Factors that predict early treatment failure for patients with locally advanced (T4) breast cancer

Radiotherapy of Breast Cancer—Professional Guideline 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

The international radiotherapy (RT) expert panel has revised and updated the RT guidelines that were accepted in 2020 at the 4th Hungarian Breast Cancer Consensus Conference, based on new scientific evidence. Radiotherapy after breast-conserving surgery (BCS) is indicated in ductal carcinoma in situ (stage 0), as RT decreases the risk of local recurrence (LR) by 50–60%. In early stage (stage I-II) invasive breast cancer RT remains a standard treatment following BCS. However, in elderly (≥70 years) patients with stage I, hormone receptor-positive tumour, hormonal therapy without RT can be considered. Hypofractionated whole breast irradiation (WBI) and for selected cases accelerated partial breast irradiation are validated treatment alternatives to conventional WBI administered for 5 weeks. Following mastectomy, RT significantly decreases the risk of LR and improves overall survival of patients who have 1 to 3 or ≥4 positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be substituted with axillary RT. After neoadjuvant systemic treatment (NST) followed by BCS, WBI is mandatory, while after NST followed by mastectomy, locoregional RT should be given in cases of initial stage III–IV and ypN1 axillary status.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Challenges of treating incidental synchronous bilateral breast cancer with differing tumour biology

A 59-year-old woman with right breast mass was diagnosed with invasive ductal carcinoma (IDC). Workup consisted of bilateral diagnostic mammogram and ultrasound (US); both showed a right breast mass with normal left breast. Core biopsy showed IDC with estrogen receptor negative (ER-)/progesterone receptor negative (PR-) and HER2/neu positive receptor status. The patient underwent carboplatin-based chemotherapy with Herceptin. The mass completely resolved. The patient desired to proceed with bilateral total mastectomy with right sentinel lymph node biopsy (SLNB). Pathology showed complete resolution of the right-sided breast mass without malignancy in right SLN. Incidentally, IDC was found in the left breast specimen, which was ER+/PR+ and HER 2/neu negative. Tumour board consensus was to obtain a left axilla US with MRI in 6 months if the US was unremarkable. Biologically different synchronous bilateral breast cancer poses a difficult clinical challenge for management due to differing responses to treatment. Use of MRI may be a diagnostic option in women who choose contralateral prophylactic mastectomy.

Mithramycin A sensitizes therapy-resistant breast cancer stem cells toward genotoxic drug doxorubicin

Chemotherapy resistance is a major clinical challenge for the management of locally advanced breast cancer. Accumulating evidence suggests a major role of cancer stem cells (CSCs) in chemoresistance evoking the requirement of drugs that selectively target CSCs in combination with chemotherapy. Here, we report that mithramycin A, a known specificity protein (Sp)1 inhibitor, sensitizes breast CSCs (bCSCs) by perturbing the expression of drug efflux transporters, ATP-binding cassette sub-family G, member 2 (ABCG2) and ATP-binding cassette sub-family C, member 1 (ABCC1), survival factors, B-cell lymphoma 2 (Bcl-2) and X-linked inhibitor of apoptosis (XIAP), and, stemness regulators, octamer-binding transcription factor 4 (Oct4) and Nanog, which are inherently upregulated in these cells compared with the rest of the tumor population. In-depth analysis revealed that aberrant overexpression of Sp1 in bCSCs transcriptionally upregulates (1) resistance-promoting genes to protect these cells from genotoxic therapy, and (2) stemness regulators to sustain self-renewal potential of these cells. However, mithramycin A causes transcriptional suppression of these chemoresistant and self-renewal genes by inhibiting Sp1 recruitment to their promoters. Under such antisurvival microenvironment, chemotherapeutic agent doxorubicin induces apoptosis in bCSCs via DNA damage-induced reactive oxygen species generation. Cumulatively, our findings raise the possibility that mithramycin A might emerge as a promising drug in combinatorial therapy with the existing chemotherapeutic agents that fail to eliminate CSCs. This will consequently lead to the improvement of therapeutic outcome for the treatment-resistant breast carcinomas.

Expression profile of inflammatory breast cancer

Inflammatory breast cancer is characterized by high malignancy, early and rapid lymphogenic and hematogenic metastasizing, and high mortality. The diagnosis of this form of cancer is based fully on the clinical criteria. Whole transcriptome analysis of tumor tissue specimens from patients with inflammatory breast cancer detected 137 differentially expressed mRNA (17 genes with low expression and 120 with high expression). Genes involved in the organization of inflammatory process, chemotaxis, and transcription regulation were active in the process of pathogenesis of inflammatory breast cancer.

[Clinical and outcome characteristics of inflammatory breast cancers in Brazzaville]

T4 breast cancers are a heterogeneous group. We conducted this study to analyze the differences between inflammatory and non-inflammatory T4 breast cancers. In a cross-sectional descriptive study over a period ranging from 2007 to 2010, we collected patients with T4 breast cancer. These patients were divided into two groups: a group of inflammatory breast cancer (IBC) and a group of breast cancer T4 non inflammatory (NIBC). We compared the epidemiological, clinical and outcome characteristics of the two groups. We identified 129 patients with T4 stage out of 343 patients with a diagnosis of breast cancer. Fifty-two IBC and 77 NIBC patients were observed. We did not found any epidemiological difference between the two groups. The two entities differed in tumor size (greater in the IBC group) and skin ulceration (less frequently found in the NIBC group). The only independent prognostic factor for failure of first line chemotherapy was, for both groups, non-compliance treatment intervals. The median overall survival in our study was 9 months in the IBC versus 13 months in the NIBC (p = 0.01, Log-rank test) patients. By multivariate analysis, IBC was the only independent prognostic factor negatively influencing the survival. IBC is a frequent entity in Brazzaville, Congo and displays a poor-prognosis.

Prognostic factors and recurrence in breast cancer: experience at the national cancer institute of Mexico

The purpose of this study was to analyze the prognostic and predictive factors that relate to locoregional or distant recurrences in breast cancer patients who have been treated at the National Cancer Institute of Mexico. Multivariate, time-dependent Cox regression analyses indicate that the pN status (positive versus negative lymph node; P = 0.003; HR (hazard ratio), 3.47; CI (confidence interval), 1.52-7.91) and the pathological complete response of the patient to neoadjuvant chemotherapy (yes versus no; P = 0.061; HR, 0.38; CI, 0.14-1.04) were important prognostic factors for recurrence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Obesity and angiolymphatic invasion in primary breast cancer

BACKGROUND

Obesity is associated with poorer breast cancer-specific survival. The purpose of this study was to investigate the relationships between obesity and the presence of angiolymphatic invasion as well as other features of invasive breast cancer, including stage at presentation, estrogen receptor (ER) status, triple-negative phenotype, and tumor grade.

METHODS

Detailed clinical and pathologic data were abstracted from the medical records of all 1,312 patients with stage I-III primary breast cancer who had breast surgery at the University of Michigan Comprehensive Cancer Center between January 1, 2000 and December 31, 2006. Bivariate and multivariate analyses were conducted to investigate the relationships between body mass index and tumor biologic features, controlling for menopausal status, diabetes and hypertension, hormone replacement therapy before diagnosis, race, and ethnicity.

RESULTS

In multivariate analyses, severe obesity was independently associated with the presence of angiolymphatic invasion [odds ratio (OR) 1.80, 95% confidence interval (CI) 1.08-2.99, joint test of significance, P = 0.03]. Severe obesity was associated with lower likelihood of triple-negative breast cancer (OR 0.39, 95% CI 0.16-0.96). Among premenopausal women with diabetes, ER-negative (OR 5.22, 95% CI 1.12-24.29) and triple-negative (OR 14.8, 95% CI 1.92-113.91) disease was significantly more common.

DISCUSSION

In this large sample of invasive breast cancers, obesity was independently associated with the presence of angiolymphatic invasion. Higher rates of angiolymphatic invasion among obese women may account in part for poorer outcomes among obese women with breast cancer.

[Locally advanced (neglected) breast cancer: the reality? Relevance of two cases and reflection how to optimise the multidisciplinary approach]

The standard treatment for breast cancer patients with untreated locally advanced breast cancer is neo-adjuvant chemotherapy or hormonal treatment. In some cases, this treatment is followed by surgery and/or radiotherapy when the multidisciplinary approach is present. In some cases of patients presenting metastatic diseases, the radiotherapy is forgotten or proposed late when the local disease is extremely advanced with symptoms and decreased quality of life. Two cases of extremely advanced non operable T4 stage breast cancer are reported and the importance of multidisciplinary approach is discussed. The place and the right time of radiotherapy in this multidisciplinary strategy is reported.

The HER-2 receptor and breast cancer: ten years of targeted anti-HER-2 therapy and personalized medicine

The human epidermal growth factor receptor (HER-2) oncogene encodes a transmembrane tyrosine kinase receptor that has evolved as a major classifier of invasive breast cancer and target of therapy for the disease. The validation of the general prognostic significance of HER-2 gene amplification and protein overexpression in the absence of anti-HER-2 targeted therapy is discussed in a study of 107 published studies involving 39,730 patients, which produced an overall HER-2-positive rate of 22.2% and a mean relative risk for overall survival (OS) of 2.74. The issue of HER-2 status in primary versus metastatic breast cancer is considered along with a section on the features of metastatic HER-2-positive disease. The major marketed slide-based HER-2 testing approaches, immunohistochemistry, fluorescence in situ hybridization, and chromogenic in situ hybridization, are presented and contrasted in detail against the background of the published American Society of Clinical Oncology-College of American Pathologists guidelines for HER-2 testing. Testing issues, such as the impact of chromosome 17 polysomy and local versus central HER-2 testing, are also discussed. Emerging novel HER-2 testing techniques, including mRNA-based testing by real-time polymerase chain reaction and DNA microarray methods, HER-2 receptor dimerization, phosphorylated HER-2 receptors, and HER-2 status in circulating tumor cells, are also considered. A series of biomarkers potentially associated with resistance to trastuzumab is discussed with emphasis on the phosphatase and tensin homologue deleted on chromosome ten/Akt and insulin-like growth factor receptor pathways. The efficacy results for the more recently approved small molecule HER-1/HER-2 kinase inhibitor lapatinib are also presented along with a more limited review of markers of resistance for this agent. Additional topics in this section include combinations of both anti-HER-2 targeted therapies together as well as with novel agents including bevacizumab, everolimus, and tenespimycin. A series of novel HER-2-targeting agents is also presented, including pertuzumab, ertumaxomab, HER-2 vaccines, and recently discovered tyrosine kinase inhibitors. Biomarkers predictive of HER-2 targeted therapy toxicity are included, and the review concludes with a consideration of HER-2 status in the prediction of response to non-HER-2 targeted treatments including hormonal therapy, anthracyclines, and taxanes.

A risk score to predict disease-free survival in patients not achieving a pathological complete remission after preoperative chemotherapy for breast cancer

BACKGROUND

We aimed to predict disease-free survival (DFS) in patients who failed to achieve a pathologic complete remission (pCR) after preoperative chemotherapy (PC).

PATIENTS AND METHODS

Data from 577 patients treated with PC and operated at the European Institute of Oncology (EIO) were used to develop a nomogram using Cox proportional hazards regression model based on both categorical (pT, positive nodes, human epidermal growth factor receptor 2 (HER2) status, vascular invasion) and continuous histological variables (estrogen receptors and Ki-67 expression) at surgery. The nomogram was tested on a second patient cohort (343 patients) treated in other institutions and subsequently operated at the EIO.

RESULTS

The nomogram for DFS based on both categorical and continuous variables had good discrimination in the training and the validation sets (concordance indices 0.73, 0.67).

CONCLUSION

The use of a nomogram based on the degree of selected histopathological variables can predict DFS and might help in the adjuvant therapeutic algorithm design.