Neoadjuvant treatment of breast cancer

Alteration of PD-L1 (SP142) status after neoadjuvant chemotherapy and its clinical significance in triple-negative breast cancer

PURPOSE

The tumor immune microenvironment can change after neoadjuvant chemotherapy (NAC) for triple-negative breast cancer (TNBC). We aimed to investigate the effects of NAC on PD-L1 (SP142) status and its clinical significance in TNBC.

METHODS

Paired samples of biopsy and resection specimens were collected from 182 patients with TNBC before and after NAC. PD-L1 (SP142) expression in immune cells in pre- and post-NAC breast cancer samples and the changes between them were analyzed, along with their relationships with the clinicopathological features and clinical outcomes of the patients.

RESULTS

Of the 182 patients, 61 (33.5%) achieved pathologic complete response (pCR) after NAC. PD-L1 (SP142) positivity, defined as immune cell staining in ≥ 1% of tumor area, was a predictor for pCR. PD-L1-positive immune cells significantly increased after NAC (2.8% to 5.2% on average) in 109 patients with measurable residual disease. Alteration of PD-L1 status was observed in 24 (22.0%) of the 109 patients with measurable residual tumors after NAC, and all PD-L1 status-converted patients, except one, revealed negative-to-positive conversion. Regarding chemotherapeutic agents, the use of platinum agents was associated with a significant increase in PD-L1-positive immune cells after NAC. In survival analyses, a positive PD-L1 status after NAC and increase of PD-L1-positive immune cells after NAC were associated with better recurrence-free survival of the patients.

CONCLUSION

PD-L1 (SP142) status changes after NAC, mostly as a positive conversion. As PD-L1 (SP142) status can convey prognostic and predictive information, it needs to be tested before and after NAC.

The NEOLETRIB trial: neoadjuvant treatment with Letrozole and Ribociclib in ER-positive, HER2-negative breast cancer

Chemotherapy is used as neoadjuvant therapy for all subgroups of breast cancer, including ER-positive, and HER2-negative cases. However, studies have suggested that using aromatase inhibitors combined with CDK4/6-inhibitors might be an appropriate alternative in selected patients. Thus, the NEOLETRIB trial evaluates the response of ER-positive, HER2-negative luminal A/B breast cancer to the combination of letrozole and ribociclib in the neoadjuvant setting. Comprehensive molecular biology procedures, including sequential single-cell RNA-sequencing of tumor biopsies, are performed during 6 months of treatment with extensive biobanking of blood samples, tumor biopsies and gut microbiome specimens. Our findings will hopefully contribute to an improved selection of patients who may benefit from this drug combination and give new insights into the intra-tumoral changes during this treatment.Trial registration number: NCT05163106 (ClinicalTrials.gov).

Efficacy and prognosis of HER2-Low and HER2-Zero in triple-negative breast cancer after neoadjuvant chemotherapy

Mounting evidence showed that HER2-Low breast cancer patients could benefit from the novel anti-HER2 antibody-drug conjugates (ADCs) treatment, which pointed the way towards better therapy for HER2-Low patients. The purpose of this study was to describe the clinicopathological features, along with chemotherapeutic effects and survival outcomes of HER2-Low and HER2-Zero in TNBC who received neoadjuvant chemotherapy (NACT). We retrospectively evaluated 638 triple-negative breast cancer patients who were treated with neoadjuvant chemotherapy between August 2014 and August 2022. Pathologic complete response (pCR) and survival outcomes were analyzed in HER2-Low cohort, HER2-Zero cohort and the overall patients, respectively. In the entire cohort, 342 (53.6%) patients were HER2-Low and 296 (46.4%) patients were HER2-Zero. No significant difference was found between HER2-Low and HER2-Zero patients based on all the clinical-pathological characteristics. 143 cases (22.4%) achieved pCR after NACT in the overall TNBC patients. The pCR rate of the HER2-Low patients and the HER2-Zero patients was 21.3% and 23.6%, respectively, exhibiting no statistical difference (p = 0.487). The survival of pCR group after NACT significantly improved compared to non-pCR group either in HER2-Low patients or in HER2-Zero patients. Although we found that patients with HER2-Low had longer DFS than patients with HER2-Zero, there was no considerable difference (p = 0.068). However, HER2-Low patients had a dramatically longer OS than HER2-Zero patients (p = 0.012). The data from present study confirmed the clinical importance of HER2-Low expression in TNBC. Further effort is needed to determine whether HER2-Low could be a more favorable prognostic marker for individual treatment.

Defining the Regulatory Logic of Breast Cancer Using Single-Cell Epigenetic and Transcriptome Profiling

Annotation of the cis-regulatory elements that drive transcriptional dysregulation in cancer cells is critical to improving our understanding of tumor biology. Herein, we present a compendium of matched chromatin accessibility (scATAC-seq) and transcriptome (scRNA-seq) profiles at single-cell resolution from human breast tumors and healthy mammary tissues processed immediately following surgical resection. We identify the most likely cell-of-origin for luminal breast tumors and basal breast tumors and then introduce a novel methodology that implements linear mixed-effects models to systematically quantify associations between regions of chromatin accessibility (i.e. regulatory elements) and gene expression in malignant cells versus normal mammary epithelial cells. These data unveil regulatory elements with that switch from silencers of gene expression in normal cells to enhancers of gene expression in cancer cells, leading to the upregulation of clinically relevant oncogenes. To translate the utility of this dataset into tractable models, we generated matched scATAC-seq and scRNA-seq profiles for breast cancer cell lines, revealing, for each subtype, a conserved oncogenic gene expression program between in vitro and in vivo cells. Together, this work highlights the importance of non-coding regulatory mechanisms that underlie oncogenic processes and the ability of single-cell multi-omics to define the regulatory logic of BC cells at single-cell resolution.

Awareness, Knowledge, and Current Practice of Breast Cancer Among Surgeons in Jordan

PURPOSE

Breast cancer (BC) is the most prevalent cancer in Jordan. De-escalation in treatment reflects a paradigm shift in BC treatment. More tailored strategies and the adoption of a multidisciplinary approach are essential to apply recent changes in management. In the era of breast surgery fellowship, adopting well-structured training is essential to apply recent therapeutic guidelines and meet patients' expectations.

METHODS

A cross-sectional study using a customized, self-reported questionnaire was used. Data collection occurred anonymously using a link via WhatsApp in the period between February 2023 and April 2023.

RESULTS

A total of 89 surgeons were involved in this study, and only 14 (15.7%) completed a subspecialty in breast surgery. About 58.4% considered the age of 40 years as the starting point for screening, and 84.3% reported that mammogram screening is associated with improved BC survival. Only 10.1% and 28.1% acknowledged the applicability of both tomosynthesis and breast magnetic resonance imaging in screening, respectively. A significant difference in the mean knowledge score about BC is observed between general surgeon and those with subspecialty. Varying levels of awareness concerning different risk factors and their correlation with the likelihood of BC occurrence observed. Although 56.2% of participants could offer breast conserving surgery and consider it oncological safe, only 48.3% defined it correctly. Of the participants, 61.8% and 76.4% stated that sentinel lymph node biopsy can be safely applied in clinically negative or suspicious axillary nodes, respectively, with <50% of surgeon performing it in their practice.

CONCLUSION

More efforts are required to enhance the knowledge and practice of surgeons in the field of breast surgery. Adopting national guidelines can facilitate the acceptance and improvement of current practices among surgeons in Jordan.

Associations of pre-diagnosis physical activity with treatment tolerance and treatment efficacy in breast cancer patients with neoadjuvant chemotherapy

PURPOSE

Higher pre-diagnosis physical activity (PA) is associated with lower all-cause mortality in breast cancer (BCa) patients. However, the association with pathological complete response (pCR) is unclear. We investigated the association between pre-diagnosis PA level and chemotherapy completion, dose delay, and pCR in BCa patients receiving neoadjuvant chemotherapy (NACT).

METHODS

180 stage I-III BCa patients receiving NACT (mean [SD] age of diagnosis: 60.8 [8.8] years) in the Sister Study were included. Self-reported recreational and total PA levels were converted to metabolic equivalent of task-hours per week (MET-hrs/wk). The pCR was defined as no invasive or in situ residual in breast or lymph node (ypT0 ypN0). Multivariable logistic regression analyses estimated odds ratios (ORs) and 95% confidence intervals (CIs) for treatment outcomes.

RESULTS

In this sample, 45 (25.0%) BCa patients achieved pCR. Higher pre-diagnosis recreational PA was not associated with lower likelihood of chemotherapy completion (highest vs. lowest tertile: OR = 0.87, 95% CI = 0.30-2.56; Ptrend = 0.84), greater dose delay (OR = 1.45, 95% CI = 0.54-3.92; Ptrend = 0.46), or greater odds of pCR (OR = 1.28, 95% CI = 0.49-3.34; Ptrend = 0.44). Associations were similar for pre-diagnosis total PA. Meeting the recommended level of recreational PA was not associated with pCR overall (≥ 7.5 vs. < 7.5 MET-hrs/wk: OR = 1.33, 95% CI = 0.59-3.01).

CONCLUSIONS

Although small sample size and limited information on exercise closer to time of diagnosis limit interpretation, pre-diagnosis PA was not convincingly associated with treatment tolerance or treatment efficacy in BCa patients receiving NACT. Future investigations are needed to better understand the impact of pre-diagnosis PA on BCa treatment.

Impact of Neoadjuvant Chemotherapy (NAC) on Biomarker Expression in Breast Cancer

Background and Objectives: This study aimed to explore biomarker change after NAC (neoadjuvant chemotherapy) and to investigate biomarker expression as a prognostic factor in patients with residual disease (RD) after NAC. Materials and Methods: We retrospectively evaluated 104 patients with invasive breast cancer, who underwent NAC and surgery at Pusan National University Hospital from 2015 to July 2022. The expression of the biomarker was assessed, and the overall survival (OS) and disease-free survival (DFS) were investigated. Results: After NAC, 24 patients (23.1%) out of 104 total patients had a pathological complete response (pCR). We found that changes in at least one biomarker were observed in 41 patients (51.2%), among 80 patients with RD. In patients with RD after NAC (n = 80), a subtype change was identified in 20 patients (25.0%). Any kind of change in the HER2 status was present 19 (23.7%) patients. The hormone receptor (HR)+/HER2+ subtype was significantly associated with better disease-free survival (DFS) (HR, 0.13; 95% CI, 0.02-0.99; p = 0.049). No change in p53 was associated with better DFS, and negative-to-positive change in p53 expression after NAC was correlated with worse DFS (p < 0.001). Negative-to-positive change in p53 was an independent, worse DFS factor in the multivariate analysis (HR,18.44; 95% CI, 1.86-182.97; p = 0.013). Conclusions: Biomarker change and subtype change after NAC were not infrequent, which can affect the further treatment strategy after surgery. The expression change of p53 might have a prognostic role. Overall, we suggest that the re-evaluation of biomarkers after NAC can provide a prognostic role and is needed for the best decision to be made on further treatment.

Neoadjuvant Chemotherapy and Neoadjuvant Chemotherapy With Immunotherapy Result in Different Tumor Shrinkage Patterns in Triple-Negative Breast Cancer

PURPOSE

This study aims to explore whether neoadjuvant chemotherapy with immunotherapy (NACI) leads to different tumor shrinkage patterns, based on magnetic resonance imaging (MRI), compared to neoadjuvant chemotherapy (NAC) alone in patients with triple-negative breast cancer (TNBC). Additionally, the study investigates the relationship between tumor shrinkage patterns and treatment efficacy was investigated.

METHODS

This retrospective study included patients with TNBC patients receiving NAC or NACI from January 2019 until July 2021 at our center. Pre- and post-treatment MRI results were obtained for each patient, and tumor shrinkage patterns were classified into three categories as follows: 1) concentric shrinkage (CS); 2) diffuse decrease; and 3) no change. Tumor shrinkage patterns were compared between the NAC and NACI groups, and the relevance of the patterns to treatment efficacy was assessed.

RESULTS

Of the 99 patients, 65 received NAC and 34 received NACI. The CS pattern was observed in 53% and 20% of patients in the NAC and NACI groups, respectively. Diffuse decrease pattern was observed in 36% and 68% of patients in the NAC and NACI groups. The association between the treatment regimens (NAC and NACI) and tumor shrinkage patterns was statistically significant (p = 0.004). The postoperative pathological complete response (pCR) rate was 45% and 82% in the NAC and NACI groups (p < 0.001), respectively. In the NACI group, 17% of patients with the CS pattern and 56% of those with the diffuse decrease pattern achieved pCR (p = 0.903). All tumor shrinkage patterns were associated with achieved a high pCR rate in the NACI group.

CONCLUSION

Our study demonstrates that the diffuse decrease pattern of tumor shrinkage is more common following NACI than that following NAC. Furthermore, our findings suggest that all tumor shrinkage patterns are associated with a high pCR rate in patients with TNBC treated with NACI.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04909554.

The Impact of Different Patterns of Residual Disease on Long-Term Oncological Outcomes in Breast Cancer Patients Treated with Neo-Adjuvant Chemotherapy

BACKGROUNDS

The majority of breast cancer (BC) patients treated with neo-adjuvant chemotherapy (NAC) achieves a pathologic partial response with different patterns of residual disease. No clear correlation between these patterns and oncological results was described. Our aims were to define the predictive factors for different patterns of residual disease and compare the outcomes between the scattered versus the circumscribed pattern.

METHODS

We reviewed 219 postoperative surgical specimens. Patients were divided into two groups: scattered versus circumscribed. Disease-free survival (DFS), distant DFS (DDFS), and overall survival (OS) were analyzed.

RESULTS

The scattered and circumscribed patterns were assessed in 111 (50.7%) and 108 (49.3%) patients. Two independent predictive factors for the circumscribed pattern were identified: discontinuation of NAC cycles (p = 0.011), and tumor size post-NAC >18 mm (p = 0.022). No difference was observed in terms of DFS and DDFS. Patients with the scattered pattern exhibited a statistically significant better OS. Discontinuation of NAC cycles, tumor size >18 mm, triple-negative BC, and ypN+ were associated with increased recurrence and poorer survival.

CONCLUSIONS

Discontinuation of NAC cycles and tumor size are independent factors associated with patterns of residual disease. The scattered pattern presents better survival. Understanding the relationship between NAC, the residual pattern, and differences in survival outcomes offers the potential to optimize the therapeutic approaches.

National trends in neoadjuvant chemotherapy utilization in patients with early-stage node-negative triple-negative breast cancer: the impact of the CREATE-X trial

PURPOSE

Neoadjuvant chemotherapy (NAC) for triple-negative breast cancer (TNBC) allows for assessment of tumor pathological response and has survival implications. In 2017, the CREATE-X trial demonstrated survival benefit with adjuvant capecitabine in patients TNBC and residual disease after NAC. We aimed to assess national rates of NAC for cT1-2N0M0 TNBC before and after CREATE-X and examine factors associated with receiving NAC vs adjuvant chemotherapy (AC).

METHODS

A retrospective cohort study of women with cT1-2N0M0 TNBC diagnosed from 2014 to 2019 in the National Cancer Database (NCDB) was performed. Variables were analyzed via ANOVA, Chi-squared, Fisher Exact tests, and a multivariate linear regression model was created.

RESULTS

55,633 women were included: 26.9% received NAC, 52.4% AC, and 20.7% received no chemotherapy (median ages 53, 59, and 71 years, p < 0.01). NAC utilization significantly increased over time: 19.5% in 2014-15 (n = 3,465 of 17,777), 27.1% in 2016-17 (n = 5,140 of 18,985), and 33.6% in 2018-19 (n = 6,337 of 18,871, p < 0.001). On multivariate analysis, increased NAC was associated with younger age (< 50), non-Hispanic white race/ethnicity, lack of comorbidities, cT2 tumors, care at an academic or integrated-network cancer program, and diagnosis post-2017 (p < 0.05 for all). Patients with government-provided insurance were less likely to receive NAC (p < 0.01). Women who traveled > 60 miles for treatment were more likely to receive NAC (p < 0.01).

CONCLUSION

From 2014 to 2019, NAC utilization increased for patients with cT1-2N0M0 TNBC. Racial, socioeconomic, and access disparities were observed in who received NAC vs AC and warrants interventions to ensure equitable care.

Emerging targeted therapeutic strategies for the treatment of triple-negative breast cancer

Triple-negative breast cancer (TNBC), a subtype of breast cancer that lacks expression of oestrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2), has clinical features including a high degree of invasiveness, an elevated risk of metastasis, tendency to relapse, and poor prognosis. It constitutes around 10-15% of all breast cancer, and having heredity of BRCA1 mutated breast cancer could be a reason for the occurrence of TNBC in women. Overexpression of cellular and molecular targets, i.e. CD44 receptor, EGFR receptor, Folate receptor, Transferrin receptor, VEGF receptor, and Androgen receptor, have emerged as promising targets for treating TNBC. Signalling pathways such as Notch signalling and PI3K/AKT/mTOR also play a significant role in carrying out and managing crucial pro-survival and pro-growth cellular processes that can be utilised for targeted therapy against triple-negative breast cancer. This review sheds light on various targeting strategies, including cellular and molecular targets, signalling pathways, poly (ADP-ribose) polymerase inhibitors, antibody-drug conjugates, and immune checkpoint inhibitors PARP, immunotherapy, ADCs have all found a place in the current TNBC therapeutic paradigm. The role of photothermal therapy (PTT) and photodynamic therapy (PDT) has also been explored briefly.

Value of ultrasound in assessing response to neoadjuvant chemotherapy in breast cancer

AIM

To analyse the utility of ultrasound in assessing response to neoadjuvant chemotherapy (NAC) and predicting residual cancer burden (RCB) index and pathological complete response (pCR) MATERIALS AND METHODS: This was a retrospective study with 417 patients over 7 years. The difference in longest diameter (LD) of the index lesion from baseline to end, baseline to mid, and mid to end was evaluated with respect to RCB class using logistic regression and ordered logistic regression.

RESULTS

Change in LD measurements from baseline to end, baseline to mid, and mid to end of chemotherapy as a predictor of RCB class show a negative relationship with a statistically significant association. This would suggest that a smaller change in LD measurements would be associated with an eventual higher RCB class. Change in LD measurements from baseline to end and baseline to mid chemotherapy as a predictor of pCR class show a negative relationship with a statistically significant association (p<0.05). This similarly indicates an inversely proportional relationship between changes in LD measurements and RCB class 0 for baseline to end and baseline to mid.

CONCLUSION

This study has shown significance in reducing LD measurements on ultrasound as a predictor of PCR and RCB class. This adds weight to the current practice of using ultrasound at the start, mid and end of chemotherapy cycles to monitor NACT responses.

The accuracy of MRI in detecting pathological complete response following neoadjuvant chemotherapy in different breast cancer subtypes

BACKGROUND

Pathological complete response (pCR) following neo-adjuvant chemotherapy (NACT) for breast cancer is associated with improved disease-free and overall survival in certain breast cancer subtypes. Magnetic Resonance Imaging (MRI) is increasingly used as standard to assess treatment response in patients receiving NACT. The aim of this study was to determine the clinical utility of MRI in accurately predicting pCR post-NACT.

METHODS

A single-centre, retrospective study was conducted in breast cancer patients, who received NACT between 2013 and 2020. Patients who had an MRI before and after NACT were included. Pathological and MRI radiological response rates to NACT were analyzed and MRI accuracy assessed in detecting pCR according to breast cancer subtype.

RESULTS

One hundred and sixty-seven patients were included in the study. Forty-one of the 167 patients achieved pCR (24.6 %), with the highest proportion in HR- HER2+ subgroup (58.3 %), followed by triple negative breast cancer (TNBC) (35 %). Only 22.2 % and 10.5 % of patients with HR + HER2+ and HR + HER2-respectively achieved pCR. The overall accuracy of MRI in predicting pCR after NACT was 77.3 %. The greatest accuracy was in TNBC (87.5 %) with a specificity and positive predictive value (PPV) of 100 % and the highest number of correctly diagnosed complete responses (14 of 40). MRI was less accurate in predicting response rates in HR + HER2- (PPV 91.2 %) and HR + HER2+ groups (PPV 90.5 %). MRI performed significantly better in predicting complete response in TNBC compared to HR + HER2-subtype (p = 0.0057).

CONCLUSION

MRI is a clinically useful adjunct in assessing pCR following NACT and appears to predict pathological response more accurately in TNBC compared to HR + HER2-breast cancer subtypes. This has significant clinical implications in terms of surgical planning, adjuvant treatment options and prognosis.

Recent advancements in artificial intelligence for breast cancer: Image augmentation, segmentation, diagnosis, and prognosis approaches

Breast cancer is a significant global health burden, with increasing morbidity and mortality worldwide. Early screening and accurate diagnosis are crucial for improving prognosis. Radiographic imaging modalities such as digital mammography (DM), digital breast tomosynthesis (DBT), magnetic resonance imaging (MRI), ultrasound (US), and nuclear medicine techniques, are commonly used for breast cancer assessment. And histopathology (HP) serves as the gold standard for confirming malignancy. Artificial intelligence (AI) technologies show great potential for quantitative representation of medical images to effectively assist in segmentation, diagnosis, and prognosis of breast cancer. In this review, we overview the recent advancements of AI technologies for breast cancer, including 1) improving image quality by data augmentation, 2) fast detection and segmentation of breast lesions and diagnosis of malignancy, 3) biological characterization of the cancer such as staging and subtyping by AI-based classification technologies, 4) prediction of clinical outcomes such as metastasis, treatment response, and survival by integrating multi-omics data. Then, we then summarize large-scale databases available to help train robust, generalizable, and reproducible deep learning models. Furthermore, we conclude the challenges faced by AI in real-world applications, including data curating, model interpretability, and practice regulations. Besides, we expect that clinical implementation of AI will provide important guidance for the patient-tailored management.

Prognostic power assessment of clinical parameters to predict neoadjuvant response therapy in HER2-positive breast cancer patients: A machine learning approach

BACKGROUND

About 15%-20% of breast cancer (BC) cases is classified as Human Epidermal growth factor Receptor type 2 (HER2) positive. The Neoadjuvant chemotherapy (NAC) was initially introduced for locally advanced and inflammatory BC patients to allow a less extensive surgical resection, whereas now it represents the current standard for early-stage and operable BC. However, only 20%-40% of patients achieve pathologic complete response (pCR). According to the results of practice-changing clinical trials, the addition of trastuzumab to NAC brings improvements to pCR, and recently, the use of pertuzumab plus trastuzumab has registered further statistically significant and clinically meaningful improvements in terms of pCR. The goal of our work is to propose a machine learning model to predict the pCR to NAC in HER2-positive patients based on a subset of clinical features.

METHOD

First, we evaluated the significant association of clinical features with pCR on the retrospectively collected data referred to 67 patients afferent to Istituto Tumori "Giovanni Paolo II." Then, we performed a feature selection procedure to identify a subset of features to be used for training a machine learning-based classification algorithm. As a result, pCR to NAC was associated with ER status, Pgr status, and HER2 score.

RESULTS

The machine learning model trained on a subgroup of essential features reached an AUC of 73.27% (72.44%-73.66%) and an accuracy of 71.67% (71.64%-73.13%). According to our results, the clinical features alone are not enough to define a support system useful for clinical pathway.

CONCLUSION

Our results seem worthy of further investigation in large validation studies and this work could be the basis of future study that will also involve radiomics analysis of biomedical images.

Longitudinal dynamic contrast-enhanced MRI radiomic models for early prediction of response to neoadjuvant systemic therapy in triple-negative breast cancer

Early prediction of neoadjuvant systemic therapy (NAST) response for triple-negative breast cancer (TNBC) patients could help oncologists select individualized treatment and avoid toxic effects associated with ineffective therapy in patients unlikely to achieve pathologic complete response (pCR). The objective of this study is to evaluate the performance of radiomic features of the peritumoral and tumoral regions from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) acquired at different time points of NAST for early treatment response prediction in TNBC. This study included 163 Stage I-III patients with TNBC undergoing NAST as part of a prospective clinical trial (NCT02276443). Peritumoral and tumoral regions of interest were segmented on DCE images at baseline (BL) and after two (C2) and four (C4) cycles of NAST. Ten first-order (FO) radiomic features and 300 gray-level-co-occurrence matrix (GLCM) features were calculated. Area under the receiver operating characteristic curve (AUC) and Wilcoxon rank sum test were used to determine the most predictive features. Multivariate logistic regression models were used for performance assessment. Pearson correlation was used to assess intrareader and interreader variability. Seventy-eight patients (48%) had pCR (52 training, 26 testing), and 85 (52%) had non-pCR (57 training, 28 testing). Forty-six radiomic features had AUC at least 0.70, and 13 multivariate models had AUC at least 0.75 for training and testing sets. The Pearson correlation showed significant correlation between readers. In conclusion, Radiomic features from DCE-MRI are useful for differentiating pCR and non-pCR. Similarly, predictive radiomic models based on these features can improve early noninvasive treatment response prediction in TNBC patients undergoing NAST.

Significance of tumor-infiltrating lymphocytes in tumor regression in breast cancer: A study in a tertiary care cancer center in South India

BACKGROUND

Tumor immunology plays a significant role in predicting tumor biology and how a tumor is going to respond to neoadjuvant chemotherapy (NACT). Tumor-infiltrating lymphocytes (TILs) are the easiest and by far the cheapest method of assessing tumor immunity. Many studies have suggested that TILs play an important role in tumor regression in breast cancer.

AIM

The aim of the current study was to determine significance of TILs in tumor regression in breast cancer.

MATERIALS AND METHODS

Patients with newly diagnosed and histologically proven breast cancer who were treated with both NACT and surgery in our institute were included in the study. TILs were assessed both before and after NACT, and were correlated with the relative amount of tumor regression and molecular subtypes based on the immunohistochemistry profile.

RESULTS

The study included 43 specimens of carcinoma breast in females. 42 cases were diagnosed with invasive carcinoma, no special type (NST), and one with lobular carcinoma. Pathological complete remission (pCR) was noted in 6 cases, partial remission (PRe) in 12 cases, and no response in 25 cases. TILs were noted before and after NACT in all cases and were correlated with other clinicopathological parameters.

CONCLUSION

The present study highlights that TILs play a vital role in tumor regression and can be included in routine reporting. It can provide an insight into tumor biology.

Advances in the application of computational pathology in diagnosis, immunomicroenvironment recognition, and immunotherapy evaluation of breast cancer: a narrative review

BACKGROUND

Breast cancer (BC) is a prevalent and highly lethal malignancy affecting women worldwide. Immunotherapy has emerged as a promising therapeutic strategy for BC, offering potential improvements in patient survival. Neoadjuvant therapy (NAT) has also gained significant clinical traction. With the advancement of computer technology, Artificial Intelligence (AI) has been increasingly applied in pathology research, expanding and redefining the scope of the field. This narrative review aims to provide a comprehensive overview of the current literature on the application of computational pathology in BC, specifically focusing on diagnosis, immune microenvironment recognition, and the evaluation of immunotherapy and NAT response.

METHODS

A thorough examination of relevant literature was conducted, focusing on studies investigating the role of computational pathology in BC diagnosis, immune microenvironment recognition, and immunotherapy and NAT assessment.

RESULTS

The application of computational pathology has shown significant potential in BC management. AI-based techniques enable improved diagnosis and classification of BC subtypes, enhance the identification and characterization of the immune microenvironment, and facilitate the evaluation of immunotherapy and NAT response. However, challenges related to data quality, standardization, and algorithm development still need to be addressed.

CONCLUSION

The integration of computational pathology and AI has transformative implications for BC patient care. By leveraging AI-based technologies, clinicians can make more informed decisions in diagnosis, treatment planning, and therapeutic response assessment. Future research should focus on refining AI algorithms, addressing technical challenges, and conducting large-scale clinical validation studies to facilitate the translation of computational pathology into routine clinical practice for BC patients.

Poly(ADP-ribose) polymerase inhibitors in the treatment landscape of triple-negative breast cancer (TNBC)

OBJECTIVE

Chemotherapy is the mainstay for triple-negative breast cancer (TNBC) patients. Over the years, the use of chemotherapy for these patients has demonstrated many adversities, including toxicity and resistance, which suggested the need to develop novel alternative therapeutic options, such as poly(ADP-ribose) polymerase inhibitors (PARPi). Herein, we provide an overview on PARPi, mechanisms of action and the role of biomarkers in PARPi sensitivity trials, clinical advances in PARPi therapy for TNBC patients based on the most recent studies and findings of clinical trials, and challenges that prevent PARP inhibitors from achieving high efficacy such as resistance and overlapping toxicities with other chemotherapies.

DATA SOURCES

Searching for relevant articles was done using PubMed and Cochrane Library databases by using the keywords including TNBC; chemotherapy; PARPi; BRCA; homologous recombination repair (HRR). Studies had to be published in full-text in English in order to be considered.

DATA SUMMARY

Although PARPi have been used in the treatment of local/metastatic breast malignancies that are HER2 negative and has a germline BRCA mutation, several questions are still to be answered in order to maximize the clinical benefit of PARP inhibitors in TNBC treatment, such as questions related to the optimal use in the neoadjuvant and metastatic settings as well as the best combinations with various chemotherapies.

CONCLUSIONS

PARPi are emerging treatment options for patients with gBRCA1/2 mutations. Determining patients that are most likely to benefit from PARPi and identifying the optimal treatment combinations with high efficacy and fewer side effects are currently ongoing.

Advances in the Management of Early-Stage Triple-Negative Breast Cancer

Triple-negative breast cancer (TNBC) is a subtype of breast cancer with both inter- and intratumor heterogeneity, thought to result in a more aggressive course and worse outcomes. Neoadjuvant therapy (NAT) has become the preferred treatment modality of early-stage TNBC as it allows for the downstaging of tumors in the breast and axilla, monitoring early treatment response, and most importantly, provides important prognostic information that is essential to determining post-surgical therapies to improve outcomes. It focuses on combinations of systemic drugs to optimize pathologic complete response (pCR). Excellent response to NAT has allowed surgical de-escalation in ideal candidates. Further, treatment algorithms guide the systemic management of patients based on their pCR status following surgery. The expanding knowledge of molecular pathways, genomic sequencing, and the immunological profile of TNBC has led to the use of immune checkpoint inhibitors and targeted agents, including PARP inhibitors, further revolutionizing the therapeutic landscape of this clinical entity. However, subgroups most likely to benefit from these novel approaches in TNBC remain elusive and are being extensively studied. In this review, we describe current practices and promising therapeutic options on the horizon for TNBC, surgical advances, and future trends in molecular determinants of response to therapy in early-stage TNBC.

Profiling the Somatic Mutational Landscape of Breast Tumors from Hispanic/Latina Women Reveals Conserved and Unique Characteristics

Somatic mutational profiling is increasingly being used to identify potential targets for breast cancer. However, limited tumor-sequencing data from Hispanic/Latinas (H/L) are available to guide treatment. To address this gap, we performed whole-exome sequencing (WES) and RNA sequencing on 146 tumors and WES of matched germline DNA from 140 H/L women in California. Tumor intrinsic subtype, somatic mutations, copy-number alterations, and expression profiles of the tumors were characterized and compared with data from tumors of non-Hispanic White (White) women in The Cancer Genome Atlas (TCGA). Eight genes were significantly mutated in the H/L tumors including PIK3CA, TP53, GATA3, MAP3K1, CDH1, CBFB, PTEN, and RUNX1; the prevalence of mutations in these genes was similar to that observed in White women in TCGA. Four previously reported Catalogue of Somatic Mutations in Cancer (COSMIC) mutation signatures (1, 2, 3, 13) were found in the H/L dataset, along with signature 16 that has not been previously reported in other breast cancer datasets. Recurrent amplifications were observed in breast cancer drivers including MYC, FGFR1, CCND1, and ERBB2, as well as a recurrent amplification in 17q11.2 associated with high KIAA0100 gene expression that has been implicated in breast cancer aggressiveness. In conclusion, this study identified a higher prevalence of COSMIC signature 16 and a recurrent copy-number amplification affecting expression of KIAA0100 in breast tumors from H/L compared with White women. These results highlight the necessity of studying underrepresented populations.

SIGNIFICANCE

Comprehensive characterization of genomic and transcriptomic alterations in breast tumors from Hispanic/Latina patients reveals distinct genetic alterations and signatures, demonstrating the importance of inclusive studies to ensure equitable care for patients. See related commentary by Schmit et al., p. 2443.

Imaging findings for response evaluation of ductal carcinoma in situ in breast cancer patients treated with neoadjuvant systemic therapy: a systematic review and meta-analysis

OBJECTIVES

In approximately 45% of invasive breast cancer (IBC) patients treated with neoadjuvant systemic therapy (NST), ductal carcinoma in situ (DCIS) is present. Recent studies suggest response of DCIS to NST. The aim of this systematic review and meta-analysis was to summarise and examine the current literature on imaging findings for different imaging modalities evaluating DCIS response to NST. More specifically, imaging findings of DCIS pre- and post-NST, and the effect of different pathological complete response (pCR) definitions, will be evaluated on mammography, breast MRI, and contrast-enhanced mammography (CEM).

METHODS

PubMed and Embase databases were searched for studies investigating NST response of IBC, including information on DCIS. Imaging findings and response evaluation of DCIS were assessed for mammography, breast MRI, and CEM. A meta-analysis was conducted per imaging modality to calculate pooled sensitivity and specificity for detecting residual disease between pCR definition no residual invasive disease (ypT0/is) and no residual invasive or in situ disease (ypT0).

RESULTS

Thirty-one studies were included. Calcifications on mammography are related to DCIS, but can persist despite complete response of DCIS. In 20 breast MRI studies, an average of 57% of residual DCIS showed enhancement. A meta-analysis of 17 breast MRI studies confirmed higher pooled sensitivity (0.86 versus 0.82) and lower pooled specificity (0.61 versus 0.68) for detection of residual disease when DCIS is considered pCR (ypT0/is). Three CEM studies suggest the potential benefit of simultaneous evaluation of calcifications and enhancement.

CONCLUSIONS AND CLINICAL RELEVANCE

Calcifications on mammography can remain despite complete response of DCIS, and residual DCIS does not always show enhancement on breast MRI and CEM. Moreover, pCR definition effects diagnostic performance of breast MRI. Given the lack of evidence on imaging findings of response of the DCIS component to NST, further research is demanded.

KEY POINTS

• Ductal carcinoma in situ has shown to be responsive to neoadjuvant systemic therapy, but imaging studies mainly focus on response of the invasive tumour. • The 31 included studies demonstrate that after neoadjuvant systemic therapy, calcifications on mammography can remain despite complete response of DCIS and residual DCIS does not always show enhancement on MRI and contrast-enhanced mammography. • The definition of pCR has impact on the diagnostic performance of MRI in detecting residual disease, and when DCIS is considered pCR, pooled sensitivity was slightly higher and pooled specificity slightly lower.

Mammographic density in relation to breast cancer recurrence and survival in women receiving neoadjuvant chemotherapy

Objective

The association between mammographic density (MD) and breast cancer (BC) recurrence and survival remains unclear. Patients receiving neoadjuvant chemotherapy (NACT) are in a vulnerable situation with the tumor within the breast during treatment. This study evaluated the association between MD and recurrence/survival in BC patients treated with NACT.

Methods

Patients with BC treated with NACT in Sweden (2005-2016) were retrospectively included (N=302). Associations between MD (Breast Imaging-Reporting and Data System (BI-RADS) 5^th Edition) and recurrence-free/BC-specific survival at follow-up (Q1 2022) were addressed. Hazard ratios (HRs) for recurrence/BC-specific survival (BI-RADS a/b/c vs. d) were estimated using Cox regression analysis and adjusted for age, estrogen receptor status, human epidermal growth factor receptor 2 status, axillary lymph node status, tumor size, and complete pathological response.

Results

A total of 86 recurrences and 64 deaths were recorded. The adjusted models showed that patients with BI-RADS d vs. BI-RADS a/b/c had an increased risk of recurrence (HR 1.96 (95% confidence interval (CI) 0.98-3.92)) and an increased risk of BC-specific death (HR 2.94 (95% CI 1.43-6.06)).

Conclusion

These findings raise questions regarding personalized follow-up for BC patients with extremely dense breasts (BI-RADS d) pre-NACT. More extensive studies are required to confirm our findings.

Individualizing Curative-Intent Therapy in HER2-Positive Early-Stage Breast Cancer

OPINION STATEMENT

Human epidermal growth factor receptor 2-positive (HER2+) breast cancers have been historically considered an aggressive entity with high rates of recurrence and poor survival. However, during the last 20 years, there has been a dramatic change in prognosis due to the incorporation of different anti-HER2 therapies into the neo/adjuvant chemotherapy backbone. Neoadjuvant dual blockade with trastuzumab and pertuzumab has become the standard of care for women with stage II and III HER2+ breast cancer. Trastuzumab emtansine (T-DM1) has been shown to improve outcomes if pathological complete response (pCR) is not achieved, and adjuvant extended therapy with neratinib has increased disease-free survival (DFS) and may have an impact in central nervous system (CNS) recurrences. However, these agents are both toxic for individual patients and costly for the overall healthcare system, and there are still patients that experience recurrence despite therapy improvements. At the same time, it has been shown that some patients with early-stage HER2+ breast cancer can be effectively treated with less intensive systemic therapy, using only taxane and trastuzumab, or that the chemotherapy backbone can be omitted completely. The current challenge is to properly identify which patients can receive a de-intensified regimen and which need new intensification strategies. Tumor size, nodal status, and pCR achievement after neoadjuvant treatment are well-known risk factors that can aid in making clinical decisions, but they do not accurately predict all patient outcomes. Various biomarkers have been proposed to better characterize the clinical and biological heterogeneity of HER2+ breast cancer. Immune infiltration, intrinsic subtype, intratumoral heterogeneity, and dynamic changes during treatment have been described as important prognostic and/or predictive features. The integration of all these factors will be key in the proper identification of the true risk, and individualized treatment strategy, for each patient.

Comprehensive Profiling of Cancer-Associated Cells in the Blood of Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy to Predict Pathological Complete Response

Neoadjuvant chemotherapy (NAC) can affect pathological complete response (pCR) in breast cancers; the resection that follows identifies patients with residual disease who are then offered second-line therapies. Circulating tumor cells (CTCs) and cancer-associated macrophage-like cells (CAMLs) in the blood can be used as potential biomarkers for predicting pCR before resection. CTCs are of epithelial origin that undergo epithelial-to-mesenchymal transition to become more motile and invasive, thereby leading to invasive mesenchymal cells that seed in distant organs, causing metastasis. Additionally, CAMLs in the blood of cancer patients are reported to either engulf or aid the transport of cancer cells to distant organs. To study these rare cancer-associated cells, we conducted a preliminary study where we collected blood from patients treated with NAC after obtaining their written and informed consent. Blood was collected before, during, and after NAC, and Labyrinth microfluidic technology was used to isolate CTCs and CAMLs. Demographic, tumor marker, and treatment response data were collected. Non-parametric tests were used to compare pCR and non-pCR groups. Univariate and multivariate models were used where CTCs and CAMLs were analyzed for predicting pCR. Sixty-three samples from 21 patients were analyzed. The median(IQR) pre-NAC total and mesenchymal CTC count/5 mL was lower in the pCR vs. non-pCR group [1(3.5) vs. 5(5.75); p = 0.096], [0 vs. 2.5(7.5); p = 0.084], respectively. The median(IQR) post-NAC CAML count/5 mL was higher in the pCR vs. non-pCR group [15(6) vs. 6(4.5); p = 0.004]. The pCR group was more likely to have >10 CAMLs post-NAC vs. non-pCR group [7(100%) vs. 3(21.4%); p = 0.001]. In a multivariate logistic regression model predicting pCR, CAML count was positively associated with the log-odds of pCR [OR = 1.49(1.01, 2.18); p = 0.041], while CTCs showed a negative trend [Odds Ratio (OR) = 0.44(0.18, 1.06); p = 0.068]. In conclusion, increased CAMLs in circulation after treatment combined with lowered CTCs was associated with pCR.

Radiomics of contrast-enhanced spectral mammography for prediction of pathological complete response to neoadjuvant chemotherapy in breast cancer

BACKGROUND

Neoadjuvant chemotherapy (NAC) has been regarded as one of the standard treatments for patients with locally advanced breast cancer. No previous study has investigated the feasibility of using a contrast-enhanced spectral mammography (CESM)-based radiomics nomogram to predict pathological complete response (pCR) after NAC.

OBJECTIVE

To develop and validate a CESM-based radiomics nomogram to predict pCR after NAC in breast cancer.

METHODS

A total of 118 patients were enrolled, which are divided into a training dataset including 82 patients (with 21 pCR and 61 non-pCR) and a testing dataset of 36 patients (with 9 pCR and 27 non-pCR). The tumor regions of interest (ROIs) were manually segmented by two radiologists on the low-energy and recombined images and radiomics features were extracted. Intraclass correlation coefficients (ICCs) were used to assess the intra- and inter-observer agreements of ROI features extraction. In the training set, the variance threshold, SelectKBest method, and least absolute shrinkage and selection operator regression were used to select the optimal radiomics features. Radiomics signature was calculated through a linear combination of selected features. A radiomics nomogram containing radiomics signature score (Rad-score) and clinical risk factors was developed. The receiver operating characteristic (ROC) curve and calibration curve were used to evaluate prediction performance of the radiomics nomogram, and decision curve analysis (DCA) was used to evaluate the clinical usefulness of the radiomics nomogram.

RESULTS

The intra- and inter- observer ICCs were 0.769-0.815 and 0.786-0.853, respectively. Thirteen radiomics features were selected to calculate Rad-score. The radiomics nomogram containing Rad-score and clinical risk factor showed an encouraging calibration and discrimination performance with area under the ROC curves of 0.906 (95% confidence interval (CI): 0.840-0.966) in the training dataset and 0.790 (95% CI: 0.554-0.952) in the test dataset.

CONCLUSIONS

The CESM-based radiomics nomogram had good prediction performance for pCR after NAC in breast cancer; therefore, it has a good clinical application prospect.

Optimizing postoperative outcomes following neoadjuvant chemotherapy and mastectomy with immediate reconstruction: A national analysis

BACKGROUND

The optimal timing between last neoadjuvant chemotherapy (NAC) session and mastectomy with immediate reconstruction (MIR) procedures has sparse data to support optimization of postoperative outcomes. Current literature suggests that timing is not a predictor of complications in patients undergoing implant-based reconstruction following NAC and other literature suggests guidelines based on tumor staging. To the best of our knowledge, this is the largest and most recent study characterizing the effect of time between NAC and mastectomy with immediate reconstruction on postoperative complications.

METHODS

Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction following NAC were identified via CPT and ICD-10 codes. Data concerning these patient's demographics, comorbidities, oncologic treatment, and outcomes were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. To meet inclusion criteria, patients needed to have an encounter for antineoplastic chemotherapy within 1 year of their associated reconstruction. Patients with other invasive procedures unrelated to their mastectomy-reconstruction pairing within 90 days of reconstruction were excluded. Outcomes analysis was limited to the 90-day postoperative period. The time between the last recorded chemotherapy encounter and breast reconstruction was computed. A multivariate logistic regression analysis was performed to ascertain the effects of age, race, coexisting conditions, reconstruction type (autologous or implant-based), and time between NAC and reconstruction on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated.

RESULTS

From over 86 million longitudinal patient records, our study population included 139 897 4371 patient records corresponding to 13 399 3759 patients who had NAC and breast reconstruction between January 2003, October 2015, and June 2019. Increased time between last antineoplastic chemotherapy and MIR reconstruction was a statistically significant, independent predictor of decreased complication likelihood. By contrast, autologous reconstruction, hypertension, and type II diabetes mellitus, and African American, White, and Hispanic race (relative to Asian) had statistically significant associations with increased complication likelihood. Waiting an additional day between a patient's most recent chemotherapy session and MIR reconstruction reduces the odds of a complication occurring by 0.25%. This corresponds to reduction in odds of complication occurrence of approximately 7% for each month between neoadjuvant therapy and breast reconstruction.

CONCLUSION

Increased time between NAC and MIR immediate reconstruction decreases the likelihood of experiencing one or more postoperative complications. Ideal time delay between 4 and 8 weeks has been shown to provide the best benefit for future breast reconstrution outcomes. In consultation with the oncologist, this information can be used to balance postoperative complication risk with increased oncologic risk in delaying mastectomy with immediate reconstruction.

Radiomic tumor phenotypes augment molecular profiling in predicting recurrence free survival after breast neoadjuvant chemotherapy

BACKGROUND

Early changes in breast intratumor heterogeneity during neoadjuvant chemotherapy may reflect the tumor's ability to adapt and evade treatment. We investigated the combination of precision medicine predictors of genomic and MRI data towards improved prediction of recurrence free survival (RFS).

METHODS

A total of 100 women from the ACRIN 6657/I-SPY 1 trial were retrospectively analyzed. We estimated MammaPrint, PAM50 ROR-S, and p53 mutation scores from publicly available gene expression data and generated four, voxel-wise 3-D radiomic kinetic maps from DCE-MR images at both pre- and early-treatment time points. Within the primary lesion from each kinetic map, features of change in radiomic heterogeneity were summarized into 6 principal components.

RESULTS

We identify two imaging phenotypes of change in intratumor heterogeneity (p < 0.01) demonstrating significant Kaplan-Meier curve separation (p < 0.001). Adding phenotypes to established prognostic factors, functional tumor volume (FTV), MammaPrint, PAM50, and p53 scores in a Cox regression model improves the concordance statistic for predicting RFS from 0.73 to 0.79 (p = 0.002).

CONCLUSIONS

These results demonstrate an important step in combining personalized molecular signatures and longitudinal imaging data towards improved prognosis.

Potential Role of Circulating miRNAs for Breast Cancer Management in the Neoadjuvant Setting: A Road to Pave

Recently, circulating microRNAs (miRNAs) have emerged as potential non-invasive biomarkers for breast cancer (BC) management. In the context of BC patients undergoing neoadjuvant chemotherapy (NAC), the possibility of obtaining repeated, non-invasive biological samples from patients before, during, and after treatment is incredibly convenient and provides the opportunity to investigate circulating miRNAs as diagnostic, predictive, and prognostic tools. The present review aims to summarize major findings in this setting, thus highlighting their potential applicability in daily clinical practice and their possible limitations. In all the contexts (diagnostic, predictive, and prognostic), circulating miR-21-5p and miR-34a-5p have emerged as the most promising non-invasive biomarkers for BC patients undergoing NAC. Specifically, their high baseline level could discriminate between BC patients and healthy controls. On the other hand, in predictive and prognostic investigations, low circulating miR-21-5p and miR-34a-5p levels may identify patients with better outcomes, in terms of both treatment response and invasive disease-free survival. However, the findings in this field have been very heterogeneous. Indeed, pre-analytical and analytical variables, as well as factors related to patients, may explain the inconsistency among different study results. Thus, further clinical trials, with more precise patient inclusion criteria and more standardized methodological approaches, are definitely needed to better define the potential role of these promising non-invasive biomarkers.

Early Assessment of Neoadjuvant Chemotherapy Response Using Multiparametric Magnetic Resonance Imaging in Luminal B-like Subtype of Breast Cancer Patients: A Single-Center Prospective Study

This study aimed to evaluate the performance of multiparametric breast magnetic resonance imaging (mpMRI) for predicting response to neoadjuvant chemotherapy (NAC) in patients with luminal B subtype breast cancer. The prospective study included thirty-five patients treated with NAC for both early and locally advanced breast cancer of the luminal B subtype at the University Hospital Centre Zagreb between January 2015 and December 2018. All patients underwent breast mpMRI before and after two cycles of NAC. Evaluation of mpMRI examinations included analysis of both morphological (shape, margins, and pattern of enhancement) and kinetic characteristics (initial signal increase and post-initial behavior of the time-signal intensity curve), which were additionally interpreted with a Göttingen score (GS). Histopathological analysis of surgical specimens included grading the tumor response based on the residual cancer burden (RCB) grading system and revealed 29 NAC responders (RCB-0 (pCR), I, II) and 6 NAC non-responders (RCB-III). Changes in GS were compared with RCB classes. A lack of GS decrease after the second cycle of NAC is associated with RCB class and non-responders to NAC.

Breast Cancer With a HER2 FISH Group 2 Result: Should HER2 Tests be Repeated?

BACKGROUND

Breast cancer with fluorescence in situ hybridization (FISH) group 2 pattern (HER2 <4 and HER2/CEP17 ratio ≥2, a subset of monosomy CEP17) was historically considered HER2-positive, but mostly HER2-negative according to updated 2018 American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP) guidelines unless 3+ by immunohistochemistry (IHC). Therapeutic relevance of this group remained elusive, therefore we assessed if repeat IHC and FISH can assist final HER2 classification.

PATIENT AND METHODS

We retrospectively reviewed HER2 FISH performed at our institution from 2014 to 2018 and identified 23 of 3554 (0.6%) breast cancer cases with at least one-time measurement of HER2 FISH categorized as group 2. Repeat HER2 tests were performed for cases with available alternative tumor samples and compared with initial testing following 2018 ASCO/CAP guidelines.

RESULTS

Only 1 of 23 group 2 cases was HER2-positive, 0/18 in primary and 1/5 in metastatic/recurrent tumors. Of 13 primary tumors with repeat HER2 results; 10 (77%) remained HER2-negative; 3 (23%) changed from HER2-negative (group 2 and IHC 2+) to HER2-positive (group 1 and IHC 2+). Among 8 of these 13 patients receiving neoadjuvant systemic therapy containing anti-HER2 agent, 3 (38%) achieved pathologic complete response (pCR). Two of 3 pCR cases were HER2-positive converters on repeat testing. Three pCR cases were ER-negative or -low positive and Ki67 ≥40%, while 5 partial responders were ER-positive and Ki67 <40% (P < .05).

CONCLUSION

Breast cancer with HER2 FISH group 2 result may represent heterogeneous populations of tumor cells being originated de novo or preferentially selected secondary to therapy. Repeat HER2 tests on alternative samples may be considered to guide anti-HER2 therapy.

Neoadjuvant chemotherapy modulates exhaustion of T cells in breast cancer patients

Breast cancer is the leading cause of cancer deaths in women worldwide. It has been observed that the incidence of breast cancer increases linearly with age after 45, which suggest a link between cancer, aging, and senescence. A growing body of evidence indicates that the immunosuppressive tumor network in breast cancer patients can lead to T-cell exhaustion and senescence. Cytotoxic chemotherapy is a common treatment for many cancers, and it is hypothesized that its efficacy may be related to immune activation. However, the effects of neoadjuvant chemotherapy on T-cell dysfunction in breast cancer patients are not fully understood. This study aimed to evaluate the impact of neoadjuvant chemotherapy on the expression of exhaustion and senescence markers in T cells in women with breast cancer. Our results showed that T cells from breast cancer patients have a reduced ability to respond to stimulation in-vitro and an increased expression of senescence and exhaustion-associated markers, such as TIM-3, LAG3, and CD57. Furthermore, we found that neoadjuvant chemotherapy has an immunomodulatory effect and reduces the expression of exhaustion markers. Our observations of the immune phenotype of T cells during neoadjuvant chemotherapy treatment highlight its ability to stimulate the immune system against cancer. Therefore, monitoring the response of T cells during chemotherapy may enable early prediction of clinical response.

Unchartered waters: Significance of fall in Ki67 index after short-term preoperative endocrine therapy in early breast cancers

BACKGROUND

Endocrine treatment for breast cancer acts largely by inhibiting tumor cell proliferation. The biomarker Ki67 is linked to the proliferative index of the tumour.

OBJECTIVE

To identify the factors affecting the fall in Ki67 value in early-stage hormone receptor (HR) positive breast cancer patients receiving short-term preoperative endocrine therapy in an Indian cohort.

METHODS

Women with hormone receptor positive, invasive, nonmetastatic, and early breast cancer (<T2, <N1) were assigned to short-term preoperative tamoxifen 20 mg daily (pre-menopausal women) or Letrozole 2.5 mg daily (post-menopausal women) for a minimum of 7 days after noting the baseline Ki67 value from the diagnostic core biopsy specimen. The postoperative Ki67 value was estimated from the surgical specimen, and the factors determining the extent of fall were evaluated.

RESULTS

The short-term preoperative endocrine therapy resulted in a reduction in the median Ki67 index, which was significantly greater among postmenopausal women who received Letrozole (63.25 (31.94-80.5)) than among premenopausal women who received Tamoxifen (0 (-28.99-62.25)) (p-value 0.001). The fall in Ki67 value was particularly marked for patients with low-grade tumors with high Estrogen and progesterone receptor expression (p-value < 0.05). The duration of treatment (<2 week or 2-4 week or >4 week) did not affect the fall in Ki67.

CONCLUSION

Preoperative therapy with Letrozole resulted in a more significant fall in Ki67, as compared to therapy with Tamoxifen. Determining the fall in Ki67 value in response to preoperative endocrine therapy could provide an insight into the response to endocrine therapy in luminal breast cancer.

NMR-Based Metabolomics to Evaluate Individual Response to Treatments

The aim of this chapter is to highlight the various aspects of metabolomics in relation to health and diseases, starting from the definition of metabolic space and of how individuals tend to maintain their own position in this space. Physio-pathological stimuli may cause individuals to lose their position and then regain it, or move irreversibly to other positions. By way of examples, mostly selected from our own work using ¹H NMR on biological fluids, we describe the effects on the individual metabolomic fingerprint of mild external interventions, such as diet or probiotic administration. Then we move to pathologies (such as celiac disease, various types of cancer, viral infections, and other diseases), each characterized by a well-defined metabolomic fingerprint. We describe the effects of drugs on the disease fingerprint and on its reversal to a healthy metabolomic status. Drug toxicity can be also monitored by metabolomics. We also show how the individual metabolomic fingerprint at the onset of a disease may discriminate responders from non-responders to a given drug, or how it may be prognostic of e.g., cancer recurrence after many years. In parallel with fingerprinting, profiling (i.e., the identification and quantification of many metabolites and, in the case of selected biofluids, of the lipoprotein components that contribute to the ¹H NMR spectral features) can provide hints on the metabolic pathways that are altered by a disease and assess their restoration after treatment.

Phenotyping of rare circulating cells in the blood of non-metastatic breast cancer patients using microfluidic Labyrinth technology

Label-free technologies for isolating rare circulating cells in breast cancer patients are widely available; however, they are mostly validated on metastatic patient blood samples. Given the need to use blood-based biomarkers to inform on disease progression and treatment decisions, it is important to validate these technologies in non-metastatic patient blood samples. In this study, we specifically focus on a recently established label-free microfluidic technology Labyrinth and assess its capabilities to phenotype a variety of rare circulating tumor cells indicative of epithelial-to-mesenchymal transition as well as cancer-associated macrophage-like (CAML) cells. We specifically chose a patient cohort that is non-metastatic and selected to undergo neoadjuvant chemotherapy to assess the performance of the Labyrinth technology. We enrolled 21 treatment naïve non-metastatic breast cancer patients of various disease stages. Our results indicate that (i) Labyrinth microfluidic technology is successfully able to isolate different phenotypes of CTCs despite the counts being low. (ii) Invasive phenotypes of CTCs such as transitioning CTCs and mesenchymal CTCs were found to be present in high numbers in stage III patients as compared to stage II patients. (iii) As the total load of CTCs increased, the mesenchymal CTCs were found to be increasing. (iv) Labyrinth was able to isolate CAMLs with the counts being higher in stage III patients as compared to stage II patients. Our study demonstrates the ability of the Labyrinth microfluidic technology to isolate rare cancer-associated cells from the blood of treatment naïve non-metastatic breast cancer patients, laying the foundation for tracking oncogenic spread and immune response in patients undergoing neoadjuvant chemotherapy.

The Role of miR-375-3p, miR-210-3p and Let-7e-5p in the Pathological Response of Breast Cancer Patients to Neoadjuvant Therapy

Background and Objectives: Prediction of response to therapy remains a continuing challenge in treating breast cancer, especially for identifying molecular tissue markers that best characterize resistant tumours. Microribonucleic acids (miRNA), known as master modulators of tumour phenotype, could be helpful candidates for predicting drug resistance. We aimed to assess the association of miR-375-3p, miR-210-3p and let-7e-5p in breast cancer tissues with pathological response to neoadjuvant therapy (NAT) and clinicopathological data. Material and methods: Sixty female patients diagnosed with invasive breast cancer at The Oncology Institute “Ion Chiricuță”, Cluj-Napoca, Romania (IOCN) were included in this study. Before patients received any treatment, fresh breast tissue biopsies were collected through core biopsy under echographic guidance and processed for total RNA extraction and miRNA quantification. The Cancer Genome Atlas Breast Invasive Carcinoma (TCGA-BRCA) database was used as an independent external validation cohort. Results: miR-375-3p expression was associated with more differentiated tumours, hormone receptor presence and lymphatic invasion. According to the Miller–Payne system, a higher miR-375-3p expression was calculated for patients that presented with intermediate versus (vs.) no pathological response. Higher miR-210-3p expression was associated with an improved response to NAT in both Miller–Payne and RCB evaluation systems. Several druggable mRNA targets were correlated with miR-375-3p and miR-210-3p expression, with upstream analysis using the IPA knowledge base revealing a list of possible chemical and biological targeting drugs. Regarding let-7e-5p, no significant association was noticed with any of the analysed clinicopathological data. Conclusions: Our results suggest that tumours with higher levels of miR-375-3p are more sensitive to neoadjuvant therapy compared to resistant tumours and that higher miR-210-3p expression in responsive tumours could indicate an excellent pathological response.

Novel Radiomic Measurements of Tumor-Associated Vasculature Morphology on Clinical Imaging as a Biomarker of Treatment Response in Multiple Cancers

PURPOSE

The tumor-associated vasculature (TAV) differs from healthy blood vessels by its convolutedness, leakiness, and chaotic architecture, and these attributes facilitate the creation of a treatment-resistant tumor microenvironment. Measurable differences in these attributes might also help stratify patients by likely benefit of systemic therapy (e.g., chemotherapy). In this work, we present a new category of computational image-based biomarkers called quantitative tumor-associated vasculature (QuanTAV) features, and demonstrate their ability to predict response and survival across multiple cancer types, imaging modalities, and treatment regimens involving chemotherapy.

EXPERIMENTAL DESIGN

We isolated tumor vasculature and extracted mathematical measurements of twistedness and organization from routine pretreatment radiology (CT or contrast-enhanced MRI) of a total of 558 patients, who received one of four first-line chemotherapy-based therapeutic intervention strategies for breast (n = 371) or non-small cell lung cancer (NSCLC, n = 187).

RESULTS

Across four chemotherapy-based treatment strategies, classifiers of QuanTAV measurements significantly (P < 0.05) predicted response in held out testing cohorts alone (AUC = 0.63-0.71) and increased AUC by 0.06-0.12 when added to models of significant clinical variables alone. Similarly, we derived QuanTAV risk scores that were prognostic of recurrence-free survival in treatment cohorts who received surgery following chemotherapy for breast cancer [P = 0.0022; HR = 1.25; 95% confidence interval (CI), 1.08-1.44; concordance index (C-index) = 0.66] and chemoradiation for NSCLC (P = 0.039; HR = 1.28; 95% CI, 1.01-1.62; C-index = 0.66). From vessel-based risk scores, we further derived categorical QuanTAV high/low risk groups that were independently prognostic among all treatment groups, including patients with NSCLC who received chemotherapy only (P = 0.034; HR = 2.29; 95% CI, 1.07-4.94; C-index = 0.62). QuanTAV response and risk scores were independent of clinicopathologic risk factors and matched or exceeded models of clinical variables including posttreatment response.

CONCLUSIONS

Across these domains, we observed an association of vascular morphology on CT and MRI-as captured by metrics of vessel curvature, torsion, and organizational heterogeneity-and treatment outcome. Our findings suggest the potential of shape and structure of the TAV in developing prognostic and predictive biomarkers for multiple cancers and different treatment strategies.

Precision Breast Cancer Medicine: Early Stage Triple Negative Breast Cancer-A Review of Molecular Characterisation, Therapeutic Targets and Future Trends

Personalised approaches to the management of all solid tumours are increasing rapidly, along with wider accessibility for clinicians. Advances in tumour characterisation and targeted therapies have placed triple-negative breast cancers (TNBC) at the forefront of this approach. TNBC is a highly heterogeneous disease with various histopathological features and is driven by distinct molecular alterations. The ability to tailor individualised and effective treatments for each patient is of particular importance in this group due to the high risk of distant recurrence and death. The mainstay of treatment across all subtypes of TNBC has historically been cytotoxic chemotherapy, which is often associated with off-target tissue toxicity and drug resistance. Neoadjuvant chemotherapy is commonly used as it allows close monitoring of early treatment response and provides valuable prognostic information. Patients who achieve a complete pathological response after neoadjuvant chemotherapy are known to have significantly improved long-term outcomes. Conversely, poor responders face a higher risk of relapse and death. The identification of those subgroups that are more likely to benefit from breakthroughs in the personalised approach is a challenge of the current era where several targeted therapies are available. This review presents an overview of contemporary practice, and promising future trends in the management of early TNBC. Platinum chemotherapy, DNA damage response (DDR) inhibitors, immune checkpoint inhibitors, inhibitors of the PI3K-AKT-mTOR, and androgen receptor (AR) pathways are some of the increasingly studied therapies which will be reviewed. We will also discuss the growing evidence for less-developed agents and predictive biomarkers that are likely to contribute to the forthcoming advances in this field. Finally, we will propose a framework for the personalised management of TNBC based upon the integration of clinico-pathological and molecular features to ensure that long-term outcomes are optimised.

Diffusion Breast MRI: Current Standard and Emerging Techniques

The role of diffusion weighted imaging (DWI) as a biomarker has been the subject of active investigation in the field of breast radiology. By quantifying the random motion of water within a voxel of tissue, DWI provides indirect metrics that reveal cellularity and architectural features. Studies show that data obtained from DWI may provide information related to the characterization, prognosis, and treatment response of breast cancer. The incorporation of DWI in breast imaging demonstrates its potential to serve as a non-invasive tool to help guide diagnosis and treatment. In this review, current technical literature of diffusion-weighted breast imaging will be discussed, in addition to clinical applications, advanced techniques, and emerging use in the field of radiomics.

Therapeutic pattern and progress of neoadjuvant treatment for triple-negative breast cancer

Triple-negative breast cancer (TNBC) is a heterogeneous disease, accounting for about 15.0-20.0% of all breast cancer cases. TNBC is associated with early recurrence and metastasis, strong invasiveness and a poor prognosis. Chemotherapy is currently the mainstay of treatment for TNBC, and achievement of a pathological complete response is closely associated with a long-term good prognosis. Improving the long-term prognosis in patients with TNBC is a challenge in breast cancer treatment, and more clinical evidence is needed to guide the choice of treatment strategies. The current study reviews the conventional treatment modality for TNBC and the selection of neoadjuvant chemotherapy (NACT) regimens available. The research progress on optimizing NACT regimens is also reviewed, and the uniqueness of the treatment of this breast cancer subtype is emphasized, in order to provide reference for the clinical practice and research with regard to TNBC treatment.

The association between breast density and breast cancer pathological response to neoadjuvant chemotherapy

Purpose

Mammographic Density (MD) refers to the amount of fibroglandular breast tissue present in the breast and is an established risk factor for developing breast cancer. The ability to evaluate treatment response dynamically renders neoadjuvant chemotherapy (NACT) the preferred treatment option in many clinical scenarios. Previous studies have suggested that MD can predict patients likely to achieve a pathological complete response (pCR) to NACT. We aimed to determine whether there is a causal relationship between BI-RADS breast composition categories for breast density at diagnosis and the pCR rate and residual cancer burden score (RCB) by performing a retrospective review on consecutive breast cancer patients who received NACT in a tertiary referral centre from 2015 to 2021.

Methods

The Mann–Whitney U Test was used to test for differences between two independent groups (i.e. those who achieved pCR and those who did not). A binary logistic regression model was used to estimate odds ratios (OR) and corresponding 95% confidence intervals (CI) for an association between the independent variables of molecular subtype, MD, histological grade and FNA positivity and the dependant variable of pCR. Statistical analysis was conducted with SPSS (IBM SPSS for Mac, Version 26.0; IBM Corp).

Results

292 patients were included in the current study. There were 124, 155 and 13 patients in the BI-RADS MD category b, c and d, respectively. There were no patients in the BI-RADS MD category a. The patients with less dense breast composition (MD category b) were significantly older than patients with denser breast composition (MD category c, d) (p = 0.001) and patients who had a denser breast composition (MD category d) were more likely to have ER+ tumours. There was no significant difference in PgR status, HER2 status, pathological complete response (pCR), FNA positivity, or RCB class dependent upon the three MD categories. A binary logistic regression revealed that patients with HER2-enriched breast cancer and triple-negative breast cancer are more likely to achieve pCR with an OR of 3.630 (95% CI 1.360–9.691, p = 0.010) and 2.445 (95% CI 1.131–5.288, p = 0.023), respectively.

Conclusion

Whilst dense MD was associated with ER positivity and these women were less likely to achieve a pCR, MD did not appear to independently predict pCR post-NACT.

Short-Term Outcomes Following Breast Cancer Surgery With and Without Neoadjuvant Chemotherapy: A Nationwide Administrative Database Study in Japan

PURPOSE

Although neoadjuvant chemotherapy (NAC) has become common for breast cancer, its impact on short-term surgical outcomes and the feasible chemotherapy-surgery interval remain unclear. Using a Japanese nationwide database, this study investigated the impact of NAC on short-term outcomes following breast cancer surgery.

METHODS

In this study of 11,722 patients with NAC and 120,538 patients without NAC who underwent surgery for stage 0-III breast cancer July 2010-March 2017, to cancel out site-specific effects, we generated a 1:4 matched-pair cohort matched for age, institution, and fiscal year of admission. We then conducted multivariable analyses adjusting for potential confounders to compare postoperative complications, duration of anesthesia, and total hospitalization costs. Additionally, we conducted three sensitivity analyses for patients with a short interval from NAC to surgery, patients receiving a particular NAC regimen, and patients undergoing a particular surgical procedure.

RESULTS

In total, the occurrence of postoperative complications was 6.0%, and the median interval from NAC to surgery was 31 (interquartile range, 24-39) days. The two groups did not differ significantly in terms of complications (odds ratio, 0.95; 95% confidence interval, 0.88-1.04), including local and general complications. NAC was significantly associated with shorter duration of anesthesia and lower total hospitalization costs. The sensitivity analyses showed similar results.

CONCLUSIONS

Our matched-pair cohort analyses revealed no significant differences in postoperative complications between patients with and without NAC for breast cancer, regardless of the interval, regimen, and surgical procedure. Patients can safely receive surgery and NAC without a lengthened interval.

Tumor Glucose and Fatty Acid Metabolism in the Context of Anthracycline and Taxane-Based (Neo)Adjuvant Chemotherapy in Breast Carcinomas

Breast cancer is characterized by considerable metabolic diversity. A relatively high percentage of patients diagnosed with breast carcinoma do not respond to standard-of-care treatment, and alteration in metabolic pathways nowadays is considered one of the major mechanisms responsible for therapeutic resistance. Consequently, there is an emerging need to understand how metabolism shapes therapy response, therapy resistance and not ultimately to analyze the metabolic changes occurring after different treatment regimens. The most commonly applied neoadjuvant chemotherapy regimens in breast cancer contain an anthracycline (doxorubicin or epirubicin) in combination or sequentially administered with taxanes (paclitaxel or docetaxel). Despite several efforts, drug resistance is still frequent in many types of breast cancer, decreasing patients’ survival. Understanding how tumor cells rapidly rewire their signaling pathways to persist after neoadjuvant cancer treatment have to be analyzed in detail and in a more complex system to enable scientists to design novel treatment strategies that target different aspects of tumor cells and tumor resistance. Tumor heterogeneity, the rapidly changing environmental context, differences in nutrient use among different cell types, the cooperative or competitive relationships between cells pose additional challenges in profound analyzes of metabolic changes in different breast carcinoma subtypes and treatment protocols. Delineating the contribution of metabolic pathways to tumor differentiation, progression, and resistance to different drugs is also the focus of research. The present review discusses the changes in glucose and fatty acid pathways associated with the most frequently applied chemotherapeutic drugs in breast cancer, as well the underlying molecular mechanisms and corresponding novel therapeutic strategies.

Contrast-free MRI quantitative parameters for early prediction of pathological response to neoadjuvant chemotherapy in breast cancer

OBJECTIVES

To assess early changes in synthetic relaxometry after neoadjuvant chemotherapy (NAC) for breast cancer and establish a model with contrast-free quantitative parameters for early prediction of pathological response.

METHODS

From March 2019 to January 2021, breast MRI were performed for a primary cohort of women with breast cancer before (n = 102) and after the first (n = 93) and second (n = 90) cycle of NAC. Tumor size, synthetic relaxometry (T1/T2 relaxation time [T1/T2], proton density), and ADC were obtained, and the changes after treatment were calculated. Prediction models were established by multivariate logistic regression; evaluated with discrimination, calibration, and clinical application; and compared with Delong tests, net reclassification (NRI), and integrated discrimination index (IDI). External validation was performed from February to June 2021 with an independent cohort of 35 patients.

RESULTS

In the primary cohort, all parameters changed after early treatment. Synthetic relaxometry decreased to a greater degree in major histologic responders (MHR, Miller-Payne G4-5) compared with non-MHR (Miller-Payne G1-3). A model combining ADC after treatment, changes in T1 and tumor size, and cancer subtype achieved the highest AUC after the first (primary/validation cohort, 0.83/0.82) and second cycles (primary/validation cohort, 0.85/0.84). No difference of AUC (p ≥ 0.27), NRI (p ≥ 0.31), and IDI (p ≥ 0.32) was found between models with different cycles and size-measured sequences. Model calibration and decision curves demonstrated a good fitness and clinical benefit, respectively.

CONCLUSIONS

Early reduction in synthetic relaxometry indicated pathological response to NAC. Contrast-free T1 and ADC combined with size and cancer subtype predicted effectively pathological response after one NAC cycle.

KEY POINTS

• Synthetic MRI relaxometry changed after early neoadjuvant chemotherapy, which demonstrated pathological response for mass-like breast cancers. • Contrast-free quantitative parameters including T1 relaxation time and apparent diffusion coefficient, combined with tumor size and cancer subtype, stratified major histologic responders. • A contrast-free model predicted an early pathological response after the first treatment cycle of neoadjuvant chemotherapy.

PD-L1 expression in breast invasive ductal carcinoma with incomplete pathological response to neoadjuvant chemotherapy

Objectives:

To investigate the expression of programmed death-ligand 1 (PD-L1) in breast cancer in association with incomplete pathological response (PR) to neoadjuvant chemotherapy (NAC).

Methods

PD-L1 expression was evaluated using immunohistochemistry in post-operative, post-NAC samples of 60 patients (n = 60) diagnosed with breast invasive ductal carcinoma with incomplete PR to NAC, including 31 matched pre-NAC and post-NAC samples (n = 31). PD-L1 protein expression was assessed using three scoring approaches, including the tumor proportion score (TPS), the immune cell score (ICS), and the combined tumor and immune cell score (combined positive score, CPS) with a 1% cut-off.

Results

In the post-operative, post-NAC samples (n = 60), positive expression rate of PD-L1 was observed in 18.3% (11/60) of cases by TPS, 31.7% (19/60) by ICS, and 25% (15/60) by CPS. In matched samples, positive expression rate of PD-L1 was observed in 19.3% (6/31) of patients by TPS, 51.6% (16/31) by ICS, and 19.3% (6/31) by CPS in pre-NAC specimens, while it was observed in 22.6% (7/31) of matched post-NAC samples by TPS, 22.6% (7/31) by ICS, and 19.3% (6/31) by CPS. In the matched samples, there was a significant decrease in PD-L1 immunoexpression using ICS in post-NAC specimens (McNemar’s, p = 0.020), while no significant differences were found using TPS and CPS between pre- and post-NAC samples (p = 1.000, p = 0.617; respectively). PD-L1 immunoexpression determined by TPS or CPS was only significantly associated with ER status (p = 0.022, p = 0.021; respectively), but not with other clinicopathological variables. We could not establish a correlation between PD-L1 expression and the overall survival rate (p > 0.05). There were no significant differences in the tumor infiltrating lymphocytes count between the paired pre- and post-NAC samples (t = 0.581, p = 0.563 or Wilcoxon’s Signed Rank test; z = -0.625, p = 0.529).

Conclusion

Our findings indicate that PD-L1 protein expression in infiltrating immune cells was significantly reduced in breast tumors that developed incomplete PR following the exposure to NAC.

Circulating Proteins Associated with Response and Resistance to Neoadjuvant Chemotherapy in HER2-Positive Breast Cancer

Simple Summary

The goal of this study was to find circulating proteins that can be easily sampled and incorporated into a clinical setting to improve predictive treatment response in HER2-positive breast cancer patients receiving neoadjuvant chemotherapy. We looked for potential biomarkers in serum, which we identified using two proteomics techniques: qualitative LC-MS/MS and a quantitative assay that assessed protein expression between responders and non-responders HER2-positive breast cancer patients to neoadjuvant chemotherapy.

Abstract

Despite the increasing use of neoadjuvant chemotherapy (NAC) in HER2-positive breast cancer (BC) patients, the clinical problem of predicting individual treatment response remains unanswered. Furthermore, the use of ineffective chemotherapeutic regimens should be avoided. Serum biomarker levels are being studied more and more for their ability to predict therapy response and aid in the development of personalized treatment regimens. This study aims to identify effective protein networks and biomarkers to predict response to NAC in HER2-positive BC patients through an exhaustive large-scale LC-MS/MS-based qualitative and quantitative proteomic profiling of serum samples from responders and non-responders. Serum samples from HER2-positive BC patients were collected before NAC and were processed by three methods (with and without nanoparticles). The qualitative analysis revealed differences in the proteomic profiles between responders and non-responders, mainly in proteins implicated in the complement and coagulation cascades and apolipoproteins. Qualitative analysis confirmed that three proteins (AFM, SERPINA1, APOD) were correlated with NAC resistance. In this study, we show that serum biomarker profiles can predict treatment response and outcome in the neoadjuvant setting. If these findings are further developed, they will be of significant clinical utility in the design of treatment regimens for individual BC patients.

Comparison of short-term and long-term neoadjuvant hormone therapy prior to radical prostatectomy: a systematic review and meta-analysis

PURPOSE

This study aimed to evaluate the efficacy of long-term neoadjuvant androgen-deprivation therapy (ADT) before radical prostatectomy (RP).

METHODS

We conducted meta-analyses and network meta-analyses, which included randomized controlled trials that assessed patients with prostate cancer (PC) who received either short-term (<6 months) or long-term (≥6 months) neoadjuvant ADT before RP.

RESULTS

Thirteen articles with 2778 patients were eligible for analysis. Short-term neoadjuvant ADT was neither associated with biochemical recurrence (OR 1.19, 95% CI, 0.93-1.51, p = 0.17), metastasis (OR 0.73, 95% CI, 0.45-1.19, p = 0.21), nor overall mortality (OR 0.72, 95% CI 0.43-1.21, p = 0.22); no study investigated survival outcomes in patients on long-term neoadjuvant ADT. In terms of pathologic outcomes, long-term neoadjuvant ADT was significantly associated with a reduced risk of positive surgical margin (SM) and an increased rate of organ-confined disease (OCD) compared to short-term neoadjuvant ADT (OR 0.56, 95% CI 0.39-0.80, p = 0.001, and OR 1.48, 95% CI 1.10-1.99, p = 0.009, respectively). These findings were confirmed in the network meta-analyses. Meanwhile, only a non-significant trend favoring long-term neoadjuvant ADT was observed for pathologic complete response (OR 1.98, 95% Crl 1.00-3.93).

CONCLUSION

Long-term neoadjuvant ADT was associated with more favorable pathologic outcomes, but whether these findings translate into favorable survival outcomes still remains unproven due to very limited evidence. Since there are no reliable survival data, long-term neoadjuvant ADT before RP should not be used in clinical practice until more robust evidence arises from ongoing trials.

Nomogram for Early Prediction of Pathological Complete Response to Neoadjuvant Chemotherapy in Breast Cancer Using Dynamic Contrast-enhanced and Diffusion-weighted MRI

RATIONALE AND OBJECTIVES

The study investigated the potential of the combined use of dynamic contrast-enhanced MRI and diffusion-weighted imaging in predicting the pathological complete response (pCR) of neoadjuvant chemotherapy (NAC) after two cycles of NAC.

MATERIALS AND METHODS

Eighty-seven patients with breast cancer who underwent MR examination before and after two cycles of NAC were enrolled. The patients were randomly assigned to a training cohort and a validation cohort (3:1 ratio). MRI parameters including tumor longest diameter, time-signal intensity curve, early enhanced ratio (E₉₀), maximal enhanced ratio and ADC value were measured, and percentage change in MRI parameters were calculated. Univariate analysis and multivariate logistic regression analysis were used to evaluate independent predictors of pCR in the training cohort. The validation cohort was used to test the prediction model, and the nomogram was created based on the prediction model.

RESULTS

This study demonstrated that the ADC value after two cycles of NAC (OR = 1.041, 95% CI (1.002, 1.081); p = 0.037), percentage decrease in E₉₀ (OR = 0.927, 95% CI (0.881, 0.977); p =0.004) and percentage decrease in tumor size (OR = 0.948, 95% CI (0.909, 0.988); p = 0.011) were significantly important for independently predicting pCR. The prediction model yielded AUC of 0.939 and 0.944 in the training cohort and the validation cohort, respectively.

CONCLUSION

The combined use of dynamic contrast-enhanced MRI and diffusion-weighted imaging could accurately predict pCR after two cycles of NAC. The prediction model and the nomogram had strong predictive value to NAC.

Pathologic Complete Response and Its Impact on Breast Cancer Recurrence and Patient's Survival after Neoadjuvant Therapy: A Comprehensive Meta-Analysis

OBJECTIVE

Earlier research has illustrated prognostic significance of pathologic complete response (pCR) in neoadjuvant therapy (NAT) for breast cancer, whereas correlation between treatment after achieving pCR and survival improvement remains underexplored. We attempted to measure the relation between pCR achieved after NAT and breast cancer recurrence or patient's survival.

METHODS

We searched PubMed, EMBASE, Web of Science, and The Cochrane Library databases to find relevant articles from their inception to November 2020. According to eligibility criteria, studies were selected and basic data were extracted. The primary endpoint was the correlation between pCR achieved after NAT and event-free survival (EFS) or overall survival (OS). The results were obtained by directly extracting specific information from the literature or estimating individual data by survival curves on DigitizeIt software, presented with HR and 95% CI. All data were processed on Stata 14.0 software.

RESULTS

Among 4338 articles, there were 25 eligible articles involving 8767 patients. The EFS of patients achieved pCR after NAT improved obviously (HR = 0.27; 95% CI, 0.24-0.31), especially in triple negative (HR = 0.17; 95% CI, 0.12-0.24) and HER2 positive (HR = 0.24; 95% CI, 0.20-0.30) breast cancer patients. As such, pCR after NAT was implicated in significantly increased OS (HR = 0.32; 95% CI, 0.27-0.37).

CONCLUSION

Achieving pCR after NAT was notably related to the improvement of EFS and OS, especially for patients with triple-negative and HER2-positive breast cancer. pCR can be a surrogate indicator for outcome of breast cancer patients after NAT, as well as a predictor of treatment efficacy after NAT. Besides, well-designed studies are still warranted for confirmation.

Natural and Synthetic Estrogens in Chronic Inflammation and Breast Cancer

The oncogenic role of estrogen receptor (ER) signaling in breast cancer has long been established. Interaction of estrogen with estrogen receptor (ER) in the nucleus activates genomic pathways of estrogen signaling. In contrast, estrogen interaction with the cell membrane-bound G-protein-coupled estrogen receptor (GPER) activates the rapid receptor-mediated signaling transduction cascades. Aberrant estrogen signaling enhances mammary epithelial cell proliferation, survival, and angiogenesis, hence is an important step towards breast cancer initiation and progression. Meanwhile, a growing number of studies also provide evidence for estrogen's pro- or anti-inflammatory roles. As other articles in this issue cover classic ER and GPER signaling mediated by estrogen, this review will discuss the crucial mechanisms by which estrogen signaling influences chronic inflammation and how that is involved in breast cancer. Xenoestrogens acquired from plant diet or exposure to industrial products constantly interact with and alter innate estrogen signaling at various levels. As such, they can modulate chronic inflammation and breast cancer development. Natural xenoestrogens generally have anti-inflammatory properties, which is consistent with their chemoprotective role in breast cancer. In contrast, synthetic xenoestrogens are proinflammatory and carcinogenic compounds that can increase the risk of breast cancer. This article also highlights important xenoestrogens with a particular focus on their role in inflammation and breast cancer. Improved understanding of the complex relationship between estrogens, inflammation, and breast cancer will guide clinical research on agents that could advance breast cancer prevention and therapy.