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Schipper RJ, de Bruijn A, van der Sangen MJC, Bloemen JG, van den Hoven I, Schepers EEM, Vriens BEP, Boerman T, Rijkaart DC, van de Winkel LMH, Brouwer C, van Warmerdam LJC, Gielens MPM, van Bommel RMG, van Riet YE, Voogd AC, Nieuwenhuijzen GAP. Oncologic outcomes of de-escalating axillary treatment in clinically node-positive breast cancer patients treated with neoadjuvant systemic therapy - A two center cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108472. [PMID: 38870876 DOI: 10.1016/j.ejso.2024.108472] [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: 04/28/2024] [Revised: 05/18/2024] [Accepted: 06/04/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND The aim of the present study was to report the 5-year axillary recurrence-free interval (aRFI) in clinically node-positive breast cancer patients treated according to a de-escalating axillary treatment protocol after neoadjuvant systemic therapy (NST). METHODS All patients diagnosed in two hospitals between October 2014 and March 2021 were identified retrospectively. Data on diagnostic workup, treatment and follow-up was collected. Adjuvant axillary treatment was considered based on the initial staging using 18F-FDG PET/CT and the results of axillary lymph node marking with a radioactive-iodine seed protocol or a targeted axillary dissection procedure. Follow-up was updated until 27th April 2024. Kaplan-Meier curves were calculated to report the 5-year aRFI with corresponding 95 % confident intervals (95%-CI). RESULTS A total of 199 patients were included. Axillary pathological complete response was reported in 66 (33.2 %). Based on the treatment protocol and initial clinical staging, no adjuvant axillary treatment was indicated in 30 patients (15 %), while 139 (70 %) received axillary radiotherapy without performance of an axillary lymph node dissection (ALND). The remaining 30 patients (15 %) underwent an ALND with additional locoregional radiotherapy. A median follow-up of 62 months (30-106) showed that 4 (2 %) patients experienced an axillary recurrence after 7, 8, 36 and 36 months, respectively. In all 4 patients, synchronous distant metastases were diagnosed. The estimated 5-year aRFI was 97.8 % (95%-CI 95.6-99.9 %) CONCLUSION: Although longer follow-up should be awaited before final conclusions can be drawn regarding the oncological safety of this approach, the implementation of a de-escalating axillary treatment protocol appears to be safe since the estimated 5-year aRFI is 97.8 %.
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Affiliation(s)
- Robert-Jan Schipper
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands; Department of Surgery, Anna Hospital, Geldrop, the Netherlands.
| | - Anne de Bruijn
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | | | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | | | | | - Birgit E P Vriens
- Department of Internal Medicine, Catharina Hospital Eindhoven, the Netherlands
| | - Thom Boerman
- Department of Pathology, Eurofins PAMM, Veldhoven, the Netherlands
| | - Dorien C Rijkaart
- Department of Radiotherapy, Catharina Hospital Eindhoven, the Netherlands
| | | | - Christel Brouwer
- Department of Nuclear Medicine, Catharina Hospital Eindhoven, the Netherlands
| | | | | | | | - Yvonne E van Riet
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
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Miligy IM, Awasthi R, Mir Y, Khurana A, Sharma V, Chandaran U, Rakha E, Maurice Y, Kearns D, Oweis R, Asar A, Ironside A, Shaaban AM. Morphological and molecular changes of oestrogen receptor-positive breast cancer following bridging endocrine therapy: a United Kingdom multicentre study. Histopathology 2024; 85:405-417. [PMID: 38845397 DOI: 10.1111/his.15238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 05/21/2024] [Accepted: 05/25/2024] [Indexed: 08/09/2024]
Abstract
AIMS Standard neoadjuvant endocrine therapy (NAET) is used for 6-9 months to downstage hormone-receptor-positive breast cancer. Bridging ET was introduced during the COVID-19 pandemic to delay surgical intervention. There are no data in the literature on the effect of short course therapy on tumour response. We aimed to analyse the effect of bridging ET and validate the previously proposed neoadjuvant ET pathological reporting criteria. METHODS AND RESULTS This was a multicentre cohort of 256 patients who received bridging ET between March and October 2020. Assessment of paired pre- and post-NAET hormone receptors and HER2 and posttherapy Ki67 expression was done. The median duration of NAET was 45 days. In all, 86% of cases achieved partial pathological response and 9% showed minimal residual disease. Histological response to ET was observed from as early as day 6 posttherapy. Central scarring was noted in 32.8% of cases and lymphocytic infiltrate was seen in 43.4% of cases. Significant changes associated with the duration of ET were observed in tumour grade (21%), with downgrading identified in 12% of tumours (P < 0.001), progesterone receptor (PR) expression with switch to PR-negative status in 26% of cases (P < 0.001), and HER2 status with a switch from HER2-low to HER2-negative status in 32% of cases (P < 0.001). The median patient survival was 475 days, with an overall survival rate of 99.6%. CONCLUSIONS Changes characteristic of tumour regression and significant changes in PR and HER2 occurred following a short course of NAET. The findings support biomarker testing on pretreatment core biopsies and retesting following therapy.
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Affiliation(s)
- Islam M Miligy
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, UK
- Histopathology Department, Menoufia University, Shebin El Kom, Egypt
| | - Rachna Awasthi
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, UK
| | - Yasmeen Mir
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Anuj Khurana
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Vijay Sharma
- Pathology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Usha Chandaran
- Histopathology Department, Salford Royal Hospital, Salford, UK
| | - Emad Rakha
- Histopathology Department, Nottingham City Hospital, Nottingham, UK
| | - Yasmine Maurice
- Histopathology Department, Heartlands General Hospital, Birmingham, UK
| | - Daniel Kearns
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, UK
| | - Rami Oweis
- Histopathology Department, Rotherham Foundation Trust, Rotherham, UK
| | - Amal Asar
- Histopathology Department, Rotherham Foundation Trust, Rotherham, UK
| | | | - Abeer M Shaaban
- Cellular Pathology, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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3
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An SJ, Thai CHNC, Ismail S, Agala CB, Hoang V, Feeney T, Lillie M, Wheless A, Selfridge JM, Ollila DW, Gallagher KK, Carey LA, Spanheimer PM. Nodal Response and Survival After Neoadjuvant Endocrine Therapy in Hormone Receptor-Positive Breast Cancer: 20-Year Experience from a Single Institution. Ann Surg Oncol 2024:10.1245/s10434-024-16059-1. [PMID: 39154153 DOI: 10.1245/s10434-024-16059-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/04/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Axillary response to neoadjuvant endocrine therapy (NET) for the treatment of hormone receptor-positive breast cancer (HR+ BC) is not well-described. This study was designed to characterize nodal response after NET. METHODS Patients receiving NET followed by curative intent surgery at a comprehensive cancer center from 1998 to 2022 in a prospectively collected registry were included. Patients with distant metastasis were excluded. Primary outcome was nodal pathologic complete response (pCR). Downstaging was defined as post-NET decrease in category. RESULTS We included 123 patients; the majority were cT2 (n = 59) or cT3 (n = 35), and cN0 (n = 81). Median age was 70.0 years (interquartile range 62.1-76.0). Forty-two patients (34.1%) were clinically node-positive. After NET, 73 (59.8%) underwent breast-conserving surgery. All patients underwent sentinel lymph node biopsy, and 12 (9.8%) underwent completion axillary lymph node dissection. In-breast downstaging was achieved in 51 (41.5%) patients, 1 (0.8%) had breast pCR, and 14 (11.4%) had breast upstaging. Axillary downstaging was achieved in 10 (23.8%), 6 patients (14.3%) had nodal pCR, and 14 (33.3%) had axillary upstaging. At 10-year follow-up, local recurrence was 1% and distant recurrence was 14%, while disease-free survival was 82%. After adjusting for demographic and clinical factors, age was the only characteristic associated with mortality (hazard ratio 1.07, 95% confidence interval 1.01-1.13). CONCLUSIONS In HR+ BC treated with NET, long-term disease-free survival is good, although nodal pCR is uncommon for cN+ patients. Future studies are needed to elucidate optimal neoadjuvant systemic therapy and to delineate oncologically safe strategies to deescalate axillary management for residual microscopic disease.
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Affiliation(s)
- Selena J An
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | | | - Sherin Ismail
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Chris B Agala
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Van Hoang
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy Feeney
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Margaret Lillie
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Amy Wheless
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Division of Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Julia M Selfridge
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - David W Ollila
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Kristalyn K Gallagher
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Lisa A Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Division of Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Philip M Spanheimer
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
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Connors C, Al-Hilli Z. De-escalation of Axillary Surgery After Neoadjuvant Therapy. Clin Breast Cancer 2024; 24:385-391. [PMID: 38735808 DOI: 10.1016/j.clbc.2024.04.009] [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: 12/15/2023] [Revised: 03/25/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024]
Abstract
Surgical de-escalation of the axilla has evolved over the past 28 years since the emergence of sentinel lymph node surgery. Well-documented complications of the once standard of care axillary lymph node dissection (ALND), including lymphedema, led physician scientists towards a progressive push to study and incorporate less invasive techniques in the axilla. Many trials have justified oncologic safety of axillary de-escalation in patients who are spared neoadjuvant treatment. The applicability in the neoadjuvant setting, however, is less clear and axillary surgical approaches in this patient population have evolved at a slower pace. This review aims to analyze current data in axillary management for patients undergoing neoadjuvant treatment and to discuss current surgical approaches based on nodal pathologic response.
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Affiliation(s)
- Casey Connors
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Zahraa Al-Hilli
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH.
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5
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van Olmen JP, Jacobs CF, Bartels SAL, Loo CE, Sanders J, Vrancken Peeters MJTFD, Drukker CA, van Duijnhoven FH, Kok M. Radiological, pathological and surgical outcomes after neoadjuvant endocrine treatment in patients with ER-positive/HER2-negative breast cancer with a clinical high risk and a low-risk 70-gene signature. Breast 2024; 75:103726. [PMID: 38599047 PMCID: PMC11017070 DOI: 10.1016/j.breast.2024.103726] [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: 02/08/2024] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVE This study aims to evaluate the response to and surgical benefits of neoadjuvant endocrine therapy (NET) in ER+/HER2-breast cancer patients who are clinically high risk, but genomic low risk according to the 70-gene signature (MammaPrint). METHODS Patients with ER+/HER2-invasive breast cancer with a clinical high risk according to MINDACT, who had a genomic low risk according to the 70-gene signature and were treated with NET between 2015 and 2023 in our center, were retrospectively analyzed. RECIST 1.1 criteria were used to assess radiological response using MRI or ultrasound. Surgical specimens were evaluated to assess pathological response. Two breast cancer surgeons independently scored the eligibility of breast conserving therapy (BCS) pre- and post- NET. RESULTS Of 72 included patients, 23 were premenopausal (100% started with tamoxifen of which 4 also received OFS) and 49 were postmenopausal (98% started with an aromatase inhibitor). Overall, 8 (11%) showed radiological complete response. Only 1 (1.4%) patient had a pathological complete response (RCB-0) and 68 (94.4%) had a pathological partial response (RCB-1 or RCB-2). Among the 26 patients initially considered for mastectomy, 14 (53.8%) underwent successful BCS. In all 20 clinical node-positive patients, a marked axillary lymph node was removed to assess response. Four out of 20 (20%) patients had a pathological complete response of the axilla. CONCLUSION The study showed that a subgroup of patients with a clinical high risk and a genomic low risk ER+/HER2-breast cancer benefits from NET resulting in BCS instead of a mastectomy. Additionally, NET may enable de-escalation in axillary treatment.
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Affiliation(s)
- Josefien P van Olmen
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Chaja F Jacobs
- Department of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Sanne A L Bartels
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Claudette E Loo
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Joyce Sanders
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Caroline A Drukker
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Marleen Kok
- Department of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
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Pawloski KR, Barrio AV. Breast surgery after neoadjuvant systemic therapy. TRANSLATIONAL BREAST CANCER RESEARCH : A JOURNAL FOCUSING ON TRANSLATIONAL RESEARCH IN BREAST CANCER 2024; 5:13. [PMID: 38751679 PMCID: PMC11093099 DOI: 10.21037/tbcr-23-50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/17/2024] [Indexed: 05/18/2024]
Abstract
For patients with operable breast cancer, neoadjuvant systemic therapy (NST) can be used to downstage the primary tumor in the breast and to facilitate breast-conserving surgery (BCS) in patients with large tumors who desire breast conservation. Rates of breast pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) are highest in patients with triple-negative and human epidermal growth factor receptor 2 (HER2) positive (HER2+) disease; however, achieving pCR is not necessary for successful downstaging and avoidance of mastectomy, and rates of conversion to BCS-eligibility are high across all receptor subtypes. Neoadjuvant endocrine therapy (NET) can be used instead of NAC in postmenopausal patients with hormone receptor positive (HR+)/HER2 negative (HER2-) breast cancer to downstage the breast, particularly when the patient has no clear indication for systemic chemotherapy, but desires breast conservation. In patients treated with NET, rates of conversion to BCS-eligibility are similar to rates observed with NAC. The oncologic safety of BCS after NAC and NET has been established in prospective trials, and local recurrence (LR) rates are acceptably low provided negative surgical margins can be obtained. Investigation is under way to determine the feasibility and safety of omitting breast surgery in patients with responsive subtypes who have no residual invasive or in situ disease identified on post-treatment tumor bed biopsies; however, the significant risk of missing residual disease-which may impact selection of adjuvant systemic therapy-may preclude future adoption of this approach.
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Affiliation(s)
- Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Ma HF, Shen J, Xu B, Shen JG. Neoadjuvant chemotherapy combined with endocrine therapy for hormone receptor-positive breast cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e35928. [PMID: 37986364 PMCID: PMC10659694 DOI: 10.1097/md.0000000000035928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/15/2023] [Accepted: 10/12/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND This study aimed to conduct a comparative analysis of the efficacy and safety of neoadjuvant chemotherapy combined with endocrine therapy against the backdrop of single neoadjuvant chemotherapy or endocrine therapy, specifically in the context of hormone receptor-positive (HR+) breast cancer treatment. METHODS We conducted a thorough literature search across several databases, including China National Knowledge Infrastructure, Wanfang, Weipu, Chinese Journal Full-text Database, PubMed, Web of Science, Cochrane Library, and EMBASE, adhering to the guidelines outlined in the PRISMA statement. Our specific focus was on identifying randomized controlled trials that directly compared the combined approach of neoadjuvant chemotherapy and endocrine therapy with single chemotherapy or endocrine therapy in the context of treating HR+ breast cancer. Subsequently, we utilized statistical packages implemented in R software to perform comparative analyses of key clinical indicators, encompassing the complete response, objective response rate (ORR), disease control rate, pathological complete response (pCR), and adverse reactions. RESULTS A total of 11 randomized controlled trials, involving 1359 patients, all of whom met our inclusion criteria and were thus included in our comprehensive analysis. Within this cohort, 688 patients (50.63%) administered neoadjuvant chemotherapy combined with endocrine therapy (NCET), 642 patients (47.24%) received neoadjuvant chemotherapy (NCT) alone, while 29 patients (2.13%) underwent neoadjuvant endocrine therapy (NET) alone. The results of our meta-analysis revealed that NCET exhibited a statistically significant enhancement in both ORR and pCR (P < .05). Nonetheless, when compared to NCT or NET, NCET did not yield a significant impact on complete response, disease control rate, and safety (P > .05). In addition, NCET demonstrated a significant improvement in ORR among patients with HR+, HER2-negative breast cancer (P < .05). However, it was also linked to a heightened incidence of serious adverse reactions within this particular patient subgroup (P < .05). CONCLUSION The combination of Neoadjuvant chemotherapy and endocrine therapy stands out as a significant contributor to enhancing the ORR and pCR for HR+ breast cancer patients. For breast cancer patients with HER2- status, NCET demonstrates a remarkable improvement in ORR but is also associated with the emergence of adverse reactions.
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Affiliation(s)
- Hong-Fang Ma
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Shen
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bin Xu
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Guo Shen
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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8
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Chaudhary LN, Jorns JM, Sun Y, Cheng YC, Kamaraju S, Burfeind J, Gonyo MB, Kong AL, Patten C, Yen T, Cortina CS, Carson E, Johnson N, Bergom C, Tsaih SW, Banerjee A, Wang Y, Chervoneva I, Weil E, Chitambar CR, Rui H. Frequent upregulation of HER2 protein in hormone-receptor-positive HER2-negative breast cancer after short-term neoadjuvant endocrine therapy. Breast Cancer Res Treat 2023; 201:387-396. [PMID: 37460683 PMCID: PMC10795510 DOI: 10.1007/s10549-023-07038-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/05/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Endocrine resistant metastatic disease develops in ~ 20-25% of hormone-receptor-positive (HR+) breast cancer (BC) patients despite endocrine therapy (ET) use. Upregulation of HER family receptor tyrosine kinases (RTKs) represent escape mechanisms in response to ET in some HR+ tumors. Short-term neoadjuvant ET (NET) offers the opportunity to identify early endocrine escape mechanisms initiated in individual tumors. METHODS This was a single arm, interventional phase II clinical trial evaluating 4 weeks (± 1 week) of NET in patients with early-stage HR+/HER2-negative (HER2-) BC. The primary objective was to assess NET-induced changes in HER1-4 proteins by immunohistochemistry (IHC) score. Protein upregulation was defined as an increase of ≥ 1 in IHC score following NET. RESULTS Thirty-seven patients with cT1-T3, cN0, HR+/HER2- BC were enrolled. In 35 patients with evaluable tumor HER protein after NET, HER2 was upregulated in 48.6% (17/35; p = 0.025), with HER2-positive status (IHC 3+ or FISH-amplified) detected in three patients at surgery, who were recommended adjuvant trastuzumab-based therapy. Downregulation of HER3 and/or HER4 protein was detected in 54.2% of tumors, whereas HER1 protein remained low and unchanged in all cases. While no significant volumetric reduction was detected radiographically after short-term NET, significant reduction in tumor proliferation rates were observed. No significant associations were identified between any clinicopathologic covariates and changes in HER1-4 protein expression on multivariable analysis. CONCLUSION Short-term NET frequently and preferentially upregulates HER2 over other HER family RTKs in early-stage HR+/HER2- BC and may be a promising strategy to identify tumors that utilize HER2 as an early endocrine escape pathway. CLINICAL TRIAL REGISTRY Trial registration number: NCT03219476.
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Affiliation(s)
- Lubna N Chaudhary
- Division of Hematology and Oncology, Department of Medicine, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Julie M Jorns
- Department of Pathology, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Yunguang Sun
- Department of Pathology, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Yee Chung Cheng
- Division of Hematology and Oncology, Department of Medicine, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Sailaja Kamaraju
- Division of Hematology and Oncology, Department of Medicine, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - John Burfeind
- Division of Hematology and Oncology, Department of Medicine, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Mary Beth Gonyo
- Department of Radiology, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Amanda L Kong
- Department of Surgery, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Caitlin Patten
- Department of Surgery, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Tina Yen
- Department of Surgery, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Chandler S Cortina
- Department of Surgery, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Ebony Carson
- Clinical Trials Office, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Nedra Johnson
- Clinical Trials Office, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Carmen Bergom
- Department of Radiation Oncology, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Shirng-Wern Tsaih
- Department of Obstetrics and Gynecology, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Anjishnu Banerjee
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, USA
| | - Yu Wang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, USA
| | - Inna Chervoneva
- Division of Biostatistics, Department of Pharmacology, Physiology and Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | - Elizabeth Weil
- Division of Pharmacy, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Christopher R Chitambar
- Division of Hematology and Oncology, Department of Medicine, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Hallgeir Rui
- Department of Pathology, Froedtert and Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
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9
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Chaudhary LN, Jorns J, Sun Y, Cheng YC, Kamaraju S, Burfeind J, Gonyo M, Kong A, Patten C, Yen T, Cortina C, Carson E, Johnson N, Bergom C, Tsaih SW, Banerjee A, Wang Y, Chervoneva I, Weil E, Chitambar CR, Rui H. Frequent Upregulation Of HER2 Protein In Hormone Receptor-Positive HER2-Negative Breast Cancer After Short-Term Neoadjuvant Endocrine Therapy. RESEARCH SQUARE 2023:rs.3.rs-2777910. [PMID: 37066270 PMCID: PMC10104267 DOI: 10.21203/rs.3.rs-2777910/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Background. Endocrine resistant metastatic disease develops in ~20-25% of hormone-receptor positive (HR+) breast cancer (BC) patients despite endocrine therapy (ET) use. Upregulation of HER family receptor tyrosine kinases (RTKs) represent escape mechanisms in response to ET in some HR+ tumors. Short-term neoadjuvant ET (NET) offers the opportunity to identify early endocrine escape mechanisms initiated in individual tumors. Methods. This was a single arm, interventional phase II clinical trial evaluating 4 weeks (+/-1 week) of NET in patients with early-stage HR+/HER2-negative (HER2-) BC. The primary objective was to assess NET-induced changes in HER1-4 proteins by immunohistochemistry (IHC) score. Protein upregulation was defined as an increase of ≥1 in IHC score following NET. Results. Thirty-seven patients with cT1-T3, cN0, HR+/HER2- BC were enrolled. In 35 patients with evaluable tumor HER protein after NET, HER2 was upregulated in 48.6% (17/35; p=0.025), with HER2-positive status (IHC 3+ or FISH-amplified) detected in three patients at surgery, who were recommended adjuvant trastuzumab-based therapy. Downregulation of HER3 and/or HER4 protein was detected in 54.2% of tumors, whereas HER1 protein remained low and unchanged in all cases. While no significant volumetric reduction was detected radiographically after short-term NET, significant reduction in tumor proliferation rates were observed. No significant associations were identified between any clinicopathologic covariates and changes in HER1-4 protein expression on multivariable analysis. Conclusion . Short-term NET frequently and preferentially upregulates HER2 over other HER-family RTKs in early-stage HR+/HER2- BC and may be a promising strategy to identify tumors that utilize HER2 as an early endocrine escape pathway. Trial registration number: NCT03219476 Date of registration for prospectively registered trials: July 17, 2017.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Tina Yen
- MCW: Medical College of Wisconsin
| | | | | | | | | | | | | | - Yu Wang
- MCW: Medical College of Wisconsin
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10
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Hunt KK, Suman VJ, Wingate HF, Leitch AM, Unzeitig G, Boughey JC, Meric-Bernstam F, Ellis MJ, Olson J. Local-Regional Recurrence After Neoadjuvant Endocrine Therapy: Data from ACOSOG Z1031 (Alliance), a Randomized Phase 2 Neoadjuvant Comparison Between Letrozole, Anastrozole, and Exemestane for Postmenopausal Women with Estrogen Receptor-Positive Clinical Stage 2 or 3 Breast Cancer. Ann Surg Oncol 2023; 30:2111-2118. [PMID: 36653664 PMCID: PMC10373661 DOI: 10.1245/s10434-022-12972-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/26/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND The ACOSOG Z1031 trial addressed the ability of three neoadjuvant aromatase inhibitors (NAIs) to reduce residual disease (cohort A) and to assess whether switching to neoadjuvant chemotherapy (NCT) after 4 weeks of receiving NAI with Ki67 greater than 10% increases pathologic complete response (pCR) in postmenopausal women with estrogen receptor-enriched (Allred score 6-8) breast cancer (BC). METHODS The study enrolled 622 women with clinical stage 2 or 3 estrogen receptor-positive (ER+) BC. Cohort A comprised 377 patients, and cohort B had 245 patients. The analysis cohort consisted of 509 patients after exclusion of patients who did not meet the trial eligibility criteria, switched to NCT or surgery due to 4-week Ki67 greater than 10%, or withdrew before surgery. Distribution of time to local-regional recurrence (LRR) was estimated using the competing-risk approach, in which distant recurrence and second primaries were considered to be competing-risk events. Patients who died without LRR, distant recurrence, or a second primary were censored at the last evaluation. RESULTS Of the 509 patients, 342 (67.2%) had breast-conserving surgery (BCS). Of 221 patients thought to require mastectomy at presentation, 50% were able to have BCS. Five (1%) patients had no residual disease in the breast or nodes at surgery. Among 382 women alive at this writing, 90% have been followed longer than 5 years. The 5-year cumulative incidence rate for LRR is estimated to be 1.53% (95% confidence interval 0.7-3.0%). CONCLUSIONS Rarely does NAI result in pCR for patients with stage 2 or 3 ER+ BC. However, a significant proportion will have downstaged to allow for BCS. Local-regional recurrence after surgery is uncommon (1.5% at 5 years), supporting the use of BCS after NAI.
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Affiliation(s)
- Kelly K Hunt
- Breast Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA.
| | - Vera J Suman
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Hannah F Wingate
- Breast Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - A Marilyn Leitch
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Matthew J Ellis
- Lester and Sue Smith Breast Center, Baylor College of Medicine, Houston, TX, USA
| | - John Olson
- Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA
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11
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Zhang S, Liu Y, Liu X, Liu Y, Zhang J. Prognoses of Patients with Hormone Receptor-Positive and Human Epidermal Growth Factor Receptor 2-Negative Breast Cancer Receiving Neoadjuvant Chemotherapy before Surgery: A Retrospective Analysis. Cancers (Basel) 2023; 15:cancers15041157. [PMID: 36831499 PMCID: PMC9953770 DOI: 10.3390/cancers15041157] [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: 12/19/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
PURPOSE To evaluate the clinical characteristics, pathological response, and prognostic significance of hormone receptor-positive and human epidermal growth factor receptor 2-negative (HR+/HER2-) breast cancer (BC) after neoadjuvant chemotherapy (NAC). METHODS A survival analysis was performed to detect the factors related to recurrence and death in 3070 consecutive patients with HR+/HER2- BC who received NAC from 2011 to 2022. All patients received current "standard of care" following neoadjuvant therapy based on guidelines, including surgery and adjuvant endocrine therapy. HER2-low was defined as immunohistochemistry (IHC) 1+ or IHC 2+ and fluorescence in-situ hybridization-negative. RESULTS The complete pathological response (pCR) (ypT0/is ypN0) rate was 14.5%. The clinical tumor size (cT), ER scores, PR status, and Ki67 levels were related to pCR. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 82.6% and 90.4%, respectively. PR, Ki67 levels, and postmastectomy radiotherapy were independent factors for DFS and OS, and the extranodal extension (ENE) correlated with DFS. However, pCR and HER2 status were related to OS. The pCR rate in PR negativity BC was significantly higher than that in PR positivity BC (21.1% vs. 12.2%, p = 0.000), but PR negativity BC had a poorer prognosis than PR positivity BC. HER2-low BC showed high ER scores (over 50%), PR positivity, large ypT, ENE, and lymphovascular invasion but a lower pCR rate than HER2-zero BC. Patients with HER2-low BC had shorter OS than those with HER2-zero BC (p = 0.037). However, there was no difference in DFS. CONCLUSIONS Depending on PR status and HER2 status, patients with ER positivity and HER2 negativity exhibit different pathologic complete response rates to neoadjuvant chemotherapy and long-term outcomes, especially patients with PR negativity or HER2-low status.
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Affiliation(s)
| | | | | | | | - Jin Zhang
- Correspondence: ; Tel.: +86-22-2334-0123
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12
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Mamtani A, Grabenstetter A, Sevilimedu V, Morrow M, Gemignani ML. Do non-classic invasive lobular carcinomas derive a benefit from neoadjuvant chemotherapy? Breast Cancer Res Treat 2023; 197:417-423. [PMID: 36394689 PMCID: PMC10118744 DOI: 10.1007/s10549-022-06813-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE Invasive lobular breast cancers (ILCs) respond poorly to neoadjuvant chemotherapy (NAC). The degree of benefit of NAC among non-classic ILC (NC-ILC) variants compared with classic ILCs (C-ILCs) is unknown. METHODS Consecutive patients with Stage I-III ILC treated from 2003 to 2019 with NAC and surgery were identified, and grouped as C-ILC or NC-ILC as per the original surgical pathology report, with pathologist (A.G.) review performed if original categorization was unclear. A subset of similarly treated invasive ductal cancers (IDCs) was identified for comparison. Clinicopathologic characteristics and pathologic complete response (pCR) rates were evaluated. RESULTS Of 145 patients with ILC, 101 (70%) were C-ILC and 44 (30%) were NC-ILC (IDC cohort: 1157 patients). ILC patients were older, more often cT3/T4 and cN2/N3, and less often high-grade compared to IDC patients. Those with NC-ILC were less often ER+/HER2- (55% versus 93%), and more often HER2 + (25% versus 7%) and TN (21% versus 0%, all p < 0.001). Breast pCR was more common among NC-ILC, but most frequent in IDC. Nodal pCR rates were also lowest among C-ILC patients, but similar among NC-ILC and IDC patients. On multivariable analysis, C-ILC (OR 0.09) and LVI (OR 0.51) were predictive of lack of breast pCR; non-ER+/HER2- subtypes and breast pCR were predictive of nodal pCR. When our analysis was repeated with patients stratified by receptor subtype, histology was not independently predictive of either breast or nodal pCR. CONCLUSION NC-ILC patients were significantly more likely to achieve breast and nodal pCR compared with C-ILC patients, but when stratified by subtype, histology was not independently predictive of breast or nodal pCR.
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66 Street, New York, NY, 10065, USA.
| | - Anne Grabenstetter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66 Street, New York, NY, 10065, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66 Street, New York, NY, 10065, USA
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13
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Martínez-Pérez C, Turnbull AK, Kay C, Dixon JM. Neoadjuvant endocrine therapy in postmenopausal women with HR+/HER2- breast cancer. Expert Rev Anticancer Ther 2023; 23:67-86. [PMID: 36633402 DOI: 10.1080/14737140.2023.2162043] [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: 10/14/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION While endocrine therapy is the standard-of-care adjuvant treatment for hormone receptor-positive (HR+) breast cancers, there is also extensive evidence for the role of pre-operative (or neoadjuvant) endocrine therapy (NET) in HR+ postmenopausal women. AREAS COVERED We conducted a thorough review of the published literature, to summarize the evidence to date, including studies of how NET compares to neoadjuvant chemotherapy, which NET agents are preferable, and the optimal duration of NET. We describe the importance of on-treatment assessment of response, the different predictors available (including Ki67, PEPI score, and molecular signatures) and the research opportunities the pre-operative setting offers. We also summarize recent combination trials and discuss how the COVID-19 pandemic led to increases in NET use for safe management of cases with deferred surgery and adjuvant treatments. EXPERT OPINION NET represents a safe and effective tool for the management of postmenopausal women with HR+/HER2- breast cancer, enabling disease downstaging and a wider range of surgical options. Aromatase inhibitors are the preferred NET, with evidence suggesting that longer regimens might yield optimal results. However, NET remains currently underutilised in many territories and institutions. Further validation of predictors for treatment response and benefit is needed to help standardise and fully exploit the potential of NET in the clinic.
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Affiliation(s)
- Carlos Martínez-Pérez
- Translational Oncology Research Group, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Breast Cancer Now Research Team, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
| | - Arran K Turnbull
- Translational Oncology Research Group, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Breast Cancer Now Research Team, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
| | - Charlene Kay
- Translational Oncology Research Group, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Breast Cancer Now Research Team, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
| | - J Michael Dixon
- Translational Oncology Research Group, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Breast Cancer Now Research Team, MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Breast Unit, Western General Hospital, Edinburgh, Scotland
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Abstract
There is growing interest in neoadjuvant endocrine therapy (NET) for the treatment of hormone receptor-positive, human epidermal growth factor receptor 2 -negative (HR + HER2-) breast cancer. Expanding the use of genomic assays demonstrates that many patients with HR + HER2-breast cancer do not benefit from chemotherapy, leading to growing interest in NET as a less toxic alternative. Although NET's ability to downsize breast tumors and achieve breast conservation is well-known, axillary surgery algorithms are not well-defined. Here we review primary endocrine therapy, the landmark NET clinical trials, and management of residual nodal disease following NET.
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Affiliation(s)
- Anna Weiss
- Division of Breast Surgery, Brigham and Women's Hospital, Dana-Farber/Brigham Cancer Center, Harvard Medical School, 450 Brookline Avenue, YC 1220, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Brigham and Women's Hospital, Dana-Farber/Brigham Cancer Center, Harvard Medical School, 450 Brookline Avenue, YC 1220, Boston, MA, USA.
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15
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Singer L, Weiss A, Bellon JR, King TA. Regional Nodal Management After Preoperative Systemic Therapy. Semin Radiat Oncol 2022; 32:228-236. [DOI: 10.1016/j.semradonc.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Reis J, Boavida J, Tran HT, Lyngra M, Reitsma LC, Schandiz H, Melles WA, Gjesdal KI, Geisler J, Geitung JT. Assessment of preoperative axillary nodal disease burden: breast MRI in locally advanced breast cancer before, during and after neoadjuvant endocrine therapy. BMC Cancer 2022; 22:702. [PMID: 35752785 PMCID: PMC9233812 DOI: 10.1186/s12885-022-09813-9] [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: 03/29/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background Axillary lymph node (LN) metastasis is one of the most important predictors of recurrence and survival in breast cancer, and accurate assessment of LN involvement is crucial. Determining extent of residual disease is key for surgical planning after neoadjuvant therapy. The aim of the study was to evaluate the diagnostic reliability of MRI for nodal disease in locally advanced breast cancer patients treated with neoadjuvant endocrine therapy (NET). Methods Thirty-three clinically node-positive locally advanced breast cancer patients who underwent NET and surgery were prospectively enrolled. Two radiologists reviewed the axillary nodes at 3 separate time points MRI examinations at baseline (before the first treatment regimen), interim (following at least 2 months after the first cycle and prior to crossing-over), and preoperative (after the final administration of therapy and immediately before surgery). According to LN status after surgery, imaging features and diagnostic performance were analyzed. Results All 33 patients had a target LN reduction, the greatest treatment benefit from week 8 to week 16. There was a positive correlation between the maximal diameter of the most suspicious LN measured by MRI and pathology during and after NET, being highest at therapy completion (r = 0.6, P ≤ .001). Mean and median differences of maximal diameter of the most suspicious LN were higher with MRI than with pathology. Seven of 33 patients demonstrated normal posttreatment MRI nodal status (yrN0). Of these 7 yrN0, 3 exhibited no metastasis on final pathology (ypN0), 2 ypN1 and 2 ypN2. Reciprocally, MRI diagnosed 3 cases of ypN0 as yrN + . Diffusion -weighted imaging (DWI) was the only axillary node characteristic significant when associated with pathological node status (χ2(4) = 8.118, P = .072). Conclusion Performance characteristics of MRI were not completely sufficient to preclude surgical axillary staging. To our knowledge, this is the first study on MRI LN assessment following NET in locally advanced breast cancer, and further studies with larger sample sizes are required to consolidate the results of this preliminary study. Trial Registration Institutional Review Board approval was obtained (this current manuscript is from a prospective, open-label, randomized single-center cohort substudy of the NEOLETEXE trial). NEOLETEXE, a phase 2 clinical trial, was registered on March 23rd, 2015 in the National trial database of Norway and approved by the Regional Ethical Committee of the South-Eastern Health Region in Norway; registration number: REK-SØ-84–2015. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09813-9.
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Affiliation(s)
- Joana Reis
- Department of Diagnostic Imaging and Intervention, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway. .,Institute of Clinical Medicine, Campus AHUS, University of Oslo, Postboks 1000, 1478, Lørenskog, Norway. .,Translational Cancer Research Group, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway.
| | - Joao Boavida
- Department of Diagnostic Imaging and Intervention, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway
| | - Hang T Tran
- Department of Diagnostic Imaging and Intervention, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway
| | - Marianne Lyngra
- Department of Pathology, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway
| | - Laurens Cornelus Reitsma
- Department of Breast and Endocrine Surgery, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway
| | - Hossein Schandiz
- Department of Pathology, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway
| | - Woldegabriel A Melles
- Department of Diagnostic Imaging and Intervention, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway
| | - Kjell-Inge Gjesdal
- Department of Diagnostic Imaging and Intervention, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway.,Sunnmøre MR-Clinic, Agrinorbygget, Langelansveg 15, 6010, Ålesund, Norway
| | - Jürgen Geisler
- Institute of Clinical Medicine, Campus AHUS, University of Oslo, Postboks 1000, 1478, Lørenskog, Norway.,Translational Cancer Research Group, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway.,Department of Oncology, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway
| | - Jonn Terje Geitung
- Department of Diagnostic Imaging and Intervention, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway.,Institute of Clinical Medicine, Campus AHUS, University of Oslo, Postboks 1000, 1478, Lørenskog, Norway.,Translational Cancer Research Group, Akershus University Hospital (AHUS), Postboks 1000, 1478, Lørenskog, Norway
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17
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Ensenyat-Mendez M, Rünger D, Orozco JIJ, Le J, Baker JL, Weidhaas J, Marzese DM, DiNome ML. Epigenetic Signatures Predict Pathologic Nodal Stage in Breast Cancer Patients with Estrogen Receptor-Positive, Clinically Node-Positive Disease. Ann Surg Oncol 2022; 29:4716-4724. [DOI: 10.1245/s10434-022-11684-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/16/2022] [Indexed: 12/30/2022]
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18
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Ye L, Rünger D, Angarita SA, Hadaya J, Baker JL, Lee MK, Thompson CK, Attai DJ, DiNome ML. Higher risk tumor features are not associated with higher nodal stage in patients with estrogen receptor-positive, node-positive breast cancer. Breast Cancer Res Treat 2022; 193:429-436. [PMID: 35389189 DOI: 10.1007/s10549-022-06581-9] [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: 02/01/2022] [Accepted: 03/24/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Studies support omission of axillary lymph node dissection (ALND) for patients with sentinel node-positive disease, with ALND recommended for patients who present with clinically positive nodes. Here, we evaluate patient and tumor characteristics and pathologic nodal stage of patients with estrogen receptor-positive (ER +) breast cancer who undergo ALND to determine if differences exist based on nodal presentation. MATERIALS AND METHODS Retrospective chart review from 2010 to 2019 defined three groups of patients with ER + breast cancer who underwent ALND for positive nodes: SLN + (positive node identified at SLN biopsy), cNUS (abnormal preoperative US and biopsy), and cNpalp (palpable adenopathy). Patients who received neoadjuvant chemotherapy or presented with axillary recurrence were excluded. RESULTS Of 191 patients, 94 were SLN + , 40 were cNUS, and 57 were cNpalp. Patients with SLN + compared with cNpalp were younger (56 vs 64 years, p < 0.01), more often pre-menopausal (41% vs 14%, p < 0.01), and White (65% vs 39%, p = 0.01) with more tumors that were low-grade (36% vs 8%, p < 0.01). Rates of PR + (p = 0.16), levels of Ki67 expression (p = 0.07) and LVI (p = 0.06) did not differ significantly among groups. Of patients with SLN + disease, 64% had pN1 disease compared to 38% of cNUS (p = 0.1) and 40% of cNpalp (p = 0.01). On univariable analysis, tumor size (p = 0.01) and histology (p = 0.04) were significantly associated with pN1 disease, with size remaining an independent predictor on multivariable analysis (p = 0.02). CONCLUSION Historically, higher risk features have been attributed to patients with clinically positive nodes precluding omission of ALND, but when restricting evaluation to patients with ER + breast cancer, only tumor size is associated with higher nodal stage.
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Affiliation(s)
- Linda Ye
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dennis Rünger
- Statistics Core, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Stephanie A Angarita
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph Hadaya
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer L Baker
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Minna K Lee
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carlie K Thompson
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Deanna J Attai
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Maggie L DiNome
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27710, USA.
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Martí C, Yébenes L, Oliver JM, Moreno E, Frías L, Berjón A, Loayza A, Meléndez M, Roca MJ, Córdoba V, Hardisson D, Rodríguez MÁ, Sánchez-Méndez JI. The Clinical Impact of Neoadjuvant Endocrine Treatment on Luminal-like Breast Cancers and Its Prognostic Significance: Results from a Single-Institution Prospective Cohort Study. Curr Oncol 2022; 29:2199-2210. [PMID: 35448153 PMCID: PMC9026529 DOI: 10.3390/curroncol29040179] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 01/02/2023] Open
Abstract
Purpose: Neoadjuvant endocrine treatment (NET) has become a useful tool for the downstaging of luminal-like breast cancers in postmenopausal patients. It enables us to increase breast- conserving surgery (BCS) rates, provides an opportunity for us to assess in vivo NET effectiveness, and allows us to study any biological changes that may act as valid biomarkers. The purpose of this study was to evaluate the safety and effectiveness of NET, and to assess the role of Ki67 proliferation rate changes as an indicator of endocrine responsiveness. Methods: From 2016 to 2020, a single-institution cohort of patients, treated with NET and further surgery, was evaluated. In patients with Ki67 ≥ 10%, a second core biopsy was performed after four weeks. Information regarding histopathological and clinical changes was gathered. Results: A total of 115 estrogen receptor-positive (ER+)/HER2-negative patients were included. The median treatment duration was 5.0 months (IQR: 2.0−6.0). The median maximum size in the surgical sample was 40% smaller than the pretreatment size measured by ultrasound (p < 0.0001). The median pretreatment Ki67 expression was 20.0% (IQR: 12.0−30.0), and was reduced to 5.0% (IQR: 1.8−10.0) after four weeks, and to 2.0% (IQR: 1.0−8.0) in the surgical sample (p < 0.0001). BCS was performed on 98 patients (85.2%). No pathological complete responses were recorded. A larger Ki67 fold change after four weeks was significantly related to a PEPI score of zero (p < 0.002). No differences were observed between luminal A- and B-like tumors, with regard to fold change and PEPI score. Conclusions: In our cohort, NET was proven to be effective for tumor size and Ki67 downstaging. This resulted in a higher rate of conservative surgery, aided in therapeutic decision making, provided prognostic information, and constituted a safe and well-tolerated approach.
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Affiliation(s)
- Covadonga Martí
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Gynecology, Hospital Universitario La Paz, 28046 Madrid, Spain
- Correspondence:
| | - Laura Yébenes
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Pathology, Hospital Universitario La Paz, 28046 Madrid, Spain
- IdiPaz—Instituto de Investigación La Paz, 28046 Madrid, Spain
| | - José María Oliver
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Radiology, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Elisa Moreno
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Gynecology, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Laura Frías
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Gynecology, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Alberto Berjón
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Pathology, Hospital Universitario La Paz, 28046 Madrid, Spain
- IdiPaz—Instituto de Investigación La Paz, 28046 Madrid, Spain
| | - Adolfo Loayza
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Gynecology, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Marcos Meléndez
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Gynecology, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - María José Roca
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Radiology, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Vicenta Córdoba
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Radiology, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - David Hardisson
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Pathology, Hospital Universitario La Paz, 28046 Madrid, Spain
- IdiPaz—Instituto de Investigación La Paz, 28046 Madrid, Spain
- Faculty of Medicine, Universidad Autónoma de Madrid, 28046 Madrid, Spain
- Center for Biomedical Research in the Cancer Network (CIBERONC), 28029 Madrid, Spain
| | - María Ángeles Rodríguez
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
| | - José Ignacio Sánchez-Méndez
- Breast Cancer Unit, Hospital Universitario La Paz, 28046 Madrid, Spain; (L.Y.); (J.M.O.); (E.M.); (L.F.); (A.B.); (A.L.); (M.M.); (M.J.R.); (V.C.); (D.H.); (M.Á.R.); (J.I.S.-M.)
- Department of Gynecology, Hospital Universitario La Paz, 28046 Madrid, Spain
- IdiPaz—Instituto de Investigación La Paz, 28046 Madrid, Spain
- Faculty of Medicine, Universidad Autónoma de Madrid, 28046 Madrid, Spain
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20
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Rubio IT, Sobrido C. Neoadjuvant approach in patients with early breast cancer: patient assessment, staging, and planning. Breast 2022; 62 Suppl 1:S17-S24. [PMID: 34996668 PMCID: PMC9097809 DOI: 10.1016/j.breast.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022] Open
Abstract
Neoadjuvant treatment (NAT) has become an option in early stage (stage I-II) breast cancer (EBC). New advances in systemic and targeted therapies have increased rates of pathologic complete response increasing the number of patients undergoing NAT. Clear benefits of NAT are downstaging the tumor and the axillary nodes to de-escalate surgery and to evaluate response to treatment. Selection of patients for NAT in EBC rely in several factors that are related to patient characteristics (i.e, age and comorbidities), to tumor histology, to stage at diagnosis and to the potential changes in surgical or adjuvant treatments when NAT is administered. Imaging and histologic confirmation is performed to assess extent of disease y to confirm diagnosis. Besides mammogram and ultrasound, functional breast imaging MRI has been incorporated to better predict treatment response and residual disease. Contrast enhanced mammogram (CEM), shear wave elastography (SWE), or Dynamic Optical Breast Imaging (DOBI) are emerging techniques under investigation for assessment of response to neoadjuvant therapy as well as for predicting response. Surgical plan should be delineated after NAT taking into account baseline characteristics, tumor response and patient desire. In the COVID era, we have witnessed also the increasing use of NAT in patients who may be directed to surgery, unable to have it performed as surgery has been reserved for emergency cases only.
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21
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Williams AD, Ciocca R, Sabol JL, Carp NZ. The use of neoadjuvant therapy increases the rate of breast conservation in men with locally advanced breast cancer. Clin Breast Cancer 2022; 22:343-358. [DOI: 10.1016/j.clbc.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/30/2022]
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22
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Hadar T, Koretz M, Nawass M, Allweis TM. Innovative Standards in Surgery of the Breast after Neoadjuvant Systemic Therapy. Breast Care (Basel) 2021; 16:590-597. [PMID: 35087362 PMCID: PMC8739938 DOI: 10.1159/000520051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/29/2021] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND The goal of neoadjuvant systemic therapy (NST) in breast cancer is to downstage tumors and downgrade treatment. Indications are constantly evolving. These changes raise practical questions for planning of surgery after NST. SUMMARY In this review we discuss current evolving aspects of surgery of the breast after NST. Breast-conserving surgery (BCS) eligibility increases after NST - both neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy. Adequate margin width in NST and upfront surgery are similar - "no tumor on ink" for invasive cancer. Oncoplastic breast surgery after NST is feasible - both for BCS and mastectomy with reconstruction. There is increasing interest in the possibility of omitting surgery in patients with a complete response to NAC. Several trials are being conducted in aim of achieving acceptable prediction of pathological complete response, by combination of imaging and percutaneous biopsy of the tumor bed, as well as assessing the safety of such an approach. KEY MESSAGES Surgery of the breast after NST should be determined not only according to biologic and anatomic parameters at diagnosis, but is dynamic, and must be tailored according to the response to therapy. The omission of surgery in exceptional responders after NAC is being explored.
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Affiliation(s)
- Tal Hadar
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Michael Koretz
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mahmood Nawass
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tanir M. Allweis
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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23
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Sella T, Weiss A, Mittendorf EA, King TA, Pilewskie M, Giuliano AE, Metzger-Filho O. Neoadjuvant Endocrine Therapy in Clinical Practice: A Review. JAMA Oncol 2021; 7:1700-1708. [PMID: 34499101 DOI: 10.1001/jamaoncol.2021.2132] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance In clinical practice, neoadjuvant endocrine therapy (NET) is rarely used despite being an effective treatment modality able to downstage tumors and facilitate breast-conserving surgery. Observations Using data from studies conducted since 2000, we provide readers with a critical in-depth review on clinical aspects related to the application of NET in the treatment of hormone receptor (HR)-positive/ERBB2 (formerly HER2)-negative breast cancer. This includes an overview of patient-selection criteria, regimen choice, treatment duration, evaluation of response by imaging, interpretation of pathology after treatment, and surgical considerations. Areas of controversy include the use of gene-expression tests for patient selection, treatment of premenopausal women, surgical management of the axilla after NET, and adjuvant systemic therapy decision-making, including the use of chemotherapy. Conclusions and Relevance NET is an optimal treatment modality for a considerable proportion of postmenopausal women diagnosed with HR-positive tumors. The treatment landscape for HR-positive breast cancer is evolving, with novel agents and the growing use of gene expression profiling to define treatment selection. As such, it is likely that NET use will increase and the practical considerations outlined here will become more important.
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Affiliation(s)
- Tal Sella
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Anna Weiss
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tari A King
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Melissa Pilewskie
- Breast Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Armando E Giuliano
- Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Health System, Los Angeles, California
| | - Otto Metzger-Filho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
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24
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Crown A, Sevilimedu V, Morrow M. Palpable Adenopathy Does Not Indicate High-Volume Axillary Nodal Disease in Hormone Receptor-Positive Breast Cancer. Ann Surg Oncol 2021; 28:6060-6068. [PMID: 33876360 DOI: 10.1245/s10434-021-09943-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/17/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Axillary metastases in the form of palpable adenopathy indicate the need for neoadjuvant chemotherapy or axillary lymph node dissection (ALND). Patients with hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) disease infrequently have nodal pathologic complete response to neoadjuvant chemotherapy and often require ALND. Sentinel lymph node biopsy is an accepted treatment for patients with two or fewer non-palpable nodal metastases who are undergoing breast conservation. The proportion of patients with HR+/HER2- disease with palpable adenopathy and two or fewer nodal metastases is unknown. METHODS Patients with cT1-T3N1 HR+/HER2- disease with palpable adenopathy were identified from a prospective database. Patients who underwent mastectomy or breast-conserving therapy with ALND were included in this study, whereas patients who received neoadjuvant chemotherapy were excluded. Clinicopathologic characteristics were compared between patients with two or fewer or more than two positive nodes on ALND. RESULTS Of 180 patients included, 78 (43%) had two or fewer positive nodes on ALND, including 40/72 patients (56%) who underwent lumpectomy. On univariate analysis, cT1 tumor, unifocal tumor, only one palpable node, and two or fewer suspicious nodes on ultrasound were associated with two or fewer positive nodes on ALND. On multivariable analysis, number of suspicious nodes on ultrasound and cT stage were independently associated with two or fewer positive nodes on ALND. CONCLUSIONS A substantial minority of patients with cT1-3N1 HR+/HER2- disease with palpable adenopathy had two or fewer positive nodes on ALND. Standard clinicopathologic features and ultrasound findings can help identify candidates for upfront sentinel lymph node biopsy as a strategy to avoid ALND. Prospective studies evaluating this approach are warranted.
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Affiliation(s)
- Angelena Crown
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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25
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Cao L, Montero AJ, Shenk R, Miller ME. ASO Author Reflections: Decisions, Decisions: Neoadjuvant Chemotherapy, Neoadjuvant Endocrine Therapy, or Primary Surgery? Ann Surg Oncol 2021; 29:562-563. [PMID: 34405294 DOI: 10.1245/s10434-021-10621-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Lifen Cao
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alberto J Montero
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert Shenk
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Megan E Miller
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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26
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Cao L, Sugumar K, Keller E, Li P, Rock L, Simpson A, Freyvogel M, Montero AJ, Shenk R, Miller ME. Neoadjuvant Endocrine Therapy as an Alternative to Neoadjuvant Chemotherapy Among Hormone Receptor-Positive Breast Cancer Patients: Pathologic and Surgical Outcomes. Ann Surg Oncol 2021; 28:5730-5741. [PMID: 34342757 PMCID: PMC8330206 DOI: 10.1245/s10434-021-10459-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/22/2021] [Indexed: 12/22/2022]
Abstract
Background Neoadjuvant chemotherapy (NCT) is considered more effective in downstaging hormone receptor-positive (HR+) breast cancer than neoadjuvant endocrine therapy (NET), particularly in node-positive disease. This study compared breast and axillary response and survival after NCT and NET in HR+ breast cancer. Methods Based on American College of Surgeons Oncology Group (ACOSOG) Z1031 criteria, women age 50 years or older with cT2-4 HR+ breast cancer who underwent NET or NCT and surgery were identified in the National Cancer Database 2010–2016. Chi-square and logistic regression analysis determined differences between the NCT and NET groups and therapy response, including downstaging and pathologic complete response (pCR, ypT0/is and ypN0). Results Of 19,829 patients, 14,025 (70.7%) received NCT and 5804 (29.3%) received NET. The NET patients were older (mean age, 68.9 vs. 60.3; P < 0.001) and had greater comorbidity (1+ Charlson–Deyo score, 21% vs. 16%; P < 0.001). Therapy achieved T downstaging (any) for 58% of the patients with NCT versus 40.5% of the patients with NET, and in-breast pCR was achieved for 9.3% of the NCT versus 1.3% of the NET patients (P < 0.001). Approximately half of the mastectomy procedures could have been potentially avoided for the patients with in-breast pCR (53.6% of the NCT and 43.8% of the NET patients). For the cN+ patients, N downstaging (any) was 29% for the NCT patients versus 18.3% for the NET patients (P < 0.001), and nodal pCR was achieved for 20.3% of the NCT versus 13.5% of the NET patients (P < 0.001). Among those with nodal pCR, axillary lymph node dissection (ALND) still was performed for 56% of the patients after NCT and 45% of the patients after NET. Conclusions Although the response rates after NCT were higher, NET achieved both T and N downstaging and pCR. Neoadjuvant endocrine therapy can be used to de-escalate surgery for patients who cannot tolerate NCT or when chemotherapy may not be effective based on genomic testing. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10459-3.
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Affiliation(s)
- Lifen Cao
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Kavin Sugumar
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Eleanor Keller
- University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Pamela Li
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Lisa Rock
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Ashley Simpson
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Mary Freyvogel
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Alberto J Montero
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert Shenk
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA
| | - Megan E Miller
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA. .,University Hospitals Research in Surgical Outcomes and Effectiveness (UH-RISES), Cleveland, OH, USA.
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27
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Murphy BM, Hoskin TL, Degnim AC, Boughey JC, Hieken TJ. Surgical Management of Axilla Following Neoadjuvant Endocrine Therapy. Ann Surg Oncol 2021; 28:8729-8739. [PMID: 34275042 PMCID: PMC8286162 DOI: 10.1245/s10434-021-10385-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/11/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Randomized clinical trials support deescalation of axillary surgery in breast cancer patients with low-volume axillary disease treated with a surgery-first approach. However, few data exist to guide axillary surgery following neoadjuvant endocrine therapy (NET). Therefore, we evaluated the extent and outcomes of axillary surgery in a contemporary cohort of NET patients, a treatment approach that has become particularly relevant during the coronavirus disease-19 (COVID-19) pandemic. PATIENTS AND METHODS We identified invasive breast cancer patients treated with NET between October 2008 and November 2019. Patients presenting with stage IV disease or recurrent disease were excluded. Statistical analyses were performed using chi-square, Fisher's exact, and Wilcoxon rank-sum tests. RESULTS 194 invasive breast cancers in 186 patients (median age 66 years) were evaluated; 81 patients had breast-conserving surgery (BCS), while 113 underwent mastectomy. Eighty-four patients (43.3%) were biopsy-proven cN+ with 4/84 (4.8%) ypN0 following NET. Among cN+ patients, 14 (16.7%) had sentinel lymph node biopsy (SLNB) only, 27 (32.1%) had SLNB + axillary lymph node dissection (ALND), and 43 (51.2%) had ALND. Among 110 cN0 patients, 99 had axillary surgery with 28/99 (28.3%) ypN+: SLNB in 83 (75.5%), SLNB+ALND in 14 (12.7%), and ALND in 2 (1.8%). Among all ypN+ patients, 23/108 (21.3%) had SLNB alone: 18/43 (41.9%) of BCS and 5/65 (7.7%) mastectomy patients (p < 0.001). After median follow-up of 35 months, no regional recurrences were observed. CONCLUSIONS Among biopsy-proven cN+ NET patients, we observed deescalation of axillary surgery in selected patients, despite a low nodal pathologic complete response (pCR) rate, without nodal recurrences. These data suggest that patients with low-volume axillary disease treated with NET may be managed similarly to patients treated with a surgery-first approach.
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Affiliation(s)
- Brenna M Murphy
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tina J Hieken
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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28
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The Present and Future of Neoadjuvant Endocrine Therapy for Breast Cancer Treatment. Cancers (Basel) 2021; 13:cancers13112538. [PMID: 34064183 PMCID: PMC8196711 DOI: 10.3390/cancers13112538] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary The treatment of breast cancer has evolved considerably over the last two decades, leading toward individualized disease management. Hormone-sensitive breast cancers constitute the vast majority of cases and endocrine therapy is the mainstay of their treatment. On the other hand, neoadjuvant or pre-surgical treatments provide a number of advantages for tumor management. In this review we will discuss the existing evidence on neoadjuvant endocrine therapy, as well as its possible future indications. Abstract Endocrine therapy (ET) has established itself as an efficacious treatment for estrogen receptor-positive (ER+) breast cancers, with a reduction in recurrence rates and increased survival rates. The pre-surgical approach with chemotherapy (NCT) has become a common form of management for large, locally advanced, or high-risk tumors. However, a good response to NCT is not usually expected in ER+ tumors. Good results with primary ET, mainly in elderly women, have encouraged studies in other stages of life, and nowadays neoadjuvant endocrine treatment (NET) has become a useful approach to many ER+ breast cancers. The aim of this review is to provide an update on the current state of art regarding the present and the future role of NET.
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29
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Schipper RJ, de Bruijn A, Voogd AC, Bloemen JG, Van Riet YE, Vriens BEP, Smidt ML, Siesling S, van der Sangen MJC, Nieuwenhuijzen GAP. Rate and predictors of nodal pathological complete response following neoadjuvant endocrine treatment in clinically biopsy-proven node-positive breast cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:1928-1933. [PMID: 34030918 DOI: 10.1016/j.ejso.2021.04.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/10/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Data on effectiveness and optimal use of neoadjuvant endocrine therapy (NET) in clinically biopsy-proven node-positive breast cancer is lacking. This study examined the incidence of axillary pathological complete response (pCR) on NET in clinically biopsy-proven node-positive breast cancer patients. Secondary, patient and tumour characteristics, as well as the optimal duration of NET in relation to the occurrence of axillary pCR were investigated. MATERIAL AND METHODS Patients diagnosed with primary hormone receptor positive, HER2 negative breast cancer between 2014 and 2019, with at least one positive axillary lymph node (pathologically proven), treated with NET were selected from the Netherlands Cancer Registry. The incidence of axillary pCR in combination with patient, tumour and treatment characteristics was analysed. RESULTS In a population of 561 patients, an axillary pCR of 7.3% on NET was observed. Median length of treatment was 8.1 months in the patients without vs. 8.8 months in those with axillary pCR, with no statistically significant difference. A p-value <0.30 was found for age, histologic type, clinical tumour status, hormone receptor status and the type of NET in univariable analysis. After multivariable logistic regression analyses, none of these variables were independently associated with the likelihood of an axillary pCR. CONCLUSION The rate of axillary pCR after NET in HR + HER2-clinically biopsy-proven node-positive breast cancer patients is low. Factors independently associated with the likelihood of an axillary pCR could not be identified. More research is warranted regarding optimizing the duration of NET and the prognostic value of residual disease in the axilla after NET.
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Affiliation(s)
| | - Anne de Bruijn
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Adri C Voogd
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Yvonne E Van Riet
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Birgit E P Vriens
- Department of Internal Medicine, Catharina Hospital Eindhoven, the Netherlands
| | - Marjolein L Smidt
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Center +, Maastricht, the Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
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30
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Crown A, Morrow M. ASO Author Reflections: Rethinking Palpable Adenopathy as a Marker of High-Volume Axillary Nodal Disease in Hormone Receptor-Positive Breast Cancer. Ann Surg Oncol 2021; 28:6069-6070. [PMID: 33876356 DOI: 10.1245/s10434-021-09984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Angelena Crown
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Kuerer HM, Blair SL. The Virtual Scientific Sessions from the American Society of Breast Surgeons During the COVID-19 Pandemic. Ann Surg Oncol 2020; 27:4585-4587. [PMID: 32812104 PMCID: PMC7433665 DOI: 10.1245/s10434-020-08946-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of General Surgery, University of California, San Diego, CA, USA.
| | - Sarah L Blair
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of General Surgery, University of California, San Diego, CA, USA
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Montagna G, Morrow M, Pilewskie M. ASO Author Reflections: Nodal Downstaging and Conversion to Breast-Conserving Surgery Following Neoadjuvant Endocrine Therapy. Ann Surg Oncol 2020; 27:693-694. [PMID: 32797378 DOI: 10.1245/s10434-020-08971-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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