Outcome of combined modality treatment including neoadjuvant chemotherapy of 128 cases of locally advanced breast cancer: Data from a tertiary cancer center in northern India

A Multi-centric retrospective study into the epidemiological distribution of breast cancer patients in India

BACKGROUND

A multicentric private hospital-based retrospective study was conducted to understand the epidemiology of breast cancer in terms of demographics and clinical characteristics (staging and hormone receptor status) at the time of diagnosis.

METHODS

The data for 5,688 female breast cancer patients were collected from the hospital and clinical records of four study centres. All statistical analysis was performed using Microsoft Excel 2016 and R software. Survival was estimated by the Kaplan-Meier method and compared by the log-rank test. A P value of <.05 was considered statistically significant.

RESULTS

The mean and median age of the study population was 52.6 (± 12.4) years and 53.0 (range 51-54 across the four centers) years, respectively. About 68% of patients were in the age category of 41 65 years, 17.6% were <40 years old among whom 23.4% of patients reported a positive family history. Most of the patients (66.3%) were diagnosed at an early stage (Stage I and II). The 3-year OS probability was 100%, 97.5%, 94.1%, and 74.7% for TNM Stages I, II, III, and IV, respectively. The 3-year RFS was 95.7%, 95.5%, 84.5%, and 49% for TNM Stages I, II, III, and IV, respectively.

CONCLUSION

The present study highlights the epidemiological distribution of breast cancer patients. It emphasizes the importance of disease awareness among the urban and educated female population as most patients were diagnosed at earlier stages and demonstrated higher OS and RFS than reported in government registries.

Locally Advanced Breast Cancer (LABC): Real-World Outcome of Patients From Cancer Institute, Chennai

PURPOSE

There are sparse data on the outcome of patients with locally advanced breast cancer (LABC). This report is on the prognostic factors and long-term outcome from Cancer Institute, Chennai.

METHODS

This is an analysis of untreated patients with LABC (stages IIIA-C) who were treated from January 2006 to December 2013.

RESULTS

Of the 4,577 patients with breast cancer who were treated, 2,137 patients (47%) with LABC were included for analysis. The median follow-up was 75 months (range, 1-170 months), and 2.3% (n = 49) were lost to follow-up at 5 years. The initial treatment was neoadjuvant concurrent chemoradiation (NACR) (77%), neoadjuvant chemotherapy (15%), or others (8%). Patients with triple-negative breast cancer had a pathologic complete response (PCR) of 41%. The 10-year overall survival was for stage IIIA (65.1%), stage IIIB (41.2%), and stage IIIC (26.7%). Recurrence of cancer was observed in 27% of patients (local 13% and distant 87%). Multivariate analysis showed that patients with a tumor size > 10 cm (hazard ratio [HR], 2.19; 95% CI, 1.62 to 2.98; P = .001), hormone receptor negativity (HR, 1.45; 95% CI, 1.22 to 1.72; P = .001), treatment modality (neoadjuvant chemotherapy, HR, 0.56; 95% CI, 0.43 to 0.73; P = .001), lack of PCR (HR, 2.36; 95% CI, 1.85 to 3.02; P = .001), and the presence of lymphovascular invasion (HR, 1.97; 95% CI, 1.60 to 2.44; P = .001) had decreased overall survival.

CONCLUSION

NACR was feasible in inoperable LABC and gave satisfactory long-term survival. PCR was significantly higher in patients with triple-negative breast cancer. The tumor size > 10 cm was significantly associated with inferior survival. However, this report acknowledges the limitations inherent in experience of management of LABC from a single center.

Effective Combined Photodynamic Therapy with Lipid Platinum Chloride Nanoparticles Therapies of Oral Squamous Carcinoma Tumor Inhibition

Encapsulating cisplatin (CDDP) into liposomes to form lipid-platinum-chloride nanoparticles (LPC NPs) has shown a promising anticancer effect in melanoma, bladder, and liver cancer models. This promising anticancer effect of LPC NPs challenges us to study its implications in combination with photodynamic therapy (PDT). Herein, we report the therapeutic efficacy of PDT+LPC on a xenograft model of oral squamous cell carcinoma (OSCC). Results showed that PDT+LPC significantly reduced the tumor volume by up to ~112%. Meanwhile, LPC, PDT+CDDP, or the CDDP group showed ~98.8%, ~73.1%, or ~39.5% volume reductions, respectively. Histological examination suggests that PDT+LPC or LPC treatment showed minimal side effects on renal damage compared to either CDDP or the PDT+CDDP group. Immunohistochemistry staining (IHC) staining on Ki-67, CD31, cleaved caspase-3, TUNEL assays, and western blots of tumor suppressor p53 confirmed consistent results. Most importantly, PDT+LPC prolonged tumor growth inhibition, which leads to minimum chemotherapy treatment administrations. Results suggest that PDT cytotoxicity provided a potent additive effect towards chemotherapy efficacy. Therefore, combined PDT with LPC NPs enhanced the therapeutic outcome in human OSCC.

Strain wave elastography in response assessment to neo-adjuvant chemotherapy in patients with locally advanced breast cancer

OBJECTIVE

The study was conducted to study the role of strain wave elastography in evaluating the response to neo-adjuvant chemotherapy (NACT) in patients with locally advanced breast cancer (LABC).

METHODS

In this Institutional review board approved study, 86 patients of LABC were investigated with strain wave elastography. Females receiving NACT had the affected breast scanned by strain wave elastography before each cycle of chemotherapy and immediately before surgery by two independent observers. Changes in elastographic parameters (size ratio, strain ratio) were documented and then compared to clinical and pathologic tumor response as evaluated after mastectomy.

RESULTS

Elastographic strain ratio parameters demonstrated high sensitivity and moderate specificity for determining response even after the first cycle of neo-adjuvant chemotherapy [97.7% sensitivity (Sn), 68.7% specificity (Sp)]. Elastographic size ratio parameters showed moderate sensitivity and specificity for response detection after second and third cycle of neo-adjuvant chemotherapy (Sn, Sp: after second cycle of NACT Sn 83.3% Sp 80%; after third cycle of NACT Sn 77.8% Sp 100%).

CONCLUSION

Strain ratio is the earliest predictor of treatment response in patients of LABC. Serial imaging with elastography has the potential to predict treatment response early during the course of NACT, which may prove vital in management of patients with breast cancer.

ADVANCES IN KNOWLEDGE

Strain wave elastography is a powerful tool to predict chemoresponse early during the course of management, thereby providing an optimal window to change treatment protocols.

Breast cancer: An overview of published Indian data

The Incidence of breast cancer has been steadily increasing in the last two decades, more so in urban areas of the sub-continent. Cancer ceters across the country have large numbers of patients being treated with multiple publications in this field. Inspite of paucity of prospective data and randomised clinical trials from India, there are large number of retrospective publications on various aspects of the disease including pathology, radiology, surgery, chemotherapy, radiation, palliative care and alternatitive treatment modalities. These published data provide an insight into the trends of breast cancer in the country and this comprehensive data review of Indian data will provide a basis for designing trials relevant to our population and planning health care.

Heterogeneity in intratumoral regions with rapid gadolinium washout correlates with estrogen receptor status and nodal metastasis

PURPOSE

To evaluate heterogeneity within tumor subregions or "habitats" via textural kinetic analysis on breast dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for the classification of two clinical prognostic features; 1) estrogen receptor (ER)-positive from ER-negative tumors, and 2) tumors with four or more viable lymph node metastases after neoadjuvant chemotherapy from tumors without nodal metastases.

MATERIALS AND METHODS

Two separate volumetric DCE-MRI datasets were obtained at 1.5T, comprised of bilateral axial dynamic 3D T1 -weighted fat suppressed gradient recalled echo-pulse sequences obtained before and after gadolinium-based contrast administration. Representative image slices of breast tumors from 38 and 34 patients were used for ER status and lymph node classification, respectively. Four tumor habitats were defined based on their kinetic contrast enhancement characteristics. The heterogeneity within each habitat was quantified using textural kinetic features, which were evaluated using two feature selectors and three classifiers.

RESULTS

Textural kinetic features from the habitat with rapid delayed washout yielded classification accuracies of 84.44% (area under the curve [AUC] 0.83) for ER and 88.89% (AUC 0.88) for lymph node status. The texture feature, information measure of correlation, most often chosen in cross-validations, measures heterogeneity and provides accuracy approximately the same as with the best feature set.

CONCLUSION

Heterogeneity within habitats with rapid washout is highly predictive of molecular tumor characteristics and clinical behavior.

Outcome of neoadjuvant chemotherapy in locally advanced breast cancer: A tertiary care centre experience

BACKGROUND

Introduction of neoadjuvant chemotherapy (NACT) has dramatically changed the management of locally advanced breast cancer (LABC). However, very few randomized trials of NACT have been carried out specifically in LABC patients in our country. In this retrospective analysis, we presented our experience with NACT in LABC patients.

MATERIALS AND METHODS

Medical records of 148 patients of stage III LABC patients treated with NACT, followed by surgery and radiotherapy from January 2006 to December 2010 were reviewed. Clinical and pathological responses to different chemotherapy regimens were assessed according to World Health Organization criteria. Various factors influencing response to NACT and clinical outcome were identified and analyzed.

RESULTS

A total of 90 (60.8%) patients received anthracycline-based chemotherapy and 52 (35.1%) patients received mixed anthracycline and taxane-based chemotherapy.119 patients (80.4%) responded to NACT either in the form of complete or partial response (PR). Complete response was seen in 27 (18.2%) patients and 92 (62.2%) patients showed PR after NACT. Pathological complete response was seen in 24 (16.2%) patients-. At a median follow-up period of 44 months 36 patients (24.3%) developed relapse of which six patients developed locoregional recurrence, while 28 (18.9%) patients developed distant metastasis. Nodal status, response to chemotherapy, pathological tumor size <3 cm and extracapsular extension (ECE) came out to be important prognostic factors in this study.

CONCLUSION

Neoadjuvant chemotherapy is a reasonable alternative to upfront surgery in the management of LABC. Clinicopathological variables such as nodal status, response to chemotherapy, pathological tumor size and presence of ECE had significant impact on disease free survival.

The actual scenario of neoadjuvant chemotherapy of breast cancer in developing country: a report of 80 cases of breast cancer from a tertiary cancer center in India

BACKGROUND

Preoperative or neoadjuvant chemotherapy is an option in patients with large operable breast cancer to facilitate the breast conservation and to downstage the disease to make inoperable breast cancer to operable one. It is also called the window of opportunity; it provides a unique opportunity to derive biological information related to tumor response. Neoadjuvant chemotherapy has been compared with standard, postoperative adjuvant chemotherapy with goals of improving survival and facilitating local therapies. Unfortunately, neoadjuvant chemotherapy does not seem to improve overall survival. There is a lack of data from India regarding the neoadjuvant chemotherapy. The present study was carried out to assess the response to neoadjuvant chemotherapy in breast cancer.

MATERIALS AND METHODS

We retrospectively analyzed the records of patients who were started on neoadjuvant chemotherapy (NACT) at our center for 1 year (August 2012 to July 2013). Case files were thoroughly reviewed, and patient's characteristics (age, pre-/postmenopausal status, family history of breast/ovarian/other cancer), mode of detection, treatment, and histological features were analyzed.

RESULTS

Out of 322 patients with breast cancer registered in our institute, 80 patients received neoadjuvant chemotherapy. Median age was 45 years. The most common presentation was left-sided breast lump (Lt > Rt) with a median duration of symptoms was 4 months. Postmenopausal patients (53.75 %) were more than premenopausal (46.25 %). Seventy-two patients were stage III and 8 were stage II disease. Bilateral breast cancer was seen in 8 patients. Most common histological type was invasive ductal carcinoma (95 %). Estrogen receptor (ER) and/or progesterone (PR) positive were seen in 47 (58.75 %) patients. Ten patients were HER2 positive and ER/PR negative, and 5 patients were triple positive. Triple-negative patients were 22 (27.5 %). The most common neoadjuvant chemotherapy protocol used was FEC. Clinical response before surgery was CR 13 %, PR 68.68 %, stable disease 11.62 %, and progressive disease 4.65 %. Pathological CR was seen in 6.9 % of tumors. Nodal status at surgery was ypN0-40 %, ypN1-28. 5 %. ypN2-27 %, and ypN3-4.28 %.

CONCLUSION

In a population of predominantly locally advanced patients, NACT with anthracyclines yielded pCR rates comparable to published studies. There were a high proportion of HER2-positive patients, most of whom could not receive anti-HER2 therapy due to financial reasons.

Evaluation of Neoadjuvant Chemotherapy Response with Dynamic Contrast Enhanced Breast Magnetic Resonance Imaging in Locally Advanced Invasive Breast Cancer

OBJECTIVE

The reliability of traditional methods such as physical examination, ultrasonography (US) and mammography is limited in determining the type of treatment response in patients with neoadjuvant chemotherapy (NAC) application for locally advanced breast cancer (LABC). Dynamic contrast-enhanced magnetic resonance imaging (MRI) is gaining popularity in the evaluation of NAC response. This study aimed to compare NAC response as determined by dynamic contrast-enhanced breast MRI in patients with LABC to histopathology that is the gold standard; and evaluate the compatibility of MRI, mammography and US with response types.

MATERIALS AND METHODS

The US, mammography and MRI findings of 38 patients who received NAC with a diagnosis of locally advanced breast cancer and surgical treatment were retrospectively analyzed and compared to histopathology results. Type of response to treatment was determined according to the "Criteria in Solid Tumors Response Evolution 1.1" by mammography, US and MRI criteria. The relationship between response types as defined by all three imaging modalities and histopathology were evaluated, and the correlation of response type as detected by MRI and pathological response and histopathological type of breast cancer was further determined. For statistical analysis, the chi-square, paired t test, correlation and kappa tests were used.

RESULTS

There is a statistical moderate positive correlation between response type according to pathology and MRI (kappa: 0.63). There was a weak correlation between response type according to mammography or US and according to pathology (kappa: 0.2). When the distribution of treatment response by MRI is stratified according to histopathological types, partial response was higher in all histopathological types similar to the type of pathologic response. When compared with pathology MRI detected treatment response accurately in 84.2% of the patients.

CONCLUSION

Dynamic contrast-enhanced breast MRI appears to be a more effective method than mammography or US in the evaluation of response to neoadjuvant chemotherapy. MRI evaluation of LABC is accepted as the appropriate radiological approach.