Neoadjuvant chemotherapy for breast cancer

Effectiveness of the Hospital-Community-Family Nursing Model in Breast Cancer Patients Discharged with PICC Lines

PURPOSE

To investigate the effectiveness of the hospital-community-family nursing model in breast cancer patients discharged with PICC lines. To investigate the effectiveness of the hospital-community-family nursing model in breast cancer patients discharged with PICC lines.

DESIGN

A randomized controlled study.

METHOD

A total of 160 breast cancer patients who had been discharged from the hospital with PICC lines were enrolled in the study and divided into observation and control groups, each consisting of 80 patients. The control group received conventional nursing care and education, while the observation group received care under the "hospital-community-family" tertiary linkage nursing model.

FINDINGS

The results of this study suggest that the adoption of the hospital-community-family tertiary linkage nursing model can improve compliance and quality of life in breast cancer patients with PICC lines. Additionally, the model can also reduce the likelihood of complications for patients.

CONCLUSION

This study highlights the importance of promoting the application of the hospital-community-family triple linkage nursing model in breast cancer patients with PICC lines to improve the therapeutic effect.

CLINICAL EVIDENCE

The hospital-community-family triple linkage nursing model is an effective strategy to improve the effectiveness of home nursing.

Effect of neoadjuvant chemotherapy on effect-site concentration of propofol for sedation in patients with breast cancer

BACKGROUND

Some studies have demonstrated that chemotherapy drugs enhance sensitivity to anesthetics owing to its systemic toxicity, while others have demonstrated that chemotherapy drugs have no effect. This study aimed to determine whether neoadjuvant chemotherapy influences the effect-site concentration (Ce) of propofol for sedation in patients withbreast cancer.

METHODS

This study included patients aged 19-75 years who were scheduled to undergobreast cancer surgery under general anesthesia. Patients who received neoadjuvant chemotherapy were assigned to group C, whereas those who never received chemotherapy wereassigned to group N. Propofol was administered through an effect-site target-controlled infusion, and the Modified Observer's Assessment of Alertness/Sedation scale (MOAA/S) scoreand Bispectral Index (BIS) were recorded. When the plasma concentration and Ce wereequal to the target Ce, and if the MOAA/S score did not change, the target Ce was increasedby 0.2 μg/ml; otherwise, the Ce was maintained for 2 min and then increased. This processwas repeated until the MOAA/S score became 0.

RESULTS

No significant differences were observed in Ce values at each sedation level between both groups. Ce values for loss of consciousness (LOC) of groups C and N were 2.76± 0.29 and 2.67 ± 0.27 μg/ml (P = 0.285), respectively. However, the BIS value at LOC ofgroup C (63.87 ± 7.04) was lower than that (68.44 ± 6.01) of group N (P = 0.018).

CONCLUSIONS

Neoadjuvant chemotherapy for breast cancer has no effect on the Ce ofpropofol for sedation.

Recent Advances in Polymer Nanomaterials for Drug Delivery of Adjuvants in Colorectal Cancer Treatment: A Scientific-Technological Analysis and Review

Colorectal cancer (CRC) is the type with the second highest morbidity. Recently, a great number of bioactive compounds and encapsulation techniques have been developed. Thus, this paper aims to review the drug delivery strategies for chemotherapy adjuvant treatments for CRC, including an initial scientific-technological analysis of the papers and patents related to cancer, CRC, and adjuvant treatments. For 2018, a total of 167,366 cancer-related papers and 306,240 patents were found. Adjuvant treatments represented 39.3% of the total CRC patents, indicating the importance of adjuvants in the prognosis of patients. Chemotherapy adjuvants can be divided into two groups, natural and synthetic (5-fluorouracil and derivatives). Both groups can be encapsulated using polymers. Polymer-based drug delivery systems can be classified according to polymer nature. From those, anionic polymers have garnered the most attention, because they are pH responsive. The use of polymers tailors the desorption profile, improving drug bioavailability and enhancing the local treatment of CRC via oral administration. Finally, it can be concluded that antioxidants are emerging compounds that can complement today's chemotherapy treatments. In the long term, encapsulated antioxidants will replace synthetic drugs and will play an important role in curing CRC.

Neoadjuvant Chemotherapy in Triple Negative Breast Cancer: An Observational Study

Triple negative breast cancer (TNBC) is a phenotype of breast cancer with aggressive clinical behavior. Because of the absence of optimal treatment, the prognosis of this disease is poor. The main purpose of this study was to detect the response to neoadjuvant chemotherapy (NACT) in a TNBC cohort and compare the long-term survival between patients with and without pathological complete response (pCR). A total of 53 patients diagnosed with TNBC from 2005 to 2013 who received NACT at the University Hospital Birmingham were enrolled in this study. Overall survival (OS) and progression-free survival (PFS) were compared between the pCR group and non-pCR group. Demographic information and clinical or pathologic parameters were also analyzed to explore potential predictive and prognostic factors. Fourteen patients (26.4%) achieved pCR to NACT. In univariate analysis, patients with pCR had longer PFS time (p = 0.013) and OS time (p = 0.054) compared with their counterparts without pCR. In multivariate analysis, the existence of lymphovascular invasion (LVI) significantly reduced OS (HR = 17.404, 95% CI = 2.923–103.644) and PFS (HR = 7.776, 95% CI = 1.645–36.753). The achievement of pCR to NACT can significantly postpone the incidence of disease progression in patients with TNBC. There is not enough evidence showing its influence on ultimate survival. LVI may be a more potent prognostic factor than pCR in the TNBC cohort.

Prediction of pathological complete response of breast cancer patients undergoing neoadjuvant chemotherapy: usefulness of breast MRI computer-aided detection

OBJECTIVE

To evaluate the usefulness of MR computer-aided detection (CAD) in patients undergoing neoadjuvant chemotherapy for prediction of the pathological complete response of tumours.

METHODS

148 patients with breast cancer (mean age, 47.3 years; range, 29-72 years) who underwent neoadjuvant chemotherapy were included in our study. They underwent MRI before and after neoadjuvant chemotherapy, and we reviewed the pathological result as the gold standard. The computer-generated kinetic features for each lesion were recorded, and the features analysed included "threshold enhancement" at 50% and 100% minimum thresholds; degree of initial peak enhancement; and enhancement profiles comprising lesion percentages of washout, plateau and persistent enhancement. The final pathological size and character of tumours were correlated with post-chemotherapy mammography, ultrasonography and MR CAD findings. Kruskal-Wallis test and intraclass correlation coefficient were used to analyse the findings.

RESULTS

We divided the 148 patients into complete pathological response and non-complete pathological response groups. A complete pathological response was defined as no histopathological evidence of any residual invasive cancer cells in the breast or axillary lymph nodes. 39 patients showed complete pathological response, and 109 patients showed non-complete pathological response. Between enhancement profiles of MR CAD, plateau proportion of tumours was significantly correlated with the pathological response of tumours (mean proportion of plateau on complete pathological response group was 27%, p = 0.007).

CONCLUSION

When plateau proportion of tumours is high, we can predict non-complete pathological response of neoadjuvant chemotherapy.

ADVANCES IN KNOWLEDGE

MR CAD can be a useful tool for the assessment of response to neoadjuvant chemotherapy and prediction of pathological results.

Clinical study of the relationship between γ-synuclein and the response of neoadjuvant chemotherapy in breast cancer

OBJECTIVES

To investigate relationships between several protein biomarkers and clinical responses to neoadjuvant chemotherapy (NAC) in breast cancer.

METHODS

Tumour tissue samples from female patients with locally advanced breast carcinoma (stages IIA to IIIC), treated with NAC regimens (including 5-fluorouracil, epirubicin, cyclophosphamide and docetaxel, epirubicin, cyclophosphamide) were analysed retrospectively. Immunohistochemical analysis was used to test for protein levels of oestrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor (HER)-2, protein 53 (p53) and γ-synuclein. Relationships between protein biomarkers and responses to NAC were analysed by multivariate logistic regression analysis.

RESULTS

Data from 154 patients (median age, 51 years; range 27-75 years) were included. Multivariate logistic regression analysis showed that γ-synuclein was an independent predictor of NAC objective response rate, and a statistically significant relationship was observed between NAC regimen, γ-synuclein levels and pathological complete response rate.

CONCLUSIONS

These study findings suggest that γ-synuclein - in combination with other markers such as ER, PR and HER-2 - may serve as a biomarker for response to NAC in breast cancer and warrants further study.

Lipid biomarkers of glioma cell growth arrest and cell death detected by 1 H magic angle spinning MRS

Biomarkers of early response to treatment have the potential to improve cancer therapy by allowing treatment to be tailored to the individual. Alterations in lipids detected by in vivo MRS have been suggested as noninvasive biomarkers of cell stress and early indicators of cell death. An improved understanding of the relationship between MRS lipids and cell stress in vitro would aid in the translation of this technique into clinical use. Rat BT4C glioma cells were treated with 50 µ m cis-dichlorodiammineplatinum II (cisplatin), a commonly used chemotherapeutic agent, and harvested at several time points up to 72 h. High-resolution magic angle spinning (1) H MRS of cells was then performed on a 600-MHz NMR spectrometer. The metabolites were quantified using a time domain fitting method, TARQUIN. Increases were detected in saturated and polyunsaturated fatty acid resonances early during the exposure to cisplatin. The fatty acid CH(2) /CH(3) ratio was unaltered by treatment after allowing for contributions of macromolecules. Polyunsaturated fatty acids increased on treatment, with the group -CH=CH-CH(2) -CH=CH- accounting for all the unsaturated fatty acid signals. Transmission electron microscopy, in addition to Nile red and 4',6-diamino-2-phenylindole co-staining, revealed that the lipid increase was associated with cytoplasmic neutral lipid droplets. Small numbers of apoptotic and necrotic cells were detected by trypan blue, annexin V-fluorescein isothiocyanate-labelled flow cytometry and DNA laddering after up to 48 h of cisplatin exposure. Propidium iodide flow cytometry revealed that cells accumulated in the G1 stage of the cell growth cycle. In conclusion, an increase in the size of the lipid droplets is detected in morphologically viable cells during cisplatin exposure. (1) H MRS can detect lipid alterations during cell cycle arrest and progression of cell death, and has the potential to provide a noninvasive biomarker of treatment efficacy in vivo.

Cloning and pharmacological characterization of a novel gene encoding human nucleoside transporter 1 (hNT1) from a human breast cancer cDNA library

AIMS

We isolated a novel gene encoding human nucleoside transporter 1 (hNT1), from a human breast cancer cDNA library.

MAIN METHODS

A nondirectional cDNA library was screened by an EST clone (GenBanktrade mark/EMBL/DDBJ: BU944345). A Xenopus laevis oocyte expression system was used for functional characterization. Membrane localization in the human breast was determined by immunohistochemistry.

KEY FINDINGS

Isolated hNT1 cDNA consisted of 246 base pairs that encoded an 82-amino acid protein. By RT-PCR analysis, hNT1 mRNA was strongly detected in the breast cancer tissues. When expressed in X. oocytes, hNT1 mediated the high affinity transport of [(3)H]5-fluorouracil (5-FU) with a K(m) value of 69.2+/-24.5 nM in time- and pH-dependent, and Na(+)-independent manners. A cis-inhibition experiment revealed that hNT1 mediated transport of [(3)H]5-FU is strongly inhibited by various nucleosides such as pyrimidine, uracil, uridine, guanosine, inosine, thymidine, adenosine, cytidine and purine suggesting that hNT1 may be involved in the trans epithelial transport of these endogenous substrates. Immunohistochemical analysis revealed that the hNT1 protein is localized in the lactiferous duct epithelium.

SIGNIFICANCE

Our present results indicate that a newly isolated cDNA clone, hNT1, is a key molecule for the breast handling of 5-FU in humans.

Alternating intravenous and oral vinorelbine plus epirubicin with pegfilgrastim as neoadjuvant treatment of locally advanced breast cancer

In order to downstage locally advanced breast cancer, neoadjuvant chemotherapy consisting of intravenous vinorelbine 25 mg/m plus epirubicin 75 mg/m given on day 1 and oral vinorelbine 60 mg/m on day 8 was administered every 3 weeks for four courses. On day 2, all patients received a single subcutaneous injection of pegfilgrastim (6 mg). From March 2004 to June 2005, 22 patients were enrolled. Patients characteristics were: median age, 53 years (range: 39-70 years); postmenopausal, 7/22; clinical TNM stage, T2 (n=14), T3 (n=8), N0 (n=17) and N1 (n=5). The median number of courses was four (range: two to six courses) with full dose intensity. National Cancer Institute grade 3 haematological toxicities observed were neutropenia in 9% of patients, anaemia in 13% of patients and thrombocytopenia in 9% of patients; no toxicity grade 4 occurred. Two patients (9%) registered grade 2 polyneuropathy; no cardiac failure was observed. Conservative surgery was performed in 14 patients (63%). All patients were evaluable for response: complete pathological response was documented in three patients (13.6%); three patients (13.6%) obtained more than 75% of tumour size reduction; 11 other patients (50%) had 50% of tumour size reduction; stable disease was observed in five patients (22.7%). The present findings indicate that vinorelbine in combination with epirubicin is an effective and safe treatment in locally advanced breast cancer: this regimen obtained more than 50% of tumour size reduction in 77% of patients; the use of pegfilgrastim allowed full dose intensity. Oral vinorelbine on day 8 offers greater convenience to the patient by reducing the need for intravenous injection and the time spent in hospital.

[Primary systemic therapy in breast cancer: clinical and molecular factors predictors of outcome and response]

PST (primary systemic therapy) represents the standard treatment of care for patients with LABC (locally advanced breast cancer). There is also an emerging role of PST in the treatment of operable breast cancer. In both situations, clinical and pathological responses, in particular when complete, are good predictors of outcome. Identifying the factors predicting response to PST would help clinicians of selecting the most appropriate treatment. There is thus a need for clinical and molecular factors predictive of response. Unfortunately, none of the molecular markers identified in breast tumors is recommended for a use in routine, with the exception of ER and HER2 respectively predictors of response to hormone therapy and Herceptin. New technologies like DNA microarrays are likely to provide in a next future surrogate markers of response to PST in Breast Cancer.

Breast-Conserving Therapy in Patients with a Relatively Large (T2 or T3) Breast Cancer: Long-Term Local Control and Cosmetic Outcome of a Feasibility Study

Breast-conserving therapy is widely accepted as an appropriate method of primary treatment of T1 and T2 breast cancers that measure up to 5 cm. For safe and cosmetically acceptable breast-conserving therapy in patients with larger breast cancers, the tumor volume has to be reduced preoperatively, and lost tissue volume should be replaced after wide local excision. In 1993, the authors' group reported encouraging short-term results of a combination of preoperative radiotherapy, breast-conserving surgery, and immediate tissue replacement by myocutaneous (myosubcutaneous) latissimus dorsi flap transplantation in patients with relatively large T2 and T3 breast cancers. To evaluate the long-term oncologic local control and cosmetic outcome of this treatment modality, the authors studied the results obtained in 20 patients after a minimum follow-up of 5 years. The local control rate was 0.95, as locoregional recurrence was observed in one patient who refused adjuvant chemotherapy. Both the observed 5-year survival (0.75) and the actuarial 10-year survival (0.60) in the authors' series equaled that of more radical surgical therapy. The cosmetic outcome compared with that obtained by conventional breast-conserving therapy modalities for small breast cancers. In general, patient assessment of cosmetic outcome (2.8 of 3) was higher than the assessment of a professional panel (6.3 of 10). Of six criteria providing a detailed description of the cosmesis of the reconstructed breast and donor area, the symmetry and shape of the reconstructed breast were felt to be most important by the patients and professionals alike. The authors conclude that breast-conserving therapy combining preoperative irradiation and immediate myocutaneous (myosubcutaneous) latissimus dorsi flap reconstruction is an oncologically safe and cosmetically rewarding but logistically straining modality of treatment of relatively large T2 and T3 breast cancers.

Preoperative FLAC/granulocyte-colony-stimulating factor chemotherapy for stage II breast cancer: a prospective randomized trial

BACKGROUND

Preoperative chemotherapy for stage II breast cancer may reduce locoregional tumors and provides initial treatment for systemic micrometastases. We conducted a prospective, randomized trial to evaluate the ability of intensive preoperative chemotherapy to enhance the outcome of this approach.

METHODS

Patients with clinical stage II breast cancer (T2N0, T1N1, and T2N1) were prospectively randomized to receive either preoperative or postoperative chemotherapy with five 21-day cycles of fluorouracil, leucovorin calcium, doxorubicin, and cyclophosphamide (FLAC)/granulocyte-colony-stimulating factor. Local therapy consisted of modified radical mastectomy or segmentectomy/axillary dissection/breast radiotherapy, according to patient preference.

RESULTS

Fifty-three women were randomized (26 preoperative chemotherapy and 27 postoperative chemotherapy). The objective clinical response rate of the primary tumor to preoperative chemotherapy was 80%, and the pathologic complete response rate was 20%. Preoperative chemotherapy reduced the overall incidence and number of axillary lymph node metastases. There was no difference in the use of breast-conserving local therapy between the two treatment arms. There were 20 local/regional or distant recurrences (9 preoperative and 11 postoperative). There was no difference in the overall or disease-free survival between the preoperative and postoperative chemotherapy arms.

CONCLUSIONS

Preoperative FLAC/granulocyte-colony-stimulating factor chemotherapy was effective against local/regional tumors in stage II breast cancer but was otherwise comparable to postoperative chemotherapy.

Measurement of volumetric and vascular changes with dynamic contrast enhanced MRI for cancer therapy monitoring

Longitudinal dynamic contrast enhanced MRI studies were undertaken to monitor therapy induced volumetric and vascular changes. Three study components are presented in this work: one animal tumor chemotherapy study (R3230 AC adenocarcinoma treated with Taxotere), one patient with invasive lobular breast cancer undergoing neoadjuvant chemotherapy (AC regimen), and one patient with brain metastasis of primary breast cancer undergoing radiation therapy (40 Gray whole brain irradiation). In the animal study two contrast media with different molecular weights, Gadodiamide and Gadomer-17, were used. Only Gadomer-17 revealed significant changes in vascular properties. The responders showed decreased V(b) (vascular volume index) and K(2) (out-flux transport rate), which preceded tumor regression. The control tumors showed increased V(b) and K(2), before tumor growth became much faster. In the patient undergoing neoadjuvant therapy, the tumor was shrinking by 45% after 2 cycles of treatment, then again by 45% after 2 additional cycles. K(2) was decreasing over time with treatment. In the patient with brain metastasis, the 2 follow-up studies were much longer apart to monitor the regression and relapse of lesions. The pre-treatment volumes of lesions in the group without recurrence were significantly smaller compared to those with recurrence. In summary, the tumor volume was more sensitive than the vascular parameters measured by the small extracellular contrast medium for the assessment of therapy response and prediction of recurrence. The vascular properties measured by macromolecular contrast medium may have the potential to serve as early therapeutic efficacy indicators.

The surgical management of patients following neoadjuvant chemotherapy for locally advanced breast cancer

The aim of this study was to evaluate the role of surgery in patients who achieve a complete clinical response (cCR) to neoadjuvant chemotherapy for locally advanced breast cancer. A retrospective study of patients with either large central (T2 >30 mm, N0 or N1, M0) or locally advanced (T3, N0 or N1, M0) tumours who received neoadjuvant chemotherapy followed by surgery to the breast and axilla and postoperative radiotherapy. All patients had operable disease at presentation. A total of 133 patients were included. Overall, 43 (32%) patients achieved a cCR following chemotherapy. Of these, 19 patients had no pathological evidence of disease in the breast (pCR) or on imaging or core biopsy and these patients received only adjuvant radiotherapy to the breast. A further 5 patients had no pathological evidence of cancer following breast surgery. 126 patients had an axillary clearance. Increasing response to chemotherapy was related to fewer pathologically involved nodes, but 7 of 24 (29%) patients with a pCR still had evidence of axillary metastases. This is the principal conclusion of the study at the present time. The patients were followed-up for a median of 30 months (range 5-83 months) with a local recurrence rate of 3.8%. There was no difference in either distant recurrence-free or overall survival between patients experiencing a pCR and the remainder.

Analysis of sentinel lymph node mapping with immediate pathologic review in patients receiving preoperative chemotherapy for breast carcinoma

BACKGROUND

Sentinel lymph node mapping (SLNM) and neoadjuvant chemotherapy are becoming established components of therapy for selected patients with breast carcinoma. However, neoadjuvant therapy has been considered a relative contraindication to SLNM. In an effort to learn whether patients who have received preoperative chemotherapy can undergo accurate SLNM, we evaluated our experience with this technique.

METHODS

From January 1997 to June 2000, SLNM and axillary lymph node dissection were concurrently performed in 35 patients who received preoperative chemotherapy. Mapping was performed with (99m)Tc sulfur colloid only in one patient and Lymphazurin dye only in 15 patients, and the two methods were combined in the remainder.

RESULTS

SLNM successfully identified a sentinel lymph node in 30 (86%) patients. Metastatic disease was identified in the sentinel lymph nodes of four patients during surgery. The intraoperative pathologic diagnosis proved to be correct in 19 (79%) of 24 patients. The final pathologic diagnosis of the sentinel lymph node reflected the status of the axillary contents in all patients in whom it was identified.

CONCLUSIONS

These results demonstrate that SLNM can be consistently performed in patients receiving preoperative chemotherapy for breast cancer, suggesting the utility of this technique in this patient population.

Contemporary management of breast cancer

Breast cancer is a heterogenous disease with significant variations in biologic potential, ranging from small, low-grade, DCIS discovered mammographically with essentially no impact on patient survival to rapidly growing, palpable, locally advanced invasive breast cancer with clinically palpable nodal metastasis. The current challenge is to identify the clinical, pathologic, and molecular factors that determine the biologic potential of a particular breast cancer. Although size, nodal status, histologic grade, age, surgical margin, and hormone receptor status of breast cancer are the most important prognostic factors, the focus of research must be beyond these factors to other nonspecific prognostic information. Bone marrow micrometastasis may be an important factor to help predict outcome (7a) and the complement of sentinel node biopsy, bone marrow analysis, and primary tumor features may allow physicians to better select therapy. With increased understanding of the individual molecular events that control the invasive potential of a particular cancer, practitioners should be better able to predict more accurately which patients have little risk of recurrent disease or metastasis and would be best served by surgery alone versus patients who have a high risk of recurrent and metastatic disease and who should receive multimodality care.

Novel cancer therapies: more efficacy, less toxicity and improved organ preservation

Novel approaches to the treatment of cancer include techniques such as gene therapy, antiangiogenic therapy, monoclonal antibodies either alone or linked with radioactive isotopes or cytotoxins, cancer immunotherapy and vaccines, oligonucleotides and antisense technologies as well as anticancer drugs targeting single metabolic processes, enzymes or oncoproteins. However, substantial improvements are also being made in more conventional cancer treatment modalities. These comprise radiotherapy given concomitantly with chemotherapy, which appears to improve treatment results in a number of common types of human cancer. Other important advances include conformal and intensity-modulated radiation therapy, which may allow for higher target doses with little or no increase in toxicity. Stereotactic radiation therapy for extracranial targets is also being developed, as well as biologically targeted radiation therapy, in which targeting is based on metabolic pathways or carrier molecules, such as boronated compounds in boron neutron capture therapy or monoclonal antibodies in radioimmunotherapy. Sentinel node biopsy and neoadjuvant chemotherapy for breast cancer represent advances in surgery and cancer chemotherapy, which may also allow for a greater chance for organ and tissue preservation without a loss in treatment efficacy.