Depression and anxiety in women with malignant ovarian germ cell (MOGCT) and sex cord stromal tumors (SCST): an analysis of the AGO-CORSETT database

INTRODUCTION

The intention of this study was to evaluate the level of anxiety and depression of malignant ovarian germ cell (MOGCT) and sex cord stromal tumors (SCST) survivors and to identify possible alterable cofactors.

METHODS

CORSETT was an observational, multicenter, mixed retrospective/prospective cohort study of the AGO Studygroup. Women who had been diagnosed with MOGCTs and SCSTs between 2001 and 2011 were asked to complete the Hospital Anxiety and Depression Scale (HADS) to evaluate distress. Predictors of distress (type of surgery, chemotherapy, time since diagnosis, recurrence, second tumor, pain) were investigated using multivariate linear regression analysis.

RESULTS

150 MOGCT and SCST patients with confirmed histological diagnosis completed the questionnaire median seven years after diagnosis. They had a HADS total score ≥ 13 indicating severe mental distress in 34% of cases. Patients after fertility-conserving surgery had lower probability of severe mental distress than those without fertility-conserving treatment (β = - 3.1, p = 0.04). Pain was associated with the level of distress in uni- and multivariate analysis (coef 0.1, p < 0.01, coef. Beta 0.5).

DISCUSSION

Severe mental distress was frequent in patients with MOGCT and SCST and the level of pain was associated with the level of distress. Fertility conserving therapy, however, was associated with less mental distress. Screening and treatment of pain and depression is required to improve mental well-being in survivors of MOGCT and SCST.

Final validation of the ProMisE molecular classifier for endometrial carcinoma in a large population-based case series

Background

We have previously developed and confirmed a pragmatic molecular classifier for endometrial cancers; ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer). Inspired by the Cancer Genome Atlas, ProMisE identifies four prognostically distinct molecular subtypes and can be applied to diagnostic specimens (biopsy/curettings) enabling earlier informed decision-making. We have strictly adhered to the Institute of Medicine (IOM) guidelines for the development of genomic biomarkers, and herein present the final validation step of a locked-down classifier before clinical application.

Patients and methods

We assessed a retrospective cohort of women from the Tübingen University Women's Hospital treated for endometrial carcinoma between 2003 and 2013. Primary outcomes of overall, disease-specific, and progression-free survival were evaluated for clinical, pathological, and molecular features.

Results

Complete clinical and molecular data were evaluable from 452 women. Patient age ranged from 29 to 93 (median 65) years, and 87.8% cases were endometrioid histotype. Grade distribution included 282 (62.4%) G1, 75 (16.6%) G2, and 95 (21.0%) G3 tumors. 276 (61.1%) patients had stage IA disease, with the remaining stage IB [89 (19.7%)], stage II [26 (5.8%)], and stage III/IV [61 (13.5%)]. ProMisE molecular classification yielded 127 (28.1%) MMR-D, 42 (9.3%) POLE, 55 (12.2%) p53abn, and 228 (50.4%) p53wt. ProMisE was a prognostic marker for progression-free (P = 0.001) and disease-specific (P = 0.03) survival even after adjusting for known risk factors. Concordance between diagnostic and surgical specimens was highly favorable; accuracy 0.91, κ 0.88.

Discussion

We have developed, confirmed, and now validated a pragmatic molecular classification tool (ProMisE) that provides consistent categorization of tumors and identifies four distinct prognostic molecular subtypes. ProMisE can be applied to diagnostic samples and thus could be used to inform surgical procedure(s) and/or need for adjuvant therapy. Based on the IOM guidelines this classifier is now ready for clinical evaluation through prospective clinical trials.

Abstract PD8-03: Conversion rates from positive to negative axillary involvement in breast cancer patients presenting with biopsy-proven axillary metastases prior to primary systemic therapy (PST) – A transSENTINA subproject

Background:

Modern chemotherapy carries a high potential of converting patients with clinically suspicious axillary nodes (cN+) prior to PST to clinically (ycN0) or pathologically (ypN0) negative nodes after PST. Clinical and sonographical axillary assessment, however, may be inadequate and therefore pathological assessment of suspicious axillary nodes is recommended. We analyzed the association between clinical / pathological parameters and positive to negative conversion in patients with biopsy-proven axillary metastases in Arm C of the SENTINA trial (i.e. patients with “true conversion”).

Methods:

Arm C of the SENTINA trial included patients converting from cN+ to ycN0 through PST from a prospective study. We limited our analysis to patients who had biopsy-proven axillary involvement. Univariate regression analysis was carried out to assess the association between patients with vs. without axillary disease after PST in i) patients with biopsy-proven involvement and ii) patients without biopsy proof of metastases.

Results:

Among 596 patients in arm C of the SENTINA trial with clinically and or sonographically suspicious ipsilateral axillary nodes, 439 (73,7%) 157 (26,3%) patients had a biopsy. In 152 patients (96,8%), lymph node metastases were confirmed and in 5 patients (3,2%), no malignant cells were identified. In both groups, we found a significant association (p&lt;0,05) between increased rate of axillary conversion and small tumor diameter after PST, absence of multifocality, absence of lymphovascular invasion (LVI), ER and/or PR negativity, HER2 negativity, triple negative disease, and complete pathological response (pCR). No multiple testing corrections were performed due to an exploratory setting. However, only among patients with biopsy-proven involvement prior to PST, we found grade-3-tumors to be significantly associated with reduced probability of residual axillary involvement (76.1 vs. 33.8%, compared to G1 and G2, p=0.0323).

Conclusion:

Our analysis demonstrates that in patients with biopsy-proven axillary involvement before NST, parameters associated with axillary conversion are similar to those among patients classified as having nodal disease based on clinical and or sonographical assessment (cN+). Our analyses demonstrate that in biopsy-proven axillary metastases before NST, modern chemotherapy regimens result in significant rates of axillary conversion. This underscores the need to deescalate axillary staging / treatment with the goal to further avoid unnecessary axillary surgery.

Citation Format: Liedtke C, Kolberg H-C, Krajewska M, Bauerfeind I, Fehm T, Fleige B, Helms G, Lebeau A, Staebler A, Loibl S, Untch M, Kühn T. Conversion rates from positive to negative axillary involvement in breast cancer patients presenting with biopsy-proven axillary metastases prior to primary systemic therapy (PST) – A transSENTINA subproject [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-03.

Malignancy rates of B3-lesions in breast magnetic resonance imaging - do all lesions have to be excised?

BACKGROUND

Approximately 10% of all MRI-guided vacuum-assisted breast biopsies (MR-VAB) are histologically classified as B3 lesions. In most of these cases surgical excision is recommended. The aim of our study was to evaluate the malignancy rates of different B3 lesions which are visible on MRI to allow a lesion-adapted recommendation of further procedure.

METHODS

Retrospective analysis of 572 consecutive MR-VAB was performed. Inclusion criteria were a representative (=successful) MR-VAB, histologic diagnosis of a B3 lesion and either the existence of a definite histology after surgical excision or proof of stability or regression of the lesion on follow-up MRI. Malignancy rates were evaluated for different histologies of B3 lesions. Lesion size and lesion morphology (mass/non-mass enhancement) on MRI were correlated with malignancy.

RESULTS

Of all MR-VAB 43 lesions fulfilled the inclusion criteria. The malignancy rate of those B3 lesions was 23.3% (10/43). The highest malignancy rate was found in atypical ductal hyperplasia (ADH) lesions (50.0%; 4/8), 33.3% (2/6) in flat epithelial atypia (FEA), 28.6% (2/7) in lobular intraepithelial neoplasia (LIN) and 12.5% (2/16) in papillary lesions (PL). All 6 complex sclerosing lesions were benign. Mass findings were significantly more frequently malignant (31.3%, 10/32; p < 0.05) than non-mass findings (0/11). Small lesions measuring 5-10 mm were most often malignant (35.0%; 7/20). All large lesions (> 20 mm) were not malignant (0/10). Intermediate sized lesions (11-20 mm) turned out to be malignant in 23.1% (3/13).

CONCLUSIONS

The malignancy rate of B3 lesions which were diagnosed after MR-VAB was 23.3%. ADH, FEA and LIN showed considerable malignancy rates (50%, 33% and 29%) and should therefore undergo surgical excision. None of the cases, which were diagnosed as radial scars, non-mass enhancement or larger lesions (> 20 mm) were malignant. Here, a follow-up MRI seems to be advisable to avoid unnecessary operations.

TRIAL REGISTRATION

Retrospective study design, waived by the IRB.

Preoperative breast MR Imaging in patients with primary breast cancer has the potential to decrease the rate of repeated surgeries

PURPOSE

The impact of preoperative MRI on re-excisions and mastectomy rate is discussed controversially in the literature. Aim of this study was to evaluate the effect of preoperative breast MRI on the surgical procedure and rate of repeated surgeries.

MATERIAL AND METHODS

A total of 991 consecutive patients in the years 2009 and 2010 with 1036 primary breast cancers were retrospectively analyzed. Sixty percent (599 patients with 626 cancers) received preoperative breast MRI. Planned surgical procedures before and after MRI and numbers of repeated surgeries in patients with (MR+ ) and without preoperative MRI (MR-) were compared.

RESULTS

The result of preoperative MRI changed the surgical procedure in 25% (157/626) of the cases. In 81% (127/157), MRI was beneficial for the patients, as otherwise occult carcinomas were removed (n=122) or further biopsy could be prevented (n=5). Mastectomy rates did not differ between MR+ and MR- group (39% vs. 39%). On multiple regression analysis, the MR+ group had a lower chance for repeated surgery (p<0.05).

CONCLUSION

Preoperative MRI could lower the chance for repeated surgery in patients with primary breast cancer. The rate of mastectomy did not differ between patients undergoing preoperative MRI and those who did not.

Repeated surgeries in invasive lobular breast cancer with preoperative MRI: Role of additional carcinoma in situ and background parenchymal enhancement

OBJECTIVES

Analysing the influence of additional carcinoma in situ (CIS) and background parenchymal enhancement (BPE) in preoperative MRI on repeated surgeries in patients with invasive lobular carcinoma (ILC) of the breast.

METHODS

Retrospective analysis of 106 patients (mean age 58.6±9.9years) with 108 ILC. Preoperative tumour size as assessed by MRI, mammography and sonography was recorded and compared to histopathology. In contrast-enhanced MRI, the degree of BPE was categorised by two readers. The influence of additionally detected CIS and BPE on the rate of repeated surgeries was analysed.

RESULTS

Additional CIS was present in 45.4% of the cases (49/108). The degree of BPE was minimal or mild in 80% of the cases and moderate or marked in 20% of the cases. In 17 cases (15.7%) at least one repeated surgery was performed. In n=15 of these cases, repeated surgery was performed after BCT (n=9 re-excisions, n=6 conversions to mastectomy), in n=2 cases after initial mastectomy. The initial surgical procedure (p=0.008) and additional CIS (p=0.046) significantly influenced the rate of repeated surgeries, while tumour size, patient age and BPE did not (p=ns).

CONCLUSIONS

Additional CIS was associated with a higher rate of repeated surgeries, whereas BPE had no influence.

Abstract P3-13-06: Development and validation of a nomogram predicting pathological axillary status (ypN0 vs. ypN+) in a subgroup of patients converting from cN+ to ycN0 through neoadjuvant therapy (NAT) – A transSENTINA substudy

Background: Particularly among patients converting from cN+ to ycN0 status through neoadjuvant therapy (NAT) the optimal method and extent of axillary staging is unclear. The aim of this analysis was to develop a nomogram predicting the probability of positive axillary status (ypN+) after PST among these patients based on clinical and pathological parameters.

Methods:Patients converting from cN+ to ycN0 due to PST included in a prospective study (SENTINA, Arm C) were included. Univariate and multivariate analyses were carried out to evaluate the association between 14 clinical/pathological parameters and pathological axillary status (ypN0 vs ypN+) using logistic regression models. Model accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were assessed applying leave-one-out cross-validation (LOOCV) and ROC analyses. Different cut-points were evaluated. Calculations were performed using the SAS Software (Version 9.4, SAS Institute Inc., Cary, NC, USA.).

Results: Arm C contained 553 patients, 369 patients were evaluable with respect to the above parameters. Univariate analyses revealed a significant association between pathological axillary status and ER status (odds ratio (OR) 4.05, 95% confidence interval (95%CI) 2.81-5.83), PR status (OR 3.07, 95%CI 2.16-4.36), multifocality (OR 2.37, 95%CI 1.57-3.58), lymphovascular invasion (OR 8.61, 95%CI 5.12-14.46), detection of a SLN after NAT (OR .56, 95%CI .36-.87), detection method (IHC vs routine: OR .46, 95%CI .27-.78; IHC vs serial HE: OR .72, 95%CI .49-1.07; serial hematoxylin eosin (HE) vs routine: OR .639, 95%CI .39-1.04), clinical tumor size (OR 1.051, 95%CI 1.03-1.07) and pCR-status in the breast (ypT0 and ypTis vs others, OR .11, 95%CI .08-.17). A multivariate model was fitted including significant clinical parameters. Stepwise backward variable selection was carried out resulting in a model including ER status (OR 3.81, 95%CI 2.25-6.44), multifocality (OR 2.22, 95%CI 1.26-3.92), LVI (OR 9.16, 95%CI 4.68-17.90), detection of a SLN after NAT (OR .50, 95%CI .26-.95) and clinical tumor size (OR 1.03, 95%CI 1.01-1.06). In LOOCV, this model demonstrated an accuracy of 73% (sensitivity 73%, specificity 72%, PPV 75%, NPV 70%) using .5 as cut-off. Based on the performed ROC analysis an area under the curve (AUC) of 0.81 was calculated.

Conclusion: A model using ER status, multifocality, LVI, detection of a SLN after NAT and clinical tumor size was built to predict pathological axillary status (ypN+) with a high accuracy. If successfully validated based upon an independent dataset, this nomogram could allow advising patients for / against axillary surgery in case of clinical axillary conversion after NAT.

Citation Format: Liedtke C, Kolberg H-C, Kerschke L, Goerlich D, Bauerfeind I, Fehm T, Fleige B, Hauschild M, Helms G, Lebeau A, Schmatloch S, Schrenk P, Schwentner L, Staebler A, von Minckwitz G, Loibl S, Untch M, Kuehn T. Development and validation of a nomogram predicting pathological axillary status (ypN0 vs. ypN+) in a subgroup of patients converting from cN+ to ycN0 through neoadjuvant therapy (NAT) – A transSENTINA substudy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-06.

CNS metastases in breast cancer patients: prognostic implications of tumor subtype

Development of brain metastases (BM) in breast cancer leads to limited survival. The therapeutical options are limited. There are less data about the risk factors and prognostic importance in BM. Objective is to investigate predictors of central nervous system metastases and outcome after diagnosis of BM according to tumor subtype. Based on medical records, 80 consecutive patients with primary non-metastatic operable breast cancer, treated at Department of Gynecology, University of Tübingen, and who developed BM during follow-up, were retrospectively analyzed. Clinicopathological parameters and their prognostic impact were evaluated. A node involvement (40 %), ER/PR negative (53.75 vs. 61.25 %), triple negative (28.75 %) and HER2+ status (40 %) were associated with BM. BM in breast cancer patients lead to a shortened survival. In cerebral metastatic breast cancer patients with HER2-negative and triple-negative, patients had significant shorter survival after detection of BM compared with HER2-positive and non-triple-negative patients (p = 0.001; p = 0.03). Risk of BM varies significantly by subtype. Understanding the biology of metastases can help categorize patients into prognostically useful categories and tailor treatment regimens for individual patients. Prospective clinical trials would be required for evaluating the potential role of screening for asymptomatic BM and of treatment of triple-negative patients.