Clinical practice guidelines for the care and treatment of breast cancer: 15. Treatment for women with stage III or locally advanced breast cancer

Significance of Serum Lactate Dehydrogenase as a Prognostic Marker and Outcome Predictor in Patients With Breast Cancer

Background Breast carcinoma has been the most prevalent cancer in women, with research-based evidence showing a significant rise in the incidence of cancer and related morbidity and mortality in the Indian subcontinent. The predictive value of plasmatic lactate dehydrogenase (LDH) levels has been studied in breast cancer. Numerous studies have connected high LDH values to a poor prognosis, increased risk of incidence, recurrence, and associated mortality in patients with breast carcinoma. This study aimed to assess the clinical profile of breast carcinoma and determine the correlation of serum lactate dehydrogenase levels with the stage of the disease and assessment of high-risk features using histopathology and immunohistochemistry. Methods A total of 75 patients with carcinoma breast were enrolled for this study and classified into two groups: upfront surgery and post-adjuvant therapy. Serum LDH levels were estimated a day before the surgery (baseline) and on postoperative days 1, 7, 14, and 30. The clinical tumor, node, metastasis (cTNM) staging was correlated with pathological tumor, node, metastasis TNM (pTNM) staging and immunohistochemistry findings. Results The clinical characteristics of breast cancer, serum LDH levels, and stage of the disease were collected and analyzed. A significant decreasing trend was noted in LDH values post-op days, and statistically significant higher LDH values were noted in the triple-negative group, positive lymph nodes, and positive lymphovascular invasion patients. Conclusion Regularly elevated levels or an unanticipated rise in serum LDH might indicate poor outcomes. Hence, this non-specific enzyme marker can be suggested to be used routinely to assess disease outcomes.

Prospective Evaluation of Response Outcomes of Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer

Introduction Breast cancer is a global health problem, with more than 1 million cases of breast cancer diagnosed worldwide each year, and is the most common cancer among Indian women. Locally advanced breast cancer (LABC) accounts for 10-20% in the Western world while in India it accounts for 40-50% of all cases. Locally advanced breast cancer is a very common clinical scenario especially in developing countries possibly due to various factors like lack of education and poor socioeconomic status. Women with the locally advanced disease require multimodality therapy and coordinated treatment planning. This study aimed to prospectively study the clinical profile of the LABC patients presenting to our institute and also to evaluate the role of neoadjuvant chemotherapy in downstaging the tumor. Materials and Methods Seventy patients diagnosed with locally advanced breast cancer were enrolled in this prospective study. After thorough preoperative workup, patients were either taken up for upfront surgery or neoadjuvant chemotherapy followed by surgery. Post chemotherapy clinical response of the tumor and postoperative histopathological evaluation of the specimen was performed. Results The mean age of the patients in our study was 45 years. Out of 70 patients, 18 underwent upfront surgery, and 52 received neoadjuvant chemotherapy followed by surgery. A total of 44 cases had a clinical response to chemotherapy with 9% having a complete response. The incidence of margin positivity in the postoperative specimen was significantly lower in patients who received neoadjuvant chemotherapy. Conclusion  Locally advanced breast cancer accounted for the predominant number of breast cancer patients mostly females in their middle age. Neoadjuvant chemotherapy was effective in downstaging the tumor in the majority of cases, although complete clinical response was lower in our study. The rate of margin positivity in mastectomy specimens can also be reduced if chemotherapy is considered prior to mastectomy.

microRNA-221 and tamoxifen resistance in luminal-subtype breast cancer patients: A case-control study

Background

Around 70% of breast cancers (BCs) are estrogen receptor-α (ERα)-positive. Adjuvant endocrine therapy is used to reduce estrogen levels and inhibit signal transduction through the ER. The anti-estrogen drugs that are most commonly used in endocrine therapy belong to the selective ER modulator (SERM) class and include tamoxifen. Although it has been used for three decades in cases of early-stage and ERα-positive BC, resistance to tamoxifen is a common problem. microRNAs (miRNAs) have a potential role in demonstrating BC resistance to tamoxifen therapy. Hence, there is a need to investigate the expression of miRNA-221 (miR-221) in luminal-subtype BC patients receiving tamoxifen therapy.

Methods

This case-control study investigated luminal-subtype BC patients who had undergone endocrine therapy for at least 1 year. The case group comprised patients with local or metastatic recurrence, and the control group comprised patients without local or metastatic recurrence.

Results

There was a significant difference in miR-221 expression (p = 0.005) between the case and control groups. There were no significant differences between the groups that were positive and negative for the progesterone receptor (PR) (p = 0.25), had high and low marker of proliferation Ki-67 levels (p = 0.60), were positive and negative for lymphovascular invasion (p = 0.14), and had stage 2 and stage 3 cancer (p = 0.25).

Conclusion

miR-221 expression was higher in tamoxifen-resistant BC cases. miR-221 is a potential biomarker of tamoxifen resistance.

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Tamoxifen is used to treat early-stage and estrogen receptor-α-positive breast cancer.

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Resistance to tamoxifen is a common problem.

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Serum microRNA-221 levels were higher in patients with local recurrence and metastasis.

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microRNA-221 is a potential serum biomarker of tamoxifen resistance.

The effect of eIF3a on anthracycline-based chemotherapy resistance by regulating DSB DNA repair

BACKGROUND

Anthracycline are inhibitors of topoisomerase II leading to DNA double strand breaks, and it is widely used for treatment of breast cancer. eIF3a is the largest subunit of eukaryotic translation initiation factor 3 (eIF3) and highly expressed in breast cancer. In this study, we investigated the role of eIF3a in DSB DNA repair and the response of breast cancer patients to anthracycline-based chemotherapy.

METHODS

MTT assay was used to detect anthracycline sensitivity in cell lines. Real-time reverse transcriptase PCR, western blotting and immunofluorescence were performed to assess changes in gene expression levels. Cometassay and end-joining activity assay were conducted to explore the effect of eIF3a in NHEJ repair. Luciferase reporter assay was performed to detect LIG4 5'UTR activity. Immunohistochemistry was used to detect eIF3a, LIG4 and DNA-PKcs expression levels in breast cancer tissues.

RESULTS

The results showed that eIF3a increased cellular response to anthracyclines by regulating DSB repair activity via influencing the expression of LIG4 and DNA-PKcs at translational level. Breast cancer patients with high level of eIF3a or low level of LIG4 or low level of DNA-PKcs had better anthracycline-based chemotherapy prognosis compared. Moreover, Combined expressions of eIF3a, LIG4 and DNA-PKcs could be better to predict PFS in breast cancer patients with anthracycline-based chemotherapy.

CONCLUSION

Our findings suggest that eIF3a effects anthracycline-based chemotherapy response by regulating DSB DNA repair.

Treatment Patterns and Outcomes of Women with Breast Cancer and Supraclavicular Nodal Metastases

BACKGROUND

In 2002, breast cancer patients with supraclavicular nodal metastases (cN3c) were downstaged from AJCC stage IV to IIIc, prompting management with locoregional treatment. We sought to estimate the impact of multimodal therapy on overall survival (OS) in a contemporary cohort of cN3c patients.

METHODS

Women ≥ 18 years with cT1-T4c/cN3c invasive breast cancer who underwent systemic therapy were identified from the 2004-2016 National Cancer Database. We compared three patient cohorts: (a) cN3c + multimodal therapy (systemic therapy, surgery, and radiation); (b) cN3c + non-standard therapy; and, (c) cM1. Logistic regression identified factors associated with receipt of multimodal therapy and Kaplan-Meier was used to estimate unadjusted OS. The Cox proportional hazards model estimated effects of diagnosis and treatment on OS after adjustment.

RESULTS

Overall, 1827 (3.7%) patients with cN3c disease and 46,919 (96.3%) cM1 patients were identified. Of cN3c patients, 74.5% (n = 1362) received multimodal therapy and 25.5% (n = 465) received non-standard therapy; receipt of multimodal therapy was associated with improved 5-year OS (multimodal: 59% vs. M1: 28% vs. non-standard: 28%, log-rank p < 0.001). Adjusting for covariates, non-standard therapy was associated with an increased risk of death compared with receipt of multimodal therapy (HR 2.20, 95% CI 1.71-2.83, p < 0.001). Private insurance was the only patient characteristic associated with a greater likelihood of receiving multimodal therapy (OR 2.81; 95% CI, 1.64-4.82; p < 0.001).

CONCLUSION

Women with cN3c breast cancer who received multimodal therapy demonstrated improved overall survival when compared with patients undergoing non-standard therapy and those with metastatic (M1) disease. Although selection bias may contribute to worse overall survival among cN3c patients undergoing non-standard therapy, national guidelines should encourage locoregional treatment in carefully selected patients.

Web portal for analytical validation of MRM-MS assay abided with integrative multinational guidelines

Multiple reaction monitoring-mass spectrometry became a mainstream method for quantitative proteomics, which made the validation of a method and the analyzed data important. In this portal for validation of the MRM-MS assay, we developed a website that automatically evaluates uploaded MRM-MS data, based on biomarker assay guidelines from the European Medicines Agency, the US Food & Drug Administration, and the Korea Food & Drug Administration. The portal reads a Skyline output file and produces the following results—calibration curve, specificity, sensitivity, carryover, precision, recovery, matrix effect, recovery, dilution integrity, stability, and QC—according to the standards of each independent agency. The final tables and figures that pertain to the 11 evaluation categories are displayed in an individual page. Spring boot was used as a framework for development of the webpage, which follows MVC Pattern. JSP, HTML, XML, and Java Script were used to develop the webpage. A server was composed of Apache Tomcat, MySQL. Input files were skyline-derived output files (csv file), and each files were organized by specific columns in order. SQL, JAVA were interworked to evaluate all the categories and show the results. Method Validation Portal can be accessed via any kind of explorer from https://pnbvalid.snu.ac.kr.

An unexpected diagnosis of breast malignancy

Inflammatory breast cancer constitutes 5% of all breast cancer diagnoses. Diagnosis is based on clinical signs including skin changes, erythema and oedema, together with rapid progression and involvement of more than one-third of the affected breast. It is an aggressive tumour with great metastatic potential, metastases being present in 30% of patients at first presentation. Primary non-Hodgkin's lymphoma of the breast is rare but is well reported. It accounts for 0.5% of all breast malignancies and 1% of all non-Hodgkin's diagnoses. Prognosis of primary breast lymphoma varies depending on the stage of disease with stage IE having a 5-year survival rate of 78-83% and stage IIE having a 5-year survival rate of 20-57%. We present a rare case of non-Hodgkin's lymphoma mimicking an inflammatory breast cancer. The aim of this case report is to highlight an unusual presentation of non-Hodgkin's lymphoma and the diagnostic difficulties that arise.

Is there a role for salvage radiotherapy in locally advanced breast cancer refractory to neoadjuvant chemotherapy?

INTRODUCTION

Locally advanced breast cancer (LABC) is a major problem, especially in developing countries. The standard treatment for LABC is neoadjuvant chemotherapy, with or without anti-Her2 therapy, followed by surgery, radiotherapy, and adjuvant systemic treatment if appropriate. However, there are few data in the literature addressing alternatives when neoadjuvant chemotherapy fails to reduce the tumour for surgery.

MATERIALS AND METHODS

We conducted a retrospective study including all patients who had non-metastatic LABC treated with neoadjuvant chemotherapy and who were not eligible for surgical resection; these patients were submitted to salvage radiotherapy (RTX) between January 2000 and December 2012 at the Brazilian National Cancer Institute.

RESULTS

Fifty-seven patients were included, with a median age of 51 (23-72) years. The most frequent clinical stages were IIIA and IIIB, corresponding to 19.3% and 70.2%, respectively; mean tumour size was 8.74 (3-18) cm, and 44 patients (77.2%) had nodal involvement. Chemotherapeutic regimens containing anthracyclines were prescribed to 98.2% of the patients. Fifteen patients (26.3%) received taxanes and anthracyclines. Radiation dose was 50 Gy divided into 25 fractions; 43 patients (75.4%) had their tumours downsized by RTX and underwent mastectomy. Overall survival (OS) was 38 (23-52) months. Patients who were submitted to surgery had an OS of 49 (28-70) months and those who were not eligible for mastectomy after radiotherapy had an OS of 18 (9-27) months.

CONCLUSION

This retrospective study confirms that RTX is an effective treatment to downsize LABC tumours with low or no response to chemotherapy, thereby enabling surgical resection which may improve overall patient outcome.

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

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

Locoregional therapy of locally advanced breast cancer: a clinical practice guideline

QUESTIONS

In female patients with locally advanced breast cancer (labc) and good response to neoadjuvant chemotherapy (nact), including endocrine therapy, what is the role of breast-conserving surgery (bcs) compared with mastectomy?In female patients with labc, is radiotherapy (rt) indicated for those who have undergone mastectomy?does locoregional rt, compared with breast or chest wall rt alone, result in a higher survival rate and lower recurrence rates?is rt indicated for those achieving a pathologic complete response (pcr) to nact?In female patients with labc who receive nact, is the most appropriate axillary staging procedure sentinel lymph node biopsy (slnb) or axillary dissection? Is slnb indicated before nact rather than at the time of surgery?How should female patients with labc that does not respond to initial nact be treated?

METHODS

This guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care (pebc) and the Breast Cancer Disease Site Group (dsg). A systematic review was prepared based on literature searches conducted using the medline and embase databases for the period 1996 to December 11, 2013. Guidelines were located from that search and from the Web sites of major guideline organizations. The working group drafted recommendations based on the systemic review. The systematic review and recommendations were then circulated to the Breast Cancer dsg and the pebc Report Approval Panel for internal review; the revised document underwent external review. The full three-part evidence series can be found on the Cancer Care Ontario Web site.

RECOMMENDATIONS

For most patients with labc, modified radical mastectomy should be considered the standard of care. For some patients with noninflammatory labc, bcs can be considered on a case-by-case basis when the surgeon deems that the disease can be fully resected and the patient expresses a strong preference for breast preservation.For patients with labc, rt after mastectomy is recommended.It is recommended that, after bcs or mastectomy, patients with labc receive locoregional rt encompassing the breast or chest wall and local node-bearing areas.It is recommended that postoperative rt remain the standard of care for patients with labc who achieve pcr to nact.It is recommended that axillary dissection remain the standard of care for axillary staging in labc, with the judicious use of slnb in patients who are advised of the limitations of the current data.Although slnb either before or after nact is technically feasible, the data are insufficient to make any recommendation about the optimal timing of slnb with respect to nact. Limited data suggest higher sentinel lymph node identification rates and lower false negative identification rates when slnb is conducted before nact; however, those data must be balanced against the requirement for two operations if slnb is not performed at the time of resection of the main tumour.It is recommended that patients receiving neoadjuvant anthracycline-taxane-based therapy (or other sequential regimens) whose tumours do not respond to the initial agent or agents, or who experience disease progression, be expedited to the next agent or agents of the regimen.For patients who, in the opinion of the treating physician, fail to respond or progress on first-line nact, several therapeutic options can be considered, including second-line chemotherapy, hormonal therapy (if appropriate), rt, or immediate surgery (if technically feasible). Treatment should be individualized through discussion at a multidisciplinary case conference, considering tumour characteristics, patient factors and preferences, and risk of adverse effects.It is recommended that prospective randomized clinical trials be designed for patients with labc who fail to respond to nact so that more definitive treatment recommendations can be developed.

Radionuclide methods for breast cancer staging

Staging at initial presentation is one of the important prognostic factors for patients with breast cancer. Depending on the extent of disease spread, staging is divided into locoregional and distant or systemic. Locoregional staging includes axillary and internal mammary lymph node evaluation and distant or systemic staging includes evaluation of sites beyond the lymph node. Fluorodeoxyglucose-positron emission tomography (FDG-PET) is not sensitive to detect small metastasis in axillary lymph node. The current standard of axillary lymph node staging in early-stage breast cancer is therefore sentinel lymph node biopsy. Internal mammary lymph nodes are not commonly included in routine staging. In advanced-stage breast cancer, FDG-PET and PET/computed tomography (CT) are the modalities of choice to evaluate locoregional and distant metastasis. FDG-PET and PET/CT often detect occult metastasis, which is not visible on any other modalities including diagnostic CT scan. Detection of occult metastasis may potentially change in treatment options. This is particularly important in locally advanced breast cancer, which tends to develop early distant metastasis.

Main complications and results of treatment with intra-arterial infusion chemotherapy through the subclavian and thoracic arteries for locally advanced breast cancer

Intra-arterial infusion chemotherapy for locally advanced breast cancer (LABC) has been previously performed. However, the main complications of this type of chemotherapy remain to be clarified. In the present study, catheterization chemotherapy was carried out for 53 LABC cases (stage IIIa–IIIc) between May, 2006 and March, 2007. For IIIB and IIIC patients, the catheters were guided to the opening of the subclavian artery. For stage IIIa patients, the catheters were placed into the thoracic artery through a subcutaneous femoral artery puncture. One to four cycles of chemotherapy (mean, 1.6 cycles) were administered for the patients using taxotere, epidoxorubicin, 5-fluorouracil and/or cyclophosphamide. The interval time between the two cycles was 21 days. Seven cases were identified as complete response (CR, 13.2%), 41 cases were partial response (PR, 77.4%) with a rate of effectiveness of (CR + PR, 90.6%), 5 cases were stable disease (SD, 9.40%) and no case was progressive. Pain of the ipsilateral upper extremity was present in 7 cases. Two cases exhibited ipsilateral upper extremity atrophy following drug administration from the opening of the subclavian artery. One case experienced neck pain and headache, while in one case necrosis of local skin was evident. Hematological toxicity over grade 3 was observed in 6 cases (11.30%). Systemic toxicity was mild and did not affect the quality of life of the patients. Overall survival was identified as 18/51 (35.3%), and free-disease survival as 10/51 (19.6%). In conclusion, intra-arterial infusion chemotherapy is an effective local control treatment for LABC. The main complications are pain of the ipsilateral upper extremity and neck as well as headache. Severe complications are ipsilateral upper extremity atrophy and necrosis of local skin. During the treatment, controlling the pressure of the tourniquet and velocity of drug administration are crucial for reducing local complications.

Lymphoepithelioma-like carcinoma of the breast: a diagnostic and therapeutic challenge

We present a patient with lymphoepithelioma-like carcinoma (LELC) of the breast whose diagnosis is illustrative of the pathology nuances that must be taken into account to successfully reach correct identification of the disease. We also present an overview of our patient's proposed treatment in the context of 16 other reported LELC cases. Although LELC cases are rare, a sufficient number have been reported to discern the natural history of this pathologic entity and to undertake a review of those cases and of the application of oncologic first principles in their management. Given the potential for locoregional spread and distant metastases in LELC, adjuvant therapy has a role in the treatment of this entity.

The use of molecular breast imaging to assess response in women undergoing neoadjuvant therapy for breast cancer: a pilot study

PURPOSE OF THE REPORT

To report our findings from a prospective pilot study evaluating the accuracy of molecular breast imaging (MBI) in assessing tumor response to neoadjuvant therapy (NT) for breast cancer.

MATERIALS AND METHODS

Twenty patients with newly diagnosed invasive breast cancer who were scheduled to receive NT underwent MBI before beginning and after completing NT before surgery. MBI was performed using a dual-detector cadmium-zinc-telluride gamma camera system mounted on a modified mammography gantry after patients had received an intravenous injection of 20 mCi of 99mTc sestamibi. Tumor extent was measured on MBI, and tumor-to-background (T/B) ratios of radiotracer uptake were determined through region-of-interest analysis. Pathologic measurement of tumor size was used as a standard and compared with post-NT tumor size derived from MBI.

RESULTS

Three patients in whom post-NT MBI could not be performed because of scheduling problems were excluded from analysis. Eighteen cancers were diagnosed in 17 patients. A correlation coefficient of r = 0.681 (P = 0.002) was found between MBI and residual tumor size. The average T/B ratio on MBI decreased from a pretreatment value of 3.0 to a posttreatment value of 1.4. The relative decrease in T/B ratio did not appear to be predictive of response.

CONCLUSIONS

Measurements of tumor size by MBI and T/B ratios are limited in their predictive value regarding the pathologic extent of residual disease in women treated with NT for breast cancer. Alternate tumor-specific radiopharmaceuticals should be evaluated to provide information to improve planning and monitoring of breast cancer treatment.

An unusual case of locally advanced glycogen-rich clear cell carcinoma of the breast

Glycogen-rich clear cell (GRCC) is a rare subtype of breast carcinoma characterized by carcinoma cells containing an optically clear cytoplasm and intracytoplasmic glycogen. We present the case of a 55-year-old woman with a palpable mass in the right breast and clinical signs of locally advanced breast cancer (LABC). The diagnosis of GRCC carcinoma was based on certain histopathological characteristics of the tumor and immunohistochemical analysis. To our knowledge, this is the first case of GRCC LABC with intratumoral calcifications. There is no evidence of recurrence or metastatic disease after 14 months’ follow-up.

Ganoderma lucidum (Reishi) inhibits cancer cell growth and expression of key molecules in inflammatory breast cancer

Inflammatory breast cancer (IBC) is the most lethal and least understood form of advanced breast cancer. Its lethality originates from its nature of invading the lymphatic system and absence of a palpable tumor mass. Different from other metastatic breast cancer cells, IBC cells invade by forming tumor spheroids that retain E-cadherin-based cell-cell adhesions. Herein we describe the potential of the medicinal mushroom Ganoderma lucidum (Reishi) as an attractive candidate for anti-IBC therapy. Reishi contains biological compounds that are cytotoxic against cancer cells. We report the effects of Reishi on viability, apoptosis, invasion, and its mechanism of action in IBC cells (SUM-149). Results show that Reishi selectively inhibits cancer cell viability although it does not affect the viability of noncancerous mammary epithelial cells. Apoptosis induction is consistent with decreased cell viability. Reishi inhibits cell invasion and disrupts the cell spheroids that are characteristic of the IBC invasive pathology. Reishi decreases the expression of genes involved in cancer cell survival and proliferation (BCL-2, TERT, PDGFB), and invasion and metastasis (MMP-9), whereas it increases the expression of IL8. Reishi reduces BCL-2, BCL-XL, E-cadherin, eIF4G, p120-catenin, and c-Myc protein expression and gelatinase activity. These findings suggest that Reishi is an effective anti-IBC therapeutic.

Increased risk of locoregional recurrence for women with T1-2N0 triple-negative breast cancer treated with modified radical mastectomy without adjuvant radiation therapy compared with breast-conserving therapy

PURPOSE

To evaluate the risk of locoregional recurrence (LRR) associated with locoregional treatment of women with primary breast cancer tumors negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (triple-negative breast cancer [TNBC]).

PATIENTS AND METHODS

Patients diagnosed with TNBC were identified from a cancer registry in a single institution (n=768). LRR-free survival was estimated using Kaplan-Meier analysis. The Cox proportional hazards regression model was used to determine risk of LRR on the basis of locoregional management: breast-conserving therapy (BCT; ie, lumpectomy and adjuvant radiation therapy [RT]) and modified radical mastectomy (MRM) in the TNBC population and T1-2N0 subgroup.

RESULTS

At a median follow-up of 7.2 years, 77 patients (10%) with TNBC developed LRR. Five-year LRR-free survival was 94%, 85%, and 87% in the BCT, MRM, and MRM + RT groups, respectively (P < .001). In multivariate analysis, MRM (compared with BCT), lymphovascular invasion and lymph node positivity were associated with increased LRR. Conversely, adjuvant chemotherapy was associated with decreased risk of LRR. For patients with T1-2N0 tumors, 5-year LRR-free survival was 96% and 90% in the BCT and MRM groups, respectively (P = .027), and MRM was the only independent prognostic factor associated with increased LRR compared with BCT (hazard ratio, 2.53; 95% CI, 1.12 to 5.75; P = .0264).

CONCLUSION

Women with T1-2N0 TNBC treated with MRM without RT have a significant increased risk of LRR compared with those treated with BCT. Prospective studies are warranted to investigate the benefit of adjuvant RT after MRM in TNBC.

Combined low initial DNA damage and high radiation-induced apoptosis confers clinical resistance to long-term toxicity in breast cancer patients treated with high-dose radiotherapy

Background

Either higher levels of initial DNA damage or lower levels of radiation-induced apoptosis in peripheral blood lymphocytes have been associated to increased risk for develop late radiation-induced toxicity. It has been recently published that these two predictive tests are inversely related. The aim of the present study was to investigate the combined role of both tests in relation to clinical radiation-induced toxicity in a set of breast cancer patients treated with high dose hyperfractionated radical radiotherapy.

Methods

Peripheral blood lymphocytes were taken from 26 consecutive patients with locally advanced breast carcinoma treated with high-dose hyperfractioned radical radiotherapy. Acute and late cutaneous and subcutaneous toxicity was evaluated using the Radiation Therapy Oncology Group morbidity scoring schema. The mean follow-up of survivors (n = 13) was 197.23 months. Radiosensitivity of lymphocytes was quantified as the initial number of DNA double-strand breaks induced per Gy and per DNA unit (200 Mbp). Radiation-induced apoptosis (RIA) at 1, 2 and 8 Gy was measured by flow cytometry using annexin V/propidium iodide.

Results

Mean DSB/Gy/DNA unit obtained was 1.70 ± 0.83 (range 0.63-4.08; median, 1.46). Radiation-induced apoptosis increased with radiation dose (median 12.36, 17.79 and 24.83 for 1, 2, and 8 Gy respectively). We observed that those "expected resistant patients" (DSB values lower than 1.78 DSB/Gy per 200 Mbp and RIA values over 9.58, 14.40 or 24.83 for 1, 2 and 8 Gy respectively) were at low risk of suffer severe subcutaneous late toxicity (HR 0.223, 95%CI 0.073-0.678, P = 0.008; HR 0.206, 95%CI 0.063-0.677, P = 0.009; HR 0.239, 95%CI 0.062-0.929, P = 0.039, for RIA at 1, 2 and 8 Gy respectively) in multivariate analysis.

Conclusions

A radiation-resistant profile is proposed, where those patients who presented lower levels of initial DNA damage and higher levels of radiation induced apoptosis were at low risk of suffer severe subcutaneous late toxicity after clinical treatment at high radiation doses in our series. However, due to the small sample size, other prospective studies with higher number of patients are needed to validate these results.

Naringenin reduces lung metastasis in a breast cancer resection model

Metastasis is the main cause of death in cancer patients. To improve the outcomes of patients undergoing a surgery, new adjuvant therapies that can effectively inhibit metastases have to be developed. Studies have shown that flavonoid naringenin, a natural product that is mainly present in grapes and citrus, may contribute to cancer prevention. It has many advantages compared to traditional chemotherapeutic drugs, such as low toxicity. To determine whether naringenin can also inhibit metastases, a breast cancer resection model that mimics clinical situations was established. We found that orally administered naringenin significantly decreased the number of metastatic tumor cells in the lung and extended the life span of tumor resected mice. Flow cytometry analysis revealed that T cells displayed enhanced antitumor activity in naringenin treated mice, with an increased proportion of IFN-γ and IL-2 expressing T cells. In vitro studies further demonstrated that relief of immunosuppression caused by regulatory T cells might be the fundamental mechanism of metastasis inhibition by naringenin. These results indicate that orally administered naringenin can inhibit the outgrowth of metastases after surgery via regulating host immunity. Thus, naringenin can be an ideal surgical adjuvant therapy for breast cancer patients.

Função pulmonar em mulheres com câncer de mama submetidas à radioterapia: um estudo piloto

O câncer de mama é a forma de câncer que mais causa mortes entre mulheres no Brasil. O tratamento consiste em intervenção cirúrgica, quimioterapia, hormonioterapia e radioterapia, esta última responsável por uma significativa diminuição na taxa de recorrência local do câncer, mas que pode afetar a função pulmonar. O objetivo deste estudo foi detectar alterações pulmonares funcionais decorrentes da radioterapia no tratamento do câncer de mama. Participaram do estudo 10 mulheres submetidas a tratamento do câncer de mama, avaliadas quanto à função pulmonar antes e após a radioterapia. Foram mensuradas capacidade inspiratória e capacidade vital forçada, por espirômetro de incentivo, e pressões inspiratória e expiratória máximas, por manovacuômetro. Embora tenha havido redução, em vários casos, dos valores medidos antes e depois da radioterapia, não foi encontrada diferença estatisticamente significativa. Nas pacientes avaliadas, pois, a radioterapia não parece ter prejudicado a função pulmonar.

International expert panel on inflammatory breast cancer: consensus statement for standardized diagnosis and treatment

BACKGROUND

Inflammatory breast cancer (IBC) represents the most aggressive presentation of breast cancer. Women diagnosed with IBC typically have a poorer prognosis compared with those diagnosed with non-IBC tumors. Recommendations and guidelines published to date on the diagnosis, management, and follow-up of women with breast cancer have focused primarily on non-IBC tumors. Establishing a minimum standard for clinical diagnosis and treatment of IBC is needed.

METHODS

Recognizing IBC to be a distinct entity, a group of international experts met in December 2008 at the First International Conference on Inflammatory Breast Cancer to develop guidelines for the management of IBC.

RESULTS

The panel of leading IBC experts formed a consensus on the minimum requirements to accurately diagnose IBC, supported by pathological confirmation. In addition, the panel emphasized a multimodality approach of systemic chemotherapy, surgery, and radiation therapy.

CONCLUSIONS

The goal of these guidelines, based on an expert consensus after careful review of published data, is to help the clinical diagnosis of this rare disease and to standardize management of IBC among treating physicians in both the academic and community settings.

Effectiveness of exercise programmes on shoulder mobility and lymphoedema after axillary lymph node dissection for breast cancer: systematic review

AIM

This article is a report of a review of the effectiveness of exercise programmes on shoulder mobility and lymphoedema in postoperative patients with breast cancer having axillary lymph node dissection, as revealed by randomized controlled trials.

BACKGROUND

Breast cancer is the most common malignancy in women. After surgery, the most common postoperative complications are reduced range of motion in the shoulder, muscle weakness in the upper extremities, lymphoedema, pain and numbness. To reduce these impairments, shoulder exercises are usually prescribed. However, conflicting results regarding the effect and timing of such exercises have been reported. Data sources. Studies were retrieved from a systematic search of published works over the period 2000-2009 indexed in the Cumulative Index to Nursing and Allied Health Literature, Ovid Medline, the British Nursing Index, Proquest, Science Direct, Pubmed, Scopus and the Cochrane Library, using the combined search terms 'breast cancer', 'breast cancer surgery', 'exercise', 'lymphoedema', 'shoulder mobility' and 'randomized controlled trials'.

METHODS

A quantitative review of effectiveness was carried out. Studies were critically appraised by three independent reviewers, and categorized according to levels of evidence defined by the Joanna Briggs Institute.

RESULTS

Six studies were included in the review. Early rather than delayed onset of training did not affect the incidence of postoperative lymphoedema, but early introduction of exercises was valuable in avoiding deterioration in range of shoulder motion.

CONCLUSION

Further studies are required to investigate the optimal time for starting arm exercises after this surgery. Nurses have an important role in educating and encouraging patients to practise these exercises to speed up recovery.

Retrospective study of neoadjuvant versus adjuvant radiochemotherapy in locally advanced noninflammatory breast cancer : survival advantage in cT2 category by neoadjuvant radiochemotherapy

PURPOSE

This retrospective study compares patients treated between 1991 and 1998 with neoadjuvant radiotherapy +/- chemotherapy (RCT) or adjuvant RCT for locally advanced noninflammatory breast cancers (LABC) in terms of pathologic complete response (pCR), 10-year relapse-free (RFS), and overall survival (OS).

PATIENTS AND METHODS

Preoperative RCT in 315 and adjuvant RCT in 329 cases consisted in 50 Gy (5 x 2 Gy/week) to the breast and the supra-/infraclavicular lymph nodes. 101 neoadjuvant patients received - in case of breast conservation - a 10-Gy interstitial boost with (192)Ir afterloading before and 214 neoadjuvant patients a preoperative electron boost after external-beam radiotherapy. In the neoadjuvant RCT group, chemotherapy was applied prior to radiotherapy in 192 patients, and simultaneously in 113; ten had no chemotherapy. In the adjuvant RCT group, chemotherapy was applied to 44 patients before surgery and to 166 after surgery; 119 had no chemotherapy.

RESULTS

Breast conservation became possible in 50.8% after neoadjuvant RCT for LABC with a pCR rate at surgery of 29.2%. A complete nodal remission (pN0) after RCT was observed in 56% (89/159) of the cN+ (clinically node-positive) neoadjuvant patients. There were trends in favor of preoperative RCT for RFS and OS (hazard ratio [HR] = 0.85; p = 0.09 for RFS; HR = 0.8130; p = 0.1037 for OS). For patients with cT2 tumors the RFS and OS were statistically significantly better (HR = 0.5090; p = 0.0130 for RFS; HR = 0.4390; p = 0.0026 for OS) after neoadjuvant compared to adjuvant RCT.

CONCLUSION

Neoadjuvant RCT achieved a pCR rate of 29.2% and a statistically significantly better RFS and OS in patients with cT2-category breast cancer.

Mitochondrial DNA content as a potential marker to predict response to anthracycline in breast cancer patients

Mutations and reduced mitochondrial DNA (mtDNA) content are commonly observed in breast cancer, yet their functional significance is not clear. This study aimed to determine whether the mtDNA content in breast cancer plays an important role in modulating the response to anthracycline treatment in vivo and in vitro. The mtDNA content in tumor cells was analyzed using quantitative polymerase chain reaction in 60 Taiwanese breast cancer patients to correlate with their survival. In addition, human breast cancer MDA-MB-231 cells were treated with ethidium bromide to decrease mtDNA copy number. Cell survival was determined by trypan blue exclusion assay and intracellular reactive oxygen species (ROS) were determined by flow cytometry. After an anthracycline-based regimen, the disease-free survival of patients with higher mtDNA content breast cancer was significantly lower than that of patients with lower mtDNA content breast cancer (p = 0.03). Moreover, the MDA-MB-231 cells with low copies of mtDNA had higher sensitivity to doxorubicin treatment and increased ROS production when compared with higher mtDNA parental cells. Our results suggest that the level of mtDNA copy number in breast cancer may be a potential biomarker for prediction of the response to anthracycline-containing regimens in breast cancer patients.

Percent positive axillary lymph node metastasis predicts survival in patients with non-metastatic breast cancer

PURPOSE

We retrospectively evaluated the impact of percent positive axillary nodal involvement on the therapeutic outcomes in patients with non-metastatic breast cancer receiving postmastectomy radiotherapy and chemotherapy.

MATERIALS AND METHODS

Between January 1994 and December 2002, the medical records of 939 eligible non metastatic breast carcinoma patients were analyzed. Chest wall radiotherapy was indicated in case of positive surgical margin, tumor size equal or more than 4 cm, skin-fascia invasion. Lymphatic irradiation was applied for more than three metastatic axillary lymph nodes, incomplete axillary dissection (<10 lymph nodes), extracapsular extension or perinodal fat tissue invasion. A total dose of 50 Gy was given to chest wall and lymph node regions with 2 Gy daily fractions. Statistical analyses were performed by Kaplan-Meier method, Log-rank test and Cox's regression analysis.

RESULTS

The median follow-up for all patients alive was 62 months. The 5-year overall survival (OS) and disease-free survival (DFS) for entire cohort were 81%, and 65%, respectively. Univariate analysis for OS revealed significance for tumour size (< or =5 cm vs. >5 cm, p<0.001), metastatic nodal involvement (0 vs. 1-3 vs. >4 LN, p<0.001), percent positive nodal involvement ([metastatic nodes/total nodes removed] x 100; 0 vs. < or =25% vs. 26-50% vs. >50%, p<0.001), surgical margin status (negative vs. positive, p=0.05), and hormonal treatment (present vs. absent, p=0.03). DFS had similarly significance for age (< or =40 years vs. >40 years, p=0.006), tumour size (0.02), metastatic nodal involvement (p<0.001), percent positive nodal involvement (p<0.001), and perinodal invasion (present vs. absent, p=0.01). Multivariate analysis revealed significance for tumour size, percent positive nodal involvement, hormonal treatment, and surgical margin status for OS. Age and percent positive nodal involvement were found to be significant for DFS.

CONCLUSION

Percent positive nodal involvement was found to be a significant prognostic factor for survival in all end-points.

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

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

Constitutive gene expression profile segregates toxicity in locally advanced breast cancer patients treated with high-dose hyperfractionated radical radiotherapy

Breast cancer patients show a wide variation in normal tissue reactions after radiotherapy. The individual sensitivity to x-rays limits the efficiency of the therapy. Prediction of individual sensitivity to radiotherapy could help to select the radiation protocol and to improve treatment results. The aim of this study was to assess the relationship between gene expression profiles of ex vivo un-irradiated and irradiated lymphocytes and the development of toxicity due to high-dose hyperfractionated radiotherapy in patients with locally advanced breast cancer. Raw data from microarray experiments were uploaded to the Gene Expression Omnibus Database (GEO accession GSE15341). We obtained a small group of 81 genes significantly regulated by radiotherapy, lumped in 50 relevant pathways. Using ANOVA and t-test statistical tools we found 20 and 26 constitutive genes (0 Gy) that segregate patients with and without acute and late toxicity, respectively. Non-supervised hierarchical clustering was used for the visualization of results. Six and 9 pathways were significantly regulated respectively. Concerning to irradiated lymphocytes (2 Gy), we founded 29 genes that separate patients with acute toxicity and without it. Those genes were gathered in 4 significant pathways. We could not identify a set of genes that segregates patients with and without late toxicity. In conclusion, we have found an association between the constitutive gene expression profile of peripheral blood lymphocytes and the development of acute and late toxicity in consecutive, unselected patients. These observations suggest the possibility of predicting normal tissue response to irradiation in high-dose non-conventional radiation therapy regimens. Prospective studies with higher number of patients are needed to validate these preliminary results.

Intensive dose-dense compared with conventionally scheduled preoperative chemotherapy for high-risk primary breast cancer

PURPOSE

To compare preoperative intense dose-dense (IDD) chemotherapy with conventionally scheduled preoperative chemotherapy in high-risk primary breast cancer (BC).

PATIENTS AND METHODS

In this randomized phase III trial a total of 668 eligible primary BC patients stratified for tumors > or = 3 cm (n = 567) or inflammatory BC (n = 101) were randomly assigned to receive concurrent preoperative epirubicin/paclitaxel every 3 weeks or dose-dense and dose-escalated sequential epirubicin followed by paclitaxel every 2 weeks. All patients received three cycles of cyclophosphamide, methotrexate, and fluorouracil chemotherapy after surgery.

RESULTS

IDD treatment significantly improved pathologic complete response rate (18% v 10%; odds ratio [OR] 1.89; P = .008), disease-free survival (DFS; hazard ratio [HR], 0.71; P = .011), and overall survival (OS; HR, 0.83; P = .041) compared to epirubicin/paclitaxel. Patients with inflammatory BC had a particularly poor prognosis and did not appear to benefit from IDD therapy in this trial (DFS HR, 1.10; P = .739; OS HR, 1.25; P = .544). In contrast, patients with noninflammatory BC significantly benefited from IDD treatment (DFS HR, 0.65, P = .005; OS HR, 0.77, P = .013). Treatment effects in multivariate analysis were significant for noninflammatory BC (DFS HR, 0.65, P = .015; OS HR, 0.79, P = .034), but not for all patients (DFS HR, 0.76; P = .088; OS HR, 0.82; P = .059). IDD therapy was associated with significantly more nonhematologic toxicities, anemia, and thrombocytopenia, but with similar neutropenia and infection rates.

CONCLUSION

Our results support the efficacy and short-term safety of IDD as preoperative chemotherapy. IDD was less well tolerated compared to standard treatment, but improved clinical outcomes in patients with noninflammatory high-risk primary BC.

Pure and predominantly pure intralymphatic breast carcinoma after neoadjuvant chemotherapy: an unusual and adverse pattern of residual disease

Neoadjuvant chemotherapy is standard of care for patients with locally advanced breast cancer. Patients who achieve a pathologic complete response have a more favorable outcome than those who do not; however, a standard system for classifying residual disease has not been adopted. Various definitions of complete response exist, some of which allow for minimal residual invasive or in situ carcinoma. The pattern of residual carcinoma restricted to lymphatic spaces without stromal invasion, herein called pure intralymphatic carcinoma, has not been well addressed. Neither has the pattern of minimal residual stromal invasive cancer accompanied by an extensive intralymphatic component, herein called predominantly pure intralymphatic carcinoma. We report the incidence, clinicopathologic features, and clinical significance of pure and predominantly pure intralymphatic carcinoma in a cohort of 146 neoadjuvant-treated breast cancer patients. We also evaluate the use of the immunohistochemical lymphatic marker D2-40 in these tissues exposed to neoadjuvant chemotherapy. Six patients (4%) had residual pure intralymphatic carcinoma. No gross abnormalities were present in the mastectomy specimens except for 1 case that had a discrete mass, corresponding to residual in situ carcinoma. Residual intralymphatic tumor size ranged from 0.2 to 6 cm. All but one had residual positive lymph nodes. Residual predominantly pure intralymphatic carcinoma was found in 5/146 (4%) patients. A discrete gross mass was observed in 3/5 specimens. Whereas residual stromal invasive carcinoma ranged in size from 0.1 to 1.8 cm, the intralymphatic component ranged from 6 to 9.3 cm. All had residual positive lymph nodes. D2-40 adequately marked lymphatic endothelium in all cases tested. Death occurred in 6/11 (55%) versus 17/135 (13%) patients with or without pure/predominantly pure intralymphatic carcinoma, respectively. After controlling for tumor stage, the presence of either of these residual intralymphatic patterns was associated with a 3-fold increase in death (Cox proportional hazards ratio=3.59, 95% confidence interval, 1.29, 9.99, P=0.014). Elevated risk for disease progression was also observed but this was not statistically significant. We conclude that pure/predominantly pure intralymphatic carcinoma is a clinically significant pattern of residual disease. This may be an underrecognized pattern because of the discordance between gross and microscopic findings and because of challenges in diagnosing intralymphatic carcinoma. D2-40 immunostaining is useful in this setting. Current staging criteria should be clarified to define whether extensive intralymphatic tumor should be incorporated in tumor stage assignment.

Locally advanced breast cancer

PURPOSE OF REVIEW

The management of locally advanced breast cancer requires a combined-modality treatment approach involving surgery, radiotherapy and systemic therapy. In this paper, we review clinical and experimental studies in order to evaluate how basic and clinical research in locally advanced breast cancer has progressed in the past year. We focus on four distinct issues: general strategies and natural history; the role of taxanes; trastuzumab in locally advanced breast cancer; and prognostic and predictive factors.

RECENT FINDINGS

This disease requires an aggressive, multimodality approach incorporating chemotherapy and mastectomy; loco-regional radiation is warranted. This should be followed by hormonal intervention for those with oestrogen-receptor-positive disease. In addition, patients with a poor response to primary chemotherapy should receive a non-cross-resistant regimen, but this issue should be further investigated in clinical trials. The addition of a taxane improves the clinical and pathological response compared with an anthracycline-based regimen. The long-term data for disease-free and overall survival are, however, still being collected. The results of ongoing studies will suggest the best schedule, dose and timing of taxanes. Trastuzumab works well as a monotherapy or in combination with chemotherapy.

SUMMARY

We are entering an exciting era in which new technologies, target therapy and classical approaches may improve operability, safety and possibly the disease-free and overall survival of patients with locally advanced breast cancer.

Radiation-induced DNA damage as a predictor of long-term toxicity in locally advanced breast cancer patients treated with high-dose hyperfractionated radical radiotherapy

This 14-year-long study makes a novel contribution to the debate on the relationship between the in vitro radiosensitivity of peripheral blood lymphocytes and normal tissue reactions after radiation therapy. The aims were (1) to prospectively assess the degree and time of onset of skin side effects in 40 prospectively recruited consecutive patients with locally advanced breast cancer treated with a hyperfractionated dose-escalation radiotherapy schedule and (2) to assess whether initial radiation-induced DNA damage in peripheral blood lymphocytes of these patients could be used to determine their likelihood of suffering severe late damage to normal tissue. Initial radiation-induced DNA double-strand breaks (DSBs) were assessed in peripheral blood lymphocytes of these patients by pulsed-field electrophoresis. Acute and late cutaneous and subcutaneous toxicity was evaluated using the Radiation Therapy Oncology Group morbidity score. A wide interindividual variation was observed in toxicity grades and in radiation-induced DNA DSBs in peripheral blood lymphocytes (mean 1.61 +/- 0.76 DSBs/Gy per 200 MBp, range 0.63- 4.08), which were not correlated. Multivariate analysis showed a correlation (P < 0.008) between late toxicity and higher prescribed protocol dose (81.6 Gy). Analysis of the 29 patients referred to 81.6 Gy revealed significantly (P < 0.031) more frequent late subcutaneous toxicity in those with intrinsic sensitivity to radiation-induced DNA DSBs of >1.69 DSBs/Gy per DNA unit. Our demonstration of a relationship between the sensitivity of in vitro-irradiated peripheral blood lymphocytes and the risk of developing late toxic effects opens up the possibility of predicting normal tissue response to radiation in individual patients, at least in high-dose non-conventional radiation therapy regimens.

An evidence-based estimation of local control and survival benefit of radiotherapy for breast cancer

BACKGROUND AND PURPOSE

Survival benefits from radiotherapy for breast cancer described in randomised trials represent only those patients eligible for trials. We estimated the benefit of radiotherapy as an adjuvant treatment for the entire population of breast cancer patients if evidence-based treatment guidelines were followed.

MATERIALS AND METHODS

Evidences on 10-year local control and overall survival gain (radiotherapy vs no radiotherapy) were identified from review of literature. The data were incorporated into the optimal radiotherapy utilization tree that we previously reported for all categories of breast cancer patients and overall local control and survival benefits were estimated.

RESULTS

The gains in 10-year local control and overall survival from optimal treatment of all breast cancer patients were 11.1% (95% CI 10.8-11.2%) and 3.1% (95% CI 3.0-3.4%), respectively. The stage-based estimates in local control and survival benefit were: 8% and 0% for Ductal Carcinoma in situ (DCIS), 12% and 2% for stage I-II cancers and 13% and 20% for stage III cancers.

CONCLUSIONS

Our model was able to estimate the contribution of radiotherapy in breast cancer treatment if all patients were treated according to the recommended guidelines. These estimates could be used to benchmark population-based survival reports and to assess the cost-effectiveness of radiotherapy for breast cancer treatment.

Prognostic significance of human epidermal growth factor receptor positivity for the development of brain metastasis after newly diagnosed breast cancer

PURPOSE

As survival in breast cancer patients is improving, brain metastases are becoming increasingly prevalent. The risk of brain metastases in newly diagnosed human epidermal growth factor receptor 2 (HER-2) -overexpressing breast cancer patients is not yet fully defined. We aimed to analyze the risk of brain metastasis in newly diagnosed HER-2-positive breast cancer patients in comparison with HER-2-negative patients.

PATIENTS AND METHODS

To determine the incidence of brain metastases in HER-2-overexpressing patients, we analyzed a cohort of newly diagnosed 301 HER-2-positive and 363 HER-2-negative patients identified between January 1998 and December 2003. The association between histologic features and the occurrence of brain metastases was evaluated with univariate and multivariate Cox regression analysis.

RESULTS

Median follow-up was 3.9 years. Brain metastases were identified in 9% (27 patients) with HER-2-overexpressing breast cancer compared with only 1.9% (7 patients) in the HER-2 negative patients (hazard ratio 4.23 [1.84-9.74], P = .0007). HER-2 overexpression, tumor size larger than 2 cm, at least one positive node, and grade 2/3 disease were predictors of brain metastases in univariate analysis. In multivariate analysis, HER-2 overexpression, tumor size larger than 2 cm, and hormone-receptor negativity were independent prognostic factors for the development of brain metastases, whereas hormone-receptor expression was protective.

CONCLUSION

Our study shows that newly diagnosed HER-2-overexpressing breast cancer patients are at increased risk for brain metastases. Because most brain metastases occur after the development of systemic disease, these findings prompt consideration of brain prophylaxis strategies with HER-2-inhibiting small molecules able to cross the blood-brain barrier and/or radiologic screening to detect asymptomatic brain metastases.