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Ahuja S, G K, Zaheer S. Evaluation of Histomorphological Changes in Breast Cancer Post-Neoadjuvant Chemotherapy. Indian J Surg Oncol 2024; 15:236-240. [PMID: 38741627 PMCID: PMC11088595 DOI: 10.1007/s13193-024-01876-3] [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: 12/15/2023] [Accepted: 01/03/2024] [Indexed: 05/16/2024] Open
Abstract
Breast cancer, a leading cause of global female mortality, demands comprehensive diagnostic and therapeutic strategies. This study delves into the nuanced realm of post-neoadjuvant chemotherapy breast cancer specimens, emphasizing the imperative need for pathologists to discern stromal and nuclear alterations adeptly. The investigation, encompassing 100 female patients with a mean age of 47.5 years, elucidates the demographic and clinicopathological parameters. Predominantly presenting as palpable lumps (85%), invasive ductal carcinoma emerged as the predominant histological type (98%). The primary focus of the study revolves around the morphological changes post-neoadjuvant chemotherapy, with a meticulous qualitative analysis encompassing stromal elements (fibrosis, elastosis, calcification) and nuclear features (pyknosis, hyperchromasia). Notably, the response to chemotherapy, classified by the International Union against Cancer criteria, delineates a substantial pathological complete response (55%), partial response (35%), and limited non-response (10%). The therapeutic landscape includes a majority of cases undergoing extensive chemotherapy cycles, primarily featuring the cyclophosphamide, doxorubicin, and paclitaxel regimen. Remarkably, this investigation unveils fibrosis (63%) and elastosis/collagenization (51%) as prevalent stromal changes, while pyknosis (58%) and hyperchromasia (48%) dominate nuclear alterations. In conclusion, this retrospective study provides a comprehensive overview of post-neoadjuvant chemotherapy breast cancer specimens, shedding light on the intricate interplay of clinical parameters, treatment responses, and histopathological changes. The findings underscore the pivotal role of pathologists in accurately diagnosing and grading tumors in the evolving landscape of breast cancer management.
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Affiliation(s)
- Sana Ahuja
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Kiruthikasri G
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sufian Zaheer
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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van de Loo ME, Andour L, van Heesewijk AE, Oosterkamp HM, Liefers GJ, Straver ME. Neoadjuvant endocrine treatment in hormone receptor-positive breast cancer: Does it result in more breast-conserving surgery? Breast Cancer Res Treat 2024; 205:5-16. [PMID: 38265568 DOI: 10.1007/s10549-023-07222-5] [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: 06/30/2023] [Accepted: 12/10/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Patients with locally advanced endocrine positive tumors who will not benefit from chemotherapy can be treated by either primary surgery or neoadjuvant endocrine therapy (NET). How often does NET result in breast-conserving surgery (BCS)? METHODS We conducted a literature search in PubMed and Embase, to identify articles on surgical treatment after NET. RESULTS In 19 studies the pathological complete response (pCR) rate was reported after NET; an overall pCR rate of 1% was found. Compared with neoadjuvant chemotherapy (NCT), the BCS rate was significantly higher after NET (OR 0.60; 95% CI, 0.51-0.69; P < 0.00001). The surgical conversion rate was reported in eight studies [4-75.9%], with a mean of 30.2%. CONCLUSION This review found that one out of three patients becomes eligible for BCS after treatment with NET.
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Affiliation(s)
- Merel E van de Loo
- Department of Surgery, Medical Center Haaglanden, The Hague, The Netherlands
| | - Layla Andour
- Department of Surgery, Medical Center Haaglanden, The Hague, The Netherlands
| | | | | | - Gerrit-Jan Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke E Straver
- Department of Surgery, Medical Center Haaglanden, The Hague, The Netherlands.
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3
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Sella T, Weiss A, Mittendorf EA, King TA, Pilewskie M, Giuliano AE, Metzger-Filho O. Neoadjuvant Endocrine Therapy in Clinical Practice: A Review. JAMA Oncol 2021; 7:1700-1708. [PMID: 34499101 DOI: 10.1001/jamaoncol.2021.2132] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance In clinical practice, neoadjuvant endocrine therapy (NET) is rarely used despite being an effective treatment modality able to downstage tumors and facilitate breast-conserving surgery. Observations Using data from studies conducted since 2000, we provide readers with a critical in-depth review on clinical aspects related to the application of NET in the treatment of hormone receptor (HR)-positive/ERBB2 (formerly HER2)-negative breast cancer. This includes an overview of patient-selection criteria, regimen choice, treatment duration, evaluation of response by imaging, interpretation of pathology after treatment, and surgical considerations. Areas of controversy include the use of gene-expression tests for patient selection, treatment of premenopausal women, surgical management of the axilla after NET, and adjuvant systemic therapy decision-making, including the use of chemotherapy. Conclusions and Relevance NET is an optimal treatment modality for a considerable proportion of postmenopausal women diagnosed with HR-positive tumors. The treatment landscape for HR-positive breast cancer is evolving, with novel agents and the growing use of gene expression profiling to define treatment selection. As such, it is likely that NET use will increase and the practical considerations outlined here will become more important.
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Affiliation(s)
- Tal Sella
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Anna Weiss
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tari A King
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Melissa Pilewskie
- Breast Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Armando E Giuliano
- Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Health System, Los Angeles, California
| | - Otto Metzger-Filho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
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4
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Abstract
Neoadjuvant endocrine therapy (NET) can be effective at downstaging patients with estrogen receptor-positive tumors and identifying those tumors that are endocrine sensitive and resistant. The optimal prognostic markers for stratification are under investigation. Use of NET will allow the identification of patients with estrogen receptor-positive tumors who might benefit from additional treatment and allow better understanding of endocrine resistance.
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Affiliation(s)
- Julie Grossman
- Department of Medicine, Washington University, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Cynthia Ma
- Department of Medicine, Washington University, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Rebecca Aft
- Department of Surgery, Washington University, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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5
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Sethi D, Sen R, Parshad S, Khetarpal S, Garg M, Sen J. Histopathologic changes following neoadjuvant chemotherapy in various malignancies. Int J Appl Basic Med Res 2013; 2:111-6. [PMID: 23776823 PMCID: PMC3678690 DOI: 10.4103/2229-516x.106353] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Various histopathological changes have been observed following neoadjuvant chemotherapy in individual tumors in the literature. AIMS AND OBJECTIVES To observe histopathologic changes seen after neoadjuvant chemotherapy in breast malignancies, squamous cell carcinomas, adenocarcinomas, and Wilms' tumor using breast cancer predominantly as the model. MATERIALS AND METHODS The present prospective study was carried out on 60 patients including 40 patients with carcinoma breast and 20 patients with other malignancies who received neoadjuvant chemotherapy. RESULTS Post neoadjuvant chemotherapy, mastectomy specimens revealed nuclear enlargement, nuclear shrinkage, necrosis, vacuolation of nucleus, vacuolation of cytoplasm, dyscohesion, and shrinkage of tumor cells with nuclear changes of nonviability like karyorrhexis, karyolysis, and pyknosis. Stromal reactions manifested as fibrosis, elastosis, collagenization, hyalinization, microcalcification, and neovascularization. Areas of necrosis included both vascular and avascular pattern. The stroma also revealed fibrinoid necrosis and mucinous change. Hyalinization of the blood vessel wall was a common finding. The most common inflammatory host response observed in the present study was lymphocytic; others included mixed inflammation, plasmacytic, prominent histiocytic, and giant cell types. Giant cell reaction was significantly correlated to all types of tumor responses (P < 0.05). Similar changes were also observed in other malignancies. A detailed review of the literature has also been done and presented. CONCLUSION The tumor grade decreases and differentiation improves, in addition to the retrogressive changes and increase in stromal component, as a result of chemotherapy in carcinoma breast as well as in other malignancies.
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Affiliation(s)
- Divya Sethi
- Department of Pathology, PGIMS, Rohtak, India
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6
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Endocrine Therapy in the Preoperative Setting and Strategies to Overcome Resistance. CURRENT BREAST CANCER REPORTS 2011. [DOI: 10.1007/s12609-011-0056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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7
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Boughey JC, Buzdar AU, Hunt KK. Recent Advances in the Hormonal Treatment of Breast Cancer. Curr Probl Surg 2008; 45:13-55. [DOI: 10.1067/j.cpsurg.2007.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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8
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Lerebours F. [Primary systemic therapy in breast cancer: clinical and molecular factors predictors of outcome and response]. ACTA ACUST UNITED AC 2006; 54:209-14. [PMID: 16753495 DOI: 10.1016/j.patbio.2004.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Accepted: 11/08/2004] [Indexed: 10/25/2022]
Abstract
PST (primary systemic therapy) represents the standard treatment of care for patients with LABC (locally advanced breast cancer). There is also an emerging role of PST in the treatment of operable breast cancer. In both situations, clinical and pathological responses, in particular when complete, are good predictors of outcome. Identifying the factors predicting response to PST would help clinicians of selecting the most appropriate treatment. There is thus a need for clinical and molecular factors predictive of response. Unfortunately, none of the molecular markers identified in breast tumors is recommended for a use in routine, with the exception of ER and HER2 respectively predictors of response to hormone therapy and Herceptin. New technologies like DNA microarrays are likely to provide in a next future surrogate markers of response to PST in Breast Cancer.
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Affiliation(s)
- F Lerebours
- Inserm E0017/oncogénétique, Saint-Cloud, France.
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9
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Dellapasqua S, Castiglione-Gertsch M. Adjuvant endocrine therapies for postmenopausal women with early breast cancer: Standards and not. Breast 2005; 14:555-63. [PMID: 16188442 DOI: 10.1016/j.breast.2005.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hormonal manipulations have been used for more than 100 years for the treatment of metastatic breast cancer and after definition of the concept of micro-metastases also in the adjuvant setting. In the postmenopausal population, tamoxifen has played the most important role for almost four decades. Progestins or the first generation of aromatase inhibitors (AIs) were only marginally used in the adjuvant setting due to their prohibitive toxicity. The new generation of anti-estrogen compounds, the selective estrogen receptor down-regulators (SERDs) like fulvestrant have a higher affinity for the estrogen receptor than tamoxifen, but none of its agonist activities, and have shown promising clinical activity in the treatment of advanced breast cancer. The third generation of AIs investigated in six large trials has been reported to be superior to tamoxifen in terms of disease-free survival, but not in terms of survival. These trials will be discussed in terms of results in different subpopulations and of toxicity.
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Affiliation(s)
- Silvia Dellapasqua
- International Breast Cancer Study Group (IBCSG) Coordinating Center, Effingerstrasse 40, 3008 Bern, Switzerland
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10
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Baena-Cañada JM, Partida-Palma F, Palomo-González MJ, Benítez E, Rueda-Ramos A, García-Curiel A. Utilidad de la gammagrafía mamaria en la valoración de la respuesta a la quimioterapia neoadyuvante en el cáncer de mama. Med Clin (Barc) 2005; 125:601-5. [PMID: 16287568 DOI: 10.1157/13080825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE We sought to evaluate the usefulness of Tc-99m-sestamibi breast scintigraphy in predicting neoadjuvant chemotherapy response in patients with breast cancer. PATIENTS AND METHOD In 50 consecutive patients with breast cancer stages II and III, physical examination, mammography and scintimammography were performed before and after the administration of neoadjuvant chemotherapy. The 3 assessments were compared for predictive value using a pathological response as reference. Values derived from visual assessment of the scintimammography, a quantitative tumor/background index, and isotope clearance were compared to the immunohistochemical expression of P-glycoprotein, vascular endothelial growth factor (VEGF) and microvessel density (CD31) in relation to neoadjuvant chemotherapy response. RESULTS Macroscopic response was obtained in 10 cases (20%). Sensitivity was 86.5% (95% confidence interval [CI], 70.4-94.9) for the physical examination, 83.3% (95% CI, 68-92.5) for the mammography and 76.5% (95% CI, 58.4-88.6) for the scintimammography. Specificity was 38.5% (95% CI, 15.1-67.7) for the physical examination, 42.9% (95% CI, 11.8-79.8) for the mammography and 8.3% (95% CI, 0.4-40.2) for the scintimammography. There were no statistically significant differences in isotope uptake and clearance with regard to response nor in relation to levels of expression of P-glycoprotein, VEGF and microvessel density. CONCLUSIONS Breast scintigraphy with Tc-99m-sestamibi is not useful in predicting the response to neoadjuvant chemotherapy in breast cancer. Traditional physical examination and mammography are more effective. Isotope uptake and clearance do not predict response and there is not an effective in vivo measurement of chemo-resistance or tumor angiogenesis.
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Affiliation(s)
- José M Baena-Cañada
- Unidad Clínica de Patología Mamaria, Hospital Universitario Puerta del Mar, Cádiz, Spain.
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11
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Mano M, Fraser G, McIlroy P, Stirling L, MacKay H, Ritchie D, Canney P. Locally advanced breast cancer in octogenarian women. Breast Cancer Res Treat 2005; 89:81-90. [PMID: 15666201 DOI: 10.1007/s10549-004-1003-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Elderly patients are more likely to present with locally advanced breast cancer than younger patients. Furthermore, due to the accelerated aging of the western population, the incidence of breast cancer in this population is expected to steadily rise in the coming decades. So far, no guidelines are available for the management of octogenarian patients presenting with inoperable disease, what frequently results in a dilemma for the treating physician. For the time being, these patients should be ideally treated within the context of a clinical trial. In all other cases, the treatment has to be individualised, frequently based on data extrapolated from different population of patients, or retrospective series. This article reviews the current evidence, options, and most promising approaches for these patients.
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Affiliation(s)
- Max Mano
- Beatson Oncology Centre, Glasgow, UK.
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12
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Raguz S, Tamburo De Bella M, Tripuraneni G, Slade MJ, Higgins CF, Coombes RC, Yagüe E. Activation of the MDR1 upstream promoter in breast carcinoma as a surrogate for metastatic invasion. Clin Cancer Res 2004; 10:2776-83. [PMID: 15102684 DOI: 10.1158/1078-0432.ccr-03-0517] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Activation of the MDR1 upstream promoter (USP) has been described previously in four lymphoblastic leukemia patients, where it is the major MDR1 promoter associated with P-glycoprotein overexpression. We asked whether MDR1 USP-derived transcripts were also present in breast carcinoma and assessed their potential as a biomarker. EXPERIMENTAL DESIGN We developed a sensitive method for detecting transcripts derived from the MDR1 USP and used it to identify MDR1 USP-derived transcripts in cell model systems, in 61 breast carcinoma biopsies of the primary tumor, and in isolated malignant epithelial cells both from the primary tumor and from the associated invaded lymph nodes. RESULTS The MDR1 USP was not active in several independent leukemic and breast cancer cell lines or nucleated peripheral blood cells (n = 9). However, transcripts derived from the MDR1 USP were detected in some drug-resistant cell lines and a high proportion of primary breast tumors (71.6%; n = 61), whereas they were present at low frequency in normal breast tissue (10%; n = 10). Activation of MDR1 USP was not due to chromosomal amplifications or rearrangements at the MDR1 locus. Transcription from the MDR1 USP correlated with metastatic node invasion [N = 0-3 versus N > 3 (N = number of lymph nodes invaded); Fisher's exact test, P = 0.011] and was detected in malignant epithelial cells from the primary tumor and those that metastasized to the lymph nodes. CONCLUSIONS MDR1 USP activation is a surrogate marker for breast carcinoma progression and can be used as a marker to study breast cancer susceptibility.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B, Member 1/metabolism
- Adult
- Aged
- Aged, 80 and over
- Alternative Splicing
- Biomarkers, Tumor
- Blotting, Southern
- Breast/pathology
- Breast Neoplasms/genetics
- Cell Line, Tumor
- Epithelial Cells/metabolism
- Female
- Genes, MDR/genetics
- Humans
- Leukemia, Lymphoid/genetics
- Lymphatic Metastasis
- Middle Aged
- Models, Genetic
- Neoplasm Metastasis
- Phenotype
- Promoter Regions, Genetic
- RNA/metabolism
- RNA, Messenger/metabolism
- Reverse Transcriptase Polymerase Chain Reaction
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Affiliation(s)
- Selina Raguz
- Clinical Sciences Centre, Medical Research Council, Imperial College, Hammersmith Hospital, London, United Kingdom
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13
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Freedman OC, Verma S, Clemons MJ. Using aromatase inhibitors in the neoadjuvant setting: evolution or revolution? Cancer Treat Rev 2004; 31:1-17. [PMID: 15707700 DOI: 10.1016/j.ctrv.2004.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite improvements in the management of patients with early breast cancer, the prognosis for women with locally advanced breast cancer (LABC) remains poor. The potential goals of neoadjuvant treatment for this disease include down-sizing tumours to allow breast conservation as well as the possibility of improving survival rates. Neoadjuvant treatment was initially dominated by chemotherapy, which increased rates of breast conserving surgery, but to date has demonstrated no survival benefit over standard adjuvant chemotherapy. With recent advances in endocrine therapy, and rapid and routine assessment of predictive factors of response such as estrogen (ER), progesterone (PR) and Her2 nu receptor status, endocrine therapy has come to the forefront of research investigating a neoadjuvant alternative to chemotherapy. Early studies of neoadjuvant endocrine therapy mainly evaluated the role of tamoxifen in the treatment of elderly postmenopausal women with LABC who were unselected for ER/PR status and were unsuitable for either surgery or chemotherapy. Response rates in these patients were found to be inferior to those traditionally obtained from trials with neoadjuvant chemotherapy. Paralleling the superiority that third-generation aromatase inhibitors have shown over tamoxifen in the metastatic and adjuvant settings however, AIs have also demonstrated superiority in the neoadjuvant setting. Recent studies have shown response rates for neoadjuvant treatment with aromatase inhibitors in carefully selected hormone receptor positive patients to be comparable to those seen with neoadjuvant chemotherapy. This is particularly important as hormone receptor positive tumours have repeatedly been shown to have lower response rates to neoadjuvant chemotherapy than hormone receptor negative tumours. Neoadjuvant endocrine treatment with aromatase inhibitors has therefore evolved from being an experimental effort to palliate women with LABC unsuitable for surgery or chemotherapy, to representing a viable and possibly preferred alternative for postmenopausal women with hormone receptor positive large tumours or LABC. Further benefits of neoadjuvant trials include allowing the study of predictive biomarkers of disease in order to provide insight into therapy resistance and sensitivity, and identifying promising systemic therapies for additional testing in larger adjuvant trials.
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Affiliation(s)
- O C Freedman
- Division of Medical Oncology, Toronto-Sunnybrook Regional Cancer Centre, 2075 Bayview Avenue, Toronto, Ont., Canada M4N 3M5
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14
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Coombes RC, Gibson L, Hall E, Emson M, Bliss J. Aromatase inhibitors as adjuvant therapies in patients with breast cancer. J Steroid Biochem Mol Biol 2003; 86:309-11. [PMID: 14623526 DOI: 10.1016/s0960-0760(03)00372-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There is increasing evidence that endocrine therapy has an important role in patients with oestrogen receptor positive breast cancer. Several large meta-analyses have reinforced the value of both ovarian ablation and tamoxifen in improving survival. Over the past decade, aromatase inhibitors have become the treatment of choice for second-line therapy of metastatic breast cancer, and the third generation inhibitors have now an established reputation for good patient tolerability. Early studies indicated that aminoglutethimide/hydrocortisone could benefit postmenopausal patients with primary breast cancer, and in 2001, the ATAC study showed that the third generation aromatase inhibitor, anastrozole, seemed superior to tamoxifen in that anastrozole-treated patients had a longer disease-free survival. Other studies will report on the relative merits of the steroidal inhibitor exemestane as well as non-steroidal letrozole. The exact duration and sequencing of treatment, together with the long-term effects on bone are at present, unknown.
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Affiliation(s)
- R Charles Coombes
- CR(UK) Department of Cancer Medicine, Imperial College, Hammersmith Hospital, Du Cane Road, London W12 ONN, UK.
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15
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McIntosh SA, Ogston KN, Payne S, Miller ID, Sarkar TK, Hutcheon AW, Heys SD. Local recurrence in patients with large and locally advanced breast cancer treated with primary chemotherapy. Am J Surg 2003; 185:525-31. [PMID: 12781879 DOI: 10.1016/s0002-9610(03)00078-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Primary chemotherapy is being given in the treatment of large and locally advanced breast cancers, but a major concern is local relapse after therapy. This paper has examined patients treated with primary chemotherapy and surgery (either breast-conserving surgery or mastectomy) and has examined the role of factors which may indicate those patients who are subsequently more likely to experience local recurrence of disease. METHODS A consecutive series of 173 women, with data available for 166 of these, presenting with large and locally advanced breast cancer (T2>/=4 cm, T3, T4, or N2) were treated with primary chemotherapy comprising cyclophosphamide, vincristine, doxorubicin, and prednisolone and then surgery (either conservation or mastectomy with axillary surgery) followed by radiotherapy were examined. RESULTS The clinical response rate of these patients was 75% (21% complete and 54% partial), with a complete pathological response rate of 15%. A total of 10 patients (6%) experienced local disease relapse, and the median time to relapse was 14 months (ranging from 3 to 40). The median survival in this group was 27 months (ranging from 13 to 78). In patients having breast conservation surgery, local recurrence occurred in 2%, and in those undergoing mastectomy 7% experience local relapse of disease. Factors predicting patients most likely to experience local recurrence were poor clinical response and residual axillary nodal disease after chemotherapy. CONCLUSIONS Excellent local control of disease can be achieved in patients with large and locally advanced breast cancers using a combination of primary chemotherapy, surgery and radiotherapy. However, the presence of residual tumor in the axillary lymph nodes after chemotherapy is a predictor of local recurrence and patients with a better clinical response were also less likely to experience local disease recurrence. The size and degree of pathological response did not predict patients most likely to experience recurrence of disease.
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Affiliation(s)
- Stuart A McIntosh
- Aberdeen Breast Unit, Ward 34, Aberdeen Royal Infirmary and University of Aberdeen, Foresterhill, AB25 2ZN, Aberdeen, Scotland, United Kingdom
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16
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Abstract
The role of neoadjuvant chemotherapy in locally advanced breast cancer is firmly established. There is now also an emerging role for neoadjuvant systemic therapy in the treatment of operable breast cancer. There is good evidence that the chances of breast conserving surgery can be increased with this approach and results of randomised studies indicate that survival is at least as good with neoadjuvant as with adjuvant chemotherapy. Similar clinical data are emerging with neoadjuvant endocrine therapy. For the future, there are important potential advantages in having an in vivo measure of chemosensitivity rather than blindly treating micrometastatic disease in the adjuvant setting. Clinical response to neoadjuvant treatment, and in particular complete pathological response, are predictors of subsequent outcome. Pathological involvement of axillary nodes following neoadjuvant therapy portends a poor prognosis. The potential for biological surrogate markers of response to predict for long-term outcome may allow individualisation of systemic treatment and the rapid assessment of new drugs in early breast cancer.
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Affiliation(s)
- Catherine Shannon
- Breast Unit, Royal Marsden NHS Trust, Fulham Road, London SW3 6JJ, UK
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17
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Boeddinghaus I, Dowsett M. Recent Developments in the Hormonal Treatment of Breast Cancer. Breast Cancer 2002. [DOI: 10.1201/b14039-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Smith IC, Heys SD, Hutcheon AW, Miller ID, Payne S, Gilbert FJ, Ah-See AK, Eremin O, Walker LG, Sarkar TK, Eggleton SP, Ogston KN. Neoadjuvant chemotherapy in breast cancer: significantly enhanced response with docetaxel. J Clin Oncol 2002; 20:1456-66. [PMID: 11896092 DOI: 10.1200/jco.2002.20.6.1456] [Citation(s) in RCA: 363] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the efficacy of neoadjuvant (NA) docetaxel (DOC) with anthracycline-based therapy and determine the efficacy of NA DOC in patients with breast cancer initially failing to respond to anthracycline-based NA chemotherapy (CT). PATIENTS AND METHODS Patients with large or locally advanced breast cancer received four pulses of cyclophosphamide 1,000 mg/m(2), doxorubicin 50 mg/m(2), vincristine 1.5 mg/m(2), and prednisolone 40 mg (4 x CVAP) for 5 days. Clinical tumor response was assessed. Those who responded (complete response [CR] or partial response [PR]) were randomized to receive further 4 x CVAP or 4 x DOC (100 mg/m(2)). All nonresponders received 4 x DOC. RESULTS One hundred sixty-two patients were enrolled; 145 patients completed eight cycles of NA CT. One hundred two patients (66%) achieved a clinical response (PR or CR) after 4 x CVAP. After randomization, 50 patients received 4 x CVAP and 47 patients received 4 x DOC. In patients who received eight cycles of CT, the clinical CR (cCR) and clinical PR (cPR) (94% v 66%) and pathologic CR (pCR) (34% v 16%) response rates were higher (P =.001 and P =.04) in those who received further DOC. Intention-to-treat analysis demonstrated cCR and cPR (85% v 64%; P =.03) and pCR (31% v 15%; P =.06). Axillary lymph node examination revealed residual tumor in 33% of patients who received 8 x CVAP and 38% of patients who received further DOC. In patients who failed to respond to the initial CVAP, 4 x DOC resulted in a cCR and cPR rate of 55% and a pCR rate of 2%. Forty-four percent of these patients had residual tumor within axillary lymph nodes. CONCLUSION NA DOC resulted in substantial improvement in responses to DOC.
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Affiliation(s)
- Ian C Smith
- Department of Academic Radiology, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom.
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Burcombe RJ, Makris A, Pittam M, Lowe J, Emmott J, Wong WL. Evaluation of good clinical response to neoadjuvant chemotherapy in primary breast cancer using [18F]-fluorodeoxyglucose positron emission tomography. Eur J Cancer 2002; 38:375-9. [PMID: 11818202 DOI: 10.1016/s0959-8049(01)00379-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To determine whether [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) can predict complete pathological response (pCR) in patients achieving a good clinical response to neoadjuvant chemotherapy for primary breast cancer, 10 patients underwent FDG PET scanning prior to definitive breast surgery. Scan reports were compared with histopathological findings. No abnormal uptake at the primary tumour site was visualised in any patient. 9 of the 10 patients had residual invasive carcinoma at operation, ranging from 2 to 20 mm in maximum dimension. One patient achieved a complete pathological response. Of the 5 patients who underwent axillary surgery, no axillary FDG uptake was seen preoperatively although 3 of the 5 were histologically node-positive. FDG PET did not reliably identify residual disease in this series of good clinical responders to neoadjuvant chemotherapy, and its discriminatory power as a tool to predict complete pathological response therefore appears to be inadequate for clinical use in this setting.
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Affiliation(s)
- R J Burcombe
- Marie Curie Research Wing, Mount Vernon Hospital, Rickmansworth Road, Middlesex HA6 2RN, Northwood, UK
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20
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Gazet JC, Ford HT, Gray R, McConkey C, Sutcliffe R, Quilliam J, Makinde V, Lowndes S, Coombes RC. Estrogen-receptor-directed neoadjuvant therapy for breast cancer: results of a randomised trial using formestane and methotrexate, mitozantrone and mitomycin C (MMM) chemotherapy. Ann Oncol 2001; 12:685-91. [PMID: 11432629 DOI: 10.1023/a:1011115107615] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We wanted to determine whether neoadjuvant systemic chemoendocrine therapy guided by the estrogen receptor (ER) status of the primary breast cancer, followed by conventional surgery and/or radiotherapy, reduces local and distant recurrence and improves survival compared with adjuvant treatment given conventionally postoperatively. PATIENTS AND METHODS Two hundred ten patients with primary breast cancer (T1-T4, N0, N1-2) were randomised to receive treatment with neoadjuvant chemoendocrine therapy or conventional post-operative chemoendocrine therapy. Systemic therapy was based on the estrogen receptor (ER) status of the primary tumour obtained by trucut core biopsy. ER-negative patients received MMM chemotherapy (methotrexate (30 mg/m2), mitozantrone (7 mg/m2) and mitomycin (7 mg/m2) three-weekly for three months and ER-positive patients who were premenopausal received goserelin (3.75 mg monthly), and post menopausal women formestane (250 mg every two weeks) over three months. RESULTS With a minimum of five years follow-up, there is no evidence of any survival benefit from the pretreatment neoadjuvant therapy regimen, with five year overall survival being 79% +/- 4.7% (neoadjuvant) and 87% +/- 3.4% (adjuvant). Similarly, there was no apparent benefit in terms of disease-free survival. There was, however, a significant reduction in the incidence of distant metastases in responders (4 of 51; 8%) compared with non-responders (17 of 49; 35%) (P < 0.01). There was a reduction in the need for surgery in responding patients with T1 and T2 tumours, since 10 of 74 (14%) had no detectable residual tumour, without any apparent increase in the risk of local or distant recurrence. CONCLUSION In this study neoadjuvant treatment with endocrine or chemotherapy provided no obvious survival benefit to women with breast cancer. However, it does allow avoidance of surgery in some cases. Also, the patients whose tumours respond to neoadjuvant systemic therapy have a lower incidence of distant metastases after five year follow-up compared to those whose tumours fail to respond.
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Affiliation(s)
- J C Gazet
- Combined Breast Clinic, St. George's Hospital, London, UK
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21
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Abstract
Preoperative hormone therapy for breast cancer has the potential to downstage a primary tumour hence increasing operability as well as making breast conservation feasible. Whether it will achieve any clinically significant survival benefit remains to be elucidated. Preoperative hormone therapy, in contrast to neoadjuvant chemotherapy, produces less severe side effects and can be continued throughout the perioperative period. Presurgical studies have demonstrated anti-tumour effects of hormone therapy, e.g. down-regulation of ER. Current clinical trials have shown that, in patients with ER positive tumours, a response approaching 70% is reached in approximately three months using the traditional hormonal agent tamoxifen. The tumour seldom progresses during this period. New agents (such as third generation aromatase inhibitors and pure anti-oestrogens) may produce more profound and rapid responses. Future trials are required to identify factors other than ER to precisely predict response so that appropriate patients can be selected. The best agents, the ideal methods of monitoring response and the optimum duration of therapy also need to be identified. Clinical trials also need to test if pre- and perioperative hormone therapy is superior to conventional adjuvant hormone therapy in patients with early breast cancer.
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Affiliation(s)
- K L Cheung
- Professorial Unit of Surgery, City Hospital, Nottingham, UK
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22
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Smith IC, Welch AE, Hutcheon AW, Miller ID, Payne S, Chilcott F, Waikar S, Whitaker T, Ah-See AK, Eremin O, Heys SD, Gilbert FJ, Sharp PF. Positron emission tomography using [(18)F]-fluorodeoxy-D-glucose to predict the pathologic response of breast cancer to primary chemotherapy. J Clin Oncol 2000; 18:1676-88. [PMID: 10764428 DOI: 10.1200/jco.2000.18.8.1676] [Citation(s) in RCA: 340] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine whether [(18)F]-fluorodeoxy-D-glucose ([(18)F]-FDG) positron emission tomography (PET) can predict the pathologic response of primary and metastatic breast cancer to chemotherapy. PATIENTS AND METHODS Thirty patients with noninflammatory, large (> 3 cm), or locally advanced breast cancers received eight doses of primary chemotherapy. Dynamic PET imaging was performed immediately before the first, second, and fifth doses and after the last dose of treatment. Primary tumors and involved axillary lymph nodes were identified, and the [(18)F]-FDG uptake values were calculated (expressed as semiquantitative dose uptake ratio [DUR] and influx constant [K]). Pathologic response was determined after chemotherapy by evaluation of surgical resection specimens. RESULTS Thirty-one primary breast lesions were identified. The mean pretreatment DUR values of the eight lesions that achieved a complete microscopic pathologic response were significantly (P =.037) higher than those from less responsive lesions. The mean reduction in DUR after the first pulse of chemotherapy was significantly greater in lesions that achieved a partial (P =.013), complete macroscopic (P =.003), or complete microscopic (P =.001) pathologic response. PET after a single pulse of chemotherapy was able to predict complete pathologic response with a sensitivity of 90% and a specificity of 74%. Eleven patients had pathologic evidence of lymph node metastases. Mean pretreatment DUR values in the metastatic lesions that responded did not differ significantly from those that failed to respond (P =.076). However, mean pretreatment K values were significantly higher in ultimately responsive cancers (P =.037). The mean change in DUR and K after the first pulse of chemotherapy was significantly greater in responding lesions (DUR, P =.038; K, P =.012). CONCLUSION [(18)F]-FDG PET imaging of primary and metastatic breast cancer after a single pulse of chemotherapy may be of value in the prediction of pathologic treatment response.
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Affiliation(s)
- I C Smith
- John Mallard Scottish Positron Emission Tomography Center, Scotland, United Kingdom.
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23
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Höffken K, Kath R. The role of LH-RH analogues in the adjuvant and palliative treatment of breast cancer. Recent Results Cancer Res 2000; 153:61-70. [PMID: 10626289 DOI: 10.1007/978-3-642-59587-5_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Ovarian ablation has a long-standing history in the treatment of metastatic breast cancer. At the end of the past century, several reports appeared on the beneficial effect of surgical removal of the ovaries in premenopausal women with advanced breast cancer. Subsequently, this treatment became the standard systemic hormone therapy for such patients. However, the disadvantage is that only a minority of patients respond, and the remainder suffer unnecessary treatment morbidity. In a random premenopausal patient population, oophorectomy produced an average 33% objective response rate. In the search for alternatives, analogues of luteinizing hormone-releasing hormone (LH-RH) have been thoroughly investigated in pre- and postmenopausal women. The results obtained have established a place for LH-RH agonists in the treatment of premenopausal women with metastatic breast cancer. In addition, these substances have replaced oophorectomy where indicated in the adjuvant hormonal treatment of premenopausal breast cancer.
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Affiliation(s)
- K Höffken
- Klinik und Poliklinik für Innere Medizin II (Onkologie, Hämatologie, Endokrinologie, Stoffwechselerkrankungen), Friedrich-Schiller-Universität Jena, Germany
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24
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Brain EG, Misset JL, Rouëss J. Primary chemotherapy or hormonotherapy for patients with breast cancer. Cancer Treat Rev 1999; 25:187-97. [PMID: 10448127 DOI: 10.1053/ctrv.1998.0118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Scientific rationale for primary treatment of breast cancer relies on experimental data showing that the incidence and growth of disease correlate with the primary tumour mass and tumoral angiogenesis. Although the strategy may be applied to both chemotherapy and hormonotherapy, only the first was extensively explored for patients with locally advanced breast cancer in order to improve survival and to avoid mastectomy through the achievement of a downstaging of the tumour. Encouraging results obtained in this clinically advanced setting combined with renewed interest for tumoral angiogenesis brought clinicians to apply this strategy to smaller tumours. Despite high clinical and radiological response rates, only pathologic information, carefully assessed in both the primary and axillae lymph nodes, stands out as the major source of prognostic information on patients' outcome. Recent developments in chemotherapy (dose-intensity, new drugs) do not seem to influence these results, indicating the possible limitations of recent developments in chemotherapy. Of 6 published randomized trials comparing primary vs adjuvant chemotherapy, none showed any significant impact of primary chemotherapy on survival, with a trend towards delayed/less distant recurrences in patients treated by primary chemotherapy in some. Some recent reports suggest that local relapse rate might be increased after conservative treatment following induction chemotherapy in subgroups analyse and this should cause oncologists to revise and define the role for conservative surgery after primary medical treatment without calling into question the global strategy. Through sequential samplings, neoadjuvant medical treatment provides indeed the opportunity (a) to identify molecular mechanisms associated with pathologic response and (b) to study the possibility to guide the choices for induction treatment and patient populations submitted to primary medical treatment.
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Affiliation(s)
- E G Brain
- Department of Medical Oncology, Cancer Centre René Huguenin, 35, rue Dailly, Saint-Cloud, 92210, France.
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25
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Abstract
Over the past decade several novel aromatase inhibitors have been introduced into clinical practice. The discovery of these drugs followed on from the observation that the main mechanism of action of aminoglutethemide was via inhibition of the enzyme aromatase, thereby reducing peripheral levels of estradiol in post-menopausal patients. The second-generation drug 4-hydroxyandrostenedione was introduced in 1990, and although its use was limited by its need to be given parenterally, it was found to be a well-tolerated form of endocrine therapy. The third-generation inhibitors include vorozole, letrozole, anastrozole and exemestane, the former three being non-steroidal inhibitors, the latter being a steroidal inhibitor. All these compounds are capable of reducing estrogen levels to within 5%-10% of baseline levels compared with 20%-30% base line levels in the case of 4-hydroxyandrostenedione. Studies are currently in progress to determine the value of these third-generation aromatase inhibitors in the adjuvant setting. These studies include head-to-head comparison of aromatase inhibitor with tamoxifen, sequential aromatase inhibitor after tamoxifen and first-line aromatase inhibitor followed by adjuvant tamoxifen. Current issues revolve around the toxicity of these compounds in terms of effects on the cardiovascular system and bone.
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Affiliation(s)
- R C Coombes
- Department of Cancer Medicine, Imperial College School of Medicine, Charing Cross Hospital, London, UK
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George ML, Hale PC, Gumpert JR, Hogbin BM, Deutsch GP, Yelland A. The use of neoadjuvant CMF to avoid mastectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1999; 25:50-3. [PMID: 10188855 DOI: 10.1053/ejso.1998.0599] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS Large operable cancers have traditionally been treated surgically by mastectomy. More recently centres have investigated the use of neoadjuvant chemotherapy to allow breast-conserving surgery. Between 1991 and 1995, a prospective study into the response of large operable breast cancers to CMF neoadjuvant chemotherapy was performed. METHODS Patients with cancers requiring mastectomy, and with or without clinically involved non-fixed lymph nodes, were offered neoadjuvant CMF chemotherapy. Patients declining neoadjuvant treatment underwent mastectomy and appropriate axillary surgery. Clinical response was assessed after two cycles in the neoadjuvant group. Subsequent surgical or non-surgical management was planned after this. RESULTS Thirty-eight patients were suitable for neoadjuvant treatment. Twenty-two underwent two cycles of CMF and were then reassessed. Seventy-three per cent achieved a response [three (14%) complete remission, 13 (60%) partial remission]. Fifteen (68%) patients avoided mastectomy, with six (27%) requiring no surgery at all with no clinically detectable residual disease. Sixteen (42%) declined neoadjuvant chemotherapy and opted for immediate mastectomy, seven of whom accepted chemotherapy post-operatively. After 3 years' follow-up there is no statistical difference in local recurrence, distant recurrence or overall survival. CONCLUSION Approximately 40% of patients offered neoadjuvant chemotherapy will demand prompt surgical treatment but will consider the use of adjuvant chemotherapy post-operatively. Sixty-eight per cent of patients receiving neoadjuvant CMF will successfully avoid mastectomy.
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Affiliation(s)
- M L George
- Department of Surgery, Royal Sussex County Hospital, Brighton, UK
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27
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Avril A, Faucher A, Bussières E, Stöckle E, Durand M, Mauriac L, Bonichon F, Dilhuydy JM, Campo ML. [Results of 10 years of a randomized trial of neoadjuvant chemotherapy in breast cancers larger than 3 cm]. CHIRURGIE; MEMOIRES DE L'ACADEMIE DE CHIRURGIE 1998; 123:247-56. [PMID: 9752515 DOI: 10.1016/s0001-4001(98)80116-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM OF THE STUDY The aim of this randomised trial was to determine advantages and drawbacks of neo-adjuvant chemotherapy in patients with operable breast cancers > 3 cm. MATERIAL AND METHODS Two hundred and seventy-two women (age 70) with operable breast cancers larger than 3 cm (T2-3/N0-1/M0) were included in a randomised trial from January 1, 1985 to April 30, 1989. Patients in group A (n = 138) were treated by mastectomy and axillary node dissection. Adjuvant chemotherapy was indicated for 104 patients with axillary node involvement (n = 82) or negative oestrogen and progesterone receptors (EPR-) (n = 22). Patients in group B (n = 134) were treated by initial chemotherapy (identical as in group A) followed by locoregional treatment according to the response. Before treatment, the average of clinical tumoural diameter was 43 mm. RESULTS The median follow-up was 124 months. In group B, 49 patients (36.5%) were resistant to chemotherapy; a conservative breast surgical treatment was performed in the other 84 patients sensitive to chemotherapy (62.6%). In this last subgroup, 19 (22.6%) needed a secondary mastectomy because of locoregional recurrence. Survival rates were not different in groups A and B, but loco-regional recurrences were frequent in group B. At 10 years, the overall survival rate was 60% and half of living patients in group B were free of cancer and with their breast. CONCLUSION Neoadjuvant chemotherapy permitted in two-thirds of cases breast conservation treatment, initially considered to be impossible. Locoregional recurrences are more frequent than after mastectomy and adjuvant chemotherapy.
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Affiliation(s)
- A Avril
- Service de chirurgie, institut Bergonié, centre régional de lutte contre le cancer, Bordeaux, France
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28
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Eltahir A, Heys SD, Hutcheon AW, Sarkar TK, Smith I, Walker LG, Ah-See AK, Eremin O. Treatment of large and locally advanced breast cancers using neoadjuvant chemotherapy. Am J Surg 1998; 175:127-32. [PMID: 9515529 DOI: 10.1016/s0002-9610(97)00279-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neoadjuvant (primary) chemotherapy is being used increasingly in the treatment of patients with large and locally advanced breast cancer with the aim of reducing the size of the primary tumor and eliminating micrometastatic disease. Response rates to, compliance with, and survival of patients following neoadjuvant chemotherapy have been variable. We report the results of a consecutive series of 77 patients with breast cancer who received neoadjuvant chemotherapy. METHODS Seventy-seven patients with locally advanced breast cancers were treated with multimodality therapy comprising up to six cycles of chemotherapy (cyclophosphamide, vincristine, doxorubicin, and prednisolone), radiotherapy, and then surgery. The median follow-up was 54 months. Clinical response rates to therapy and overall survival have been documented. In addition, prognostic factors for survival were identified using the Cox proportional hazards model. RESULTS The overall objective response rate of the primary tumor to chemotherapy alone was 87% (25% complete and 62% partial responses, UICC criteria). Following radiotherapy the response rate was 90% (52% complete and 38% partial responses). The overall 5-year survival for all patients was 0.48. However, the probability of survival at 5 years was 0.74 in those with a complete response, and 0.36 if there was a partial clinical response, but no patients who had either stasis of disease or progression survived for 5 years. Independent predictors of better survival that were identified were a complete histopathological response after chemotherapy and radiotherapy, a complete clinical response to chemotherapy, and five or six cycles of chemotherapy versus four or less. CONCLUSIONS Neoadjuvant chemotherapy in patients with large and locally advanced breast cancers can result in satisfactory local control and overall survival rates, especially in patients with a complete clinical or histopathological response after treatment.
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Affiliation(s)
- A Eltahir
- Department of Surgery, University of Aberdeen, Scotland, United Kingdom
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29
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Chang HT, Mok KT, Tzeng WS. Induction intraarterial chemotherapy for T4 breast cancer through an implantable port-catheter system. Am J Clin Oncol 1997; 20:493-9. [PMID: 9345335 DOI: 10.1097/00000421-199710000-00012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Eleven patients with T4 breast cancer received induction intraarterial chemotherapy (IACT) as the first step in multidisciplinary therapy. The IACT agents (epirubicin and mitomycin C), were delivered weekly in the outpatient department by bolus injection through an implantable port-catheter system. A modified technique of port-catheter system implantation was used. The precise localization of the catheter was dually confirmed by angiography and dye test. The effectiveness of the treatment was evaluated by clinical appearance, image study, and microscopic examination. A 91% response rate was obtained, and the lesions were resectable in < or = 8 weeks. No obvious systemic toxicity resulted from the IACT. Our results show that weekly IACT by bolus injection through a port-catheter system for treating locally advanced T4 breast cancer is feasible and efficacious.
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Affiliation(s)
- H T Chang
- Department of Surgery, Veterans General Hospital-Kaohsiung, School of Medicine, National Yang-Ming University, Taiwan, R.O.C
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30
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Wiseman LR, Goa KL. Formestane. A review of its pharmacological properties and clinical efficacy in the treatment of postmenopausal breast cancer. Drugs Aging 1996; 9:292-306. [PMID: 8894526 DOI: 10.2165/00002512-199609040-00006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Formestane (4-hydroxyandrostenedione) is an aromatase inhibitor which significantly reduces plasma levels of estrogen and has shown antitumour activity in postmenopausal women with breast cancer. Objective response rates in heavily pretreated patients with advanced breast cancer generally range between 20 and 30% during treatment with intramuscular formestone 250 or 500mg once every 2 weeks, and a further 20 to 30% of patients experience disease stabilisation. The median duration of response is between 8 and 14 months. Highest response rates are observed in soft tissue metastases, in patients with estrogen-responsive tumours and in those showing a response to previous endocrine therapy. Furthermore, there is some evidence to suggest that higher response rates are achieved with formestane 500 versus 250mg once every 2 weeks. In comparative studies, the clinical efficacy of intramuscular formestane 250mg did not differ significantly from that of oral megestrol when administered as second-line endocrine therapy to patients with advanced disease in whom previous tamoxifen therapy had failed. In addition, formestane produced a response rate, duration of response and overall survival rate that was not significantly different from that of oral tamoxifen when administered as first-line endocrine therapy to patients with advanced disease, but tamoxifen was superior in some measures. Further investigation of these 2 agents, including the higher dosage of formestane (500mg), is necessary to confirm their relative efficacies. Formestane is well tolerated by the majority of patients; adverse events rarely necessitate cessation of therapy. The most common adverse events are local reactions at the injection site and systemic events usually related to the effect of the drug on the hormonal milieu. The systemic tolerability of formestane is similar to that of tamoxifen but better than that of megestrol. Thus, formestane is effective and well tolerated as first-line endocrine therapy for advanced disease. However, at present, it is unlikely to challenge tamoxifen in this indication, based on recent findings from a large comparative study and the fact that formestane requires intramuscular administration. Nonetheless, formestane, which appears to have a better tolerability profile than other currently available second-line agents (including megestrol and the aromatase inhibitor aminoglutethimide), is a valuable drug for the second-line treatment of postmenopausal women with advanced breast cancer.
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Affiliation(s)
- L R Wiseman
- Adis International Limited, Auckland, New Zealand
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