Long-term clinical outcomes of preoperative brachytherapy in early-stage cervical cancer

OBJECTIVE

The treatment of early-stage cervical cancer (CC) is primarily based on surgery. Adjuvant (chemo)radiotherapy can be necessary in presence of risk factors for relapse (tumor size, deep stromal invasion, lymphovascular space invasion (LVSI), positive margins, parametrial or lymph node involvement), increasing the risk of treatment toxicity. Preoperative brachytherapy can reduce tumor extension before surgery, potentially limiting the need for adjuvant radiotherapy. This study reports long-term clinical outcomes on efficacy and toxicity of preoperative pulse-dose-rate (PDR) brachytherapy in early-stage CC.

METHODS

All patients treated at Institut Curie between 2007 and 2022 for early-stage CC by preoperative brachytherapy were included. A PDR technique was used. Patients underwent hysterectomy associated with nodal staging following brachytherapy.

RESULTS

73 patients were included. The median time from brachytherapy to surgery was 45 days [range: 25-78 days]. With a median follow-up of 51 months [range: 4-185], we reported 3 local (4 %), 1 locoregional (1 %) and 8 metastatic (11 %) relapses. At 10 years, OS was 84.1 % [95 % CI: 70.0-100], DFS 84.3 % [95 % CI:74.6-95.3] and LRFS 92.8 % [95 % CI:84.8-100]. Persistence of a tumor residue, observed in 32 patients (44 %), was a significant risk factor for metastatic relapse (p = 0.02) and was associated with the largest tumor size before brachytherapy (p = 0.04). Five patients (7 %) experienced grade 3 toxicity. One patient (1 %) developed grade 4 toxicity. Ten patients (14 %) received adjuvant radiotherapy, increasing the risk of lymphedema (HR 1.31, 95 % CI [1.11-1.54]; p = 0.002).

CONCLUSIONS

PDR preoperative brachytherapy for early-stage cervical cancer provides high long-term tumor control rates with low toxicity.

Abstract P3-11-01: Interaction between molecular subtype and stromal immune infiltration dynamics in breast cancer patients treated with neoadjuvant chemotherapy

Purpose: High levels of tumor-infiltrating lymphocytes (TILs) before neoadjuvant chemotherapy (NAC) are associated with higher pathological complete response (pCR) rates, and better survival in TNBC and HER2-positive breast cancers (BCs). We investigated the value of changes in TIL levels and final TIL levels after treatment, by evaluating lymphocyte infiltration before and after NAC in a real-life BC cohort.

Patients and methods: We assessed stromal TIL levels in 716 pre- and post-treatment matched paired specimens, according to the guidelines of the international TIL working group.

Results: Pre-NAC TIL levels were higher in tumors for which pCR was achieved than in cases of residual disease (33.9% versus 20.3%, p=0.001), in luminal tumors and TNBCs, but not in HER2-positive BCs, (pInteraction =0.001). The association between pre-NAC TIL levels and pCR was non-linear in TNBCs (p=0.005). Mean TIL levels decreased during NAC (pre-NAC TILs: 24.1% versus post-NAC TILs: 13.0%, p<0.001). This decrease was strongly associated with high pCR rates, and TIL level variation was strongly inversely correlated with pre-NAC TIL levels (r=-0.80, p<0.001). Pre-NAC TILs and disease-free survival (DFS) were associated in a non-linear manner (p<0.001). High post-NAC TIL levels were associated with aggressive tumor characteristics and with impaired DFS in HER2-positive BCs (HR=1.04, CI [1.02-1.06], p=0.001), but not in luminal tumors or TNBCs (pInteraction =0.04).

Conclusion: The associations of pre, post-NAC TIL levels with response to treatment and DFS differ between BC subtypes and may deviate from linearity. The characterization of immune subpopulations may improve our understanding of the complex interactions between pre- or post-NAC setting, BC subtype, response to treatment and prognosis.

Citation Format: Hamy A-S, Bonsang-Kitzis H, De Croze D, Laas E, Darrigues L, Topciu L, Menet E, Vincent-Salomon A, Lerebours F, Pierga J-Y, Brain E, Feron J-G, Benchimol G, Lam G-T, Laé M, Reyal F. Interaction between molecular subtype and stromal immune infiltration dynamics in breast cancer patients treated with neoadjuvant chemotherapy [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 P3-11-01.

Stromal lymphocyte infiltration after neoadjuvant chemotherapy is associated with aggressive residual disease and lower disease-free survival in HER2-positive breast cancer

Background

The role of tumor-infiltrating lymphocytes (TILs) in breast cancer has been extensively studied over the last decade. High TILs levels have been associated with pathological response rate in the neoadjuvant setting and with better outcomes in the adjuvant setting. However, little attention has been paid to changes in TILs and residual TIL levels after neoadjuvant chemotherapy (NAC). We investigated TIL levels before, after chemotherapy, and their dynamics during treatment; and we assessed the correlation of these levels with response to NAC and prognosis.

Materials and methods

We identified 175 patients with primary HER2-positive breast cancers receiving NAC+/- trastuzumab between 2002 and 2011. Microbiopsy specimens and paired surgical samples were evaluated for stromal lymphocyte infiltration. Univariate and multivariate analyses were carried out to assess the association of clinical and pathological factors with pathological complete response (pCR) and disease-free survival.

Results

Baseline TIL levels were not significantly associated with pCR. TIL levels decreased during treatment in 78% of the patients. The magnitude of the decrease was strongly associated with pCR. After chemotherapy, TIL levels were high in tumors displaying aggressive patterns (high residual cancer burden score, mitotic index >22, tumor cellularity >5%). In the population with residual disease, TIL levels >25% at the end of NAC were significantly associated with an adverse outcome (TILs >25%, HR = 7.98, P = 0.009) after multivariate analyses including BMI, post-NAC mitotic index and tumor grade.

Conclusion

A decrease in TIL levels during chemotherapy was positively associated with response to treatment. In tumor failing to achieve pCR, post-NAC lymphocytic infiltration was associated with higher residual tumor burden and adverse clinical outcome. Further studies are required to characterize immune infiltration in residual disease to identify candidates who could benefit from second-line therapy trials including immune checkpoint inhibitors.

Abstract P3-06-11: Withdrawn

This abstract was withdrawn by the authors.

Abstract P2-03-04: Lymphovascular invasion in breast carcinoma following neodjuvant chemotherapy is a strong prognosis factor

Purpose : Lymphovascular invasion (LVI) is a poor prognosis factor in breast cancer (BC), but data on its value in the neoadjuvant setting is scarce. This study evaluates the relationships between post-NAC LVI and prognosis in BC.

Methods: We identified 1197 patients with primary BC receiving NAC +/- trastuzumab between 2002 and 2011. Information on LVI in post-NAC surgical specimen was retrieved from review of medical charts. Univariate and multivariate analyses were performed to assess the association of clinical, pathological factors with disease free survival (DFS) and overall survival (OS) was assessed using a cox proportional hazard model.

Results: On 1197 tumors, 528 were luminal (44.1%), 375 were triple negative breast cancer (TNBC) (31.3%) and 294 were HER2-positive (24.6%). On post-NAC surgical specimens, LVI was present in 302 (25.2%), absent in 531 (44.4%), and was not mentionned in 364 cases (30.4%). The presence of post-NAC LVI was associated with an impaired DFS (HR=2.17, 95 CI [1.65 - 2.86], p<0.001) and the magnitude of this impact varied by BC subtype (p-value for interaction=0.02), (luminal BC: HR=1.75, p=0.006; TNBC : HR=2.77, p<0.001 ; HER2-positive BC : HR=5.12, p<0.001).

Table 1 Univariate analysis and multivariate analysis on DFS (whole population)   Univariate  Multivariate VariableClassHRClpHRCIpAge< 451 0.35    45-550.82[0.62 - 1.08]     >550.87[0.64 - 1.19]    Menopausal statuspremenopausal1.04[0.81 - 1.34]0.75    postmenopausal1     BMI class19-251      < 191.24[0.75 - 2.05]0.41    > 251.36[1.06 - 1.75]0.01   Tumor sizeT1-T21      T31.77[1.38 - 2.27]<0.011.77[ 1.32 - 2.38 ]<0.001Clinical nodal statusN01      N1-N2-N31.35[1.05 - 1.72]0.021.43[ 1.07 - 1.91 ]0.016HistologyDuctal1      Other1.24[0.87 - 1.78]0.24   GradeGrade I-II1      III1.24[0.87 - 1.78]0.07   Ki 67<201      >201.54[1.06 - 2.22]0.02   Mitotic index≤221      >221.18[0.9 - 1.53]0.23   DCIS componentno1      yes1.33[0.88 - 2.01]0.18   Pre-NAC LVIno1      yes1.35[0.88 - 2.01]0.09   ER statusnegative1      positive0.72[0.56 - 0.91]<0.01   PR statusnegative1      positive0.66[0.51 - 0.85]<0.01   HER2 statusnegative1      positive0.84[0.62 - 1.14]0.26   BC subtypeluminal1      TNBC1.53[1.17 - 2]<0.012.67[ 1.93 - 3.69 ]<0.001 HER20.99[0.72 - 1.38]0.971.25[ 0.82 - 1.88 ]0.299Post NAC parametersPost-NAC LVI (breast)no1      yes2.17[1.65 - 2.86]<0.012.3[ 1.72 - 3.08 ]<0.001pCRNo pCR1      pCR0,4[0.27 - 0.59]<0.01   Pathological nodal involvement0       1-31.48[1.11 - 1.97]<0.01    ≥4 N+3.13[2.34 - 4.19]<0.01   RCB class01      10.97[0.36 - 2.64]0.96    22.88[1.69 - 4.89]<0.01    35.21[3.01 - 9.02]<0.01   ER: oestrogene receptor PR: progesteron receptor RCB: residual cancer burden

Post-NAC LVI was an independent predictor of poor DFS, that overwhelmed the prognostic impact of pathological complete response in all 3 BC subtypes. Post-NAC LVI was also an independent predictor of poor OS in the whole cohort and in all BC subtypes.

Table 1 resumes univariate and multivariate analysis on DFS in whole population.

Conclusion: Post-NAC LVI is a strong independent prognostic factor associated with poor DFS and OS, that (i) should be systematically mentioned in pathological reports following NAC and (ii) could be used to select high risk patients candidates to second line trials in the post-neoadjuvant window.

Citation Format: Hamy-Petit A-S, Lam G-T, Laas E, Darrigues L, Balezeau T, Guerin J, Livartowski A, Sadacca B, Pierga J-Y, Vincent-Salomon A, Bidard F-C, Lerebours F, Brain E, Becette V, Rouzier R, Lae M, Reyal F. Lymphovascular invasion in breast carcinoma following neodjuvant chemotherapy is a strong prognosis factor [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-04.

[Clinical practice guidelines: Benign breast tumor--Aims, methods and organization]

Conversely to breast cancer, few data and guidelines are available to explore and manage benign breast disorders. Therefore, the Collège national des gynécologues et obstétriciens français (CNGOF - French College of Gynaecologists and Obstetricians) decided to establish clinical practice guidelines for benign breast tumour (BBT). CNGOF appointed a committee with responsibility for selecting experts, compiling questions and summarizing the recommendations. The summary of valid scientific data for each question analyzed by the experts included a level of evidence, based on the quality of the data available and defined accordingly rating scheme developed by the Haute Autorité de santé (French National Authority for Health).

[Exploration of breast inflammation excluding pregnancy and breastfeeding: Guidelines]

Breast inflammation, excluding breast-feeding and pregnancy, is a rare breast pathology. We conducted a PubMed database search of all studies focusing on mastitis or breast inflammation exploration. While the most frequent aetiologies are infectious and inflammatory, inflammatory breast cancer can be diagnosed (LE2). Aetiologic diagnostic is difficult due to the absence of any clinical and imaging specific signs (LE3). The presence of mass, suspect lymph nodes or skin thickening in a woman older than 40 years old should orient toward inflammatory breast cancer (LE3). A suspect lesion must lead to perform a biopsy under sonography (grade A). In the absence of evidence for a malignant pathology after initial evaluation, we recommend starting an antibiotic treatment (grade C) with a clinical follow-up at the end of the treatment (grade B). If the symptoms persist, we recommend a new imaging (± MRI) (grade C) and a biopsy (grade C). Benign inflammatory pathologies may require a biopsy to exclude an inflammatory breast cancer and precise the diagnosis. Their specific management and treatment are presented in detail in the following chapters and may involve steroids.

Prognostic impact of discrepant Ki67 and mitotic index on hormone receptor-positive, HER2-negative breast carcinoma

Background:

Inconsistencies between mitotic index (MI) and Ki67 measures have been identified in many breast tumour samples. The aim of this study was to describe the prognosis of hormone receptor-positive (HR+) HER2− tumours having discrepant MI and Ki67.

Methods:

We included a cohort of breast cancer patients initially treated by surgery between 2001 and 2005 in the Institut Curie. Breast cancer-specific survival (BCSS) and disease-free survival (DFS) were analysed according to three proliferation groups: high MI/high Ki67 (MI=3, Ki67>20%), low MI/low Ki67 (MI<3, Ki67⩽20%) and discrepant (high MI/low Ki67 or low MI/high Ki67).

Results:

Among the 1430 patients, 19.6% had discrepant Ki67 and MI, 11.6% had high markers and 68.8% had low markers. The 5-year BCSS was 95.8%, 95% CI (0.93–0.98) in the discrepant group, 99.3%, 95% CI (0.993–0.999) in the low-proliferation group and 91.8%, 95% CI (0.88–0.96) in the high-proliferation group. In multivariate analysis, the survival of the discrepant group was lower than that of the low-proliferation group: BCSS hazard ratio (HR)=3.01 (1.32–6.84; P=0.008) and DFS HR=2.07, 95% CI (1.31–3.26; P=0.002). Among grade 2 tumours in multivariate analysis, DFS of the discrepant group was lower than that of the low MI/low Ki67 group: HR=1.98, 95% CI (1.14–3.46), P=0.02. Regarding BCSS, the obtained results were similar.

Conclusion:

The prognosis of patients with discrepant MI and Ki67 appears intermediate between that of low MI/low Ki67 and high MI/high Ki67 groups. These markers should be jointly analysed to clarify prognosis.

Fertility before and after surgery for deep infiltrating endometriosis with and without bowel involvement: a literature review

AIM

Endometriosis affects from 10% to 15% of women of childbearing age and 20% of these women have deep infiltrating endometriosis (DIE). The goal of this review was to assess the impact of various locations of DIE on spontaneous fertility and the benefit of surgery and Medically Assisted Reproduction (MAR) (in vitro fertilization and intrauterine insemination) on fertility outcomes.

METHODS

MEDLINE search for articles on fertility in women with DIE published between 1990 and April 2013 using the following terms: "deep infiltrative endometriosis", "colorectal", "bowel", "rectovaginal", "uterosacral", "vaginal", "bladder" and "fertility" or "infertility". Twenty-nine articles reporting fertility outcomes in 2730 women with DIE were analysed.

RESULTS

Among the women with DIE and no bowel involvement (N.=1295), no preoperative data on spontaneous pregnancy rate (PR) were available. The postoperative spontaneous PR rate in these women was 50.5% (95% Confidence Interval [CI] =46.8-54.1) and overall PR (spontaneous pregnancies and after MAR) was 68.3% (95% CI=64.9-71.7). No evaluation of fertility outcome according to locations of DIE was feasible. For women with DIE with bowel involvement without surgical management (N.=115), PR after MAR was 29%; 95% CI=20.7-37.4). For those with bowel involvement who were surgically managed (N.=1320), postoperative spontaneous PR was 28.6% (95% CI=25-32.3) and overall postoperative PR was 46.9% (95% CI=42.9-50.9).

CONCLUSION

For women with DIE without bowel involvement, surgery alone offers a high spontaneous PR. For those with bowel involvement, the low spontaneous and relatively high overall PR suggests the potential benefit of combining surgery and MAR.

[Obstetric and neonatal outcomes of adolescent pregnancies: a cohort study in a hospital in Seine-Saint-Denis France]

OBJECTIVES

The aim of this study was to describe the characteristics, monitoring, obstetrical complications, childbirth and neonatal outcomes of pregnancies among minors in a cohort of adolescents from Seine-Saint-Denis (France).

PATIENTS AND METHODS

This is a retrospective, cohort, comparative study, conducted from January 1, 1996 to July 31, 2011, made from the database of Jean-Verdier hospital in Seine-Saint-Denis. Three groups were established: patients aged less than 16 years old, patients aged over 16 years old and under 18 years old compared to a group consisting of older primiparas from 18 to 25 years old. The criteria considered were the characteristics of pregnancy, terms of delivery, neonatal outcome and conduct of post-partum.

RESULTS

Minor patients were statistically more likely to be single, student, smoking and anemia compared to young adults. The obstetrical care was lower for minor compared to the control group with a number of consultations and ultrasounds lower (P < 0.001). Obstetrical complications were similar in the three groups outside of preterm labor. Adolescentes under 16 years old had a higher preterm delivery risk in multivariate analysis (RR = 0.33 CI 95% [0.12; 0.90] P = 0.03). Adolescents had fewer cesarean and instrumental deliveries (P < 0.05).

DISCUSSION AND CONCLUSION

Teenage pregnancy remains an important managing issue for maternities, particularly from a social standpoint. On the medical side, one preterm delivery appears to be more common among these adolescents.

P1-10-06: Economic Analysis of Chemotherapy Costs for Adjuvant Therapy in Breast Cancer in France

Background: Total costs of adjuvant chemotherapy can be estimated using different perspectives. To date, only few studies are available in France and only few of these studies have incorporated all the relevant cost items. Indeed the total cost of adjuvant chemotherapy for breast cancer should include not only the drug costs and their administration but also supportive care, transportation and part of the work absenteeism, because all these costs are borne by the French social security. The study objective was to estimate the total costs of adjuvant chemotherapy in France using two different perspectives: the French social security and society.

Methods: We conducted a retrospective study to calculate the total cost of first line adjuvant chemotherapy for breast cancer in France. We developed an electronic CRF to collect clinical data, chemotherapy drug details, side effects and personal data such as the type of transportation from home to hospital for chemotherapy treatments and duration of work absenteeism. We added the cost of medical consultations, radiology and biology. We also calculated the exact cost of paramedical time and material. All data were collected after patient's acceptance from clinical records and by phone. Medical resource data were collected from patients’ files for which data were recorded in February 2010 in Tenon hospital (Paris). Unit costs were collected from the French medical insurance database, and other public sources such as national statistics and the technical agency for hospitalization information.

Results: We collected data from 30 patients who had adjuvant chemotherapy for breast cancer. Median age was 57.7 years and 37.9% of patients had a regular work. Using the social security perspective, the mean cost (+/− SD) for pre chemotherapy exams and management (biology, oncologist consultation, implantable port system) was €320 +/−€32. For each chemotherapy cycle, the costs of chemotherapy drugs, preventive medications and chemotherapy administration were €1267 +/− €1424. The cost of chemotherapy adverse events was €405 +/− €829 and €39 +/− €28 for usual monitoring of chemotherapy (biology tests and medical consultations). Transportation costs were estimated at €11 +/− €12 and sick leave payments at €445 +/− €521. The mean total cost per cycle was €1806 +/− €1226 per chemotherapy cycle and €12724 +/− €8426 for the whole adjuvant chemotherapy regimen. Using a broader societal perspective, the total cost of chemotherapy was €14668 +/− €9707 per patient, as it included the full cost of lost productivity due to work absenteeism.

Conclusion: We reported the first cost analysis of adjuvant chemotherapy for breast cancer in France using two different perspectives (the French social security and the society). Using the social security perspective, chemotherapy drugs and their administration accounted for 70% of the total cost of chemotherapy against 60% when using the societal perspective.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-10-06.