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Kapetas P, Aggarwal R, Altuwayjiri B, Pinker K, Clauser P, Helbich TH, Baltzer PAT. A model combining BI-RADS® descriptors from pre-treatment B-mode breast ultrasound with clinicopathological tumor features shows promise in the prediction of residual disease after neoadjuvant chemotherapy. Eur J Radiol 2024; 178:111649. [PMID: 39094464 DOI: 10.1016/j.ejrad.2024.111649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE To create a simple model using standard BI-RADS® descriptors from pre-treatment B-mode ultrasound (US) combined with clinicopathological tumor features, and to assess the potential of the model to predict the presence of residual tumor after neoadjuvant chemotherapy (NAC) in breast cancer (BC) patients. METHOD 245 female BC patients receiving NAC between January 2017 and December 2019 were included in this retrospective study. Two breast imaging fellows independently evaluated representative B-mode tumor images from baseline US. Additional clinicopathological tumor features were retrieved. The dataset was split into 170 training and 83 validation cases. Logistic regression was used in the training set to identify independent predictors of residual disease post NAC and to create a model, whose performance was evaluated by ROC curve analysis in the validation set. The reference standard was postoperative histology to determine the absence (pathological complete response, pCR) or presence (non-pCR) of residual invasive tumor in the breast or axillary lymph nodes. RESULTS 100 patients (40.8%) achieved pCR. Logistic regression demonstrated that tumor size, microlobulated margin, spiculated margin, the presence of calcifications, the presence of edema, HER2-positive molecular subtype, and triple-negative molecular subtype were independent predictors of residual disease. A model using these parameters demonstrated an area under the ROC curve of 0.873 in the training and 0.720 in the validation set for the prediction of residual tumor post NAC. CONCLUSIONS A simple model combining standard BI-RADS® descriptors from pre-treatment B-mode breast US with clinicopathological tumor features predicts the presence of residual disease after NAC.
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Affiliation(s)
- Panagiotis Kapetas
- Department of Biomedical Imaging and Image-guided treatment, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY 10065, USA.
| | - Reena Aggarwal
- University Hospitals of Leicester, NHS Trust, LE1 5WW Leicester, Leicestershire, United Kingdom.
| | | | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th St, New York, NY 10065, USA.
| | - Paola Clauser
- Department of Biomedical Imaging and Image-guided treatment, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Thomas H Helbich
- Department of Biomedical Imaging and Image-guided treatment, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Pascal A T Baltzer
- Department of Biomedical Imaging and Image-guided treatment, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Washington I, Palm RF, White J, Rosenberg SA, Ataya D. The Role of MRI in Breast Cancer and Breast Conservation Therapy. Cancers (Basel) 2024; 16:2122. [PMID: 38893241 PMCID: PMC11171236 DOI: 10.3390/cancers16112122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/19/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Contrast-enhanced breast MRI has an established role in aiding in the detection, evaluation, and management of breast cancer. This article discusses MRI sequences, the clinical utility of MRI, and how MRI has been evaluated for use in breast radiotherapy treatment planning. We highlight the contribution of MRI in the decision-making regarding selecting appropriate candidates for breast conservation therapy and review the emerging role of MRI-guided breast radiotherapy.
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Affiliation(s)
- Iman Washington
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Russell F. Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Julia White
- Department of Radiation Oncology, The University of Kansas Medical Center, 4001 Rainbow Blvd, Kansas City, KS 66160, USA;
| | - Stephen A. Rosenberg
- Department of Radiation Therapy, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Dana Ataya
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, 10920 N. McKinley Drive, Tampa, FL 33612, USA;
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Kiaei DS, El-Jalbout R, Décarie JC, Perreault S, Dehaes M. Development of a semi-automatic segmentation technique based on mean magnetic resonance imaging intensity thresholding for volumetric quantification of plexiform neurofibromas. Heliyon 2024; 10:e23445. [PMID: 38173515 PMCID: PMC10761559 DOI: 10.1016/j.heliyon.2023.e23445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
Rationale and objectives Plexiform neurofibromas (PNs) are peripheral nerve tumors that occur in 25-50 % of patients with neurofibromatosis type 1. PNs may have complex, diffused, and irregular shapes. The objective of this work was to develop a volumetric quantification method for PNs as clinical assessment is currently based on unidimensional measurement. Materials and methods A semi-automatic segmentation technique based on mean magnetic resonance imaging (MRI) intensity thresholding (SSTMean) was developed and compared to a similar and previously published technique based on minimum image intensity thresholding (SSTMini). The performance (volume and computation time) of the two techniques was compared to manual tracings of 15 tumors of different locations, shapes, and sizes. Performance was also assessed using different MRI sequences. Reproducibility was assessed by inter-observer analysis. Results When compared to manual tracing, quantification performed with SSTMean was not significantly different (mean difference: 1.2 %), while volumes computed by SSTMini were significantly different (p < .0001, mean difference: 13.4 %). Volumes quantified by SSTMean were also significantly different than the ones assessed by SSTMini (p < .0001). Using SSTMean, volumes quantified with short TI inversion recovery, T1-, and T2-weighted imaging were not significantly different. Computation times used by SSTMean and SSTMini were significantly lower than for manual segmentation (p < .0001). The highest difference measured by two users was 8 cm3. Conclusion Our method showed accuracy compared to a current gold standard (manual tracing) and reproducibility between users. The refined segmentation threshold and the possibility to define multiple regions-of-interest to initiate segmentation may have contributed to its performance. The versatility and speed of our method may prove useful to better monitor volumetric changes in lesions of patients enrolled in clinical trials to assessing response to therapy.
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Affiliation(s)
- Dorsa Sadat Kiaei
- Institute of Biomedical Engineering, University of Montréal, Montréal, Canada
- Research Center, CHU Sainte-Justine Hospital University Centre, Montréal, Canada
| | - Ramy El-Jalbout
- Research Center, CHU Sainte-Justine Hospital University Centre, Montréal, Canada
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Montreal, Canada
| | - Jean-Claude Décarie
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Montreal, Canada
| | - Sébastien Perreault
- Research Center, CHU Sainte-Justine Hospital University Centre, Montréal, Canada
- Department of Neurosciences, University of Montreal, Montreal, Canada
| | - Mathieu Dehaes
- Institute of Biomedical Engineering, University of Montréal, Montréal, Canada
- Research Center, CHU Sainte-Justine Hospital University Centre, Montréal, Canada
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Montreal, Canada
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Alamoodi M, Wazir U, Mokbel K, Patani N, Varghese J, Mokbel K. Omitting Sentinel Lymph Node Biopsy after Neoadjuvant Systemic Therapy for Clinically Node Negative HER2 Positive and Triple Negative Breast Cancer: A Pooled Analysis. Cancers (Basel) 2023; 15:3325. [PMID: 37444434 DOI: 10.3390/cancers15133325] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Recent advances in systemic treatment for breast cancer have been underpinned by recognising and exploiting subtype-specific vulnerabilities to achieve higher rates of pathologic complete response (pCR) after neo-adjuvant systemic therapy (NAST). This down-staging of disease has permitted safe surgical de-escalation in patients who respond well. Triple-negative (TNBC) or HER2-positive breast cancer is most likely to achieve complete radiological response (rCR) and pCR after NAST. Hence, for selected patients, particularly those who are clinically node-negative (cN0) at diagnosis, the probability of disease in the sentinel node after NAST could be low enough to justify omitting axillary surgery. The aim of this pooled analysis was to determine the rate of sentinel node positivity (ypN+) in patients with TNBC or HER2-positive breast cancer who were initially cN0, achieving rCR and/or pCR in the breast after NAST. MedLine was searched using appropriate search terms. Five studies (N = 3834) were included in the pooled analysis, yielding a pooled ypN+ rate of 2.16% (95% CI: 1.70-2.63). This is significantly lower than the acceptable false negative rate of sentinel lymph node biopsy (SLNB) and supports consideration of omission of SLNB in this subset of patients.
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Affiliation(s)
- Munaser Alamoodi
- Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK
| | - Umar Wazir
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK
- Department of Surgery, Khyber Teaching Hospital, Peshawar 25120, Pakistan
| | - Kinan Mokbel
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK
- College of Medicine and Health, University of Exeter Medical School, Exeter EX1 2LU, UK
| | - Neill Patani
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK
- Department of General Surgery, University College London Hospital, Euston Road, London NW1 2BU, UK
| | - Jajini Varghese
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK
- Department of General Surgery, Royal Free Hospital, London NW3 2QG, UK
| | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, London W1U 5NY, UK
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Hayward JH, Linden OE, Lewin AA, Weinstein SP, Bachorik AE, Balija TM, Kuzmiak CM, Paulis LV, Salkowski LR, Sanford MF, Scheel JR, Sharpe RE, Small W, Ulaner GA, Slanetz PJ. ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer: 2022 Update. J Am Coll Radiol 2023; 20:S125-S145. [PMID: 37236739 DOI: 10.1016/j.jacr.2023.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Imaging plays a vital role in managing patients undergoing neoadjuvant chemotherapy, as treatment decisions rely heavily on accurate assessment of response to therapy. This document provides evidence-based guidelines for imaging breast cancer before, during, and after initiation of neoadjuvant chemotherapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Olivia E Linden
- Research Author, University of California, San Francisco, San Francisco, California
| | - Alana A Lewin
- Panel Chair, New York University Grossman School of Medicine, New York, New York
| | - Susan P Weinstein
- Panel Vice-Chair, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Tara M Balija
- Hackensack University Medical Center, Hackensack, New Jersey; American College of Surgeons
| | - Cherie M Kuzmiak
- University of North Carolina Hospital, Chapel Hill, North Carolina
| | | | - Lonie R Salkowski
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | | | | | | | - William Small
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, Illinois
| | - Gary A Ulaner
- Hoag Family Cancer Institute, Newport Beach, California, and University of Southern California, Los Angeles, California; Commission on Nuclear Medicine and Molecular Imaging
| | - Priscilla J Slanetz
- Specialty Chair, Boston University School of Medicine, Boston, Massachusetts
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Surgical Planning after Neoadjuvant Treatment in Breast Cancer: A Multimodality Imaging-Based Approach Focused on MRI. Cancers (Basel) 2023; 15:cancers15051439. [PMID: 36900231 PMCID: PMC10001061 DOI: 10.3390/cancers15051439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Neoadjuvant chemotherapy (NACT) today represents a cornerstone in the treatment of locally advanced breast cancer and highly chemo-sensitive tumors at early stages, increasing the possibilities of performing more conservative treatments and improving long term outcomes. Imaging has a fundamental role in the staging and prediction of the response to NACT, thus aiding surgical planning and avoiding overtreatment. In this review, we first examine and compare the role of conventional and advanced imaging techniques in preoperative T Staging after NACT and in the evaluation of lymph node involvement. In the second part, we analyze the different surgical approaches, discussing the role of axillary surgery, as well as the possibility of non-operative management after-NACT, which has been the subject of recent trials. Finally, we focus on emerging techniques that will change the diagnostic assessment of breast cancer in the near future.
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Diffusion-Weighted MRI in the Evaluation of Early-Stage Breast Cancer Treated with a Short Preoperative Radiotherapy: Preliminary Results. J Belg Soc Radiol 2023; 107:8. [PMID: 36817566 PMCID: PMC9912849 DOI: 10.5334/jbsr.2815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 12/30/2022] [Indexed: 02/10/2023] Open
Abstract
Objective To assess tumor response with diffusion-weighted MRI (DW-MRI) after a short preoperative radiotherapy in early-stage breast cancer (BCa). Materials and Methods This was a prospective, single-center pilot study. 3T-MRI were performed before and after radiotherapy. The longest diameter (LD) and the apparent diffusion coefficient (ADC) value of a region of interest (ROI) of the tumors were recorded. Histopathology and immunohistochemistry, including the Ki-67 index of the core biopsy and of the surgical specimen, were the reference standards. Results Nineteen patients with 22 early-stage BCa were included. The mean ROI ADC value was 1.093 ± 0.278 × 10-3 mm2/s before radiotherapy and 1.490 ± 0.429 × 10-3 mm2/s (p-value < 0.001) after radiotherapy. The Ki-67 index was 9.2 ± 9.1% at the percutaneous biopsy before radiotherapy and 4.9 ± 7.5% (p-value = 0.005) after radiotherapy at the surgical specimen. After neoadjuvant radiotherapy, a 4.7% decrease in LD and a 36.3% increase in ROI-ADC of the tumors were measured at MRI and a 46.7% decrease in Ki-67 index was observed at histology of the surgical specimen in comparison with the percutaneous core biopsy. Conclusion In early-stage BCa, a significant increase in ROI-ADC at DWI and a significant decrease in Ki-67 index were observed after a short preoperative radiotherapy, suggesting early tumor response.
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Hottat NA, Badr DA, Lecomte S, Besse-Hammer T, Jani JC, Cannie MM. Value of diffusion-weighted MRI in predicting early response to neoadjuvant chemotherapy of breast cancer: comparison between ROI-ADC and whole-lesion-ADC measurements. Eur Radiol 2022; 32:4067-4078. [PMID: 35015127 DOI: 10.1007/s00330-021-08462-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/20/2021] [Accepted: 11/08/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The aim of the study was to assess DWI with ROI-ADC and WL-ADC measurements in early response after NAC in breast cancer. METHODS Between January 2016 and December 2019, 55 women were enrolled in this prospective single-center study. MRI was performed at three time points for each patient: before treatment (MRI 1: DW and DCE MRI), after one cycle of NAC (MRI 2: noncontrast DW MRI), and after completion of NAC before surgery (MRI 3: DW and DCE MRI). ROI-ADC and WL-ADC measurements were obtained on MRI and were compared to histology findings and to the RCB class. Patients were categorized as having pCR or non-pCR. RESULTS Among 48 patients, 9 experienced pCR. An increase of ROI-ADC between MRI 1 and 2 of more than 47.5% had a sensitivity of 88.9% and a specificity of 63.4% in predicting pCR, whereas WL-ADC did not predict pCR. An increase of ROI-ADC between MRI 1 and 2 of more than 47.5% had a sensitivity of 83.3% and a specificity of 64.9% in predicting radiologic complete response. An increase of WL-ADC between MRI 1 and 2 of more than 25.5% had a sensitivity of 83.3% and a specificity of 75.5% in predicting radiologic complete response. CONCLUSION After one cycle of NAC, a significant increase in breast tumor ROI-ADC at DWI predicted complete pathologic and radiologic responses. KEY POINTS • An increase of WL-ADC between MRI 1 and 2 of more than 25.5% had a sensitivity of 83.3% and a specificity of 75.5% in predicting radiologic complete response. • An increase of ROI-ADC between MRI 1 and 2 of more than 47.5% had a sensitivity of 88.9% and a specificity of 63.4% in predicting pCR, and a sensitivity of 83.3% and a specificity of 64.9% in predicting radiologic complete response. • A significant increase in breast tumor ROI-ADC at DWI predicted complete pathologic and radiologic responses.
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Affiliation(s)
- Nathalie A Hottat
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Place A. Van Gehuchten 4, 1020, Brussels, Belgium. .,Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Dominique A Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Sophie Lecomte
- Department of Pathology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Tatiana Besse-Hammer
- Department of Clinical Research Unit University, Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Place A. Van Gehuchten 4, 1020, Brussels, Belgium.,Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Clinical Impact of FDG-PET/CT Compared with CE-CT in Response Monitoring of Metastatic Breast Cancer. Cancers (Basel) 2021; 13:cancers13164080. [PMID: 34439232 PMCID: PMC8392540 DOI: 10.3390/cancers13164080] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary The method of treatment evaluation in patients with chronic breast cancer may affect clinical decision making and treatment protocols. In this study, we compared the two imaging modalities for the evaluation of treatment responses in 65 patients with spread breast cancer. We included 34 patients who underwent contrast-enhanced computed tomography (CE-CT) and 31 patients who underwent positron emission tomography/computed tomography (FDG-PET/CT). Then, we compared the response categories and clinical effects within the two modalities during a follow-up period of an average of 17.3 months. Our results showed that CE-CT modality reported more scans as stable disease, while FDG-PET/CT modality reported regressive metastatic disease more often. This means that FDG-PET/CT responds more precisely with respect to the changes in patients’ clinical condition, while CE-CT tends to report stable disease in most of the scans. Therefore, FDG-PET/CT may be a more suitable imaging modality than CE-CT for the evaluation of treatment in patients with metastatic breast cancer. Abstract We compared response categories and impacts on treatment decisions for metastatic breast cancer (MBC) patients that are response-monitored with contrast-enhanced computed-tomography (CE-CT) or fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT). A comparative diagnostic study was performed on MBC patients undergoing response monitoring by CE-CT (n = 34) or FDG-PET/CT (n = 31) at the Odense University Hospital (Denmark). The responses were assessed visually and allocated into categories of complete response (CR/CMR), partial response (PR/PMR), stable disease (SD/SMD), and progressive disease (PD/PMD). Response categories, clinical impact, and positive predictive values (PPV) were compared for follow-up scans. A total of 286 CE-CT and 189 FDG-PET/CT response monitoring scans were performed. Response categories were distributed into CR (3.8%), PR (8.4%), SD (70.6%), PD (15%), and others (2.1%) by CE-CT and into CMR (22.2%), PMR (23.8%), SMD (31.2%), PMD (18.5%), and others (4.4%) by FDG-PET/CT, revealing a significant difference between the groups (P < 0.001). PD and PMD caused changes of treatment in 79.1% and 60%, respectively (P = 0.083). PPV for CE-CT and FDG-PET/CT was 0.85 (95% CI: 0.72–0.97) and 0.70 (95% CI: 0.53–0.87), respectively (P = 0.17). FDG-PET/CT indicated regression of disease more frequently than CE-CT, while CE-CT indicated stable disease more often. FDG-PET/CT seems to be more sensitive than CE-CT for monitoring response in metastatic breast cancer.
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Flores-Funes D, Aguilar-Jiménez J, Martínez-Gálvez M, Ibáñez-Ibáñez MJ, Carrasco-González L, Gil-Izquierdo JI, Chaves-Benito MA, Ayala-De La Peña F, Nieto-Olivares A, Aguayo-Albasini JL. Development of a predictive score of axillary lymph node dissection based on targeted axillary dissection in patients with breast cancer diagnosis, affected lymph nodes, and neoadjuvant treatment. Surg Oncol 2021; 38:101629. [PMID: 34171793 DOI: 10.1016/j.suronc.2021.101629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/07/2021] [Accepted: 06/15/2021] [Indexed: 11/29/2022]
Abstract
AIM To determine predictive factors of axillary lymph node dissection (ALND) results in breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), and subsequent staging using Targeted Axillary Dissection (TAD). MATERIAL AND METHOD Case-control study between January 2016 and August 2019. Patients with BC, cN1 staging, marked with a metallic clip prior to NACT, and subsequently staged with TAD and ALND were included. They were divided into 2 groups: ALND patients with or without metastatic involvement (group 1 and group 2, respectively). We carried out a univariate analysis comparing clinical, radiological, surgical and pathological variables, and a logistic regression, (dependent variable: positive result of ALND; independent variables: number of suspicious lymph nodes in diagnostic ultrasound, positive hormone receptors, HER2 positive, complete clinical-radiological response to NACT, positive TAD, and biopsy of ≤2 nodes in TAD). A score for prediction of a metastatic ALND was proposed, with an internal validation study. RESULTS 60 patients were included: Group 1: 33 (55.0%); Group 2: 27 (45.0%). Tumor size (Odds Ratio (OR) = 1.67; 95%CI 1.02-2.74), number of suspected nodes in ultrasound (OR = 2.20; 95%CI 1.01-4, 77), HER2 positive (OR 0.04; 95%CI 0.003-0.54), clinical-radiological response to NACT (OR = 0.07; 95%CI 0.01-0.75), and positive TAD (OR 15.48; 95%CI 1.68-142.78) were independent predictors of a positive result in ALND. We developed a "positive ALND predictive score", with good calibration (Hosmer-Lemeshow test: p = 0.65), and discrimination (AUC = 0.93; 95% CI 0, 87-0.99), with highest Youden index (0.7) at cut-off point of 17% risk of positive ALND (sensitivity = 100%; specificity = 70%). CONCLUSION Tumor size, number of suspected nodes, positive HER2, response to NACT, and metastatic TAD are independent predictors of ALND. The predictive score for positive ALND would be a good indicator to safely omit ALND.
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Affiliation(s)
- Diego Flores-Funes
- General Surgery Department, Morales Meseguer University Hospital, Murcia, Spain.
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The use of breast ultrasound for prediction of pathologic complete response in different subtypes of early breast cancer within the WSG-ADAPT subtrials. Breast 2021; 59:58-66. [PMID: 34166854 PMCID: PMC8239457 DOI: 10.1016/j.breast.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE We assessed the value of breast ultrasound (US) performed at week 3 and 6 and at the end (EOT) of neoadjuvant therapy (NAT) for prediction of pathologic complete response (pCR, ypT0/is ypN0) in patients with HR+/HER2+, HR-/HER2-or HR-/HER2+ early breast cancer enrolled in the WSG-ADAPT subtrials. METHODS US was performed at week 3 and 6 of NAT and at EOT in 401, 517, and 553 patients, respectively. Tumors with complete or partial response by US (RECIST 1.1) were classified as responders and those with stable or progressive disease as non-responders. RESULTS pCR rate was higher in US responders than in non-responders. US tended to yield the highest positive predictive value in HR-/HER2+ (69%) and HR-/HER2-tumors (65%) at week 3, and the highest negative predictive value in HR+/HER2+ tumors at week 6 and at EOT (88.9% and 86.9%, respectively) and in HR-/HER2-tumors at EOT (87.9%). Multivariable analysis of patients with US at week 3 and 6 identified tumor subtype (HR-/HER2+ vs HR+/HER2+; odds ratio (OR) 2.77, 95%CI 1.45-5.29, and OR 4.17, 95%CI 2.26-7.68, respectively) and each 10% change in lesion dimension on US from baseline (OR 1.15, 95%CI 1.08-1.24, and OR 1.25, 95%CI 1.16-1.35, respectively) as parameters associated with pCR. CONCLUSIONS Our data support the use of week 3 and EOT US for prediction of pCR in response-guided NAT and in planning of breast-conserving surgery. Change in tumor diameter on US as a continuous variable could be a valuable alternative to categorical RECIST 1.1 criteria.
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Apte A, Marsh S, Chandrasekharan S, Chakravorty A. Avoiding breast cancer surgery in a select cohort of complete responders to neoadjuvant chemotherapy: The long-term outcomes. Ann Med Surg (Lond) 2021; 66:102380. [PMID: 34026113 PMCID: PMC8134025 DOI: 10.1016/j.amsu.2021.102380] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Lately, there has been a resurgence of interest in de-escalation of breast surgery in complete responders to neoadjuvant chemotherapy (NAC). Advanced cytotoxic & targeted therapies have improved tumour response.This study evaluates long-term outcomes of post-NAC breast cancer patients, in relation to their surgical management dictated by the NAC response. MATERIALS AND METHODS Post-NAC breast cancer patients from January 2000 to December 2010 were divided into "No surgery", "WLE" and "Mastectomy" groups. ANOVA and Kaplan-Meier statistical analyses were used to compare overall survival (OS) and disease-free-survival (DFS) in these groups. RESULTS This retrospective study included 121 patients with a long median follow-up of 11.5 years. At 10 years the OS was 66.10% and DFS was 59.82%. Complete NAC-responders did not undergo breast surgery but received radiotherapy. Patients were divided into No surgery (n = 28), WLE (n = 44), Mastectomy (n = 49) groups.Comparisons of OS and DFS between groups showed statistically significant differences (p = 0.0003, p = 0.0007 respectively). The no surgery group showed low local recurrence (7.14%). CONCLUSION The observed slightly better long-term outcomes with low local recurrences in complete NAC-responders who did not undergo breast surgery but received radiotherapy could be linked to cautious response assessment and meticulous patient selection with early, biologically favourable breast cancer.Importance of PCR assessment cannot be underestimated if breast surgery were to be de-escalated or even omitted in complete NAC-responders.Considering the study limitations, avoiding surgery in all complete NAC-responders may still not be the preferred option. Future appropriate clinical trials with well-defined protocols may pave the way forward.
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Affiliation(s)
- Anuradha Apte
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, Turner Road, Colchester, CO4 5JL, UK
| | - Simon Marsh
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, Turner Road, Colchester, CO4 5JL, UK
| | - Sankaran Chandrasekharan
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, Turner Road, Colchester, CO4 5JL, UK
| | - Arunmoy Chakravorty
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, Turner Road, Colchester, CO4 5JL, UK
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Graeser M, Schrading S, Gluz O, Strobel K, Würstlein R, Kümmel S, Schumacher C, Grischke E, Forstbauer H, Braun M, Christgen M, Adams J, Nitzsche H, Just M, Fischer HH, Aktas B, Potenberg J, von Schumann R, Kolberg‐Liedtke C, Harbeck N, Kuhl CK, Nitz U. Early response by MR imaging and ultrasound as predictor of pathologic complete response to 12-week neoadjuvant therapy for different early breast cancer subtypes: Combined analysis from the WSG ADAPT subtrials. Int J Cancer 2021; 148:2614-2627. [PMID: 33533487 PMCID: PMC8048810 DOI: 10.1002/ijc.33495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 12/31/2022]
Abstract
We evaluated the role of early response after 3 weeks of neoadjuvant treatment (NAT) assessed by ultrasound (US), magnetic resonance imaging (MRI) and Ki-67 dynamics for prediction of pathologic complete response (pCR) in different early breast cancer subtypes. Patients with HR+/HER2+, HR-/HER2- and HR-/HER2+ tumors enrolled into three neoadjuvant WSG ADAPT subtrials underwent US, MRI and Ki-67 assessment at diagnosis and after 3 weeks of NAT. Early response was defined as complete or partial response (US, MRI) and ≥30% proliferation decrease or <500 invasive tumor cells (Ki-67). Predictive values and area under the receiver operating characteristic (AUC) curves for prediction of pCR (ypT0/is ypN0) after 12-week NAT were calculated. Two hundred twenty-six had MRI and 401 US; 107 underwent both MRI and US. All three methods yielded a similar AUC in HR+/HER2+ (0.66-0.67) and HR-/HER2- tumors (0.53-0.63), while MRI and Ki-67 performed better than US in HR-/HER2+ tumors (0.83 and 0.79 vs 0.56). Adding MRI+/-Ki-67 increased AUC of US in HR-/HER2+ tumors to 0.64 to 0.75. MRI and Ki-67 demonstrated highest sensitivity in HR-/HER2- (0.8-1) and HR-/HER2+ tumors (1, both). Negative predictive value was similar for all methods in HR+/HER2+ (0.71-0.74) and HR-/HER2- tumors (0.85-1), while it was higher for MRI and Ki-67 compared to US in HR-/HER2+ subtype (1 vs 0.5). Early response assessed by US, MRI and Ki-67 is a strong predictor for pCR after 12-week NAT. Strength of pCR prediction varies according to tumor subtype. Adding MRI+/-Ki-67 to US did not improve pCR prediction in majority of our patients.
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Affiliation(s)
- Monika Graeser
- West German Study GroupMoenchengladbachGermany
- Ev. Hospital Bethesda, Breast Center NiederrheinMoenchengladbachGermany
- Department of GynecologyUniversity Medical Center HamburgHamburgGermany
| | - Simone Schrading
- Department of Diagnostic and Interventional RadiologyHospital of the University of Aachen, RWTHAachenGermany
| | - Oleg Gluz
- West German Study GroupMoenchengladbachGermany
- Ev. Hospital Bethesda, Breast Center NiederrheinMoenchengladbachGermany
- University Hospital CologneCologneGermany
| | - Kevin Strobel
- Department of Diagnostic and Interventional RadiologyHospital of the University of Aachen, RWTHAachenGermany
| | - Rachel Würstlein
- West German Study GroupMoenchengladbachGermany
- Breast Center, Department of Gynecology and Obstetrics and CCCLMULMU University HospitalMunichGermany
| | - Sherko Kümmel
- West German Study GroupMoenchengladbachGermany
- Breast UnitKliniken Essen‐MitteEssenGermany
- University Hospital Charité, Humboldt University BerlinBerlinGermany
| | | | | | | | - Michael Braun
- Department of GynecologyBreast Center, Red Cross Hospital MunichMunichGermany
| | | | | | - Henrik Nitzsche
- Ev. Hospital Bethesda, Breast Center NiederrheinMoenchengladbachGermany
| | | | | | - Bahriye Aktas
- Department of Gynecology and ObstetricsUniversity Clinics EssenEssenGermany
- Department of GynecologyUniversity Hospital LeipzigLeipzigGermany
| | | | | | - Cornelia Kolberg‐Liedtke
- University Hospital Charité, Humboldt University BerlinBerlinGermany
- Department of Gynecology and ObstetricsUniversity Clinics EssenEssenGermany
| | - Nadia Harbeck
- West German Study GroupMoenchengladbachGermany
- Breast Center, Department of Gynecology and Obstetrics and CCCLMULMU University HospitalMunichGermany
| | - Christiane K. Kuhl
- Department of Diagnostic and Interventional RadiologyHospital of the University of Aachen, RWTHAachenGermany
| | - Ulrike Nitz
- West German Study GroupMoenchengladbachGermany
- Ev. Hospital Bethesda, Breast Center NiederrheinMoenchengladbachGermany
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FDG-PET/CT for Response Monitoring in Metastatic Breast Cancer: The Feasibility and Benefits of Applying PERCIST. Diagnostics (Basel) 2021; 11:diagnostics11040723. [PMID: 33921580 PMCID: PMC8073831 DOI: 10.3390/diagnostics11040723] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 12/18/2022] Open
Abstract
Background: We aimed to examine the feasibility and potential benefit of applying PET Response Criteria in Solid Tumors (PERCIST) for response monitoring in metastatic breast cancer (MBC). Further, we introduced the nadir scan as a reference. Methods: Response monitoring FDG-PET/CT scans in 37 women with MBC were retrospectively screened for PERCIST standardization and measurability criteria. One-lesion PERCIST based on changes in SULpeak measurements of the hottest metastatic lesion was used for response categorization. The baseline (PERCISTbaseline) and the nadir scan (PERCISTnadir) were used as references for PERCIST analyses. Results: Metastatic lesions were measurable according to PERCIST in 35 of 37 (94.7%) patients. PERCIST was applied in 150 follow-up scans, with progression more frequently reported by PERCISTnadir (36%) than PERCISTbaseline (29.3%; p = 0.020). Reasons for progression were (a) more than 30% increase in SULpeak of the hottest lesion (n = 7, 15.9%), (b) detection of new metastatic lesions (n = 28, 63.6%), or both (a) and (b) (n = 9, 20.5%). Conclusions: PERCIST, with the introduction of PERCISTnadir, allows a graphical interpretation of disease fluctuation that may be beneficial in clinical decision-making regarding potential earlier termination of non-effective toxic treatment. PERCIST seems feasible for response monitoring in MBC but prospective studies are needed to come this closer.
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Shaikh A, Tariq MU, Khan SM, Idress R, Vohra LM, Shaikh SF, Waheed H. Concordance Between Clinical and Pathological Response Assessment After Neo-Adjuvant Chemotherapy in Patients With Invasive Lobular Carcinoma. Cureus 2021; 13:e14341. [PMID: 33972899 PMCID: PMC8103980 DOI: 10.7759/cureus.14341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Neo-adjuvant chemotherapy (NAC) is frequently administered in breast carcinoma patients. The clinical response to NAC guides further treatment. The pathological response is not only an independent prognostic factor, but it also guides further treatment and prognosis. Objectives The aim of our study was to find the degree of concordance between clinical and pathological response assessments after NAC in Invasive lobular Carcinoma (ILC) cases by using World Health Organization (WHO) criteria and different pathological systems, respectively. We also tried to identify any useful parameter of clinical assessment that could better correlate with pathologic assessment and provide a better estimation of residual tumor. Methods This retrospective study was conducted on 26 ILC tumors diagnosed in 24 patients who were treated with NAC followed by surgical resection between January 2009 and December 2020. Medical records and microscopy glass slides were reviewed for clinical and pathological response assessments, respectively. Results The pre-treatment tumor area ranged from 1.8-255 cm2 and the mean±SD was 52.2±66.8 cm2. After NAC, complete clinical response was observed in four (15.3%) cases. The clinically assessed mean tumor area significantly reduced from 52.2±66.8 cm2 to 17.2±22.6 cm2 (p-value<0.001). The pathologically assessed mean tumor area (27.4±24.1 cm2) didn't differ significantly from the clinically assessed mean tumor area (17.2±22.6 cm2) (p-value=0.114). Pathologically, the majority of the cases showed partial response, and a complete pathological response was achieved in only two (7.7%) cases. The concordance rates between clinical assessment by the WHO method and pathological assessment of the breast using the Sataloff method, Miller-Payne (MP) system, Residual Cancer Burden system, and Chevallier method were 26.7%, 15.8%, 9%, and 3.5%, respectively, with insignificant p-values. Percentage reduction in clinical size and percentage reduction in tumor cellularity differed significantly (p-value=0.038). Conclusion Clinical response assessment provides a less accurate estimation of residual disease, as it shows poor concordance with pathological assessment using different assessment systems/methods.
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Affiliation(s)
- Aisha Shaikh
- Surgery, Aga Khan University Hospital, Karachi, PAK.,Surgery, Shaheed Mohtarma Benazir Bhutto Medical University, Larkana, PAK
| | - Muhammad Usman Tariq
- Histopathology, Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, PAK
| | | | - Romana Idress
- Histopathology, Aga Khan University Hospital, Karachi, PAK
| | | | | | - Hira Waheed
- Radiology, Aga Khan University Hospital, Karachi, PAK
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16
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Ochi T, Tsunoda H, Matsuda N, Nozaki F, Suzuki K, Takei H, Yamauchi H. Accuracy of morphologic change measurements by ultrasound in predicting pathological response to neoadjuvant chemotherapy in triple-negative and HER2-positive breast cancer. Breast Cancer 2021; 28:838-847. [PMID: 33560514 DOI: 10.1007/s12282-021-01220-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 01/13/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) is standard therapy in triple-negative breast cancer (TNBC) and HER2-positive breast cancer (HER2 + ve BC). There are concerns about the accurate imaging modalities to measure residual tumor during or after NAC. Up to now no standard imaging method for monitoring the efficacy of NAC has been established, and few reports showed ultrasonographic change. We aimed to assess the echogenicity in ultrasonography (US) as the predictive marker of pathological complete response (pCR) for not only TNBC, but also HER2 + ve BC. Furthermore, we also investigated the change in depth (D) and width (W) of the tumor as the predictive value of pCR. METHODS We retrospectively reviewed a consecutive 59 patients with TNBC and 41 patients with HER2 + ve BC who received NAC. In all of 100 patients, echogenicity, D and W of the tumor were measured before (pre-NAC) and after NAC (post-NAC). The tumor echogenicity was measured at representative region of interest (ROI), and calculated as the relative comparative assessment with fat echogenicity (ROI ratio). RESULTS pCR was significantly associated with higher post-NAC ROI ratio in TNBC (p = 0.010), while there was no association in HER2 + ve BC (p = 0.885). pCR was significantly associated with smaller sizes of post-NAC D and W in TNBC (p = 0.001, 0.003), while no trend was observed in HER2 + ve BC (p = 0.259, 0.435). The area under the curve (AUC) for post-NAC ROI ratio and D were 0.701, 0.755, respectively. Combined with them, AUC became higher up to 0.762. CONCLUSION TNBC and HER2 + ve BC showed different morphologic features of residual disease. Echogenicity and tumor size after NAC were both useful to predict pCR for TNBC, but not HER2 + ve BC. In future, radiological imaging needs to be analyzed in terms of breast cancer subtypes.
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Affiliation(s)
- Tomohiro Ochi
- Departments of Breast Surgical Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan. .,Department of Breast Surgery and Oncology, Nippon Medical School, Tokyo, Japan.
| | - Hiroko Tsunoda
- Departments of Radiology, St. Luke's International Hospital, Tokyo, Japan
| | - Naoko Matsuda
- Departments of Breast Surgical Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Fumi Nozaki
- Departments of Pathology, St. Luke's International Hospital, Tokyo, Japan
| | - Koyu Suzuki
- Departments of Pathology, St. Luke's International Hospital, Tokyo, Japan
| | - Hiroyuki Takei
- Department of Breast Surgery and Oncology, Nippon Medical School, Tokyo, Japan
| | - Hideko Yamauchi
- Departments of Breast Surgical Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
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Avoiding Axillary Sentinel Lymph Node Biopsy after Neoadjuvant Systemic Therapy in Breast Cancer: Rationale for the Prospective, Multicentric EUBREAST-01 Trial. Cancers (Basel) 2020; 12:cancers12123698. [PMID: 33317077 PMCID: PMC7763449 DOI: 10.3390/cancers12123698] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/29/2020] [Accepted: 12/04/2020] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Improvements in systemic treatments for breast cancer have increased the rates of pathologic complete response (pCR) in patients receiving preoperative systemic therapy (PST), offering the opportunity to de-escalate, and perhaps eliminate, surgery in patients who have a pCR. We propose a clinical trial in which only patients with the highest likelihood of having a pCR after PST will be included and type of surgery will be defined according to the response to PST rather than on the classical T (for tumor size in the breast) and N (for axillary lymph node involvement) status at presentation. In the planned trial, axillary surgery will be eliminated completely (no axillary sentinel lymph node biopsy) for initially clinical node-negative patients with radiologic complete remission and a breast pCR as determined in the lumpectomy specimen. Abstract Currently, axillary surgery for breast cancer is considered only as staging procedure, since the risk of developing metastasis depends on the biological behavior of the primary. The postsurgical therapy should be considered on the basis of biologic tumor characteristics rather than nodal involvement. Improvements in systemic treatments for breast cancer have increased the rates of pathologic complete response (pCR) in patients receiving neoadjuvant systemic therapy (NAST), offering the opportunity to de-escalate surgery in patients who have a pCR. European Breast Cancer Research Association of Surgical Trialists (EUBREAST)-01 is a clinical trial in which only patients with the highest likelihood of having a pCR after NAST (triple-negative or HER2-positive breast cancer) will be included and type of surgery will be defined according to the response to NAST rather than on the classical T (for tumor size in the breast) and N (for axillary lymph node involvement) status. In the discussed trial, axillary surgery will be eliminated completely (no axillary sentinel lymph node biopsy) for initially clinical node-negative (cN0) patients with radiologic complete remission and a breast pCR in the lumpectomy specimen. The trial design is a multicenter single-arm study with a limited number of patients (n = 267), which might give practice-changing results in a short period of time, sparing the time and the costs of a randomized comparison.
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Skarping I, Förnvik D, Heide-Jørgensen U, Rydén L, Zackrisson S, Borgquist S. Neoadjuvant breast cancer treatment response; tumor size evaluation through different conventional imaging modalities in the NeoDense study. Acta Oncol 2020; 59:1528-1537. [PMID: 33063567 DOI: 10.1080/0284186x.2020.1830167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NACT) is offered to an increasing number of breast cancer (BC) patients, and comprehensive monitoring of treatment response is of utmost importance. Several imaging modalities are available to follow tumor response, although likely to provide different clinical information. We aimed to examine the association between early radiological response by three conventional imaging modalities and pathological complete response (pCR). Further, we investigated the agreement between these modalities pre-, during, and post-NACT, and the accuracy of predicting pathological residual tumor burden by these imaging modalities post-NACT. MATERIAL AND METHODS This prospective Swedish cohort study included 202 BC patients assigned to NACT (2014-2019). Breast imaging with clinically used modalities: mammography, ultrasound, and tomosynthesis was performed pre-, during, and post-NACT. We investigated the agreement of tumor size by the different imaging modalities, and their accuracy of tumor size estimation. Patients with a radiological complete response or radiological partial response (≥30% decrease in tumor diameter) during NACT were classified as radiological early responders. RESULTS Patients with an early radiological response by ultrasound had 2.9 times higher chance of pCR than early radiological non-responders; the corresponding relative chance for mammography and tomosynthesis tumor size measures was 1.8 and 2.8, respectively. Post-NACT, each modality, separately, could accurately estimate tumor size (within 5 mm margin compared to pathological evaluation) in 43-46% of all tumors. The diagnostic precision in predicting pCR post-NACT was similar between the three imaging modalities; however, tomosynthesis had slightly higher specificity and positive predictive values. CONCLUSION Breast imaging modalities correctly estimated pathological tumor size in less than half of the tumors. Based on this finding, predicting residual tumor size post-NACT is challenging using conventional imaging. Patients with early radiological non-response might need improved monitoring during NACT and be considered for changed treatment plans.
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Affiliation(s)
- Ida Skarping
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Daniel Förnvik
- Department of Translational Medicine, Medical Radiation Physics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lisa Rydén
- Department of Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Sophia Zackrisson
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Signe Borgquist
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Texture Analysis of Dynamic Contrast-Enhanced MRI in Evaluating Pathologic Complete Response (pCR) of Mass-Like Breast Cancer after Neoadjuvant Therapy. JOURNAL OF ONCOLOGY 2019; 2019:4731532. [PMID: 31949430 PMCID: PMC6944972 DOI: 10.1155/2019/4731532] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/28/2019] [Accepted: 12/09/2019] [Indexed: 01/09/2023]
Abstract
Objectives MRI is the standard imaging method in evaluating treatment response of breast cancer after neoadjuvant therapy (NAT), while identification of pathologic complete response (pCR) remains challenging. Texture analysis (TA) on post-NAT dynamic contrast-enhanced (DCE) MRI was explored to assess the existence of pCR in mass-like cancer. Materials and Methods A primary cohort of 112 consecutive patients (40 pCR and 72 non-pCR) with mass-like breast cancers who received preoperative NAT were retrospectively enrolled. On post-NAT MRI, volumes of the residual-enhanced areas and TA first-order features (19 for each sequence) of the corresponding areas were achieved for both early- and late-phase DCE using an in-house radiomics software. Groups were divided according to the operational pathology. Receiver operating characteristic curves and binary logistic regression analysis were used to select features and achieve a predicting formula. Overall diagnostic abilities were compared between TA and radiologists' subjective judgments. Validation was performed on a time-independent cohort of 39 consecutive patients. Results TA features with high consistency (Cronbach's alpha >0.9) between 2 observers showed significant differences between pCR and non-pCR groups. Logistic regression using features selected by ROC curves generated a synthesized formula containing 3 variables (volume of residual enhancement, entropy, and robust mean absolute deviation from early-phase) to yield AUC = 0.81, higher than that of using radiologists' subjective judgment (AUC = 0.72), and entropy was an independent risk factor (P < 0.001). Accuracy and sensitivity for identifying pCR were 83.93% and 70.00%. AUC of the validation cohort was 0.80. Conclusions TA may help to improve the diagnostic ability of post-NAT MRI in identifying pCR in mass-like breast cancer. Entropy, as a first-order feature to depict residual tumor heterogeneity, is an important factor.
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Nakagawa M, Ikeuchi M, Morimoto M, Takechi H, Toba H, Yoshida T, Okumura K, Hino N, Nishisho A, Tangoku A. Phase II Study of S-1 Combined With Low-Dose Docetaxel as Neoadjuvant Chemotherapy for Operable Breast Cancer Patients (N-1 Study). Clin Breast Cancer 2018; 19:10-16. [PMID: 30340871 DOI: 10.1016/j.clbc.2018.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 09/12/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND To improve the pathological complete response (pCR) rate, we devised new neoadjuvant chemotherapy. Efficacy and safety of the oral fluoropyrimidine derivative S-1 (Taiho Pharmaceutical Co, Tokyo, Japan) combined with low-dose docetaxel (S-1+DOC) were evaluated. PATIENTS AND METHODS Patients were treated with docetaxel (40 mg/m2 intravenously on day 1) and S-1 (40 mg/m2 orally twice per day on days 1-14) every 3 weeks for 4 cycles. In accord with the Response Evaluation Criteria In Solid Tumors version 1.1 criteria, the patients who showed a complete response (CR) underwent surgery, and those who achieved a partial response (PR) underwent 4 more cycles of S-1+DOC. Patients who achieved stable disease (SD) or progressive disease (PD) received EC (epirubicin and cyclophosphamide) or HT (trastuzumab and paclitaxel) according to their HER2 status. The primary end point was the pCR rate. RESULTS Ninety-four patients entered the study. After 4 cycles of S-1+DOC, CR was noted in 5 patients, PR in 57, SD in 18, and PD in 3. Of the patients who achieved SD and PD, 12 received EC, and 9 received HT. Among the 83 assessable patients, the pCR rate was 34.9%, and the response rate was 80.7%. The pCR rates were 19.5% in the luminal type group, 53.8% in the luminal HER2 group, 46.1% in the HER2 group, and 50.0% in the triple-negative group. CONCLUSION The S-1+DOC regimen in this study could be well tolerated and a new candidate neoadjuvant chemotherapy in operable breast cancer patients. It is also expected to be effective even in patients with luminal type disease. However, further randomized control trials are needed to ascertain whether pCR can contribute to favorable outcomes.
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Affiliation(s)
- Misako Nakagawa
- Department of Thoracic, Endocrine Surgery and Oncology, Institute of Medical Bio-Sciences, The University of Tokushima Kuramoto-cho, Tokushima, Japan
| | - Mayumi Ikeuchi
- Department of Thoracic, Endocrine Surgery and Oncology, Institute of Medical Bio-Sciences, The University of Tokushima Kuramoto-cho, Tokushima, Japan
| | - Masami Morimoto
- Department of Thoracic, Endocrine Surgery and Oncology, Institute of Medical Bio-Sciences, The University of Tokushima Kuramoto-cho, Tokushima, Japan
| | - Hirokazu Takechi
- Department of Thoracic, Endocrine Surgery and Oncology, Institute of Medical Bio-Sciences, The University of Tokushima Kuramoto-cho, Tokushima, Japan
| | - Hiroaki Toba
- Department of Thoracic, Endocrine Surgery and Oncology, Institute of Medical Bio-Sciences, The University of Tokushima Kuramoto-cho, Tokushima, Japan.
| | - Takahiro Yoshida
- Department of Thoracic, Endocrine Surgery and Oncology, Institute of Medical Bio-Sciences, The University of Tokushima Kuramoto-cho, Tokushima, Japan
| | - Kazumasa Okumura
- Department of Thoracic, Endocrine Surgery and Oncology, Institute of Medical Bio-Sciences, The University of Tokushima Kuramoto-cho, Tokushima, Japan
| | - Naoki Hino
- Department of Surgery, Tokushima Municipal Hospital 2-34, Kitajyosanjima-cho, Tokushima, Japan
| | - Aya Nishisho
- Department of Surgery, Tokushima Municipal Hospital 2-34, Kitajyosanjima-cho, Tokushima, Japan
| | - Akira Tangoku
- Department of Thoracic, Endocrine Surgery and Oncology, Institute of Medical Bio-Sciences, The University of Tokushima Kuramoto-cho, Tokushima, Japan
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Escrivá-de-Romaní S, Arumí M, Zamora E, Bellet M. Neoadjuvant Model as a Platform for Research in Breast Cancer and Novel Targets under Development in this Field. Breast Care (Basel) 2018; 13:251-262. [PMID: 30319327 DOI: 10.1159/000492122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
For decades, the neoadjuvant setting has provided a useful scenario for research in breast cancer. Historically, neoadjuvant clinical trials, either hormone therapy-based or chemotherapy-based, have tried to recapitulate the results of their counterpart adjuvant studies, but with smaller patient numbers, more rapid outcomes (clinical response and/or pathologic complete response (pCR)), together with additional biologic information. As for neoadjuvant chemotherapy trials, the increase in pCR rates has been recently accepted as an appropriate surrogate marker to accelerate drug approval in high-risk breast cancer patients. In this setting, with the exception of luminal A tumors, pCR has been associated with improved long-term outcomes, particularly when the analysis is based on specific trials for each breast cancer subtype. For luminal tumors receiving neoadjuvant endocrine therapy, Ki67 at 2-4 weeks and the preoperative endocrine prognostic index score are the most accepted intermediate markers of efficacy, which will be validated in ongoing larger trials. In this review, we describe the different neoadjuvant designs: from the classical randomized trials in which treatment is delivered for 6 or more months to short non-therapeutic presurgical studies lasting just 2 or 3 weeks. We also review the main neoadjuvant trials, either ongoing or completed, for luminal, triple-negative, and HER2-positive breast cancer. The translational effort and research of biomarkers conducted in these studies will be particularly addressed.
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Affiliation(s)
- Santiago Escrivá-de-Romaní
- Medical Oncology, Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Miriam Arumí
- Medical Oncology, Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Esther Zamora
- Medical Oncology, Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Meritxell Bellet
- Medical Oncology, Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
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Sharma U, Agarwal K, Sah RG, Parshad R, Seenu V, Mathur S, Gupta SD, Jagannathan NR. Can Multi-Parametric MR Based Approach Improve the Predictive Value of Pathological and Clinical Therapeutic Response in Breast Cancer Patients? Front Oncol 2018; 8:319. [PMID: 30159254 PMCID: PMC6104482 DOI: 10.3389/fonc.2018.00319] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/26/2018] [Indexed: 11/13/2022] Open
Abstract
The potential of total choline (tCho), apparent diffusion coefficient (ADC) and tumor volume, both individually and in combination of all these three parameters (multi-parametric approach), was evaluated in predicting both pathological and clinical responses in 42 patients with locally advanced breast cancer (LABC) enrolled for neoadjuvant chemotherapy (NACT). Patients were sequentially examined by conventional MRI; diffusion weighted imaging and in vivo proton MR spectroscopy at 4 time points (pre-therapy, after I, II, and III NACT) at 1.5 T. Miller Payne grading system was used for pathological assessment of response. Of the 42 patients, 24 were pathological responders (pR) while 18 were pathological non-responders (pNR). Clinical response determination classified 26 patients as responders (cR) while 16 as non-responders (cNR). tCho and ADC showed significant changes after I NACT, however, MR measured tumor volume showed reduction only after II NACT both in pR and cR. After III NACT, the sensitivity to detect responders was highest for MR volume (83.3% for pR and 96.2% for cR) while the specificity was highest for ADC (76.5% for pR and 100% for cR). Combination of all three parameters exhibited lower sensitivity (66.7%) than MR volume for pR prediction, however, a moderate improvement was seen in specificity (58.8%). For the prediction of clinical response, multi-parametric approach showed 84.6% sensitivity with 100% specificity compared to MR volume (sensitivity 96.2%; specificity 80%). Kappa statistics demonstrated substantial agreement of clinical response with MR volume (k = 0.78) and with multi-parametric approach (k = 0.80) while moderate agreement was seen for tCho (k = 0.48) and ADC (k = 0.46). The values of k for tCho, MR volume and ADC were 0.31, 0.38, and 0.18 indicating fair, moderate, and slight agreement, respectively with pathological response. Moderate agreement (k = 0.44) was observed between clinical and pathological responses. Our study demonstrated that both tCho and ADC are strong predictors of assessment of early pathological and clinical responses. Multi-parametric approach yielded 100% specificity in predicting clinical response. Following III NACT, MR volume emerged as highly suitable predictor for both clinical and pathological assessments. PCA demonstrated separate clusters of pR vs. pNR and cR vs. cNR at post-therapy while with some overlap at pre-therapy.
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Affiliation(s)
- Uma Sharma
- Department of NMR and MRI Facility, All India Institute of Medical Sciences, New Delhi, India
| | - Khushbu Agarwal
- Department of NMR and MRI Facility, All India Institute of Medical Sciences, New Delhi, India
| | - Rani G Sah
- Department of NMR and MRI Facility, All India Institute of Medical Sciences, New Delhi, India
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Vurthaluru Seenu
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Mathur
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Siddhartha D Gupta
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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23
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Jiang X, Xie F, Liu L, Peng Y, Cai H, Li L. Discrimination of malignant and benign breast masses using automatic segmentation and features extracted from dynamic contrast-enhanced and diffusion-weighted MRI. Oncol Lett 2018; 16:1521-1528. [PMID: 30008832 PMCID: PMC6036451 DOI: 10.3892/ol.2018.8805] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 04/21/2017] [Indexed: 12/16/2022] Open
Abstract
Magnetic resonance imaging exhibits high sensitivity but low specificity for breast cancer. The present study aimed to investigate whether combining morphology, texture features and kinetic features with diffusion-weighted imaging using quantitative analysis improves the accuracy of discriminating malignant from benign breast masses. In total, 104 and 171 malignant lesions in 205 women were included. Additionally, 13 texture and 11 morphology features were computed from each lesion using a semi-automated segmentation method. To increase prediction accuracy, a newly designed classification model, difference-weighted local hyperplane, was used for statistical analysis of the combined effects of the features for predicting lesion type. The mean apparent diffusion coefficient (ADC) value for each lesion was calculated. Diagnostic performances of morphology and texture features, kinetic features and ADC alone and the combination of them were evaluated using receiver operating characteristics analysis. Malignant lesions had lower mean ADCs than benign lesions. By using 10-fold cross validation scheme, combined morphological and kinetic features achieved a diagnostic average accuracy of 0.87. Adding an ADC threshold of 1.37×10−3 mm2/sec increased the overall averaged accuracy to 0.90. A multivariate model combining ADC values with 6 morphological and kinetic parameters best discriminated malignant from benign lesions. Incorporating morphology and texture features, kinetic features and ADC into a multivariable diagnostic model improves the discriminatory power of breast lesions.
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Affiliation(s)
- Xinhua Jiang
- Department of Medical Imaging, Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong 510060, P.R. China
| | - Fei Xie
- Department of Medical Imaging, Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong 510060, P.R. China
| | - Lizhi Liu
- Department of Medical Imaging, Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong 510060, P.R. China
| | - Yanxia Peng
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Hongmin Cai
- Department of Computer Science, School of Computer Science and Engineering, South China University of Technology, Guangzhou, Guangdong 510006, P.R. China
| | - Li Li
- Department of Medical Imaging, Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong 510060, P.R. China
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24
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Slanetz PJ, Moy L, Baron P, diFlorio RM, Green ED, Heller SL, Holbrook AI, Lee SJ, Lewin AA, Lourenco AP, Niell B, Stuckey AR, Trikha S, Vincoff NS, Weinstein SP, Yepes MM, Newell MS. ACR Appropriateness Criteria ® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer. J Am Coll Radiol 2018; 14:S462-S475. [PMID: 29101985 DOI: 10.1016/j.jacr.2017.08.037] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 12/28/2022]
Abstract
Patients with locally advanced invasive breast cancers are often treated with neoadjuvant chemotherapy prior to definitive surgical intervention. The primary aims of this approach are to: 1) reduce tumor burden thereby permitting breast conservation rather than mastectomy; 2) promptly treat possible metastatic disease, whether or not it is detectable on preoperative staging; and 3) potentially tailor future chemotherapeutic decisions by monitoring in-vivo tumor response. Accurate radiological assessment permits optimal management and planning in this population. However, assessment of tumor size and response to treatment can vary depending on the modality used, the measurement technique (such as single longest diameter, 3-D measurements, or calculated tumor volume), and varied response of different tumor subtypes to neoadjuvant chemotherapy (such as concentric shrinkage or tumor fragmentation). As discussed in further detail, digital mammography, digital breast tomosynthesis, US and MRI represent the key modalities with potential to help guide patient management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Priscilla J Slanetz
- Principal Author, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Linda Moy
- Panel Vice Chair, NYU Clinical Cancer Center, New York, New York
| | - Paul Baron
- Roper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons
| | | | - Edward D Green
- The University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | - Su-Ju Lee
- University of Cincinnati, Cincinnati, Ohio
| | - Alana A Lewin
- New York University School of Medicine, New York, New York
| | - Ana P Lourenco
- Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
| | | | - Ashley R Stuckey
- Women and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists
| | | | - Nina S Vincoff
- Hofstra Northwell School of Medicine, Manhasset, New York
| | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mary S Newell
- Panel Chair, Emory University Hospital, Atlanta, Georgia
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25
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Didonato R, Shapiro N, Koenigsberg T, D'Alfonso T, Jaffer S, Fineberg S. Invasive mucinous carcinoma of the breast and response patterns after neoadjuvant chemotherapy (NAC). Histopathology 2018; 72:965-973. [DOI: 10.1111/his.13451] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 12/03/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Rosemarie Didonato
- Department of Pathology; Montefiore Medical Center and the Albert Einstein College of Medicine; Bronx NY USA
| | - Nella Shapiro
- Montefiore Medical Center and The Eastchester Center for Cancer Care; Bronx NY USA
| | - Tova Koenigsberg
- Division of Breast Imaging; Montefiore Medical Center and the Albert Einstein College of Medicine; Bronx NY USA
| | - Timothy D'Alfonso
- Weill Cornell Medical Center and Cornell Medical College; New York NY USA
| | - Shabnam Jaffer
- Breast Pathology; Mount Sinai Medical Center; New York NY USA
| | - Susan Fineberg
- Department of Pathology; Montefiore Medical Center and the Albert Einstein College of Medicine; Bronx NY USA
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26
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The use of breast imaging for predicting response to neoadjuvant lapatinib, trastuzumab and their combination in HER2-positive breast cancer: Results from Neo-ALTTO. Eur J Cancer 2017; 89:42-48. [PMID: 29227816 DOI: 10.1016/j.ejca.2017.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 10/31/2017] [Indexed: 11/22/2022]
Abstract
AIM To determine the value of mammography and breast ultrasound (US) in predicting outcomes in HER2 positive breast cancer patients (pts) within Neo-ALTTO trial. PATIENTS AND METHODS Mammography and US were required at baseline, week 6 and surgery. Two independent blinded investigators reviewed the measurements and assigned the corresponding response category. Pts showing complete or partial response according to RECIST (v1.1) were classified as responders. The association between imaging response at week 6 or prior to surgery was evaluated with respect to pathological complete response (pCR) and event-free Survival (EFS). RESULTS Of the 455 pts enrolled in the trial, 267 (61%) and 340 (77%) had evaluable mammography and US at week 6; 248 (56%) and 309 (70%) pts had evaluable mammography and US prior to surgery. At week 6, 32% and 43% of pts were classified as responders by mammography and US, respectively. pCR rates were twice as high for responders than non-responders (week 6: 46% versus 23% by US, p < 0.0001; 41% versus 24% by mammography, p = 0.007). Positive and negative predictive values of mammography and US prior to surgery were 37% and 35%, and 82% and 70%, respectively. No significant correlation was found between response by mammography and/or US at week 6/surgery and EFS. CONCLUSIONS Mammography and US were underused in Neo-ALTTO although US had the potential to assess early response whereas mammography to detect residual disease prior to surgery. Our data still emphasise the need for further imaging studies on pts treated with neoadjuvant HER2-targeted therapy.
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27
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Sorace AG, Harvey S, Syed A, Yankeelov TE. Imaging Considerations and Interprofessional Opportunities in the Care of Breast Cancer Patients in the Neoadjuvant Setting. Semin Oncol Nurs 2017; 33:425-439. [PMID: 28927763 DOI: 10.1016/j.soncn.2017.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To discuss standard-of-care and emerging imaging techniques employed for screening and detection, diagnosis and staging, monitoring response to therapy, and guiding cancer treatments. DATA SOURCES Published journal articles indexed in the National Library of Medicine database and relevant websites. CONCLUSION Imaging plays a fundamental role in the care of cancer patients and specifically, breast cancer patients in the neoadjuvant setting, providing an excellent opportunity for interprofessional collaboration between oncologists, researchers, radiologists, and oncology nurses. Quantitative imaging strategies to assess cellular, molecular, and vascular characteristics within the tumor is needed to better evaluate initial diagnosis and treatment response. IMPLICATIONS FOR NURSING PRACTICE Nurses caring for patients in all settings must continue to seek education on emerging imaging techniques. Oncology nurses provide education about the test, ensure the patient has appropriate pre-testing instructions, and manage patient expectations about timing of results availability.
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28
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Iotti V, Ravaioli S, Vacondio R, Coriani C, Caffarri S, Sghedoni R, Nitrosi A, Ragazzi M, Gasparini E, Masini C, Bisagni G, Falco G, Ferrari G, Braglia L, Del Prato A, Malavolti I, Ginocchi V, Pattacini P. Contrast-enhanced spectral mammography in neoadjuvant chemotherapy monitoring: a comparison with breast magnetic resonance imaging. Breast Cancer Res 2017; 19:106. [PMID: 28893303 PMCID: PMC5594558 DOI: 10.1186/s13058-017-0899-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neoadjuvant-chemotherapy (NAC) is considered the standard treatment for locally advanced breast carcinomas. Accurate assessment of disease response is fundamental to increase the chances of successful breast-conserving surgery and to avoid local recurrence. The purpose of this study was to compare contrast-enhanced spectral mammography (CESM) and contrast-enhanced-MRI (MRI) in the evaluation of tumor response to NAC. METHODS This prospective study was approved by the institutional review board and written informed consent was obtained. Fifty-four consenting women with breast cancer and indication of NAC were consecutively enrolled between October 2012 and December 2014. Patients underwent both CESM and MRI before, during and after NAC. MRI was performed first, followed by CESM within 3 days. Response to therapy was evaluated for each patient, comparing the size of the residual lesion measured on CESM and MRI performed after NAC to the pathological response on surgical specimens (gold standard), independently of and blinded to the results of the other test. The agreement between measurements was evaluated using Lin's coefficient. The agreement between measurements using CESM and MRI was tested at each step of the study, before, during and after NAC. And last of all, the variation in the largest dimension of the tumor on CESM and MRI was assessed according to the parameters set in RECIST 1.1 criteria, focusing on pathological complete response (pCR). RESULTS A total of 46 patients (85%) completed the study. CESM predicted pCR better than MRI (Lin's coefficient 0.81 and 0.59, respectively). Both methods tend to underestimate the real extent of residual tumor (mean 4.1mm in CESM, 7.5mm in MRI). The agreement between measurements using CESM and MRI was 0.96, 0.94 and 0.76 before, during and after NAC respectively. The distinction between responders and non-responders with CESM and MRI was identical for 45/46 patients. In the assessment of CR, sensitivity and specificity were 100% and 84%, respectively, for CESM, and 87% and 60% for MRI. CONCLUSION CESM and MRI lesion size measurements were highly correlated. CESM seems at least as reliable as MRI in assessing the response to NAC, and may be an alternative if MRI is contraindicated or its availability is limited.
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Affiliation(s)
- Valentina Iotti
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy.
| | - Sara Ravaioli
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Rita Vacondio
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Chiara Coriani
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Sabrina Caffarri
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, AUSL Reggio Emilia, via Amendola 2, Reggio Emilia, 42122, Italy
| | - Roberto Sghedoni
- Medical Physics Unit, Department of Oncology and Advanced Technologies, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Andrea Nitrosi
- Medical Physics Unit, Department of Oncology and Advanced Technologies, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Moira Ragazzi
- Pathology Unit, Department of Oncology and Advanced Technologies, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Elisa Gasparini
- Oncology Unit, Hospital C. Magati, AUSL Reggio Emilia, Via Martiri della Libertà, No. 8, Scandiano (RE), 42019, Italy
| | - Cristina Masini
- Oncology Unit, Department of Oncology and Advanced Technologies, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Giancarlo Bisagni
- Oncology Unit, Department of Oncology and Advanced Technologies, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Giuseppe Falco
- Breast Surgery Unit, Department of Surgery, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Guglielmo Ferrari
- Breast Surgery Unit, Department of Surgery, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Luca Braglia
- Scientific Directorate, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Alberto Del Prato
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
| | - Ivana Malavolti
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, AUSL Reggio Emilia, via Amendola 2, Reggio Emilia, 42122, Italy
| | - Vladimiro Ginocchi
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, AUSL Reggio Emilia, via Amendola 2, Reggio Emilia, 42122, Italy
| | - Pierpaolo Pattacini
- Radiology Unit, Department of Diagnostic Imaging and Laboratory Medicine, Arcispedale Santa Maria Nuova - IRCCS, Viale Umberto I, No. 50, 42123, Reggio Emilia, Italy
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Guerrero-Zotano AL, Arteaga CL. Neoadjuvant Trials in ER + Breast Cancer: A Tool for Acceleration of Drug Development and Discovery. Cancer Discov 2017; 7:561-574. [PMID: 28495849 PMCID: PMC5497752 DOI: 10.1158/2159-8290.cd-17-0228] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/03/2017] [Accepted: 04/17/2017] [Indexed: 12/17/2022]
Abstract
Neoadjuvant therapy trials offer an excellent strategy for drug development and discovery in breast cancer, particularly in triple-negative and HER2-overexpressing subtypes, where pathologic complete response is a good surrogate of long-term patient benefit. For estrogen receptor-positive (ER+) breast cancers, however, use of this strategy has been challenging because of the lack of validated surrogates of long-term efficacy and the overall good prognosis of the majority of patients with this cancer subtype. We review below the clinical benefits of neoadjuvant endocrine therapy for ER+/HER2-negative breast cancer, its use and limitations for drug development, prioritization of adjuvant and metastatic trials, and biomarker discovery.Significance: Neoadjuvant endocrine therapy is an excellent platform for the development of investigational drugs, triaging of novel combinations, biomarker validation, and discovery of mechanisms of drug resistance. This review summarizes the clinical and investigational benefits of this approach, with a focus on how to best integrate predictive biomarkers into novel clinical trial designs. Cancer Discov; 7(6); 561-74. ©2017 AACR.
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Affiliation(s)
- Angel L Guerrero-Zotano
- Departments of Medicine and Cancer Biology; Breast Cancer Program, Vanderbilt-Ingram Cancer Center; Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos L Arteaga
- Departments of Medicine and Cancer Biology; Breast Cancer Program, Vanderbilt-Ingram Cancer Center; Vanderbilt University Medical Center, Nashville, Tennessee.
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30
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Jovanović B, Mayer IA, Mayer EL, Abramson VG, Bardia A, Sanders ME, Kuba MG, Estrada MV, Beeler JS, Shaver TM, Johnson KC, Sanchez V, Rosenbluth JM, Dillon PM, Forero-Torres A, Chang JC, Meszoely IM, Grau AM, Lehmann BD, Shyr Y, Sheng Q, Chen SC, Arteaga CL, Pietenpol JA. A Randomized Phase II Neoadjuvant Study of Cisplatin, Paclitaxel With or Without Everolimus in Patients with Stage II/III Triple-Negative Breast Cancer (TNBC): Responses and Long-term Outcome Correlated with Increased Frequency of DNA Damage Response Gene Mutations, TNBC Subtype, AR Status, and Ki67. Clin Cancer Res 2017; 23:4035-4045. [PMID: 28270498 DOI: 10.1158/1078-0432.ccr-16-3055] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/17/2017] [Accepted: 03/02/2017] [Indexed: 12/31/2022]
Abstract
Purpose: Because of inherent disease heterogeneity, targeted therapies have eluded triple-negative breast cancer (TNBC), and biomarkers predictive of treatment response have not yet been identified. This study was designed to determine whether the mTOR inhibitor everolimus with cisplatin and paclitaxel would provide synergistic antitumor effects in TNBC.Methods: Patients with stage II/III TNBC were enrolled in a randomized phase II trial of preoperative weekly cisplatin, paclitaxel and daily everolimus or placebo for 12 weeks, until definitive surgery. Tumor specimens were obtained at baseline, cycle 1, and surgery. Primary endpoint was pathologic complete response (pCR); secondary endpoints included clinical responses, breast conservation rate, safety, and discovery of molecular features associated with outcome.Results: Between 2009 and 2013, 145 patients were accrued; 36% of patients in the everolimus arm and 49% of patients in the placebo arm achieved pCR; in each arm, 50% of patients achieved complete responses by imaging. Higher rates of neutropenia, mucositis, and transaminase elevation were seen with everolimus. Clinical response to therapy and long-term outcome correlated with increased frequency of DNA damage response (DDR) gene mutations, Basal-like1 and Mesenchymal TNBC-subtypes, AR-negative status, and high Ki67, but not with tumor-infiltrating lymphocytes.Conclusions: The paclitaxel/cisplatin combination was well tolerated and active, but addition of everolimus was associated with more adverse events without improvement in pCR or clinical response. However, discoveries made from correlative studies could lead to predictive TNBC biomarkers that may impact clinical decision-making and provide new avenues for mechanistic exploration that could lead to clinical utility. Clin Cancer Res; 23(15); 4035-45. ©2017 AACR.
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Affiliation(s)
| | | | | | | | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | - Patrick M Dillon
- University of Virginia Health Sciences Center, Charlottesville, Virginia
| | | | - Jenny C Chang
- Methodist Hospital Research Institute, Houston, Texas
| | | | - Ana M Grau
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | | | - Yu Shyr
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Quanhu Sheng
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
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