Antibody-drug conjugates in lung and breast cancer: Current evidence and future directions - a position statement from the ETOP IBCSG Partners Foundation

Following the approval of the first antibody-drug conjugates (ADCs) in the early 2000s, development has increased dramatically, with 14 ADCs now approved and >100 in clinical development. In lung cancer, trastuzumab deruxtecan (T-DXd) is approved in human epidermal growth factor receptor 2 (HER2)-mutated, unresectable or metastatic non-small cell lung cancer, with ADCs targeting HER3 (patritumab deruxtecan), trophoblast cell-surface antigen 2 (datopotamab deruxtecan and sacituzumab govitecan [SG]) and mesenchymal-epithelial transition factor (telisotuzumab vedotin) in late-stage clinical development. In breast cancer, several agents are already approved and widely used, including trastuzumab emtansine, T-DXd and SG, and multiple late-stage trials are ongoing. Thus, in the coming years, we are likely to see significant changes to treatment algorithms. As the number of available ADCs increases, biomarkers (of response and resistance) to better select patients are urgently needed. Biopsy sample collection at the time of treatment selection and incorporation of translational research into clinical trial designs are therefore critical. Biopsy samples taken peri- and post-ADC treatment combined with functional genomics screens could provide insights into response/resistance mechanisms as well as the impact of ADCs on tumour biology and the tumour microenvironment, which could improve understanding of the mechanisms underlying these complex molecules. Many ADCs are undergoing evaluation as combination therapy, but a high bar should be set to progress clinical evaluation of any ADC-based combination, particularly considering the high cost and potential toxicity implications. Efforts to optimise ADC dosing/duration, sequencing and the potential for ADC rechallenge are also important, especially considering sustainability aspects. The ETOP IBCSG Partners Foundation are driving strong collaborations in this field and promoting the generation/sharing of databases, repositories and registries to enable greater access data. This will allow the most important research questions to be identified and prioritised, which will ultimately accelerate progress and help to improve patient outcomes.

Multiplexed high-throughput immune cell imaging in patients with high-risk triple negative early breast cancer: Analysis from the International Breast Cancer Study Group (IBCSG) Trial 22-00

BACKGROUND

Triple-negative breast cancer (TNBC) is the most aggressive breast cancer (BC) subtype, with dismal prognosis and limited option in advanced settings, yet stromal tumor infiltrating lymphocytes (sTILs) in this subtype has a predictive role.

PATIENTS AND METHODS

The International Breast Cancer Study Group (IBCSG) Trial 22-00 is a randomized phase III clinical trial testing the efficacy of low-dose metronomic oral Cyclophosphamide-Methotrexate (CM) maintenance following standard adjuvant chemotherapy treatment for early-stage hormone receptor-negative breast cancer patients. A case-cohort sampling was used. We characterized immune cells infiltrates in patients with TNBC by 6 plex immunofluorescence (IF) staining for CD4, FOXP3, CD3, cytokeratine and CD8 RESULTS: We confirmed that high immune CD3+ T cells as well as stromal and intra-epithelial Tregs (CD4+Foxp3+ T cells) infiltrates were associated with a better Distant Recurrence-Free Interval (DRFI), especially in LN+ patient, regardless of the treatment. More importantly, we showed that the spatial distribution of immune cells at baseline is crucial, as CM maintenance was detrimental for T cells excluded LN+ TNBC patients.

CONCLUSIONS

immune spatial classification on immune cells infiltrates seems crucial and could help patients' selection in clinical trial and greatly improve responses to specific therapies.

CDK12 promotes tumorigenesis but induces vulnerability to therapies inhibiting folate one-carbon metabolism in breast cancer

Cyclin-dependent kinase 12 (CDK12) overexpression is implicated in breast cancer, but whether it has a primary or only a cooperative tumorigenic role is unclear. Here, we show that transgenic CDK12 overexpression in the mouse mammary gland per se is sufficient to drive the emergence of multiple and multifocal tumors, while, in cooperation with known oncogenes, it promotes earlier tumor onset and metastasis. Integrative transcriptomic, metabolomic and functional data reveal that hyperactivation of the serine-glycine-one-carbon network is a metabolic hallmark inherent to CDK12-induced tumorigenesis. Consistently, in retrospective patient cohort studies and in patient-derived xenografts, CDK12-overexpressing breast tumors show positive response to methotrexate-based chemotherapy targeting CDK12-induced metabolic alterations, while being intrinsically refractory to other types of chemotherapy. In a retrospective analysis of hormone receptor-negative and lymph node-positive breast cancer patients randomized in an adjuvant phase III trial to 1-year low-dose metronomic methotrexate-based chemotherapy or no maintenance chemotherapy, a high CDK12 status predicts a dramatic reduction in distant metastasis rate in the chemotherapy-treated vs. not-treated arm. Thus, by coupling tumor progression with metabolic reprogramming, CDK12 creates an actionable vulnerability for breast cancer therapy and might represent a suitable companion biomarker for targeted antimetabolite therapies in human breast cancers.

Finding biomarkers for targeted therapy is a promising approach to treat cancer. Here, the authors show that in breast cancer preclinical models and patients, CDK12 promotes tumourigenesis but induces selective vulnerability to therapies that target folate one-carbon metabolism.

Systematic review and meta-analysis of post-progression outcomes in ER+/HER2- metastatic breast cancer after CDK4/6 inhibitors within randomized clinical trials

Background

Cyclin-dependent kinase 4/6 (CDK4/6) inhibitors and endocrine therapy (ET) deeply transformed the treatment landscape of hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2−) advanced breast cancer. Randomized clinical trials suggest that second progression-free survival (PFS2) was not compromised and time to subsequent chemotherapy (TTC) may be delayed. We carried out a meta-analysis to assess the benefit on PFS2 and on delaying the TTC.

Methods

We conducted a systematic literature search of randomized clinical trials with CDK4/6 inhibitors and ET reporting PFS2 or TTC of HR+/HER2− pre- or postmenopausal metastatic breast cancer. We also reviewed abstracts and presentations from all major conference proceedings. We calculated the pooled hazard ratios (HR) for PFS2 and TTC using random-effects models with 95% confidence intervals (CI). I² was used to quantify heterogeneity between results of the studies.

Results

Eight studies (MONALEESA-2/3/7, MONARCH-2/3, PALOMA-1/2/3) were included in this analysis (N = 4580 patients). PFS2 benefit was observed in patients who received CDK4/6 inhibitors plus ET (pooled HR = 0.68, 95% CI = 0.62-0.74, I² = 0%) and also a delay in subsequent TTC (pooled HR = 0.65, 95% CI = 0.60-0.71, I² = 0%). A benefit in terms of PFS (pooled HR = 0.55, 95% CI = 0.51-0.59, I² = 0%) and overall survival (pooled HR = 0.76, 95% CI = 0.69-0.84, I² = 0%) was also observed.

Conclusions

CDK4/6 inhibitors plus ET compared with ET alone improve PFS2 and TTC. The delay of chemotherapy may postpone the start of a more toxic treatment option, delaying related toxicities and potentially maintaining a better quality of life for patients, for a longer time. The benefit in PFS2 may postpone the onset of endocrine resistance and help further validate this treatment approach.

•

Eight RCTs (MONALEESA-2/3/7, MONARCH-2/3, PALOMA-1/2/3) were included in this analysis on pooled HR for PFS2 and TTC.

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Patients who received CDK4/6 inhibitors plus ET had a clear PFS2 benefit and a delay in subsequent TTC.

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CDK4/6 inhibitors plus ET compared with ET alone improve PFS2 and TTC.

Evaluation of endocrine therapy and patients preferences in early breast cancer: results of Elena study

PURPOSE

The development of the adjuvant therapy requires that clinicians and patients should discuss the magnitude of benefit of treatment for individual patient, estimating the pros and cons and the personal preferences. The aim of the present study was to determine the preferences of women treated with adjuvant hormonal therapy (HT) for breast cancer.

METHODS

The analyses were conducted into three different groups of early breast cancer patients to evaluate the survival benefit needed to make treatment worthwhile before starting HT (A), after a few months from the beginning (B) and after several years of HT (C). The questionnaires, showing hypothetical scenarios based on potential survival times and rates without HT, were used to determine the lowest gains women judged necessary to make the treatment worthwhile.

RESULTS

A total of 452 patients were included in the study: 149 in group A, 150 in group B and 153 in group C. In group C, 65% of patients were receiving HT with aromatase inhibitors (with or without a LHRH analogue). In the groups A, B, C 8%, 20% and 26%, respectively, received adjuvant chemotherapy. Overall, 355 women (79%) had children. The responses were quite similar between the three groups. A median gain of 10 years was judged necessary to make adjuvant HT worthwhile based on the hypothetical scenario of untreated mean survival time of 5 and 15 years. Median gain of 20% more women surviving was judged necessary to make adjuvant HT worthwhile based on an untreated 5-year survival rate expectation of 60%. Cognitive dysfunction was considered the side effect least compatible with the continuation of treatment in all three groups.

CONCLUSIONS

This is a large study of patient preferences on HT. Compared with other studies with similar design, the patients included in the present study required larger benefits to make adjuvant therapy worthwhile.

Abstract P1-10-06: A randomized phase II trial evaluating the endocrine activity and efficacy of neoadjuvant degarelix versus triptorelin in premenopausal patients receiving letrozole for primary endocrine responsive breast cancer (TREND; IBCSG 41-13)

Background: Neoadjuvant endocrine therapy (NET) with gonadotropin-releasing hormone (GnRH) agonist and aromatase inhibitors is effective in selected premenopausal patients (pts). Degarelix, an antagonist of GnRH, has immediate onset of action through binding to GnRH receptors in the pituitary gland and thereby suppressing the production of LH and FSH. Its suppressing activity in premenopausal women might be faster and free of estrodial breakthrough on continued treatment compared with a GnRH angonist, and thereby provide significant clinical value for pts who are candidates for short-term NET.

Methods: Eligible pts were premenopausal women with cT2-4b, any nodal stage, ER and PgR >50%, HER2-negative (by IHC and/or ISH) breast cancer who were not candidates for breast conserving surgery. Premenopausal status was determined locally with estradiol (E2) levels >54 pg/mL (or >198 pmol/L), measured within 14 days prior to randomization. Pts were randomized 1:1 to Triptorelin (T) 3.75 mg i.m. on day 1 of every cycle or Degarelix (D) 240 mg s.c. given as two injections of 120 mg on day 1 of cycle 1, then 80 mg s.c. on day 1 of cycles 2-6 with letrozole (L) 2.5 mg/day for 6 cycles. Each cycle was 28 days. Definitive surgery was performed within 2-3 weeks after the last administration of T or D. Serum was collected prior to the first injection (baseline), 24 and 72 hours, 7 and 14 days, then prior to injection on day 1 of cycles 2-6. The primary endpoint was time to optimal ovarian function suppression (OFS) calculated as time from the first injection of D or T to the first assessment of centrally assessed 17-β-estradiol (E2) level in the range of optimal OFS (≤2.72 pg/mL or ≤10 pmol/L) during the 6 cycles of NET. The trial had 90% power to detect a difference using a logrank test, 2-sided α=0.05. Secondary endpoints included tolerability, Ki67changes, PEPI score, best overall response. NCT02005887

Results: TREND completed accrual of 51 pts in January 2017. A preliminary analysis based on the first 45 pts is reported here. 89% of patients were ≥40 yrs, 76% had T1-2 and 22% T3 tumors, and 51% were node-positive. Dominant histology type was ductal (93%). The table summarizes centrally-assessed E2 according to treatment at baseline and for the first 5 assessment time points indicating immediate suppression for the D+L arm. E2 levels on day 1 of cycles 2-6 were all below the limit of quantification (0.625 pg/mL) for the D+L arm. For the T+L arm continued OFS was not maintained in 4 pts.

 BaselineCycle 1Cycle 2Day:01371429No. Pts      D+L222221212221T+L232321232222Median (IQR)     D+L96.2 (64.2,206.8)10.1 (4.0,21.8)0.6 (0.6,1.0)0.6 (0.6,0.6)0.6 (0.6,0.6)0.6 (0.6, 0.6)T+L85.1 (49.7,118.0)37.4 (17.9,59.2)12.8 (7.7,23.8)9.0 (1.2,29.7)0.6 (0.6,1.4)0.6 (0.6, 0.6)

Conclusion: Evidence from this first analysis demonstrates rapid and maintained OFS with the combination of D+L as a NET in premenopausal breast cancer patients. The final analysis of the total population, including secondary endpoints, will be presented at the symposium.

Citation Format: Colleoni M, Gray K, Munzone E, Dellapasqua S, Zamagni C, Gianni L, Johansson H, Viale G, Kammler R, Maibach R, Rabaglio-Poretti M, Di Leo A, Coates AS, Gelber RD, Regan MM, Goldhirsch A. A randomized phase II trial evaluating the endocrine activity and efficacy of neoadjuvant degarelix versus triptorelin in premenopausal patients receiving letrozole for primary endocrine responsive breast cancer (TREND; IBCSG 41-13) [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 P1-10-06.

Abstract P2-08-08: Circulating tumor cells count-based nomograms to predict survival of metastatic breast cancer patients: Results from the European pooled analysis

Background: The European Pooled Analysis of CTC (EPAC) in metastatic breast cancer, based on 1,944 individual data from patients with various tumor types and clinical settings (Bidard et al, Lancet Oncol 2014), has established CTC count (CellSearch) at baseline and during therapy as a level of evidence 1 independent prognostic biomarker and demonstrated its superiority over serum blood markers. As part of the study pre-planned objectives, we sought to establish nomograms allowing accurate individual survival predictions.

Methods: Using individual data from 17 centers, we built simplified multivariate prognostic models taking into account the independent prognostic clinico-pathological (CP) characteristics including CTC count, dichotomized using the 5CTC/7.5ml threshold, at baseline and at 3-5 weeks after the start of a new treatment regimen, and derived nomograms for progression-free survival (PFS) and overall survival (OS) prediction at baseline and after 3-5 weeks of treatment. We report here the internal validation of these nomograms. Discrimination of the models was assessed using the c-index estimated by a jackknife procedure and the calibration was visually assessed through 10-fold crossvalidated calibration plots at 1,2,3 years for OS and 1,2 years for PFS.

Results: Multivariate models at baseline for PFS and OS were fitted on 1501 and 568 individual patient data with CTC count at baseline and CTC count at baseline and after 3-5 weeks, respectively. Models include tumor subtype, the number of previous chemotherapy lines (0/1/≥2), PS, age (<=50/>50-65/>65 years), metastasis-free intervals (0/>0-3/>3 years), metastatic sites (liver and CNS) and CTC count at baseline and eventually at 3-5 weeks of treatment. The C-index increased from 0.722 to 0.755 (increase in C-index:0.033, 95% CI [0.019;0.045]) when adding baseline CTC to the CP only model for OS (n=1501). For those patients with CTC values at 3-5 weeks (n=568), there was an additional increase in the C-index when adding CTC at 3-5 weeks to a model with already CP and baseline CTC from 0.731 to 0.743 (increase in C-index 0.013, 95% CI [-0.004;0.025]). The model with CP and baseline CTC counts showed a good calibration for OS at 1,2,3 years and the model with CP, baseline CTC and CTC count at 3-5 weeks a moderately good calibration. Similar results were obtained for PFS.

Conclusion: From the largest database with individual CTC data, we were able to build PFS and OS survival nomograms, with satisfactory discrimination and calibration. Our planned next step is to validate the nomogram in an additional cohort.

Citation Format: Bidard F-C, Peeters D, Fehm T, Nole F, Gisbert-Criado R, Mavroudis D, Grisanti S, Generali D, Garcia-Saenz JA, Stebbing J, Caldas C, Gazzaniga P, Manso L, Zamarchi R, Fernandez de Lascoiti A, de Mattos-Arruda L, Ignatiadis M, van Laere SJ, Meier-Stiegen F, Sandri M-T, Vidal-Martinez J, Politaki E, Consoli F, Bottini A, Diaz-Rubio E, Krell J, Dawson S-J, Raimondi C, Rutten A, Janni W, Munzone E, Carañana V, Agelaki S, Almici C, Dirix L, Solomayer E, Zorzino L, Reis-Filho JS, Squifflet P, Pantel K, Beije N, Sleijfers S, Pierga J-Y, Michiels S. Circulating tumor cells count-based nomograms to predict survival of metastatic breast cancer patients: Results from the European pooled analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-08.

Outcomes of special histotypes of breast cancer after adjuvant endocrine therapy with letrozole or tamoxifen in the monotherapy cohort of the BIG 1-98 trial

BACKGROUND

We investigated the outcomes of postmenopausal women with hormone receptor-positive, early breast cancer with special histotypes (mucinous, tubular, or cribriform) enrolled in the monotherapy cohort of the BIG 1-98 trial.

PATIENTS AND METHODS

The intention-to-treat BIG 1-98 monotherapy cohort (5 years of therapy with tamoxifen or letrozole) included 4922 women, of whom 4091 had central pathology review. Histotype groups were defined as: mucinous (N = 100), tubular/cribriform (N = 83), ductal (N = 3257), and other (N = 651). Of 183 women with either mucinous or tubular/cribriform tumors, 96 were randomly assigned to letrozole and 87 to tamoxifen. Outcomes assessed were disease-free survival (DFS), overall survival (OS), breast cancer-free interval (BCFI), and distant recurrence-free interval (DRFI). Median follow-up in the analytic cohort was 8.1 years.

RESULTS

Women with tubular/cribriform breast cancer had the best outcomes for all end points compared with the other three histotypes, and had less breast cancer recurrence (97.5% 5-year BCFI) than those with mucinous (93.5%), ductal (88.9%), or other (89.9%) histotypes. Patients with mucinous or tubular/cribriform carcinoma had better DRFI (5-year rates 97.8% and 98.8%, respectively) than those with ductal (90.9%) or other (92.1%) carcinomas. Within the subgroup of women with special histotypes, we observed a nonsignificant increase in the hazard of breast cancer recurrence with letrozole [hazard (letrozole versus tamoxifen): 3.31, 95% confidence interval 0.94-11.7; P = 0.06].

CONCLUSIONS

Women with mucinous or tubular/cribriform breast cancer have better outcomes than those with other histotypes, although the observation is based on a limited number of events. In postmenopausal women with these histotypes, the magnitude of the letrozole advantage compared with tamoxifen may not be as large in patients with mucinous or tubular/cribriform disease.

CLINICALTRIALSGOV

NCT00004205.

Abstract P1-15-03: Preoperative endocrine treatment with letrozole ± triptorelin in patients with ER (estrogen receptor) and PgR (progesterone receptor) positive locally advanced breast cancer

Background: Neoadjuvant endocrine therapy demonstrated activity in endocrine responsive locally advanced breast cancer. Proper duration of neoadjuvant therapy has not yet established. We aimed to assess the efficacy and safety of longer duration of letrozole alone or combined with triptorelin in pre-or postmenopausal breast cancer patients.

Methods: Premenopausal and postmenopausal patients (pts) with ER and PgR-positive > 50% of the cells, HER2-negative, T2-T4b breast cancer were considered eligible. Patients received letrozole 2,5 mg per day (plus triptorelin 3,75 mg/month in premenopausal pts) for 3-9 months. Tumor response was measured by caliper, ultrasound (US) and mammography. The primary endpoint was overall tumour response (ORR) (complete response plus partial response), during the neoadjuvant treatment period for the intention-to-treat population.

Results: Between 2009 and 2013, 54 pts were enrolled and 46 (34 pre- and 12 post-menopausal) pts were evaluable for ORR. Median age was 44 and 55 years, respectively. 44 patients are evaluable. The ORR was 77% in the premenopausal group and 67% in the postmenopausal group. One premenopausal patient had a pathological complete response (pCR). The mean time to complete/partial response was 4.9 months (95% CI: 3.8-6.0) in the premenopausal group and 3.6 months (95% CI: 0.8-6.4) in the postmenopausal group. Overall, 56% of premenopausal and 58% of postmenopausal pts underwent breast conservative surgery. Ki67-LI after surgery had a mean decrease of 33% (95% CI: 16%-50%, p-value = 0.0005) and 42% (95% CI: 18%-65%, p-value = 0.0030) in pre-and postmenopausal pts, respectively. Therapy was well tolerated in both groups with no grade 3/4 toxicity. The most common adverse events in both groups were hot flashes, fatigue, arthralgias/stiffness, and myalgias.

Conclusions: The results of this preliminary analysis support neoadjuvant endocrine therapy for a duration of up to 9 months. The combination of letrozole plus triptorelin might represent an alternative neoadjuvant treatment option for premenopausal women with early stage endocrine-responsive breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-15-03.

Abstract PD6-5: Pooled analysis of circulating tumor cells in metastatic breast cancer: Findings from 1944 individual patients data

Background: Clinical validity of CTCs (CellSearch®) in metastatic breast cancer (MBC) patients has previously been assessed in studies with limited statistical power. We aimed to pool all European studies to obtain high-level evidence on the prognostic value of CTCs, to investigate their effects across different clinico-pathological characteristics and therapies and to further validate the MD Anderson/Institut Curie/Fox Chase CTC-based prognostic nomogram established in first-line treated MBC patients (Giordano et al, Clin Cancer Res 2013).

Material and methods: Methods were predefined in a written protocol. In December 2012, we searched for eligible studies that accrued patients in 2003-2012. We contacted all European laboratories using CellSearch®. We used likelihood ratio tests (LR) in Cox regression models stratified by study to assess the independent prognostic value of CTC when added to a clinicopathological (CP) model for progression-free (PFS) and overall survival (OS). Landmark analyses were used to assess the prognostic effect of early changes in CTC. The CTC-based nomogram (http://cancernomograms.com/CTCOnline.html) score was retrieved for every patient; we calculated C-indices, drew calibration plots and Kaplan-Meier curves according to quintiles of the nomogram score.

Results: We collected individual data of 1944 MBC patients, from 20 different studies (some unpublished), from 17 centers in 7 European countries. We observed 1507 PFS events and 929 deaths. Baseline CTC count was significantly associated with several patient characteristics, such as performance status (PS, p<10-4), synchronous metastasis (p<10- 2) tumor subtype (p<10-4), liver & bone metastases (p<10-4), CEA & CA15-3 levels (p<10-4). The CP model for OS included PS, MBC subtypes, number of previous lines of treatment, patient's age, metastasis-free interval, metastatic sites (p<0.01 for all). In a multivariate analysis containing the CP model parameters and CTC count at baseline, elevated CTC count (≥5) was a significant independent predictor of OS (n = 1444, HR = 2.7, 95%CI [2.2-3.2], LR p<10-4). Baseline serum markers added either no or marginal effect to the CP plus baseline CTC model for OS. In contrast, early changes in CTC status at week 3-5 significantly added prognostic information for OS to the model with CP factors and baseline CTC+ (n = 569, HR = 1.8 [2.2-3.2], LR p<0.001). In the population of interest (MBC treated by first line chemotherapy, n = 402 patients, 176 deaths), the CTC-based nomogram exhibited a good C-index for OS (0.69), was well calibrated and showed clear separation of the survival curves. Additional results, including subgroup analyses by tumor subtype and treatments will be presented at the meeting.

Conclusions: This pooled analysis is the largest study ever reported on CTC in MBC, with a previously unreached statistical power. It provides a clear level-of-evidence 1 on the independent prognostic value of CTCs before and during treatment in MBC. Also, the CTC-based prognostic nomogram is independently validated.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD6-5.

Outcome and clinical-biological characteristics of patients with advanced breast cancer undergoing removal of ovarian/pelvic metastases

BACKGROUND

Patients with metastatic breast cancer to the ovary, without tumor debulking and after systemic therapy, have a 5-year survival rate < 10%.

PATIENTS AND METHODS

We analyzed a series of 37 patients, operated in one institution over 10 years, for both the primary tumor (PT) and ovarian/pelvic metastases (OPM). Estrogen receptors (ER), progesterone receptors (PgR), HER-2 and Ki-67 were determined.

RESULTS

Patients were predominantly young: 27 (73%) patients were < 50 years. Average ER/PgR expression did not change significantly between PT (mean ER = 66%, PgR = 35%) and OPM (mean ER = 67%, PgR = 28%). Median time to OPM was 42 months (range 0-176); 5-year OS after OPM was 51% (95% confidence interval 32% to 67%). When combining ER and PgR status, patients with ER > 50% on both PT and OPM and with PgR > 50% on PT and/or OPM (good prognosis, 11 patients) had a better outcome versus0 patients with ER and PgR ≤ 50% on both PT and OPM (bad prognosis, eight patients) and also versus the remaining patients (intermediate prognosis, 18 patients), P value = 0.010.

CONCLUSION

Patients with OPM from breast cancer show a favorable prognosis after tumor debulking, whether it was radical or not, especially when a high expression of ER and PgR is present in both PT and OPM.

CMF revisited in the 21st century

Over the last 35 years, classical CMF (combination chemotherapy with cyclophosphamide, methotrexate and fluorouracil) has been a milestone in the adjuvant treatment of women with breast cancer. However, after an early burst of success lasted just over 10 years, classical CMF has been supplanted by 'third-generation' regimens containing taxanes and anthracyclines. Questions have been raised in the past years concerning the true effectiveness of adjuvant CMF for specific subgroups of patients and particularly, recent retrospective data support the fact that the CMF might have a role in the treatment of patients with triple-negative breast cancer. One possible justification for supporting this role of CMF may be sought in the mechanism of action of drugs used in the regimen, as triple-negative cells may be sensitive to alkylating agents that cause double-strand breaks in DNA. The lesson learned from the CMF could lead us to identify new combinations of drugs that could include the optimal chemotherapy backbone for triple-negative breast cancer such as platinum compounds or alkylating agents or Poly (ADP-ribose) polymerase inhibitors. In conclusion, although we have learned a lot from the use of CMF, many questions are still open and hopefully stimulate our thinking, as clinicians, leading us to find new and more effective ways to treat breast cancer.

Abstract P3-02-13: Is HER2 Evaluation with the CellSearch System a Method Reliable for Detecting HER2 Overexpression?

Background. Circulating tumor cells (CTCs) detected in patients with both localized and metastatic breast cancer are significantly associated with a worse outcome. In addition to enumeration, an exciting area of CTC research involves the phenotyping and expression profiling of CTCs. In this regard, in patients with metastatic breast cancer, the evaluation of CTCs could be considered as a “real-time” biopsy allowing the detection of possible changes in tumor phenotype, such as a shift in patients HER2- negative on the primary tumor to HER2-positive CTCs. This could be of relevance as these patients may become suitable to targeted anti-HER2 therapy. Currently, there is no standardized and widely accepted method available for the determination of HER2 status on CTC. Aims. Objectives of this study were: 1. verifying the feasibility and reliability of HER2 determination on cells from scraping of breast cancer tissue by FISH analysis, 2. evaluating the concordance of HER2 status determined on primary breast tumor by immunohistochemistry (IHC) and on scraped cells, obtained from the same breast tumor and spiked in blood from healthy subjects, using the CellSearch System, and finally 3. evaluating the concordance of HER2 expression determinated by FISH analysis and by CellSearch on the same scraped cells. Methods. Cells from scraping of fresh breast cancer tissues with different level of HER2 expression were spiked in 18 healthy subjects blood samples. The determination of the HER2 expression on these cells was performed with the CellSearch System (Veridex, USA) by the addition of a fluorescein conjugated monoclonal antibody to be used in conjunction with the CellSearch™ Epithelial Cell Kit to phenotype CTCs for the presence of HER-2/neu. The HER2 characterisation of the primary breast tumors was performed by IHC by FISH analysis according to standard procedures. FISH was also performed on cells from scraping of fresh breast cancer tissues after CellSearch enumeration and characterization, by removing them from the “MagNest” cartridge. Tumors with a score of 3+ were considered positive.

Results. The results of the FISH analysis performed on the cells aspirated from the cartridge demonstrated a 100% concordance with the FISH performed on fresh tissue (9 not amplified and 9 amplified). The evaluation of HER2 expression on scraped cells by CellSearch System and by IHC on the corresponding tumor showed that the CellSearch method is reliable in identifying HER2 overexpression, as in all the 3+ tumors it was possible to detect variable percentage of scraped cells overexpressing HER2. Finally, different number of HER2+ scraped cells were found in 16 out of the 18 samples: the only 2 negative samples were both IHC negative and FISH not amplified. On the contrary 2 of the 4 remaining negative/1+ IHC samples, showed some scraped cells HER2+ which resulted FISH amplified. Conclusion. This study demonstrates that FISH analysis is feasible and the results are reliable when performed on cells after CellSearch procedure. Moreover HER2 expression may be evaluated with the CellSearch System and it may be used as a preliminary method to indicate possibly HER2 positive samples which may be confirmed by FISH analysis.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-02-13.

Abstract P1-13-03: Is Bone Biopsy of Metastatic Sites Useful in Advanced Breast Cancer Management?

Background: Biopsies of metastatic sites are not recommended in clinical practice to evaluate changes in biological features in advanced breast cancer (ABC) women. We assessed discordance in expression levels for estrogen receptor (ER), progesterone receptor (PgR) and epidermal growth factor receptor 2 (HER2), between primary tumor and bone metastases and its clinical impact on patient management.

Material and Methods: We retrospectively analyzed 109 ABC patients (pts) underwent computed tomography guided bone biopsy at the European Institute of Oncology in Milan, Italy, from 1997 to 2009. Data on ER and PgR status [positive if ≥1% by immunohistochemistry (IHC)] and on HER2 status (positive if IHC3+ and/or FISH amplified), both primary tumor and bone metastases were collected. Fisher and McNemar's test were used for statistical analysis.

Results: Median time from primary diagnosis to bone biopsy was 4.2 years (range 0-18.9). Overall discordance rate (ODR) in ER expression was 20.5% (95% CI: 13.4%-29.5%): 3/7 pts (42.9%) shifted from ER negative to positive and 19/100 pts (19%) from ER positive to negative [p=0.0006]. ODR in PgR expression was 43.9% (95% CI: 34.3%-53.8%): 4/21 pts (19%) changed from PgR negative to positive and 43/86 pts (50%) from PgR positive to negative [P&lt;0.0001]. ODR in HER2 status was 6.9% (95% CI: 2.6%-14.6%): 4/78 pts (5.1%) changed from HER2 negative to positive and 2/8 pts (25%) turned from HER2 positive to negative [p=0.41]. Thirteen out of 21 pts (61.9%) with discordant ER status and 23/77 pts (29.8%) with concordant ER status [p=0.01] changed endocrine therapy; there were no differences in chemotherapy [p=0.80]. Four out of 6 pts (66.6%) with discordant HER2 status and 6/72 pts (8.3%) with concordant HER2 status changed immunologic therapy [p=0.002], 3/6 pts (50%) started trastuzumab and 1/6 patient (16.6%) stopped it; there were no differences in chemotherapy [p=0.68]. All pts well tolerated the invasive procedure, requiring only local analgesia. Discussion: Our analysis showed that receptor profile may significantly change between primary breast cancer and bone metastases, with relevant impact on therapy. Bone biopsy might be useful and should be considered in selected cases to optimize therapeutic choices. Large prospective trials are needed to investigate these outcomes.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-13-03.

Abstract P6-11-14: Long-Term Disease Control with Vinorelbine, Cisplatin and Continuous Infusion of 5-Fluorouracil -ViFuP Regimen-in Metastatic Triple Negative Breast Cancer Patients

Background: Triple negative breast cancers (TNBCs) are characterized by lack of estrogen, progesterone, HER-2-neu receptors expression and comprise 15% to 20% of all breast cancers. Studies have suggested that

TNBCs may be more sensitive to DNA damaging agents like cisplatin. Our previous experience had identified a combination chemotherapy -the ViFuP regimen-with noteworthy efficacy and safety as a first or subsequent line treatment for metastatic breast cancer (MBC) patients (pts). In this view we retrospectively examined the activity of ViFuP regimen in 2 cohorts (A and B) of metastatic TNBC pts.

Material and Methods: From January 2000 to December 2008, 115 pts with MBC were treated with ViFuP regimen, at the European Institute of Oncology, Milan, Italy. Among these, 35 pts (30%) had TNBC. Pts received continuous infusion 5-fluorouracil 200 mg/m2/day, vinorelbine 20 mg iv on days 1 and 3 and cisplatin 60 mg/m2on day 1. Therapy was given every three weeks. In A 22 pts (63%) were triple negative on primary tumor and in B 13 pts (37%) were triple negative in metastatic site. Median age was 54 years (range 35-73), 11 pts (31%) were pre-treated for MBC and 21 pts (60%) had ≥3 metastatic sites.

Results: Thirty three pts were evaluable for response and 34 pts were assessable for toxicity. Median duration of treatment was 3.57 months (range 1-5.7). Four pts (12%) had complete responses, 14 pts (42%) had partial responses and 11 pts (33%) had stable disease with a clinical benefit (CB) of 73% (95% CI, 55%-87%). Four pts (12%) had progressive disease. Median time to progression was 6 months (95% CI, 5-8 months). Main toxicity was haematological with 62% of the pts showing grade 3/4 leuco-neutropenia. Alopecia was almost absent.

Discussion: Treatment with ViFuP regimen was effective and safe in metastatic TNBC providing long-term disease control in a high proportion of pts. The prolonged CB supports this regimen as an additional therapeutic opportunity in this category of pts.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-11-14.

Circulating endothelial cells (CECs), progenitors (CEPs), and circulating tumor cells (CTCs) for prediction of response in patients with advanced breast cancer (ABC) receiving metronomic oral vinorelbine (oV): Preliminary results

e14572

Background: Metronomic administration of chemotherapy given once or more per week with no extended gaps was shown to be effectively anti-angiogenic, causing growth arrest or apoptosis of endothelial cells in tumor neo-vessels. Preclinical and clinical studies indicate that ultra-low concentrations of various microtubule inhibitors inhibit proliferation or migration of endothelial cells. We investigated in a phase II study the activity of metronomic administration of oV in ABC, kinetics and response prediction of CECs, CEPs, CTCs and of other biomarkers of angiogenesis (soluble VEGF, VEGFr2, TSP1, bFGF). CT perfusion scans were also performed. Methods: From February 2008, 47 pts with ABC received oV (50 mg/die TTW). Currently 20 pts are evaluable for both activity and biomarker assessment. Baseline levels of biomarkers of angiogenesis were correlated with clinical response. Results: Shown in Table . Conclusions: We found that the baseline value of apoptotic cells (expressed as % of total cells) was significantly correlated with outcome. The baseline total, viable, and apoptotic CEC count and CTCs might provide an indirect measure for angiogenic turnover and an indicator of better response to anti-angiogenic therapy, supporting the use of metronomic treatments in patients expressing high levels of baseline CECs. Updated results will be presented together with correlation with perfusion CT scan and levels of CTCs.

[Table: see text]

No significant financial relationships to disclose.

Circulating tumor cells in operable breast cancer: a pilot study

Abstract #5028

Background. Circulating tumor cells (CTCs) in the peripheral blood are an ideal source for the detection of disseminated tumor cells because of an easy sampling procedure. Their prognostic significance has been demonstrated in metastatic breast cancer, while little data exist in operable patients. Aims of this study are the evaluation of the prevalence and kinetics of CTCs before and after surgical treatment and the possible correlation between CTCs and clinico-pathological characteristics and biological features. Methods. We analyzed 30 ml of peripheral blood from 60 T1-T3, any N, M0 breast cancer pts, before surgery and after 5 days. In case of positivity of one of the perioperative samples, a further sample was taken after 30 days. The presence of CTCs was assessed with the CellSearch System (Veridex, USA). Samples were subjected to immunomagnetic enrichment with an anti-Epcam-antibody: CTCs were defined as nucleated cells expressing cytokeratin 8, 18 and 19 but lacking CD45. A sample was considered positive when 1 or more cells were detected. Results. Data are available for 50 pts. We found ≥1 CTC in 28% of the pts (n=14/50) before surgery, and in 29% of the patients (n= 12/42 ) at 5 days. The median number of CTCs was 1, with a range of 1-3. We found a borderline significant association between the presence of CTCs at baseline and the presence of vascular invasion (p=0.09). The presence of CTCs at baseline did not correlate with tumor size (p=0.66), grading (p=0.88), presence of estrogens receptor (p=0.30), presence of progesteron receptor (p=0.30), HER2/neu status of the tumor (p=1.0), or with the presence of lymph node metastases (p=0.71). In 42 pts we have the data of CTCs determined at baseline and at day 5: 27 patients showed concordant results (23 negative and 4 positive). Among the 15 patients with different results, 8 were negative at baseline and positive at day 5: 6 out of the 8 patients had positive nodes. At day 30 we analyzed samples from 18 subjects: persistence of at least 1 CTC was found in 18 % of patients (n=5). Conclusions. The results of this explorative study are very preliminary and a larger number of patients and a long-term follow-up will be required. However, it is of interest the borderline correlation between presence of CTCs at baseline and vascular invasion, and between appearance of CTCs and nodal involvement in postoperative samples. The study is ongoing and the patients will be followed during and after adjuvant treatment to explore the prognostic significance of persistency of CTCs. Complete data will be presented.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5028.

Variation of circulating tumor cell levels during treatment of metastatic breast cancer: prognostic and therapeutic implications

BACKGROUND

This study aimed to evaluate the prognostic significance of circulating tumor cells (CTCs) detection in advanced breast cancer patients.

PATIENTS AND METHODS

We tested 80 patients for CTC levels before starting a new treatment and after 4, 8 weeks, at the first clinical evaluation and every 2 months thereafter. CTCs were detected using the CellSearch System.

RESULTS

Forty-nine patients had >or=5 CTCs at baseline. At the multivariate analysis, baseline number of CTCs was significantly associated with progression-free survival [hazard ratio (HR) 2.5; 95% confidence interval (CI) 1.2-5.4]. The risk of progression for patients with CTCs >or=5 at last available blood draw was five times the risk of patients with 0-4 CTCs at the same time point (HR 5.3; 95% CI 2.8-10.4). Patients with rising or persistent >or=5 CTCs at last available blood draw showed a statistically significant higher risk of progression with respect to patients with <5 CTCs at both blood draws (HR 6.4; 95% CI 2.8-14.6).

CONCLUSION

CTCs basal value is a predictive indicator of prognosis and changes in CTC levels during therapy may indicate a clinical response. Testing CTC levels during targeted treatments might substitute other measurement parameters for response evaluation.

Optimizing clinical care of patients with metastatic breast cancer: a new oral vinorelbine plus trastuzumab combination

BACKGROUND

Trastuzumab (T) combined with i.v. vinorelbine (i.v.VNR) is an active regimen for patients with advanced breast cancer (ABC). In order to further improve quality of life of patients undergoing treatment for ABC, a new regimen using oral vinorelbine (oVNR) (d1 + d3) plus q3wks T was tested (ToVNR).

PATIENTS AND METHODS

Thirty-nine patients with ABC, human epidermal growth factor receptor 2/neu 3+ or FISH positive received 288 treatment cycles with T 6 mg/kg (loading dose, 8 mg/kg) on d1 and oVNR 55 mg/m(2) on d1 + d3, q3wks until disease progression or unacceptable toxicity.

RESULTS

Thirty-seven patients and 286 treatment cycles were evaluated (two patients were lost to follow-up). Treatment was very well tolerated. Two patients had complete response (CR), 14 partial response (PR), 17 stable disease (SD) and four disease progression (PD) (overall response rate: 43%). Clinical benefit rate (CR + PR + SD >24 months) was 73%. Median time to progression was 8.9 months (range 2-27) and median duration of response was 10.9 months (range 2-27).

CONCLUSIONS

The ToVNR combination is active and very well tolerated. It favorably compares with the combination of T and weekly i.v. administered VNR, allowing a more convenient once every three weeks hospital admission and leaving patients and care providers free from the unpleasant effect of i.v.VNR.

Brain metastases in patients with advanced breast cancer

BACKGROUND

The incidence of brain metastases (BM) is apparently rising in patients with advanced breast cancer (ABC). We performed a case control study to define current features of breast cancer related to central nervous system (CNS) metastases.

PATIENTS AND METHODS

From March 1999 to May 2006, we identified 72 patients with symptomatic BM of breast cancer. A comparison group was randomly selected assigning to each case two patients with primary breast cancer and no BM, matched for year of diagnosis, age and tumour stage (pT status and nodal status).

RESULTS

Cases had a significantly higher rate of negative estrogen receptors (ERs) (60% in cases vs. 29% in controls), negative progesterone receptors (PgRs) (79% vs. 43%), HER2/neu over expression (44% vs. 13%) and immunostaining for Ki-67 > or =20% (84% vs. 55%), with p-value <0.001 for all four parameters in univariate analyses. On multivariate analysis, HER2/neu over expression and Ki-67 -20% were independent predictive factors of brain relapse (Odds Ratio (OR) 2.55, 95% confidence intervals (CI) 1.10-5.94 and OR 2.97, 95% CI 1.01-8.73, respectively). Endocrine unresponsive tumours (both ER and PgR <10%) showed an increased risk of relapse with BM of borderline significance (OR 1.91, 95% CI 0.87-4.12).

CONCLUSION

Patients with ER and PgR negative tumours either with or without HER-2/neu over expression should be considered at higher risk of BM.

A phase II trial of dacarbazine (DTIC) and bevacizumab in patients with metastatic melanoma

8579

Background: Dacarbazine (DTIC) has been approved for treating metastatic melanoma in the 1970s, and as a single agent gives a response rate of about 20%. There have been efforts to ameliorate this poor result by using DTIC in different combinations without a significant improvement. In addition, new studies with melanoma cells in vitro show that DTIC causes transcriptional up-regulation of vascular endothelial growth factor (VEGF), suggesting a potential clinical benefit from the concomitant treatment of DTIC and anti-VEGF therapy. The purpose of this study is to determine whether a combination therapy of bevacizumab and DTIC is safe and can increase response rate and progression-free survival in patients (pts) with metastatic melanoma. Methods: From June 2006 to December 2006, 8 chemo-naive pts (1 female and 7 males) with metastatic melanoma were enrolled in the study. The median age was 53 (43–74) and PS was 0–1. Patients received DTIC 800 mg/m2 iv every 4 weeks and bevacizumab 10 mg/kg iv every 2 weeks. A treatment cycle consisted of 28 days. Results: Among 5 evaluable pts there were 1 partial response, 2 stable disease and 2 progressions, 3 pts were not evaluable because it is too early. Median number of administered cycles was 2 (2–6). The toxicity profile was particularly favourable with no G3/G4 haematological toxicity. Other most commonly seen toxicities were: nausea/vomiting (22%), mucositis (13%), diarrhea (9%). Proteinuria 1+ was reported in 3 cycles (13%). One patient with an early progression had also a G2 increase in blood pressure with a dilatative cardiomyopathy. Conclusions: The combination treatment resulted well tolerated and with a sufficient anti-tumor activity to warrant the continuing of enrolment. Updated efficacy and safety data will be presented.

No significant financial relationships to disclose.

Pegylated liposomal doxorubicin (PLA) at a metronomic schedule for patients with advanced breast cancer (ABC)

10571

Background: The anti-angiogenic efficacy of chemotherapy (CT) is probably best obtained by administration of low doses of cytotoxics on a frequent or continuous schedule. The aim of this pilot study was to assess feasibility, clinical efficacy and tolerability of PLA, using a “metronomic” schedule in ABC. This schedule has been previously tested in the treatment of Kaposi sarcoma. Methods: From January to November 2005, 36 pts with ABC were treated with PLA, at a dose 20 mg/m2 q14. Almost all the pts were heavily pretreated for ABC and 44% of them received previous anthracycline therapy in adjuvant or metastatic setting. Results: Thirty-four pts were evaluable for toxicity and 29 for response. One pt (3%) had CR, 3 (11%) PR, 12 (41%) NC and 13 (45%) PD, for an overall clinical benefit of 28%. Median response duration was 2.59 mos; median TTP was 3.38 mos (95% CI 2.11–4.64). Treatment was well tolerated with neither G3-G4 NCI-CTC hematological toxicity. Only one pt experienced G3 palmar-plantar erythrodysesthesia (PPE). PPE was observed in other 15 pts (39%), with G2 occurring in 7 (21%). Other common G2 non-hematological toxicities were mucositis in 3 pts (9%) and constipation in 3 pts (9%) Dose reduction, due to subjective or hematological toxicity, was required in 10 pts (36%). No decrease in LVEF > 10% from baseline was observed. Conclusions: Metronomic PLA schedule in pretreated ABC pts seems to be an active and well-tolerated regimen. As to dose-dense CT, targets of metronomic CT might be, in addition to malignant cells, also endothelial and other stromal cells of the progressing metastasis, leading ultimately to the stability and eventually regression of the neoplastic lesion. The lower toxicity profile of the metronomic schedules make their use in pts with ABC very attractive and their testing in the adjuvant setting extremely challenging.

No significant financial relationships to disclose.

Dose-finding and pharmacokinetic study of an all-oral combination regimen of oral vinorelbine and capecitabine for patients with metastatic breast cancer

PURPOSE

A phase I study was performed to determine the maximal tolerated dose, recommended doses (RDs), safety and efficacy of oral vinorelbine when combined with capecitabine in an all-oral chemotherapy regimen in patients with metastatic breast cancer (MBC), with pharmacokinetic blood sampling to investigate potential drug-drug interactions.

PATIENTS AND METHODS

Forty-four patients with MBC received as first- or second-line chemotherapy, oral vinorelbine at a dose of 60 or 80 mg/m2 on days 1 and 8 (and 15) with escalating doses of capecitabine from 1650 to 2500 mg/m2/day days 1-14 every 3 or 4 weeks. Three schedules were tested: day 1, day 8 and weekly regimens of oral vinorelbine with a 14-day course of capecitabine every 3 weeks; and a days 1 and 8 regimen of oral vinorelbine with a 14-day course of capecitabine every 4 weeks.

RESULTS

With oral vinorelbine at 60 mg/m2, the RDs were established as oral vinorelbine 60 mg/m2 on days 1 and 8 plus capecitabine 2250 mg/m2/day days 1-14 and oral vinorelbine 60 mg/m2/week plus capecitabine 2000 mg/m2/day days 1-14. With oral vinorelbine at 80 mg/m2, the RD was oral vinorelbine 80 mg/m2 on days 1 and 8 plus capecitabine 2000 mg/m2/day days 1-14. Neutropenia was the main dose-limiting toxicity of the combination; it was reported in 40 patients (90.9%), with grade 3 in 14 patients (31.8%) and 6.2% of cycles, and grade 4 in 12 patients (27.3%) and 4.3% of cycles. Complications were rare with only three patients experiencing febrile neutropenia (one episode each). The most frequent non-haematological toxicity was gastrointestinal; however, the incidence of grade 3 was low, with no episode of grade 4. Hand-foot syndrome was reported in 14 patients (31.8%) and 22.6% of cycles, with grade 2 in two patients (4.5%) and 1.2% of cycles (two episodes each). No episode of grade 3 was observed. Objective responses were reported in 18 patients (three complete responses and 15 partial responses), yielding a response rate of 40.9% in the intention-to-treat population according to the investigator assessment. Results from the pharmacokinetic study demonstrated the absence of mutual pharmacokinetic interactions when both drugs were co-administered.

CONCLUSIONS

The combination of oral vinorelbine and capecitabine is safe and easy to administer in an outpatient setting. This all-oral combination chemotherapy may offer a good alternative to the intravenous route for patients with MBC. Based on these promising results, a phase II study has started using oral vinorelbine 60 mg/m2/week with capecitabine 2000 mg/m2/day days 1-14 every 3 weeks as first-line chemotherapy in patients with MBC.

Systemic effects of surgery: quantitative analysis of circulating basic fibroblast growth factor (bFGF), Vascular endothelial growth factor (VEGF) and transforming growth factor beta (TGF-beta) in patients with breast cancer who underwent limited or extended surgery

BACKGROUND

To assess if feature, extent and duration of surgery could influence levels of systemic proangiogenic cytokines vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and transforming growth factor beta (TGF-beta).

PATIENTS AND METHODS

We collected blood samples from 82 consecutive breast cancer patients who underwent various types of surgery, classified according to the magnitude of tissue injury in: minimal (quadrantectomy), moderate (mastectomy without reconstruction), and heavy [mastectomy followed by reconstruction with transversus recto-abdominal muscle cutaneous flap (TRAM)]. Samples were collected one day before surgery (D(-1)), at the end of surgical tumor removal (D0), and on 1st (D(+1)), 2nd (D(+2)) and 5th (D(+5)) day after surgery. Serum VEGF, bFGF and TGF-beta levels were measured by the enzyme immunoassay method.

RESULTS

On average a continuous decrease was observed for all growth factors from the day before operation to the 5th day after operation. On day (D(+5)) an increase was observed for patients who underwent extended respect to moderate surgery. These differences were found statistically significant for bFGF and VEGF (p = 0.05 and p = 0.025 respectively). A statistically different trend for type of operation was observed also for TGF-beta at 24-48 h: a minor reduction, compared to time of operation, was observed for minimal surgery, an intermediate reduction for moderate surgery and a higher decrease for extended surgery.

CONCLUSIONS

Angiogenic cytokines perioperative levels could be increased on 5th day (D(+5)) by extent of surgery and should induce perioperative stimulation of residual cancer cells. A better understanding of the time interval during which the sequelae of events in wound healing occur may be the basis for defining new therapeutic strategies that can interfere with tumor outgrowth sparing wound healing processes.

Breast cancer vaccines: a clinical reality or fairy tale?

The characterization of tumor antigens recognized by immune effector cells has opened the perspective of developing therapeutic vaccines in the field of breast cancer. The potential advantages of the vaccines are: (i) the induction of a robust immune response against tumors that are spontaneously weekly immunogenic; (ii) the tumor specificity for some antigens; (iii) the good tolerance and safety profile and (iv) the long-term immune memory, critical to prevent efficiently tumor recurrence. Most trials evaluating breast cancer vaccines have been carried out in patients with extended metastatic breast cancer, characterized by aggressive tumors, resistant to standard cytotoxic treatments, so that clinical efficacy was difficult to achieve. However, some significant immune responses against tumor antigens induced upon vaccinations were recorded. The aim of this review is to analyze the activity of vaccination strategies in current clinical trials. Data of clinical activity have been observed by using vaccines targeting HER2/neu protein, human telomerase reverse transcriptase, carcinoembryonic antigen and carbohydrate antigen given after stem cell rescue. The review discusses possible future directions for vaccine development and applications in the adjuvant setting.

Dose-finding study of weekly docetaxel, anthracyclines plus fluoropyrimidines as first-line treatment in advanced breast cancer

BACKGROUND

The efficacy and safety of prolonged fluoropyrimidines, either intravenously or orally, prompted their integration with taxanes and anthracyclines in the treatment of advanced breast cancer (ABC). We conducted three subsequent dose-finding studies on first-line chemotherapy in ABC with anthracyclines, either epirubicin (E) or doxorubicin (A), and docetaxel (T), both given on days 1 and 8 every 3 weeks, plus continuous infusion (CI) 5-fluorouracil (F) or capecitabine (X).

PATIENTS AND METHODS

Sixty-two patients (37% dominant visceral disease, 48% locally advanced disease, 45% two or more sites involved), received different doses of T (60--80 mg/m(2)), A (40--50 mg/m(2)) or E (60--90 mg/m(2)) and X (1,650 and 2,000 mg/m(2)), or CI F at a fixed daily dose of 200 mg/m(2). Cardiac function was monitored at baseline and then every four cycles by echocardiography.

RESULTS

The median number of cycles per patient with all regimens was four (range one to eight). Haematological and gastrointestinal toxicity defined the maximum tolerated doses, at T-80/E-90 mg/m(2) with TEF, T-70/A50/X-2,000 mg/m(2) with TAX and T-70/E-80/X-1,650 mg/m(2) with TEX. Two patients treated with TEF developed transient cardiac toxicity (dilatative cardiomyopathy and coronary subtotal stenosis requiring stenting) after cumulative E doses of 400 mg and 1,100 mg/m(2), respectively. Fifty-nine patients were evaluable for response; the overall response rates (ORR) were comparable between regimens (54% with TEF, 71% with TAX and 86% with TEX), with an 81% ORR in 31 patients with locally advanced disease.

CONCLUSIONS

The addition of fluoropyrimidines to weekly, intermittent ET is well tolerated and active in ABC.

Response of bilateral choroidal metastases of breast cancer to therapy with trastuzumab

Intraocular metastases, especially those of the choroidal plexus, are not common in metastatic breast cancer patients and are typically associated with a poor prognosis and impaired quality of life. A 45-year-old woman with breast cancer overexpressing HER2 and metastasizing to choroidal plexus, lymph nodes and skin received a combination of trastuzumab and paclitaxel as first-line treatment. Subsequently, at progression, trastuzumab was reintroduced together with vinorelbine. Administration of trastuzumab with either paclitaxel or vinorelbine led to a rapid improvement of the ocular symptoms, associated with a rapid objective response of all metastatic lesions and a prompt improvement in the quality of life. Choroidal metastases from breast cancer overexpressing HER2 are responsive to trastuzumab and chemotherapy (paclitaxel or vinorelbine). The susceptibility of ocular metastases to this approach seems different to that of other sanctuary disease sites.

Effect of tamoxifen on GH and IGF-1 serum level in stage I-II breast cancer patients

OBJECTIVE

Tamoxifen suppresses insulin-like growth factor-1 (IGF-1) plasma levels in early and advanced breast cancer patients. Relationships between tamoxifen (GH) and IGF-1 are complex and not completely described yet. The present investigation was performed to evaluate the effect of acute and chronic tamoxifen administration on GH response to growth hormone-releasing hormone (GHRH), as well as on IGF-1 serum levels.

MATERIALS AND METHODS

Evaluation of GH after administration of GHRH was performed (a) at baseline, (b) 3 hours after 20 mg oral administration of tamoxifen and (c) after 12 weeks of 20 mg a day oral tamoxifen treatment, in fifteen postmenopausal stage I-II breast cancer patients. IGF-I was measured at baseline and after chronic tamoxifen administration.

RESULTS

The GH response to GHRH was significantly reduced after 12 weeks of tamoxifen 10 mg administered twice a day orally (mean peak 3.2 +/- 0.2 micrograms/l, mean AUC 261.3 +/- 18.2 micrograms/minute p < 0.01 versus basal AUC). A concomitant significant reduction of IGF-1 was observed after 3 months of tamoxifen treatment. Basal pretreatment levels of 113.2 +/- 15.5 micrograms/l were suppressed to 70 +/- 7.9 micrograms/l (p < 0.01).

CONCLUSION

Our study confirm the inhibitory effect of tamoxifen on IGF-I and suggested, as shown in previous in vitro data, that its suppression could be directly related to GH reduction in response to GHRH stimulation.