless of the lack of substantial data, this subset of patients could be treated with curative intent; the appropriate candidates could be mostly young women, for whom a multidisciplinary aggressive approach appears suitable. We provide a global perspective on the current treatment paradigms of OMBC.
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Affiliation(s)
- Vittoria Barberi
- Medical Oncology 1, Regina Elena National Cancer Institute, IRCCS, 00144 Rome, Italy; (V.B.); (F.C.)
| | - Antonella Pietragalla
- Scientific Directorate, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (A.P.); (G.S.)
| | - Gianluca Franceschini
- Comprehensive Cancer Center, Multidisciplinary Breast Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (G.F.); (R.M.)
| | - Fabio Marazzi
- UOC Radiotherapy, Department of Imaging Diagnostic, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy;
| | - Ida Paris
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Francesco Cognetti
- Medical Oncology 1, Regina Elena National Cancer Institute, IRCCS, 00144 Rome, Italy; (V.B.); (F.C.)
| | - Riccardo Masetti
- Comprehensive Cancer Center, Multidisciplinary Breast Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (G.F.); (R.M.)
| | - Giovanni Scambia
- Scientific Directorate, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (A.P.); (G.S.)
| | - Alessandra Fabi
- Unit of Precision Medicine in Breast Cancer, Scientific Directorate, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
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22
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Loibl S, Poortmans P, Morrow M, Denkert C, Curigliano G. Breast cancer. Lancet 2021; 397:1750-1769. [PMID: 33812473 DOI: 10.1016/s0140-6736(20)32381-3] [Citation(s) in RCA: 665] [Impact Index Per Article: 221.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/29/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023]
Abstract
Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.
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Affiliation(s)
- Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Centre for Haematology and Oncology Bethanien, Frankfurt, Germany.
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carsten Denkert
- German Breast Group, Neu-Isenburg, Germany; Institute of Pathology, Philipps University of Marburg, Marburg, Germany; University Hospital Marburg, Marburg, Germany
| | - Giuseppe Curigliano
- European Institute of Oncology IRCCS, Milan, Italy; University of Milano, Milan, Italy
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Abstract
PURPOSE OF REVIEW To critically analyze the available evidence on oligometastatic breast cancer and to suggest therapeutic approaches for optimal management of these patients. RECENT FINDINGS Unlike metastatic breast cancer, which remains incurable, patients with a limited number and extent of metastatic lesions, that is, oligometastatic disease, might achieve disease control and long-term survival when radical therapy of the primary tumor, if present, and metastatic disease is added to standard systemic therapy. However, the lack of a clear definition, variety of presentations, and the absence of biomarkers makes oligometastatic breast cancer a poorly understood clinical entity for which there is no standard treatment. SUMMARY Improvements in systemic therapies along with radical treatment of the primary tumor and metastatic lesions, together with optimization in the use of imaging tools, may help to increase the percentage of patients with metastatic breast cancer who achieve no-evidence-of-disease status or, at least, chronification of the disease. However, the fundamental question remains: which patients may benefit the most from a radical therapeutic approach? In this article, we propose strategies for the appropriate selection and comprehensive management of these patients.
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Ingle P, Khandare P, Rajput M, Tiwari M, Patil M, Mehta A. Solitary Pancreatic Head Metastasis from Ductal Carcinoma of Breast: A Case Report. Indian J Surg Oncol 2021; 12:193-196. [PMID: 33994746 DOI: 10.1007/s13193-021-01284-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/27/2021] [Indexed: 11/29/2022] Open
Abstract
Liver, bones, and brain are common sites for breast cancer metastasis. We report here a rare scenario of metastasis to pancreatic head from breast cancer after a disease free interval of 7 years. A 60-year old breast cancer survivor noticed upper abdominal pain for 2 weeks, and her investigations revealed a pancreatic head mass lesion. Computed tomography imaging revealed a solitary pancreatic mass lesion with portal cavernoma formation and a guided biopsy yielded adenocarcinoma on histopathological examination. Immunohistochemistry processing demonstrated estrogen receptor, cytokeratin 7, and GATA 3 positivity which confirmed it to be a metastasis. Therapy was initiated with palbociclib and exemestane. Later, everolimus was started in view of failure of hormonal therapy. The patient is still alive 21 months after diagnosing the recurrence.
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Affiliation(s)
- Parag Ingle
- Department of Surgical Oncology, HCG NCHRI Cancer Centre, Khasra No. 50, 51, Mouja Wanjri, Bande Nawaz Nagar, Near Automotive Square, Kalamna Ring Road, Nagpur, Maharashtra 440026 India
| | - Pravin Khandare
- Department of Medical Oncology, HCG NCHRI Cancer Centre, Nagpur, Maharashtra 440026 India
| | - Manjit Rajput
- Department of Pathology, Strands Life Sciences, HCG NCHRI Cancer Centre, Nagpur, Maharashtra 440026 India
| | - Megha Tiwari
- Department of Radiodiagnosis, HCG NCHRI Cancer Centre, Nagpur, Maharashtra 440026 India
| | - Mangesh Patil
- Department of Radiation Oncology, HCG NCHRI Cancer Centre, Nagpur, Maharashtra 440026 India
| | - Ajay Mehta
- Department of Surgical Oncology, HCG NCHRI Cancer Centre, Khasra No. 50, 51, Mouja Wanjri, Bande Nawaz Nagar, Near Automotive Square, Kalamna Ring Road, Nagpur, Maharashtra 440026 India
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25
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van Ommen-Nijhof A, Steenbruggen TG, Schats W, Wiersma T, Horlings HM, Mann R, Koppert L, van Werkhoven E, Sonke GS, Jager A. Prognostic factors in patients with oligometastatic breast cancer - A systematic review. Cancer Treat Rev 2020; 91:102114. [PMID: 33161237 DOI: 10.1016/j.ctrv.2020.102114] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/16/2022]
Abstract
AIM Oligometastatic breast cancer (OMBC) is a disease-entity with potential for long-term remission in selected patients. Those with truly limited metastatic load (rather than occult widespread metastatic disease) may benefit from multimodality treatment including local ablative therapy of distant metastases. In this systematic review, we studied factors associated with long-term survival in patients with OMBC. METHODS Eligible studies included patients with OMBC who received a combination of local and systemic therapy as multimodal approach and reported overall survival (OS) or progression-free survival (PFS), or both. The Quality in Prognosis Studies (QUIPS) tool was used to assess the quality of each included study. Independent prognostic factors for OS and/or PFS are summarized. RESULTS Of 1271 screened abstracts, 317 papers were full-text screened and twenty studies were included. Eleven of twenty studies were classified as acceptable quality. Definition of OMBC varied between studies and mostly incorporated the number and/or location of metastases. The 5-year OS ranged between 30 and 79% and 5-year PFS ranged between 25 and 57%. Twelve studies evaluated prognostic factors for OS and/or PFS in multivariable models. A solitary metastasis, >24 months interval between primary tumor and OMBC, no or limited involved axillary lymph nodes at primary diagnosis, and hormone-receptor positivity were associated with better outcome. HER2-positivity was associated with worse outcome, but only few patients received anti-HER2 therapy. CONCLUSIONS OMBC patients with a solitary distant metastasis and >24 months disease-free interval have the best OS and may be optimal candidates to consider a multidisciplinary approach.
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Affiliation(s)
- Annemiek van Ommen-Nijhof
- Department of Medical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, PO Box 90203, 1006 BE Amsterdam, the Netherlands.
| | - Tessa G Steenbruggen
- Department of Medical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, PO Box 90203, 1006 BE Amsterdam, the Netherlands
| | - Winnie Schats
- Department of Scientific Information Service, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, PO Box 90203, 1006 BE Amsterdam, the Netherlands
| | - Terry Wiersma
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, PO Box 90203, 1006 BE Amsterdam, the Netherlands
| | - Hugo M Horlings
- Department of Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, PO Box 90203, 1006 BE Amsterdam, the Netherlands
| | - Ritse Mann
- Department of Radiology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, PO Box 90203, 1006 BE Amsterdam, the Netherlands
| | - Linetta Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, PO Box 2060, 3000 CB Rotterdam, the Netherlands
| | - Erik van Werkhoven
- Department of Biostatistics, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, PO Box 90203, 1006 BE Amsterdam, the Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, PO Box 90203, 1006 BE Amsterdam, the Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, PO Box 2060, 3000 CB Rotterdam, the Netherlands
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26
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Lan B, Abudureheiyimu N, Zhang J, Wang C, Jiang S, Wang J, Ma F, Luo Y, Chen S, Xu B, Fan Y. Clinical features and prognostic factors for extracranial oligometastatic breast cancer in China. Int J Cancer 2020; 147:3199-3205. [PMID: 32535918 DOI: 10.1002/ijc.33152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/26/2020] [Accepted: 06/03/2020] [Indexed: 12/17/2022]
Abstract
Evidence of an oligometastatic state in metastatic breast cancer (MBC) is relatively limited. The aim of our study was to investigate the clinical features and prognostic factors for extracranial oligometastatic breast cancer and to identify the best treatment approaches in this select population. Fifty postoperative inpatients diagnosed with extracranial oligometastatic breast cancer at the National Cancer Center in China between 2009 and 2014 were consecutively enrolled. Oligometastatic breast cancer was defined as MBC with three or fewer metastatic lesions confined to one organ; de novo Stage IV disease and local-regional recurrence were excluded. The median progression-free survival (PFS) and overall survival (OS) times were 15.2 and 78.9 months, respectively, and the 2-year PFS and 5-year OS rates were 40% and 58%, respectively. First-line treatment approach with standard systemic treatment + surgical resection for all metastatic lesions was an independent prognostic factor for prolonged PFS (hazard ratio = 0.32; 95% confidence interval [CI], 0.14-0.73; P = .006) and OS (hazard ratio = 0.35; 95% CI, 0.14-0.86; P = .022). Subgroup analysis showed that patients with a disease-free interval (DFI) ≥24 months, one metastatic lesion or the hormone receptor (HR) + subtype were more likely to get benefit from resection. Patients with oligometastatic breast cancer have a relatively good prognosis. Surgical resection for metastatic lesions could significantly improve PFS and OS. Further prospective research is warranted to confirm the results and to develop biomarkers for better patient selection.
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Affiliation(s)
- Bo Lan
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nilupai Abudureheiyimu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingyi Zhang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenyu Wang
- Department of Internal Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Shiyu Jiang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiayu Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Ma
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Luo
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shanshan Chen
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Binghe Xu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Fan
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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