Association Between Treated Periodontal Disease and Febrile Neutropenia in Perioperative Chemotherapy for Breast Cancer: A Retrospective Cohort Study

BACKGROUND

This study aimed to examine whether the incidence of febrile neutropenia (FN) during perioperative chemotherapy for breast cancer increased in patients with periodontal disease who had received prior dental treatment.

METHODS

This retrospective cohort study conducted at a single tertiary care center included patients diagnosed with clinical stages I-III of breast cancer and had started neoadjuvant or adjuvant intravenous chemotherapy between July 2015 and November 2021. The exposure was periodontal disease (probing depth ≥6 mm) diagnosed by dentists before the start of chemotherapy. Almost all the patients received dental treatment and oral care before initiating chemotherapy. The primary outcome was FN incidence during chemotherapy. We used a multivariable logistic regression model adjusted for age, diabetes mellitus, chemotherapy regimen, and the mean relative dose intensity.

RESULTS

Based on the eligibility criteria of this study, 141 women were included. The incidence of FN in the periodontal group (probing depth ≥6 mm) and control group (probing depth <6 mm) was 36.4% and 25.9%, respectively. The crude odds ratio (OR) for FN incidence was 1.63 (95% confidence interval [CI], 0.71-3.74; P = 0.24), and the adjusted OR was 1.52 (95% CI, 0.62-3.73; P = 0.36).  Conclusions: Occurrence of FN during perioperative chemotherapy for breast cancer is not a concern in patients undergoing dental treatment for periodontal disease before or during chemotherapy.

Long-term outcomes of indocyanine green fluorescence imaging-guided laparoscopic lateral pelvic lymph node dissection for clinical stage II/III middle-lower rectal cancer: a propensity score-matched cohort study

BACKGROUND

We previously reported that indocyanine green fluorescence imaging (ICG-FI)-guided laparoscopic lateral pelvic lymph node dissection (LPLND) was able to increase the total number of harvested lateral pelvic lymph nodes without impairing functional preservation. However, the long-term outcomes of ICG-FI-guided laparoscopic LPLND have not been evaluated. The aim of the present study was to compare the long-term outcomes of ICG-FI-guided laparoscopic LPLND to conventional laparoscopic LPLND without ICG-FI.

METHODS

This was a retrospective, multi-institutional study with propensity score matching. The study population included consecutive patients with middle-low rectal cancer (clinical stage II to III) who underwent laparoscopic LPLND between January 2013 and February 2018. The main evaluation items in this study were the 3-year overall survival, relapse-free survival (RFS), local recurrence rate, and lateral local recurrence (LLR) rate.

RESULTS

A total of 172 patients with middle-lower rectal cancer who had undergone laparoscopic LPLND were included in this study. After propensity score matching, 58 patients were matched in each of the ICG-FI and non-ICG-FI groups. There were no substantial differences in the baseline characteristics between the two groups. The ICG-FI group and non-ICG-FI group included 40 and 38 women and had a median age of 65 (IQR 60-72) and 66 (IQR 60-73) years, respectively. The median follow-up for all patients was 63.7 (IQR 51.3-76.8) months. The estimated respective 3-year overall survival, RFS, and local recurrence rates were 93.1%, 70.7%, and 5.2% in the ICG-FI group and 85.9%, 71.7%, and 12.8% in the non-ICG-FI group (p = 0.201, 0.653, 0.391). The 3-year cumulative LLR rate was 0% in the ICG-FI group and 9.3% in the non-ICG-FI group (p = 0.048).

CONCLUSIONS

This study revealed that laparoscopic LPLND combined with ICG-FI was able to decrease the LLR rate. It appears that ICG-FI could contribute to improving the quality of laparoscopic LPLND and strengthening local control of the lateral pelvis.

TRIALS REGISTRATION

This study was registered with the Japanese Clinical Trials Registry as UMIN000041372 ( http://www.umin.ac.jp/ctr/index.htm ).

Initial experience with the transanal approach for lateral pelvic lymph node dissection in rectal cancer

BACKGROUND

The efficacy and safety of transanal lateral pelvic lymph node dissection (TaLPLND) in rectal cancer has not yet been clarified. The aim of the present study was to evaluate the short-term results as an initial experience of TaLPLND.

METHODS

This retrospective study included patients with middle to lower rectal cancer who underwent TaLPLND from July 2018 to July 2021. Our institutions targeted lymph nodes in the internal iliac area and the obturator area for lateral pelvic lymph node dissection (LPLND).

RESULTS

A total of 30 consecutive patients with rectal cancer were included in this analysis. The median age was 60 years (range, 36-83 years), and the male-female ratio was 2:1. The median operative time was 362 min (IQR, 283-661 min), and the median intraoperative blood loss was 74 ml (IQR, 5-500 ml). Intraoperative blood transfusion was required in one case. No cases required conversion to laparotomy. TaLPLND was performed bilaterally in 13 patients (43.3%). Five patients (16.7%) underwent LPLND with combined resection of the internal iliac vessels. The median distance of the distal margin from the anal verge was 20 mm. The pathological radial margin (pRM) was positive in one case, and the negative pRM rate was 96.7%. Short-term postoperative complications (Clavien-Dindo classification grade ≥ II) were observed in nine cases (30.0%). There were no cases of reoperation or mortality. The median number of harvested lateral pelvic lymph nodes was 11 (range, 3-28). On pathological examination, lateral pelvic lymph nodes were positive for metastasis in seven cases (23.3%).

CONCLUSIONS

TaLPLND appeared to be beneficial from an oncological point of view because it was close to the upstream lymphatic drainage from the tumor. The short-term outcomes of this initial experience indicate that this novel approach is feasible.

Abstract P5-09-01: Neoadjuvant hormonal therapy plus palbociclib versus hormonal therapy plus placebo in women with operable, hormone sensitive and HER2-negative primary breast cancer

Background: Early biologic response to endocrine therapy, such as changes in Ki67 labeling index (LI), has been suggested to predict long-term outcomes in hormone sensitive breast cancer. The addition of a CDK4/6 inhibitor to endocrine therapy has been shown to augment biological response in breast cancer. Pre-operative Endocrine Prognostic Index (PEPI) scores, generated based on post-treatment Ki67 LI, have been shown to predict patient outcomes. EndoPredict® is a multigene assay that predicts the risk of distant recurrence in patients with operable estrogen receptor (ER)-positive HER2-negative breast cancer. This study was conducted to evaluate the efficacy of the neoadjuvant endocrine therapy plus palbociclib versus neoadjuvant endocrine therapy plus placebo. Patients and Methods: This is a phase III randomized, double-blind study of neoadjuvant hormonal therapy plus palbociclib versus neoadjuvant hormonal therapy plus placebo in untreated pre/peri- and post-menopausal women with operable, hormone receptor-positive (ER and/or progesterone receptor), HER2-negative breast cancer. The other major inclusion criteria included tumor size ≥ 15mm, T1c-3N0-1, Ki67 LI ≥14% by central assessment, and no previous history of radiotherapy or systemic therapy for breast cancer. Patients were randomly assigned 1:1 to receive 16 weeks of hormonal therapy plus palbociclib or hormonal therapy plus placebo. Hormonal therapy consisted of letrozole for post-menopausal patients and tamoxifen plus LH-RH agonist for pre/peri-menopausal patients. The co-primary endpoints included PEPI score and EPclin Risk Score, a score combining EndoPredict® molecular score with clinical factors. These scores were sequentially analyzed on a modified intent-to-treat basis according to the gatekeeping procedure: if statistical significance was detected on the PEPI score, the statistical significance of EPclin Risk Score would be assessed. The sample size was 100 patients in each arm, which was calculated with &lt; 5% type I error rate (two sided) and 80% power. Results: Between 16 July 2019 – 7 July 2021, 141 eligible patients were randomized from 25 participating institutes in Japan, Korea, Taiwan, Hong Kong and Australia. One hundred twenty-six patients completed the treatment duration and surgical samples were collected to evaluate endpoints. All randomized patients were evaluable for safety assessment. Randomization was well-balanced in terms of age, menopausal status and cancer stage. The proportion of patients who had a low, moderate, or high PEPI score was 15.2%, 50.0% and 34.8% in the hormonal therapy plus palbociclib arm and 13.3%, 55.0% and 31.7% in the hormonal therapy plus placebo arm, respectively. There was no statistically significant difference in PEPI score between two arms (one-sided p-value=0.563). The proportion of patients who had a high risk EPclin Risk Score seemed lower in the palbociclib arm than in the placebo arm (62.1% vs 68.3%) although hypothesis testing was not performed on EPclin Risk Score because statistical significance was not detected on the PEPI score. No new safety signals were found in the study. Permanent discontinuation from the study in association with adverse events was reported for 7 (9.7%) patients in the hormonal therapy plus palbociclib arm and for 0 patients in the hormonal therapy plus placebo arm. Conclusions: The addition of palbociclib to neoadjuvant hormonal therapy did not improve efficacy measured by PEPI score. In palbociclib arm, the rate of patients who had a high risk EPclin Risk Score after treatment was lower than in placebo arm. Translational researches are ongoing to analyze molecular changes by treatments. The role of chemotherapy after neoadjuvant therapy is under investigation. Clinical trial identification: NCT03969121 Funding: Pfizer Inc.

Citation Format: Takayuki Ueno, Louis W.C. Chow, Wonshik Han, Chiun Sheng Huang, G Bruce Mann, Satoshi Morita, Hironori Haga, Elham Fakhrejahani, Takayuki Kobayashi, Kenichi Inoue, Mariko Tokiwa, Hirofumi Suwa, Tomoyuki Aruga, Sachiko Minamiguchi, Yosuke Yamada, Yuko Tanabe, Masahiro Takada, Toshinari Yamashita, Hiroji Iwata, Chi-Feng Chung, Sachiko Takahara, Eriko Tokunaga, Shigeru Imoto, Eun Sook Lee, Yasuaki Sagara, Jee Hyun Kim, Richard H DeBoer, Hyun-Ah Kim, Hung Wen Lai, Ming-Feng Hou, Michelle White, Yoshiko Umeyama. Neoadjuvant hormonal therapy plus palbociclib versus hormonal therapy plus placebo in women with operable, hormone sensitive and HER2-negative primary breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-09-01.

Half Dose Pegfilgrastim for Patients With Breast Cancer During Chemotherapy: A Case-series

BACKGROUND/AIM

This study aimed to show the trend of neutrophil counts and frequency of febrile neutropenia after changing pegfilgrastim from 3.6 mg to 1.8 mg.

PATIENTS AND METHODS

This case-series study was performed between April 2016 and December 2021 at Hyogo Prefectural Amagasaki General Medical Center. All patients who reduced their normal dose of 3.6 mg pegfilgrastim to 1.8 mg due to adverse events or markedly elevated neutrophil counts were included. Any type of chemotherapy was acceptable. Patients who dropped out within 1 month of receiving 1.8 mg pegfilgrastim were excluded. The primary outcome was the neutrophil counts after receiving 1.8 mg pegfilgrastim. The secondary outcome was febrile neutropenia, which was evaluated by the Common Terminology Criteria for Adverse Events v5.0.

RESULTS

The study included seven patients who used a regimen of dose-dense epirubicin and cyclophosphamide, trastuzumab, pertuzumab, and docetaxel, docetaxel, or docetaxel and cyclophosphamide. After using 1.8 mg pegfilgrastim, neutrophil counts changed from a mean of 18,944 [standard deviation (SD)=-7,768] to only 4,447 (SD=1,224). The patients experienced grades 1 to 3 adverse events during the use of 1.8 mg and 3.6 mg pegfilgrastim doses, including febrile neutropenia, and pain. Four patients (57%) complained of grade 1 or 2 fatigue and anorexia. After switching from 3.6 mg pegfilgrastim to 1.8 mg, three patients (42%) experienced adverse events.

CONCLUSION

In patients who experienced adverse events due to markedly elevated neutrophil counts with pegfilgrastim, reducing the dose of pegfilgrastim by half may reduce adverse events.

Abstract P2-26-07: Alteration of gut microbiota signatures and its association with diarrhea during abemaciclib treatment: A multicenter prospective cohort study (KBCRN-A002 study)

Background: Abemaciclib is a selective CDK4 and CDK6 inhibitor with demonstrated efficacy in hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer. The most common adverse event across previous trials was early-onset diarrhea, affecting the patients’ quality of life and necessitating dose reductions. However, the exact mechanism for the lower rate of diarrhea in the other CDK4 and CDK6 inhibitors compared with abemaciclib is unknown. Ample evidence indicates that the gut microbiome is a tumor-extrinsic factor associated with the anti-tumor response; however, reported microbial signatures associated with adverse events by anti-cancer agent are inconsistent. To determine the underlying mechanism, we evaluated the correlation between diarrhea with abemaciclib and microbiota signatures in a metastatic breast cancer cohort.

Methods: The KBCRN-A002 study is a multicenter, prospective cohort study, which aims to evaluate the association between gut microbiota signatures and abemaciclib-induced diarrhea in breast cancer patients. Patients with metastatic breast cancer who were receiving abemaciclib were eligible. The primary objective of this study is the correlation between diarrhea and the microbiota signatures and immune profile. Incidence and severity of diarrhea were evaluated by the Bristol stool scale at baseline, from day 1 to day 14, and at day 90 of treatment. Stool samples were collected at baseline and at day 90 after the start of abemaciclib treatment. The gut microbiota signature was evaluated by 16S rRNA analysis. Blood samples were collected at baseline and at days 14 and 90 after starting abemaciclib to evaluate the correlation between the gut microbiota signatures and the systemic immune profile in peripheral blood mononuclear cells (PBMCs). The immune profile was evaluated by mass cytometry, multi-plex cytokines assay, and RNA-sequencing of bulk PBMCs. We characterized the gut microbiota signatures, immune cell composition, immune cell signature, comprehensive cytokines, and severity of diarrhea in all patients.

Results: We analyzed 39 patients, 77 stool samples, and 117 blood samples. In the preplanned interim analysis, among the 39 patients, 90% experienced diarrhea. Depleted gut microbiome α-diversity was positively associated with abemaciclib treatment and the severity of diarrhea. The relative abundances of 10 intestinal bacteria species increased and those of 18 intestinal bacteria decreased significantly after abemaciclib treatment, including bacteria known to be involved in diarrhea severity and anti-tumor immunity, such as Faecalibacterium (Table). The immune cell and cytokine profiles in PBMCs were also associated with the gut microbiota signatures.

Conclusions: Gut microbiota signatures are associated with abemaciclib-induced diarrhea and the immune profile in metastatic breast cancer patients. These findings can help to elucidate the mechanism of diarrhea caused by abemaciclib and offer strategies for its management and prevention.

Intestinal Microbiota Altered by Abemaciclib

Citation Format: Kosuke Kawaguchi, Yurina Maeshima, Hiroshi Ishiguro, Kazuhiko Yamagami, Sachiko Takahara, Hirofumi Suwa, Masae Torii, Shigenori Nagai, Yasuaki Sagara, Wakako Tsuji, Hiroyasu Yamashiro, Takeshi Kotake, Shinji Fukuda, Kuniaki Saito, Yasuko Yamamoto, Masako Kataoka, Yuki Himoto, Atsushi Yonezawa, Yukiko Fukui, Yuki Nakamura, Wei Li, Sunao Tanaka, Satoshi Morita, Masakazu Toi. Alteration of gut microbiota signatures and its association with diarrhea during abemaciclib treatment: A multicenter prospective cohort study (KBCRN-A002 study) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-26-07.

Abstract P2-05-02: Potential Empowerment and risk of Genetic Counseling with Genetic Breast cancer risk assessment in Personalized Health Care: Prospective Cohort Study using Genetic Counseling Outcome Scale (GCOS-24)

[Introduction] Personalized health care is recommended for the prevention and early detection of breast cancer. Advances in technology have made it possible to estimate genetic risk, PGV (pathogenic/likely-pathogenic germline variant) or PRS (polygenic risk score), in practice. However, linkage after risk assessment to personalized health care is still developing. One of the issues is how to tell the result especially in case of newly diagnosed PGV after Genetic Panel Testing or PRS. In this study, we evaluated genetic counseling (GC) using an established patient-reported outcome measure for clinical genetics services scale (Genetic Counseling Outcome Scale24 (GCOS24)) at genetic counseling for disclosure the results of the previous study, and examined the association with management after GC. [Method] We performed targeted sequencing for 11 breast cancer-related genes using peripheral blood DNA from 1995 female breast cancer patients. Of 1995 cases, 101 patients were PGV carriers, who were candidates of this study. Participants were referred to the Clinical Genetics unit, Kyoto University Hospital from 10 institutions (January 2018-March 2022). GCOS24 and relating questionaries were asked before and after GC. GCOS24 is a scale consisting of 24 items that assess five factors: decision control, cognitive control, behavioral control, emotional regulation, and hope. (In light of the current status of hereditary breast cancer care in Japan, 23 items were used.) Each item is rated on a scale of 1-7 points, for a total score of 23-161. In addition, we reviewed medical records to evaluate the post-GC management. [Results] Of the 101 cases, 38 cases were enrolled. The reasons of 63 not-enrolled cases were: 30 cases without follow-up (deaths or transfer to another hospital), 11 cases already diagnosed in clinical practice, 18 cases that did not wish to know their results, and 4 cases whose hospital were developing for hereditary breast cancer care. Median age at the time of genetic GC was 55 (min-max 30-83) years. Details of PGV cases were: BRCA2 23 cases, BRCA1 2, PALB2 4, PTEN 3, TP53 3, ATM 1, CHEK2 1 and NF1 1. GCOS24 after GC were improved than before GC. (Average 99 (min-max 17-124) vs 114 (91-138), Mean difference 23.9, 95% Confidence intervals (CI) 29.6 to 18.3). Thirty patients (79%) had higher increase in scores than 10.3, which was the previously reported Minimum Clinically Important Difference (MCID) of this scale. In all items except 4 items (#6,11,13,21), GCOS24 after GC were significantly improved than before GC. In post-GC management, 8 patients received or planned RRSO (risk reducing salpingo-oophorectomy) among 25 BRCA1/2 cases. There was a case with dysplastic cells detected in the resected ovary. After GC, average of GCOS24 in RRSO cases was 120 (95% CI 110 to 129), while average of GCOS24 of other BRCA1/2 cases was 110 (95% CI 104 to 116). On the other hand, two patients stopped visiting to the hospital because of fear after GC. Average of GCOS24 of 15 junior-high/high school graduate cases were 111 (95% CI 105 to 117), while average of GCOS24 of 23 college graduate cases were 117 (95% CI 111 to 122). [Discussion] In patients diagnosed with hereditary breast cancer by genetic panel testing, GC worked well except for 4 items. These 4 items (#6,11,13,21) were related to emotion. This study revealed there was also a risk to reject surveillance due to fear, suggesting that it is necessary to provide psychological support in some cases. Although the limitation of this study is the small number of cases, GCOS24 were high in RRSO cases, suggesting that GC played an important role when proceeding with intervention. We believe that the findings are helpful for the future implementation of genetic panel testing or PRS testing in healthy subjects for personalized health care.

Citation Format: Nobuko Kawaguchi-Sakita, Noriko Senda, Yukiko Inagaki-Kawata, Hiromi Murakami, Sayaka Honda, Takahiro Yamada, Yuki Kataoka, Shoko Takahara, Shigeru Tsuyuki, Kazuhiko Yamagami, Yoshio Moriguchi, Masae Torii, Tatsushi Kato, Hirofumi Suwa, Wakako Tsuji, Eiji Suzuki, Akira Yamauchi, Ryuji Okamura, Shinji Kosugi, Masakazu Toi. Potential Empowerment and risk of Genetic Counseling with Genetic Breast cancer risk assessment in Personalized Health Care: Prospective Cohort Study using Genetic Counseling Outcome Scale (GCOS-24) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-05-02.

Promoters of BRCA testing under insurance coverage for non-metastatic breast cancer patients in Japan: a retrospective cohort study

BACKGROUND

We investigated the barriers to and promoters of taking BRCA testing, after the start of national healthcare insurance coverage for non-metastatic breast cancer patients in Japan.

PATIENTS AND METHODS

This was a multi-center, retrospective, cohort study. We included stage 0 to III breast cancer patients who were diagnosed and met the criteria for insurance coverage of BRCA testing between April 2020 and December 2021. We examined the association between BRCA testing and possible exposures: breast cancer diagnosis at 45 years or younger, triple-negative breast cancer (TNBC) diagnosis at the age of 60 or younger, two or more primary breast cancers, family history of breast cancer or ovarian cancer in the third degree of relatives, male breast cancer, medical expense limits, and parity. We used logistic regression analysis.

RESULTS

We included 222 patients and 123 (55.4%) of them underwent the test. In univariate analysis, a family history of ovarian cancer (odds ratio (OR) 10.59; 95% CI 1.35-82.96, p = 0.025), diagnosis of breast cancer at the age of 45 or younger (OR 2.78; 95% CI 1.52-5.14, p = 0.0009), and diagnosis of TNBC at the age of 60 or younger (OR 3.95; 95% CI 1.55-10.07, p = 0.004) were associated with taking the test. After multivariate logistic regression analysis, a family history of ovarian cancer (adjusted OR 12.80; 95% CI 1.51-108.80, p = 0.0195), diagnosis of breast cancer at the age of 45 or younger (adjusted OR 4.43; 95% CI 1.98-9.90, p = 0.0003), and TNBC at the age of 60 or younger (adjusted OR 5.28; 95% CI 1.90-14.66, p = 0.0014) were consistently associated.

CONCLUSION

For non-metastatic breast cancer patients whose BRCA testing is covered by insurance, costs would no longer be a definite barrier. Physicians should keep in mind that a family history of ovarian cancer, breast cancer diagnosis at 45 years of age or younger and TNBC diagnosis at 60 years of age or younger are strong promoters.

Phase Ib/II study of nivolumab combined with palliative radiation therapy for bone metastasis in patients with HER2-negative metastatic breast cancer

Radiation therapy (RT) can enhance the abscopal effect of immune checkpoint blockade. This phase I/II study investigated the efficacy and safety of nivolumab plus RT in HER2-negative metastatic breast cancer requiring palliative RT for bone metastases. Cohort A included luminal-like disease, and cohort B included both luminal-like and triple-negative disease refractory to standard systemic therapy. Patients received 8 Gy single fraction RT for bone metastasis on day 0. Nivolumab was administered on day 1 for each 14-day cycle. In cohort A, endocrine therapy was administered. The primary endpoint was the objective response rate (ORR) of the unirradiated lesions. Cohorts A and B consisted of 18 and 10 patients, respectively. The ORR was 11% (90% CI 4-29%) in cohort A and 0% in cohort B. Disease control rates were 39% (90% CI 23-58%) and 0%. Median progression-free survival was 4.1 months (95% CI 2.1-6.1 months) and 2.0 months (95% CI 1.2-3.7 months). One patient in cohort B experienced a grade 3 adverse event. Palliative RT combined with nivolumab was safe and showed modest anti-tumor activity in cohort A. Further investigations to enhance the anti-tumor effect of endocrine therapy combined with RT plus immune checkpoint blockade are warranted.Trial registration number and date of registration UMIN: UMIN000026046, February 8, 2017; ClinicalTrials.gov: NCT03430479, February 13, 2018; Date of the first registration: June 22, 2017.

VARIATION IN RADIATION DOSE RATES FROM RADIONUCLIDES DISCHARGED BY THE SPENT NUCLEAR FUEL REPROCESSING PLANT IN ROKKASHO UNDER DIFFERENT YEARLY WEATHER CONDITIONS

The radiation dose rate from radionuclides released by the spent nuclear fuel reprocessing plant in Rokkasho, Japan, was assessed for a year specified in the safety review during which the weather conditions were not significantly different from those of the other 10 y. However, the actual year-by-year variation in annual radiation dose rate was not examined. A model system for evaluating the dose rate from the radionuclides released into the atmosphere was constructed. In this study, the radiation dose rate in the weather conditions of 24 weather bins was estimated for a standard year by the model. The annual maximum dose rate from 1959 to 2012 was estimated using a simplified method that integrated the dose rates of each weather bin in the standard year by estimating the annual frequency of the bin in the target year. We obtained ~1.3 as the maximum/minimum ratio of the annual maximum dose rate.

Effectiveness of eribulin as first-line or second-line chemotherapy for HER2-negative hormone-resistant advanced or metastatic breast cancer: findings from the multi-institutional, prospective, observational KBCRN A001: E-SPEC study

BACKGROUND

The optimal positioning of eribulin treatment remains unclear. This study aimed to investigate the effectiveness of eribulin administration as first- and second-line chemotherapy in patients with endocrine-resistant advanced or metastatic breast cancer (AMBC) in the real-world clinical setting.

METHODS

This multi-institutional prospective cohort study enrolled patients with triple-negative AMBC or estrogen receptor-positive AMBC refractory to at least one previous endocrine therapy. The overall survival (OS) from the start of first-line (OS1) and second-line chemotherapy (OS2) was assessed. Data analysis included real-world chemotherapy sequences of first- to third-line chemotherapy regimens. The adjusted hazard ratio (HR) with 95% confidence interval (CI) for treatment regimen comparison was calculated using a stratified proportional hazards model.

RESULTS

Among 201 patients enrolled, 180 were included in the final analysis. Eribulin was administered as first- and second-line chemotherapy to 46 (26.6%) and 70 (47.9%) patients, respectively. Median OS1 and OS2 were 2.25 (95% CI 1.07-2.68) and 1.75 (95% CI, 1.28-2.45) years for first- and second-line eribulin, respectively. Oral 5-FU followed by eribulin had a numerically longer OS1 (2.84 years) than the other sequences. Among patients who proceeded to second-line or later chemotherapy, the median OS1 for those treated with anthracycline or taxane as first- or second-line (n = 98) was 2.56 years (95% CI 2.27-2.74), while it was 2.87 years (95% CI 2.20-4.32) for those who avoided anthracycline and taxane as first- and second-line (n = 48) (adjusted HR, 1.20; 95% CI 0.70-2.06). In the exploratory analysis, OS1 was 2.55 (95% CI 2.14-2.75) and 2.91 years (95% CI 2.61-4.32) for those aged < 65 and ≥ 65 years, respectively (adjusted HR of ≥ 65, 0.91; 95% CI 0.56-1.46).

CONCLUSIONS

Eribulin or oral 5-FU administration in first- and second-line chemotherapy without anthracycline/taxane was acceptable in the real-world setting.

TRIAL REGISTRATION

This study is registered with Clinical Trials.gov (NCT 02,551,263).

Optimization of prediction methods for risk assessment of pathogenic germline variants in the Japanese population

Predicting pathogenic germline variants (PGVs) in breast cancer patients is important for selecting optimal therapeutics and implementing risk reduction strategies. However, PGV risk factors and the performance of prediction methods in the Japanese population remain unclear. We investigated clinicopathological risk factors using the Tyrer‐Cuzick (TC) breast cancer risk evaluation tool to predict BRCA PGVs in unselected Japanese breast cancer patients (n = 1,995). Eleven breast cancer susceptibility genes were analyzed using target‐capture sequencing in a previous study; the PGV prevalence in BRCA1, BRCA2, and PALB2 was 0.75%, 3.1%, and 0.45%, respectively. Significant associations were found between the presence of BRCA PGVs and early disease onset, number of familial cancer cases (up to third‐degree relatives), triple‐negative breast cancer patients under the age of 60, and ovarian cancer history (all P < .0001). In total, 816 patients (40.9%) satisfied the National Comprehensive Cancer Network (NCCN) guidelines for recommending multigene testing. The sensitivity and specificity of the NCCN criteria for discriminating PGV carriers from noncarriers were 71.3% and 60.7%, respectively. The TC model showed good discrimination for predicting BRCA PGVs (area under the curve, 0.75; 95% confidence interval, 0.69‐0.81). Furthermore, use of the TC model with an optimized cutoff of TC score ≥0.16% in addition to the NCCN guidelines improved the predictive efficiency for high‐risk groups (sensitivity, 77.2%; specificity, 54.8%; about 11 genes). Given the influence of ethnic differences on prediction, we consider that further studies are warranted to elucidate the role of environmental and genetic factors for realizing precise prediction.

Investigation of a Novel S-1 Administration Schedule for Treating Metastatic and Recurrent Breast Cancer (KBCOG13)

BACKGROUND/AIM

S-1, a 5-fluorouracil(5-FU) oral anti-cancer drug, has been traditionally used with a schedule of 4-week oral administration followed by 2-week rest for breast cancer treatment. We, herein, aimed to investigate the clinical efficacy and safety of a schedule of 2-week oral administration followed by 1-week rest for patients with metastatic breast cancer.

PATIENTS AND METHODS

We enrolled patients with HER2-negative metastatic breast cancer who had not received prior chemotherapy. S-1 was administered consecutively for 2-weeks followed by a 1-week rest.

RESULTS

Between September 1, 2013 and August 31, 2016, 32 patients were enrolled. The median follow-up time was 32.1 months. The median progression-free survival (PFS) was 9.4 months. Overall survival (OS) was 41.0 months, time to treatment failure (TTF) was 7.8 months, response rate (RR) was 31.3%, and disease control rate (DCR) was 78.1%. The incidence of grade 3 side-effects was not high.

CONCLUSION

The 3-week schedule of S-1 can be considered useful as a treatment for patients with metastatic breast cancer, helping in maintaining a high quality of life.

Abstract PS13-31: Prospective observational study to explore the effectiveness of eribulin as first- or second- line chemotherapy in patients with HER2-negative hormone-resistant advanced or metastatic breast cancer (KBCRN A001: E-SPEC study)

BackgroundEribulin (E) is a chemotherapeutic drug that prolongs overall survival (OS) of patients with HER2-negative advanced or metastatic breast cancer (AMBC), mainly in multi-line chemotherapy (ChT) or later. However, the effectiveness and optimal scheduling of E remain unclear. We prospectively investigated the impact of E use in 1st- and 2nd-line ChT (early E) for patients with endocrine-resistant AMBC.

Methods In this multi-institutional prospective cohort study, we registered patients with hormone receptor-positive AMBC who relapsed during or within 6 months after ending adjuvant endocrine therapy, were refractory to at least one previous endocrine therapy, or patients with triple negative AMBC. The endpoints were 1st-line OS (OS1), 2nd-line OS (OS2), and 3rd-line OS (OS3), defined as the time from the start of treatment to death. In addition, the time from the start of 1st-line ChT to death was also analyzed for 2nd-line and 3rd-line ChT groups. In addition to E therapy, oral FU-based therapies (FU) and anthracycline or taxane-based therapies (A/T) were also analyzed (ClinicalTrial.gov number, NCT02551263).

Results Between June 2015 and July 2017, a total of 201 patients were enrolled, and full analysis was conducted for 180 patients. The median OS1, OS2, and OS3 of all patients was 2.69, 1.74, and 1.13 years, respectively. Major patient characteristics are described in the Table. Concurrent or maintenance endocrine therapy was used by 14.9%, 31.6%, and 12.9% of patients receiving E, FU and A/T in 1st-line ChT, respectively. The median OS of patients using E was OS1: 2.25 years (N=47), OS2: 1.75 years (N=70) and OS3: 0.94 years (N=16). The median OS of patients using A/T was OS1: 2.60 years (N=70), OS2: 1.69 years (N=44) and OS3: 0.96 years (N=49). The median OS of patients using FU was OS1: 3.49 years (N=57), OS2: 2.33 years (N=27), and OS3: 1.45 years (N=24). The time from the start of 1st-line ChT to death was 2.58 and 3.18 years among patients who received E in 2nd- and 3rd-line ChT, respectively. Multivariate analysis of patients who used 1st-line and 2nd-line E demonstrated that higher LDH (≥300) (HR 3.50, 95% CI 1.78-6.73; p&lt;0.001), brain metastasis (HR 2.64, 95% CI 1.02-6.83; p=0.045) and smoker (HR 2.33, 95% CI 1.20-4.53; p=0.013) were associated with shorter OS. Overall, OS data for E were comparable to those for A/T. While OS tended to be better for FU, patient characteristics for 1st-line ChT showed that FU was often used for patients with less aggressive AMBC. We also present data on second progression-free survival and new metastasis-free survival, prognostic factor analysis and prognostic factor-adjusted comparison, and predictive factor analysis for early E.

Conclusions This prospective observational study of AMBC patients showed that E and A/T had similar survival outcomes in each treatment line. While FU led to relatively longer survival, it was often used for patients with less aggressive AMBC. Analysis data on survival outcomes will also be presented.

Patient characteristics according to 1st-line therapyE (n=47)Oral FU based (n=57)A/T based (n=70)Median age (IQR)61(54-71)64(51-68)59(48-66)Triple negative, n (%)15(31.9)11(19.3)23(32.9)Disease-free interval, n (%)&lt;2 years15(31.9)9(15.8)12(17.1)2-5 years12(25.5)18(31.6)15(21.4)5-8 years4(8.5)9(15.8)9(12.9)&gt;8years3(6.4)10(17.5)8(11.4)Stage49(19.1)9(15.8)23(32.9)(neo) Adjuvant chemotherapy, n (%)30(63.8)36(63.2)32(45.7)Metastatic sites at 1st-line ChT, n (%)Liver16(34.0)12(21.1)22(31.4)Lung15(31.9)17(29.8)25(35.7)Bone24(51.1)27(47.3)36(51.4)Brain6(12.8)1(1.8)2(2.9)

Citation Format: Yuri Fujimoto, Yuichiro Kikawa, Takeshi Kotake, Shigeru Tsuyuki, Sachiko Takahara, Hiroyasu Yamashiro, Hiroshi Yoshibayashi, Masahiro Takada, Rie Yasuoka, Kazuhiko Yamagami, Hirofumi Suwa, Toshitaka Okuno, Ichiro Nakayama, Tatsuji Kato, Nobuko Ogura, Yoshio Moriguchi, Hiroshi Ishiguro, Tatsuo Kagimura, Tetsuya Taguchi, Tomoharu Sugie, Masakazu Toi. Prospective observational study to explore the effectiveness of eribulin as first- or second- line chemotherapy in patients with HER2-negative hormone-resistant advanced or metastatic breast cancer (KBCRN A001: E-SPEC study) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-31.

Real-World Outcomes of Treating Advanced Breast Cancer Patients With Palbociclib: A Multicenter Retrospective Cohort Study in Japan-The KBCOG-14 Study

Background

Clinical studies have shown that palbociclib improves progression-free survival in hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) patients with advanced breast cancer (ABC). However, there are insufficient data on its use in a real-world setting in Japan. The aim of this study was to investigate the effectiveness, predictive factors, and safety of palbociclib among Japanese patients in routine clinical practice.

Methods

Between December 1, 2017, and April 30, 2019, we recruited patients from 9 hospitals and retrospectively evaluated the data on HR+/HER2- patients with ABC who received palbociclib for at least 1 week. The correlation between time-to-treatment discontinuation (TTD) and clinical background was investigated via univariate and multivariate analyses using Cox hazards models.

Results

A total of 177 women were available for analysis. Of these patients, 58 (33%) patients were treated with palbociclib with an aromatase inhibitor and 117 (66%) patients were treated with palbociclib and a selective estrogen receptor degrader. Approximately three-fourths of the patients (n = 130, 73%) received palbociclib as third- or later-line therapy. One-third of the patients had 3 or more metastatic sites (n = 59, 33%), and one-third of the patients had liver metastasis (n = 59, 33%). The median follow-up duration at the time of data cutoff was 8.9 months, the median TTD was 6.3 months, and the median overall survival was not reached. Liver metastasis (hazard ratio [HR]: 1.54 [95% confidence interval {CI}: 1.03-2.27]), high serum lactate dehydrogenase (LDH) level (>300 U/L) (HR: 2.58 [95% CI: 1.49-4.26]), and high neutrophil-to-lymphocyte ratio (NLR) (⩾3.0) (HR: 1.76 [95% CI: 1.13-2.69]) were significantly associated with shorter TTD. The most common hematologic adverse event was neutropenia, which occurred in 93% of the patients.

Conclusion

Based on the results of the pivotal phase 3 trials, the median TTD recorded in this study was shorter than expected. Our results suggest that liver metastasis, serum LDH level, and NLR may be predictive factors for HR+/HER2- ABC treatment outcomes.

Genetic and clinical landscape of breast cancers with germline BRCA1/2 variants

The genetic and clinical characteristics of breast tumors with germline variants, including their association with biallelic inactivation through loss-of-heterozygosity (LOH) and second somatic mutations, remain elusive. We analyzed germline variants of 11 breast cancer susceptibility genes for 1,995 Japanese breast cancer patients, and identified 101 (5.1%) pathogenic variants, including 62 BRCA2 and 15 BRCA1 mutations. Genetic analysis of 64 BRCA1/2-mutated tumors including TCGA dataset tumors, revealed an association of biallelic inactivation with more extensive deletions, copy neutral LOH, gain with LOH and younger onset. Strikingly, TP53 and RB1 mutations were frequently observed in BRCA1- (94%) and BRCA2- (9.7%) mutated tumors with biallelic inactivation. Inactivation of TP53 and RB1 together with BRCA1 and BRCA2, respectively, involved LOH of chromosomes 17 and 13. Notably, BRCA1/2 tumors without biallelic inactivation were indistinguishable from those without germline variants. Our study highlights the heterogeneity and unique clonal selection pattern in breast cancers with germline variants.

Yukiko Inagaki-Kawata et al. report an analysis of germline variants in breast cancer susceptibility genes in 1,995 Japanese breast cancer patients. They find that 5.1% of the patients carry germline variants in cancer-linked genes and investigate the characteristics of patients with germline mutations in BRCA1/2.

Predicting the efficacy of nivolumab combined with radiation therapy by longitudinal liquid biopsy with artificial intelligence for patients with metastatic breast cancer (translational research of the KBCRN-B-002 trial)

e15046

Background: Advances in immuno-oncology (IO), i.e., programmed cell-death protein 1 (PD-1) inhibitors, are revolutionizing cancer treatment by offering hope for a cure. However, the benefit of IO agents in metastatic breast cancer (MBC) remains limited. For immunotherapy to be successful, it is essential to understand the tumor immune contexture. Systemic immune alterations, such as the signature of peripheral blood mononuclear cells (PBMC) and cytokine expression, are one of the hallmarks of successful immunotherapy in MBC. The abscopal effect induced by radiation therapy (RT) is known to be a modulator of systemic immune alterations, and the abscopal effect is considered as a systemic anti-tumor immune response. In this study, we integrated time series multi-omics data in order to identify alteration of the immune signatures after RT combined with nivolumab, a PD-1 inhibitor, using a longitudinal liquid biopsy with artificial intelligence. Methods: This study was conducted as translational research, part of the KBCRN-B-002 trial, which is a multicenter phase Ib/II study evaluating the safety and efficacy of nivolumab in combination with RT in patients with HER2-negative MBC (UMIN: UMIN000026046). Twenty-nine patients were included in the translational analysis set. The multi-omics data included data from RNAseq, mass cytometry (CyTOF) and multiple cytokines, using PBMC, serum and plasma. We collected time series data, which covered the baseline, two weeks after starting therapy, four weeks after starting therapy and the timing of progressive disease. For integrated analysis of the multi-omics data, a machine-learning method was developed. Results: Our integrated analysis (involving a longitudinal liquid biopsy and machine-learning method) identified an apparent cluster of responder groups and alteration of the systemic immune signatures. Single-cell analysis using CyTOF results including the signature of the immune cell composition, effector immune cells and immune suppressor cells. Conclusions: Our method clustered responders well and identified candidates of the systemic immune signatures for actionable hallmarks of RT combined with IO agent by a longitudinal liquid biopsy. Clinical trial information: NCT03430479 .

Abstract P4-10-33: Alteration of the tumor immune microenvironment signatures by nivolumab combined with radiation therapy for patients with metastatic breast cancer (Translational Research of the KBCRN-B-002 trial)

BACKGROUND: Advances in imuuno-oncology (IO), i.e., a programmed cell death protein 1 (PD-1) inhibitors are revolutionizing cancer treatment by offering hope for a cure. However, the benefit of IO agents in metastatic breast cancer (MBC) is still limited. For immunotherapy to be successful, it is essential to understand the tumor immune contexture. Tumor immune microenvironment (TIME) alterations, such as increased effector-cell composition, inflamed immune cells, and the activated effector immune cells create conditions that enhance immunotherapy in MBC. The abscopal effect induced by Radiation therapy (RT) is known as a modulator of TIME. Then, abscopal effect is considered to be a systemic anti-tumor immune response. In this study, we integrated time series multi-omics data to identify alteration of the TIME signatures with RT combined with N\nivolumab, a PD-1 inhibitor, using a machine learning method.

PATIENTS AND METHODS: This study was conducted as a translational research of the KBCRN-B-002 trial, which is a multicenter phase Ib/II study for evaluating the safety and efficacy of nivolumab in combination with RT in patients with HER2-negative MBC (Takada M et al. will make presentation the main results of the study. (UMIN: UMIN000026046; ClinicalTrials.gov: NCT03430479)). Twenty-nine patients were included in the translational analysis set. The multi-omics data included data from RNAseq, DNAseq, mass cytometry (CyTOF), multiple cytokines, human leukocyte antigen, radiomics, drug concentrations, tuberculin reaction using peripheral blood mononuclear cells (PBMCs), serum, plasma, imaging, and Formalin-Fixed Paraffin-Embedded (FFPE) samples. We collected time series data, which included data for the baseline, two weeks after starting therapy, four weeks after starting therapy, and the timing of progressive disease. For the integrated analysis, a unique machine learning method was developed.

RESULTS: Our integrated analysis identified the alteration of the tumor immune microenvironment signatures using nivolumab combined with RT for MBC. These results included the signature of the immune cell composition, effector immune cells, and immune suppressor cells, via single-cell analysis using CyTOF. The types of analysis are given in the table.

CONCLUSIONS: We identified candidates for TIME signatures for actionable hallmarks of RT combined with IO agent by our machine learning method.

Type of AnalysisSampleTime PointBaseline2 Weeks4 WeeksProgressive DiseaseRNAseqFFPE✓RNAseqPBMCs✓✓✓✓DNAseqFFPE✓CyTOFPBMCs✓✓✓✓CytokinesSerum✓✓✓✓Nivolumab ConcentrationSerum✓✓✓✓TILsFFPE✓HLAPBMCs✓Tuberculin ReactionSkin✓

Citation Format: Kosuke Kawaguchi, Masahiro Takada, Takeshi Kotake, Michio Yoshimura, Ryuji Uozumi, Masako Kataoka, Takahiko Koyama, Reitaro Tokumasu, Maya Honda, Rikiya Yamashita, Atsushi Yonezawa, Yuki Himoto, Natsuko Onishi, Hironori Kato, Hiroshi Yoshibayashi, Hirofumi Suwa, Wakako Tsuji, Hiroyasu Yamashiro, Tatsuki Kataoka, Hiroshi Ishiguro, Laxmi Parida, Satoshi Morita, Masakazu Toi. Alteration of the tumor immune microenvironment signatures by nivolumab combined with radiation therapy for patients with metastatic breast cancer (Translational Research of the KBCRN-B-002 trial) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-10-33.

Abstract P2-10-12: Relationship between predicted risks of carrying breast cancer susceptibility genes and the presence of germline variants in Japanese patients with primary breast cancer

Background: Breast cancer risk models are used to predict the risk of carrying a variant, for one of the most common breast cancer susceptibility genes such as BRCA1 and BRCA2, and the lifetime risk of developing breast cancer. The prediction of harboring a germline variant of the BRCA gene and the development of breast or ovarian cancer over time affects the decision-making for undergoing genetic testing and screening using imaging techniques as the common practice. For instance, the American Cancer Society and the National Comprehensive Cancer Network (NCCN) recommends screening using MRI in women with 20% or greater lifetime risk of having breast cancer. We aimed to investigate the prediction of these risks in Japanese women, particularly on the relationship between the presence of pathogenic germline variants and breast cancer susceptibility genes, using a cohort of 1016 primary breast cancer patients.

Patients and Methods: We analyzed a cohort of Japanese patients with primary breast cancer who were treated at the Kyoto University Hospital and the related institutions or hospitals from the period of 2011 to 2016. The germline variants were examined for a set of 13 breast cancer susceptibility genes, using targeted-capture sequencing of pooled DNA, and it was found that 66 out of 1016 patients had pathogenic variants. These included 11 functionally well-established genes (BRCA1, BRCA2, TP53, PTEN, CDH1, STK11, NF1, PALB2, ATM, CHEK2, and NBN) and two additional genes (BARD1 and BRIP1), which are recommended for the screening of high-risk patients with hereditary breast cancer in the NCCN guidelines. Using this cohort, we studied the association of the calculated risk of carrying a germline variant of BRCA1/ BRCA2, using the Tyrer-Cuzick model Breast Cancer Risk Evaluation Tool, within the laboratory germline test results.

Results: Pathogenic germline variants of BRCA1/ BRCA2 were carried by 54 (5.3%) out of the 1016 patients (12 cases of BRCA1 and 42 cases of BRCA2). According to the NCCN guidelines, which focus on Genetic/ Familial High-Risk Assessment: Breast and Ovarian, it was found that 500 out of 1016 (49.2%)patients were categorized for considering germline testing. In fact, 38 (7.6%) of the 500 patients, harbored a pathogenic germline variant of BRCA1/ BRCA2. In the remaining 516 patients, 16 (3.1%) harbored the pathogenic germline variant of BRCA1/ BRCA2. The predictive risks of the Tyrer-Cuzick model Breast Cancer Risk Evaluation Tool were recorded as follows: Area under the ROC curve, BRCA1 (area 0.750, 95% CI- 0.581-0.919), BRCA2 (area 0.741, 95% CI- 0.661-0.820), BRCA1 or BRCA2 (Area 0.749, 95% CI: 0.675-0.822), suggesting that the Tyrer-Cuzick model may be useful for the Japanese population. In the mammography breast density analysis, 484 patients showed almost entirely fat or scattered fibroglandular breast tissue, and 362 cases had heterogeneous or extreme fibroglandular breast tissue. In this study, the correlations of breast tissue density with age and breast or ovarian cancer familial history have been reported in greater detail.

Discussion and Conclusions: In a retrospective cohort of 1016 Japanese patients with primary breast cancer, 5.3% had pathogenic germline variants of BRCA1/ BRCA2. In a group recommended by NCCN guidelines for considering genetic testing, the BRCA1/ BRCA2 variant rate was 7.6%. Predictive risks calculated by the Tyrer-Cuzick model similar with the known data. Further data are reported.

Citation Format: Noriko Senda, Nobuko Kawaguchi-Sakita, Masahiro Kawashima, Yukiko Inagaki-Kawata, Kenichi Yoshida, Tomomi Nishimura, Masahiro Takada, Eiji Suzuki, Yuki Kataoka, Fumiaki Sato, Yoshiaki Matsumoto, Masae Torii, Hiroshi Yoshibayashi, Kazuhiro Yamagami, Shigeru Tsuyuki, Akira Yamauchi, Nobuhiko Shinkura, Hironori Kato, Yoshio Moriguchi, Ryuji Okamura, Norimichi Kan, Hirofumi Suwa, Shingo Sakata, Susumu Mashima, Fumiaki Yotsumoto, Tsuyoshi Tachibana, Mitsuru Tanaka, Takashi Inamoto, Masahiro Sugimoto, Seishi Ogawa, Masakazu Toi. Relationship between predicted risks of carrying breast cancer susceptibility genes and the presence of germline variants in Japanese patients with primary breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-10-12.

Abstract P5-12-07: Influence of aromatase inhibitor-related adverse events on the prognosis in postmenopausal Japanese patients with breast cancer: A prospective multicenter cohort study on patient-reported outcomes

Background Five-year adjuvant treatment with aromatase inhibitors is a standard treatment for postmenopausal women with estrogen receptor-positive breast cancer. However, aromatase inhibitor-related adverse events, including joint and vasomotor symptoms, have a strong impact on patient quality of life and sometimes cause the discontinuation of treatment. The aim of this prospective cohort study based on patient-reported outcomes (PROs) was to examine the influence of adverse events on prognosis in Japanese postmenopausal patients with breast cancer treated with adjuvant anastrozole. Patients and Methods A total of 391 postmenopausal Japanese women with estrogen receptor-positive breast cancer who were treated with adjuvant anastrozole were enrolled from 28 centers in this prospective cohort study (SAVS-JP, UMIN000002455). PRO assessments of adverse events, which included joint and vasomotor symptoms, were obtained at baseline and 3, 6, 9, and 12 months. Symptoms were assessed and assigned to one of four categories: none (G0), mild (G1), moderate (G2), and severe (G3). The questionnaires covered joint symptoms (arthralgia, decrease in range of joint motion, and joint stiffness), vasomotor symptoms (hot flashes, night sweats, and cold sweats), and adherence to anastrozole. The median follow-up was 82 months, and we analyzed the prognosis in patients, focusing on the occurrence of joint and vasomotor symptoms induced by treatment. Results Of the 391 patients, 204 (52.2%) completed 5-year treatment, 75 (19.2%) discontinued (adverse events (n=35), recurrence (n=19), secondary malignancies (n=4), death from non-breast cancer (n=4), and other reasons (n=13)), 48 (12.3%) are receiving treatment, and 64 (16.4%) were unknown. Patients who experienced G2+3 joint symptoms had significantly better disease-free survival (DFS) compared with patients with G0+1 joint symptoms (5-year DFS, 96.1% vs. 83.3%, p=0.002). Similarly, the DFS in patients with G2+3 vasomotor symptoms was significantly better than that in those with G0+1 vasomotor symptoms (5-year DFS, 93.5% vs. 86.3%, p=0.049). Joint symptoms were marginally associated with overall survival (OS) (p=0.062), but no significant association was found with vasomotor symptoms. The DFS was superior in patients with G2+3 joint and vasomotor symptoms (5-year DFS, 100%), inferior in those with G0+1 joint and vasomotor symptoms (5-year DFS, 82.6%), and intermediate in others (5-year DFS, 93.3%; p=0.0024). By multivariable analysis including tumor size and grade, G2+3 joint symptoms were a significant and independent predictive factor for DFS (hazard ratio, 0.298, 95% confidence interval 0.122-0.621, p=0.0007). Conclusion Although adverse events might make patients uncomfortable and reduce their quality of life, it is suggested that worse or new vasomotor symptoms and severe joint symptoms, especially if they are grade 2 or 3, seem to associate with better prognosis.

Citation Format: Chiyomi Egawa, Shintaro Takao, Kazuhiro Yamagami, Masaru Miyashita, Masashi Baba, Shigetoshi Ichii, Muneharu Konishi, Yuichiro Kikawa, Junya Minohata, Toshitaka Okuno, Keisuke Miyauchi, Kazuyuki Wakita, Hirofumi Suwa, Takashi Hashimoto, Masayuki Nishino, Takashi Matsumoto, Toshiharu Hidaka, Yutaka Konishi, Yoko Sakoda, Akihiro Miya, Masahiro Kishimoto, Hidefumi Nishikawa, Seishi Kono, Ikuo Kokufu, Isao Sakita, Koushiro Kitatsuji, Koushi Oh, Yasuo Miyoshi. Influence of aromatase inhibitor-related adverse events on the prognosis in postmenopausal Japanese patients with breast cancer: A prospective multicenter cohort study on patient-reported outcomes [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-12-07.

Abstract P3-09-07: A multicenter phase Ib/II study for evaluating safety and efficacy of Nivolumab in combination with radiation therapy in patients with HER2-negative metastatic breast cancer (KBCRN-B-002 trial)

BACKGROUND: In metastatic breast cancer, Overall Response Rate (ORR) for checkpoint inhibitor monotherapy has been limited. Since Radiation Therapy (RT) stimulates anti-cancer immune responses, we evaluated safety and efficacy of a combinatorial therapy of RT with Nivolumab (a Programmed cell death protein 1 (PD-1) inhibitor) on HER2-negative metastatic breast cancer patients in a multicenter and non-randomized phase Ib/II study. PATIENTS AND METHODS: Patients with HER2-negative breast cancer, measurable metastasis (RECIST1.1) and at least one bone metastasis requiring radiation therapy were enrolled. The patients were divided into two cohorts, A and B. Cohort A constitutes estrogen and/or progesterone receptor-positive breast cancer patients that had 1 or 2 lines of endocrine therapy for the metastatic disease. Cohort B constitutes triple negative breast cancer patients that had two or more lines of chemotherapy for metastatic disease and anthracycline and taxane treatment for any disease setting. Single fraction RT of 8 Gy was delivered on day 0. Patients received 3 mg/kg Nivolumab intravenously every 2 weeks from day 1 until the disease progressed. Combined use of endocrine therapy of the physician’s choice was allowed in Cohort A. Primary endpoints were safety and ORR (RECIST1.1) in phase Ib and phase II, respectively. Secondary endpoints were Duration of Response (DOR), Disease Control Rate (DCR) and Progression-Free Survival (PFS). For translational research, we integrated time series multi-omics data that are correlated with Tumor Immune Microenvironment (TIME) to identify novel drug sensitivity-associated signatures using machine learning method. The multi-omics data included data from RNAseq, DNAseq, mass cytometry (CyTOF), multiple cytokines, human leukocyte antigen, radiomics, drug concentrations, tuberculin reaction using Peripheral Blood Mononuclear Cells (PBMCs), serum, plasma, imaging and Formalin-Fixed Paraffin-Embedded (FFPE) samples. RESULTS: 31 patients were enrolled from Jan 2017 to Nov 2018 and 29 patients (18 in Cohort A and 11 in Cohort B) were included in the full analysis set. While seven patients in Cohort A had received 1 or 2 lines of chemotherapy earlier for the metastatic disease, eight patients in Cohort B received three or more lines of chemotherapy. Dose limiting toxicities were not observed in phase Ib. In Cohort A, the ORR was 11.1% (90% with a Confidence Interval (CI) of 3.7-28.6). The best overall responses were: Partial Response (PR) in 2 patients (11.1%), Stable Disease (SD) in 11 patients (61.1%) and Progressive Disease (PD) in 5 patients (27.8%). In Cohort B, ORR was 0% as none of the patients responded to the treatment. The best overall responses were: SD in 4 patients (36.4%), PD in 6 patients (54.5%) and one patient (9.1%) was not evaluated (NE). While the DCR for Cohorts A and B were 72.2% (90% CI: 52.9-85.8) and 36.4% (90% CI: 17.5-60.6), respectively, the median PFS were 4 months (95% CI: 2.1-5.5 months) and 2 months (95% CI: 1.2-4.0 months), respectively. Common toxicities were mild; including 3 patients in Cohort A (16.7%) and 2 patients in Cohort B (18.2%) that experienced grade 3 or 4 toxicity. There were no deaths due to adverse effects. Furthermore, our integrated analysis identified novel candidates for drug sensitivity-associated signatures. CONCLUSIONS: The combination of RT and Nivolumab had a manageable safety profile and demonstrated clinically significant disease control outside the RT fields. Periodic abscopal response data and multi-omics data are also presented. (UMIN: UMIN000026046; ClinicalTrials.gov: NCT03430479).

Citation Format: Masahiro Takada, Michio Yoshimura, Kosuke Kawaguchi, Takeshi Kotake, Ryuji Uozumi, Masako Kataoka, Takahiko Koyama, Hironori Kato, Hiroshi Yoshibayashi, Hirofumi Suwa, Wakako Tsuji, Hiroyasu Yamashiro, Tatsuki Kataoka, Hiroshi Ishiguro, Reitaro Tokumasu, Maya Honda, Rikiya Yamashita, Atsushi Yonezawa, Yuki Himoto, Natsuko Onishi, Laxmi Parida, Satoshi Morita, Masakazu Toi. A multicenter phase Ib/II study for evaluating safety and efficacy of Nivolumab in combination with radiation therapy in patients with HER2-negative metastatic breast cancer (KBCRN-B-002 trial) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-09-07.

Baseline neutrophil-to-lymphocyte ratio and c-reactive protein predict efficacy of treatment with bevacizumab plus paclitaxel for locally advanced or metastatic breast cancer

The effect of bevacizumab plus paclitaxel therapy on progression-free survival (PFS) is prominent; however, no overall survival (OS) benefit has been demonstrated. Our aim was to study the predictive efficacy of peripheral immune-related parameters, neutrophil-to-lymphocyte ratio (NLR), absolute lymphocyte count (ALC), and c-reactive protein (CRP) in locally advanced and metastatic breast cancers. A total of 179 patients treated with bevacizumab plus paclitaxel were recruited from three institutes in the test cohort. The cut-off values of NLR, ALC, and CRP were set at 3, 1500/μL, and 1.0 mg/dL, respectively, and baseline values of these factors were measured. The PFS of patients with NLR-low was significantly longer than that of patients with -high (median, 12.6 vs. 7.2 months; hazard ratio (HR), 0.48, 95% confidence interval (95% CI), 0.31–0.73; p = 0.0004). OS of patients with NLR-low was significantly better than those with-high (22.2 vs. 13.5 months; HR, 0.57, 95% CI, 0.39–0.83; p = 0.0032). Similarly, improved PFS and OS were recognized in patients with CRP-low as compared with patients with -high (HR, 0.44, 95% CI, 0.28–0.68; p = 0.0001 and HR, 0.39, 95% CI, 0.26–0.61, p < 0.0001, respectively). In the validation cohort from two institutes (n = 57), similar significant improvements in PFS and OS were confirmed for patients with NLR-low (p = 0.0344 and p = 0.0233, respectively) and CRP-low groups (p < 0.0001 and p = 0.0001, respectively). Low levels of NLR and CRP at baseline were significantly associated with improved prognosis in patients treated with bevacizumab plus paclitaxel.

[Analysis of Five Days of Administration of S-1 Followed by a Two-Day Rest in Patients with Metastatic Breast Cancer]

Although S-1 is an effective oral anticancer drug in patients with metastatic breast cancer, it is difficult for some patients to continue taking S-1 because of its side effects in the approved regimen of 4 weeks of administration followed by a 2-week rest. When S-1 is administered for 5 days followed by a 2-day rest(5-day on/2-day off), the drug concentration is almost equal to that of the approved regimen, and it can be administered for longer without deterioration of its clinical effect. We retrospectively analyzed the effect and safety in 25 cases in which S-1 was administered using the "5-day on/2-day off" regimen in patients with metastatic breast cancer between November 2006 and August 2014 in our hospital. Patients were all female, and their median age was 68 years(44-87). ER was positive/negative in 15/10 cases, and PS 0/1/2were found in 8/ 10/7 cases. They had no prior chemotherapy and had measurable lesions. S-1 was administered at a dose of 80mg/m2 twice a day on a "5-day on/2-day off" schedule and was reduced when its side effects were appeared. The median treatment duration was 25(3-214)weeks, and CR/PR/long SD/SD/PD as clinical responses were observed in 0/8/5/5/7 cases. The overall response rate was 32% and clinical benefit rate was 52%. There was no difference in response rates whether visceral metastases were present or not. In terms of hematologic toxicity, anemia was seen in one case, and there were no cases of neutropenia. In non-hematologic toxicity, no more than Grade 3 side effects were shown. Discontinuance was observed in only one case because of diarrhea. A "5-day on/2-day off" regimen of S-1 in metastatic breast cancer is well tolerated, and we can continue administering it to elderly patients or those with poor PS without reducing QOL; thus, it can be considered as one of the effective metronomic treatments. In the future, a prospective study is warranted to ascertain these results.

Predictive impact of absolute lymphocyte counts for progression-free survival in human epidermal growth factor receptor 2-positive advanced breast cancer treated with pertuzumab and trastuzumab plus eribulin or nab-paclitaxel

Background

Although peripheral blood-based parameters (PBBPs) are reported as prognostic indicators in patients with breast cancers, their utility has not been studied in human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer (ABC). Tumor-infiltrating lymphocytes (TILs) might be a predictive factor in patients with HER2-positive ABC treated with pertuzumab and trastuzumab (PT) plus docetaxel. We aimed to evaluate whether PBBPs could have predictive value in HER2-positive ABC treated with pertuzumab and trastuzumab (PT) combined with eribulin (ERI) or nab-paclitaxel (Nab-PTX).

Methods

Data from 51 patients included in two single-arm, phase II trials were included in this retrospective-prospective study; the ERI + PT (N = 30) and Nab-PTX + PT (N = 21) combinations were registered under clinical trials number UMIN000012375 and UMIN000006838, respectively. We assessed PBBPs using prospectively collected data and investigated the association with progression-free survival (PFS); we evaluated absolute lymphocyte count (ALC), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR). The cutoff values for ALC, NLR, and PLR were set at 1000 or 1500 cells/μL, 2, and 250, respectively.

Results

PFS was significantly improved in patients with ALC ≥1500/μL compared to those with ALC 1000–, <1500/μL or ALC < 1000/μL (P = 0.0106). High baseline ALC was significantly associated with improved PFS (≥1500/μL; hazard ratio [HR]: 0.3715; 95% confidence interval [CI]: 0.1735–0.7955; P = 0.0108). In contrast, improved PFS was not significantly associated with NLR or PLR. Improved PFS in patients with ALC ≥1500/μL was observed irrespective of visceral metastasis or chemotherapy regimen.

Conclusions

Our results showed that baseline ALC was a predictive factor for PFS in HER2-positive ABC treated with PT irrespective of combined chemotherapy regimen. Anti-tumor effects might be mediated not only by the tumor microenvironment, but also by systemic peripheral circulating lymphocytes. Baseline systemic parameters such as peripheral lymphocyte count might be beneficial in addition to disease extent for predicting the efficacy of PT treatment.

Trial registration

UMIN000012375, registration date: 21NOV2013, and UMIN000006838, registration date: 6DEC2011.

Survival Outcomes of Retreatment with Trastuzumab and Cytotoxic Chemotherapy for HER2-Positive Recurrent Patients With Breast Cancer Who Had Been Treated with Neo/adjuvant Trastuzumab Plus Multidrug Chemotherapy: A Japanese Multicenter Observational Study

Background:

There are little data on the usefulness of trastuzumab (TZM) retreatment as the first-line treatment for patients with HER2 (human epidermal growth factor receptor 2)–positive breast cancer recurrence after perioperative treatment with TZM.

Aim:

To clarify the outcome and safety of TZM retreatment in patients with recurrent HER2-positive breast cancer.

Method:

An observational study was conducted on patients who relapsed after primary systemic therapy with TZM using the central registration system. The primary end point was progression-free survival (PFS). Secondary end points consisted of the response rate, overall survival (OS), and safety.

Result:

In total, 34 patients were registered between July 2009 and June 2012. The median follow-up time was 23.7 months (2-24 months). The 1- and 2-year PFS rates were 46.9% (95% confidence interval (95% CI): 29.2%-62.9%) and 29.8% (95% CI: 15.0%-46.3%), respectively (median 10.6 months). The median PFS time for patients receiving TZM combined with CTx was 13.9 months. The 1-and 2-year OR rates were 93.9 (95% CI: 77.9%-98.4%) and 84.8% (95% CI: 67.4%-93.4%). Trastuzumab-induced grade 3/4 adverse events were not observed.

Conclusions:

This study suggests that the PFS and OS in Japanese patients who relapsed after perioperative TZM therapy improved or were similar to those in previous reports. Differences in patient backgrounds and treatments must be considered when interpreting the results. Trastuzumab should be used combination with CTx and/or HTx for retreatment. Retreatment with TZM is safe.

Trial registration: UMIN000002738.

Distribution of the Carbohydrate Antigens, Du-Pan-2 and Ca19-9, in Tumors of the Lung

Aims and background

The carbohydrate chains of malignant cells appear to be related to oncofetal differentiation. The serum levels of CA19-9 have been reported to be evaluated in some patients with lung carcinomas, however, the distribution of carbohydrate antigens were not precisely described. We have investigated in this study the distribution of DU-PAN-2 and CA19-9 antigens in lung tumors.

Methods

Ninety five specimens of lung tumors were selected from surgical specimens. The expression of DU-PAN-2 and CA19-9 were studied by immunohystochemical techniques. The relationship between the expression of these antigens and the classification or the differentiation degree of the tumors were examined.

Results

DU-PAN-2 or CA19-9 antigens were detected in 41 (54%) and 45 (59%) cases of the 76 malignant epithelial tumors investigated. These antigens were detected in all types of malignant epithelial tumors, including squamous cell carcinomas, where they were mainly localized to the entire cell surface of malignant cells. In adenocarcinomas, large cell carcinomas and small cell carcinomas, however, these antigens were commonly detected both on the cell membrane and in the cytoplasm. There was positive correlation between the degree of differentiation and DU-PAN-2, but not CA19-9 expression. Among the non-epithelial tumors investigated, those antigens were detected in pulmonary blastomas but not in mesotheliomas.

Conclusions

Immunohistochemical studies for DU-PAN-2 and CA19-9 are useful for defining characteristics of the lung tumors. DU-PAN-2 could be a marker for differentiating between malignant epithelial tumors and mesotheliomas.

Abstract P2-09-31: Predictive impact of absolute lymphocyte counts for progression-free survival in HER2-positive advanced breast cancer treated with pertuzumab and trastuzumab plus eribulin or nab-paclitaxel

Background: Tumor-infiltrating lymphocytes might be a one of predictive outcome of human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer (ABC) patients (pts) who treated with trastuzumab and pertuzumab (TP) plus docetaxel. Although peripheral blood-based parameter (PBBP) is reported as a prognostic indicator of patients with early breast cancers, utility of PBBP has not been studied in HER2-positive ABC.

Objective:The aim of our study was to determine whether PBBP is significant for predictive efficacy in HER2-positive ABC treated with TP combined with eribulin (ERI) or nab-paclitaxel (Nab-PTX).

Methods: The 51 patients' data from two single arm phase II trials was included in this retrospective-prospective study; ERI + TP (n=30) or Nab-PTX + TP (n=21) registered with UMIN000012375 or UMIN000006838, respectively. We assessed the PBBP in prospectively collected data and investigated their association with progression-free survival (PFS). In consideration of PBBP, we evaluated absolute lymphocyte count (ALC), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR). The cutoff values of ALC, NLR, and PLR were set at 1000 cells/μL, 2, and 250, respectively.

Results:Median age at baseline was 58 years (range: 31-77). Median number of previous chemotherapy was 3 (range: 1-10). Pts had multiple metastases, 53% with LNs, 35% with bone, 25% with lung, 20% with liver, and 6% with brain. The objective response rate (CR+PR) and clinical benefit rate (CR+PR+ more than 6 month SD) were 37% (n=19) and 59% (n=30), respectively. The median PFS of all pts was 301 days (range: 21-1281). The PFS of pts with ALC-High was significantly better than those of ALC-low (hazard ratio (HR): 2.74, 95% confidence interval (CI): 1.28 to 5.86; p= .0097). Furthermore, improved PFS was obtained in pts with ALC greater than 1500 cells/μL compared with less than 1000 cells/uL (HR: 4.05, 95% CI: 1.60 to 11.6; p= .0029). Significant associations seem to exist irrespective of number of previous chemotherapy. Since we combined different studies for evaluating PBBP, ERI and Nab-PTX were calculated separately. Marginally significant associations between ALC and PFS were obtained both in ERI (HR: 2.18, 95% CI: 0.87 to 5.60; p=.0973) and Nab-PTX (HR: 3.26, 95% CI: 0.80 to 12.4; p=.0939). The PFS of NLR-low pts was significantly better than those of NLR-high (HR: 2.29, 95% CI: 1.01 to 5.90; p= .0477), but this statistical difference was inferior to those of ALC. There was no significant association between PLR and PFS.

Conclusions: Pre-treatment ALC-High was significantly correlated with favorable PFS of pts treated with TP irrespective of combination chemotherapy in HER2-positve ABC. Prolonged PFS of TP combination therapy might be obtained mediating through host systemic onco-immunity. These data obtained here suggest that a usefulness of ALC for selecting pts who might have clinical benefit from TP combination therapy for heavily treated HER2-positve ABC.

Citation Format: Araki K, Ito Y, Fukada I, Kobayashi K, Ohno S, Miyagawa Y, Imamura M, Kira A, Takatsuka Y, Egawa C, Suwa H, Miyoshi Y. Predictive impact of absolute lymphocyte counts for progression-free survival in HER2-positive advanced breast cancer treated with pertuzumab and trastuzumab plus eribulin or nab-paclitaxel [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 P2-09-31.

Randomized clinical trial of single-incision versus multiport laparoscopic colectomy

BACKGROUND

The efficacy and safety of single-incision laparoscopic colectomy (SILC) for colonic cancer remain unclear. The aim of this study was to determine the outcomes of SILC compared with multiport laparoscopic colectomy (MPLC) for colonic cancer.

METHODS

Patients with histologically proven colonic carcinoma located in the caecum, ascending, sigmoid or rectosigmoid colon, clinically diagnosed as stage 0-III by CT, were eligible for this study. Patients were randomized before surgery and underwent tumour dissection with complete mesocolic excision. Safety analyses were conducted according to randomization groups.

RESULTS

A total of 200 patients were enrolled and randomized to the MPLC (100 patients) or SILC (100 patients) arm. Surgical outcomes were similar between the MPLC and SILC arms, including duration of operation (mean 162 versus 156 min respectively; P = 0·273), blood loss (mean 8·8 versus 21·4 ml; P = 0·102), conversion to open laparotomy (2·0 versus 1·0 per cent; P = 0·561), reoperation (3·0 versus 3·0 per cent; P = 1·000), time to first flatus (both median 1 day; P = 0·155) and postoperative hospital stay (both median 6; P = 0·372). The total skin incision length was significantly shorter in the SILC arm (mean 4·4 cm versus 6·8 cm in the MPLC arm; P < 0·001). The median duration of analgesia use was 5 days in the MPLC and 4 days in the SILC arm (P = 0·485). Overall complication rates were equivalent (15·0 versus 12·0 per cent respecitvely; P = 0·680).

CONCLUSION

SILC is not superior to MPLC.

REGISTRATION NUMBER

UMIN000007220 (http://www.umin.ac.jp/ctr/index.htm).

Estimation of 85Kr dispersion from the spent nuclear fuel reprocessing plant in Rokkasho, Japan, using an atmospheric dispersion model

The spent nuclear fuel reprocessing plant of Japan Nuclear Fuel Limited (JNFL) located in Rokkasho, Japan, discharged small amounts of (85)Kr into the atmosphere during final tests of the plant with actual spent fuel from 31 March 2006 to October 2008. During this period, the gamma-ray dose rates due to discharged (85)Kr were higher than the background rates measured at the Institute for Environmental Sciences and at seven monitoring stations of the Aomori prefectural government and JNFL. The dispersion of (85)Kr was simulated by means of the fifth-generation Penn State/NCAR Mesoscale Model and the CG-MATHEW/ADPIC models (ver. 5.0) with a vertical terrain-following height coordinate. Although the simulated gamma-ray dose rates due to discharged (85)Kr agreed fairly well with measured rates, the agreement between the estimated monthly mean (85)Kr concentrations and the observed concentrations was poor. Improvement of the vertical flow of air may lead to better estimation of (85)Kr dispersion.

Risk factors for joint symptoms in postmenopausal Japanese breast cancer patients treated with anastrozole: a prospective multicenter cohort study of patient-reported outcomes

BACKGROUND

Endocrine treatment-related adverse events have a strong impact on patients' quality of life and sometimes result in treatment discontinuation. Since joint symptoms are the most frequently recognized side effect of aromatase inhibitors, evaluation of associated risk factors may yield significant findings.

PATIENTS AND METHODS

A total of 391 postmenopausal Japanese women with estrogen receptor-positive breast cancer and treated with adjuvant anastrozole were enrolled from 28 centers for assessment of patient-reported outcomes (PROs) in this prospective cohort study (SAVS-JP, UMIN000002455). Patients completed the self-report questionnaire at baseline and after 3, 6, 9, and 12 months of treatment for evaluation of frequency of treatment-related joint symptoms (arthralgia, decrease in range of joint motion, and joint stiffness).

RESULTS

We obtained PROs from 362 patients (92.6 %) at baseline and at one or more subsequent points. New or worsening from baseline of joint symptoms were reported by 260 patients (71.8 %). More than 90 % of the symptoms were mild or moderate and nearly 80 % had occurred by 6 months. Multivariate analysis showed that a short time span after menopause [odds ratio (OR) 0.95, 95 % confidence interval (CI) 0.90-0.99; P = 0.02] and adjuvant chemotherapy (OR 2.29, 95 % CI 1.06-4.95; P = 0.03) were significant independent risk factors for joint symptoms. No significant relationships between body mass index (BMI) and joint symptoms were identified. Eighteen patients discontinued treatment during the 1st year and eight of them reported joint symptoms.

CONCLUSION

Taking into consideration that PROs may yield higher prevalence rates than physician ratings for symptoms published in pivotal clinical trials, we found that a short time span after menopause and use of adjuvant chemotherapy, but not high BMI, were significantly associated with joint symptoms. These findings might prove useful for counseling before initiating treatment with adjuvant aromatase inhibitors in postmenopausal Japanese women.

[A case of long remission for about 5 years as an outpatient with second-line chemotherapy of weekly PTX after palliative distal gastrectomy for pStage IV advanced gastric cancer]

A 59-year-old man underwent palliative distal gastrectomy for Stage IV advanced gastric cancer with cytological and histopathological peritoneal dissemination. After surgery, he began to receive chemotherapy by S-1 oral administration as an outpatient. About one year and 9 months after surgery, cartinomatous peritonitis grew, and severe obstruction of gastrojejunostomy and dilatation of residual stomach were detected by CT tomography. Then, second-line chemotherapy by weekly paclitaxel(PTX)was started. After one course of weekly PTX was completed, he was feeling better gradually with obvious improvement of carcinomatous peritonitis, which was revealed by sequential CT tomography examinations. Weekly PTX chemotherapy has been continued successfully for 43 courses, and he remains alive today with a good QOL, about 5 years after surgery. He is an outpatient with only a grade 2 or less complication of peripheral neuropathy.

Comparison of the indocyanine green fluorescence and blue dye methods in detection of sentinel lymph nodes in early-stage breast cancer

PURPOSE

To assess the diagnostic performance of sentinel lymph node (SLN) biopsy using the indocyanine green (ICG) fluorescence method compared with that using the blue dye method, a prospective multicenter study was performed.

METHODS

Patients with T1-3 primary breast cancer without clinical lymph node involvement were included in this study. ICG as a fluorescence-emitting source and indigo carmine as blue dye were injected into the subareolar area. Extracted lymph nodes were examined to identify the first, second, and other SLNs. The identified nodes were classified according to the ICG fluorescence signal and blue dye uptake.

RESULTS

Ninety-nine eligible patients were included in this study. The ICG fluorescence method identified an average of 3.4 SLNs (range, 1-8) in 98 of 99 patients (detection rate, 99 %). The number of lymph nodes identified by the fluorescence method was significantly higher than that identified by the blue dye method (p < 0.001). SLN involvement was identified in 20 % (20 of 99) of patients, all of whom tested positive for the first SLN. In 16 patients, complete axillary lymph node dissection (ALND) was performed. In 25 % (4 of 16) of these patients, axillary metastases were identified; however, no axillary involvement was found in 8 patients with only one involved node, which was isolated as the first SLN.

CONCLUSIONS

High rate of SLN detection was achieved using the ICG fluorescence method. The first SLN identified by fluorescence imaging provides an exact indication of the axillary status. Therefore, the ICG fluorescence method provides precise information required to avoid unnecessary ALND.

Primary systemic chemotherapy for operable breast cancer with docetaxel followed by cyclophosphamide, epirubicin, and fluorauracil (DOC-CEF)

11085

Background: Primary systemic chemotherapy (PSC) for breast cancer has been considered to be useful controlling the micrometastasis and shown to increase the breast conserving surgery rate, result in similar survival rate as usual post-operative adjuvant chemotherapy. Recently, doxorubicin based regimen followed by taxan regimen in neoadjuvant chemotherapy has shown a high response rate and sequential administration is supposed to be important. However, taxan regimens sequentially followed by doxorubicin are not so common. The purpose of this study is to evaluate the efficacy of primary systemic chemotherapy with docetaxel followed by cyclophosphamide, epirubicin and fluoraouracil (DOC-CEF) in breast cancer. Methods: Since 2003, 80 women histologically proven as the primary breast cancer, measurable lesion >= 2cm or inflammatory breast cancer, age 20–75, PS 0–1 were enrolled. The patients received 4 cycles of DOC (75mg/m2) every 3 weeks followed by CEF (500mg/m2, 75mg/m2, 500mg/m2) every 3 weeks as the primary systemic chemotherapy. After administrations, clinical responses and tumor vascularities were recorded by ultrasonography and pathological responses were examined after surgery for all patients. Results: 57 out of 80 patients (T2: 45, T3 6, T4 6) were analyzed at this time. Clinical response rate recorded by ultrasonography and pathological response rate were 82.4% (47/57) and 91.2% (52/57) respectively. Pathological CR rate was 26.3% (15/57). 8 pCR cases showed ER/PR-negative tumors of which 3 cases showed ER/PR-negative/Her2-negative (triple negative pattern). Breast conservative surgery was underwent in 51 patients (89.5%). Among the response group, the tumor vascularities were almost remarkably decreased in the early phase (mostly until 2–3 cycles) of the chemotherapy. Grade 4 neutropenia was observed in 16% (9/57) and 4% (2/57) had febrile neutropenia. Conclusion: This regimen is well tolerated and has good feasibility because most patients have experienced the early reduction of tumor by high response rate of docetaxel.

No significant financial relationships to disclose.

[A case of advanced gastric cancer with peritoneal dissemination responding remarkably to TS-1/CDDP combination chemotherapy]

A 57-year-old woman visited a physician with complaints of anorexia and pollakiuria. Because a pelvic tumor and ascites were detected, she was referred to our department. Douglas pouch puncture revealed adenocarcinoma cells. Further examination showed an advanced gastric cancer with peritoneal dissemination. The cancer was judged to be unresectable. Chemotherapy with a combination of TS-1 and CDDP was performed before the operation. After 2 courses of the chemotherapy, her complaints disappeared, although abdominal CT confirmed remaining peritoneal dissemination. After 7 courses of chemotherapy, abdominal CT showed that the peritoneal dissemination had disappeared. Total gastrectomy and lymph node dissection were performed. Histological findings of the stomach revealed complete disappearance of cancer cells in the stomach and the regional lymph nodes. We confirmed that the TS-1/CDDP therapy resulted in a complete response to advanced gastric cancer and peritoneal dissemination. We recommend that chemotherapy be continued until the peritoneal dissemination disappears.

A case of nodular pseudoangiomatous stromal hyperplasia (pash)

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a common microscopic lesion that is found at breast biopsy, and presents with proliferation of the stromal cells and slit-like pseudovascular spaces with endothelial-like spindle cells. In contrast, nodular PASH is relatively rare. We report here a case of nodular PASH with multiple palpable masses. A 49-year-old woman who had experienced gradual enlargement of her breasts for 13 years noticed an elastic but firm palpable mass in her breast. We were able to detect 7 masses in her right breast and 2 in the left. Ultrasonography and mammography demonstrated nonspecific findings, and FNA and CNB did not establish a diagnosis. An excisional biopsy was performed, and the pathological findings revealed nodular PASH. Eighteen months after the excisional biopsy, the size of the nodules and the whole breast had decreased remarkably. While the possibility of a change in the hormonal background or the influence of drugs was considered, we were not able to reach a single specific conclusion regarding the pathogenesis.

Clinical implication of anti-p53 antibodies and p53-protein in pancreatic disease

p53 gene mutations play an important role in the pathogenesis of pancreatic carcinomas. Anti-p53 antibodies and p53 protein have been detected in the sera of patients with pancreatic carcinomas. However, very little is known about the clinical significance of these p53 antibodies. We investigated the relationship between anti-p53 antibodies and the presence of p53 protein in cancer cells and the serum, as well as other clinical factors. Anti-p53 antibodies were detected in 19 (23%) of 82 pancreatic-duct-cell carcinomas, and in one (5%) of 21 cases of chronic pancreatitis. However, no antibodies were detected in mucin-producing tumors or in islet-cell tumors of the pancreas. The anti-p53 antibodies were detected in both early and advanced stages. In those patients undergoing surgical resection for pancreatic duct-cell carcinomas, the prognosis of patients who were negative for the anti-p53 antibodies was better than patients who were positive. Of the 11 cases that were positive for anti-53 antibodies, 8 (73%) were also positive for the immunohistochemical expression of p53 protein in cancer cells. However, there was no significant correlation between the presence of anti-p53 antibodies and the serum p53 protein levels. These results suggest that the benefits of measuring the anti-p53 antibody titier as a screening test to detect pancreatic carcinoma are limited, but the presence of anti-p53 antibodies predicts a poor prognosis for postoperative pancreatic carcinoma patients.

Immunoglobulin A secretion into pancreatic juice as a novel marker of local immune defense and exocrine pancreatic function

The importance of secretory immunoglobulin A (IgA) of local immune defense in the gastrointestinal tract has gained increasing acceptance. Bacterial contamination is a major factor related to mortality in acute pancreatitis. However, very little is known about IgA in pancreatic juice. Pure pancreatic juice was collected from 40 patients undergoing pancreatoduodenectomy. The patients were divided into three groups according to the degree of preoperative pancreatic duct obstruction, as follows: normal, narrowed, and obstructed. IgA concentration, amylase activity, and daily volume of pancreatic juice were measured. Daily IgA secretion into pancreatic juice was constant during the early period after the operation. The concentration of IgA in the control group was 5 +/- 0.8 microg/ml, and IgA daily secretion was 1.2 +/- 0.2 mg/day. Pancreatic duct obstruction resulted in a marked decrease in both amylase and pancreatic juice secretion. The concentration of IgA, however, was markedly increased in the narrowed group (11.1 +/- 2.4 microg/ml) and the obstructed group (32.5 +/- 5.4 microg/ml). The concentration of amylase increased with the increase in pancreatic juice. Conversely, the concentration of IgA increased with the decrease in volume of pancreatic juice. Similarly, the increased in IgA concentrations positively correlated with the decrease in amylase activity. In conclusion, the mechanisms that modulate IgA secretion in the human pancreas are essentially different from those that modulate digestive enzyme and fluid secretion. IgA in pancreatic juice may play an important role in pathological conditions such as pancreatic duct obstruction. As such, the measurement of IgA in pancreatic juice may potentially be used as a new marker of local immune defense and exocrine pancreatic function.

Clinical analysis and prognostic study of ossified ligamentum flavum of the thoracic spine

OBJECT

A variety of factors may affect surgery-related outcome in patients with ossification of the ligamentum flavum (OLF) of the thoracic spine. The aim of this study was to determine these factors on the basis of preoperative clinical and radiological findings.

METHODS

The authors treated 31 cases of symptomatic thoracic OLF between 1988 and 1999. The following factors were retrospectively studied: patient age, sex, morbidity level, initial symptoms, chief complaint, duration of symptoms, patellar reflex, Achilles reflex, computerized tomography (CT) finding, presence of intramedullary change determined by magnetic resonance imaging, coexistent spinal lesions, preoperative grade, and postoperative grade. A decompressive laminectomy was performed in all cases. In 29 patients (94%) improved symptoms were demonstrated postoperatively. In terms of functional prognosis, the preoperative duration of symptoms was significantly shorter in the group of patients with excellent outcomes than in those with fair outcomes (p < 0.05). No significant difference was observed in the correlation between other factors. To evaluate the degree of preoperative thoracic stenosis and the severity/extent of OLF-induced spinal compression, we used an original OLF CT scoring system. A score of excellent on the CT scale tended to indicate an excellent prognosis (p < 0.01).

CONCLUSIONS

Thoracic OLF frequently develops in the lower-thoracic spine in middle-aged men, and it is complicated by various spinal lesions in many cases. Early diagnosis and treatment are important for understanding the clinical symptoms and imaging diagnosis because the present findings suggest that a delay in diagnosis and treatment correlates with the functional prognosis postoperatively.