Survival analysis of carboplatin added to an anthracycline/taxane-based neoadjuvant chemotherapy and HRD score as predictor of response-final results from GeparSixto

Background

In the neoadjuvant GeparSixto study, adding carboplatin to taxane- and anthracycline-based chemotherapy improved pathological complete response (pCR) rates in patients with triple-negative breast cancer (TNBC). Here, we present survival data and the potential prognostic and predictive role of homologous recombination deficiency (HRD).

Patients and methods

Patients were randomized to paclitaxel plus nonpegylated liposomal doxorubicin (Myocet®) (PM) or PM plus carboplatin (PMCb). The secondary study end points disease-free survival (DFS) and overall survival (OS) were analyzed. Median follow-up was 47.3 months. HRD was among the exploratory analyses in GeparSixto and was successfully measured in formalin-fixed, paraffin-embedded tumor samples of 193/315 (61.3%) participants with TNBC. Homologous recombination (HR) deficiency was defined as HRD score ≥42 and/or presence of tumor BRCA mutations (tmBRCA).

Results

A significantly better DFS (hazard ratio 0.56, 95% CI 0.34-0.93; P = 0.022) was observed in patients with TNBC when treated with PMCb. The improvement of OS with PMCb was not statistically significant. Additional carboplatin did not improve DFS or OS in patients with HER2-positive tumors. HR deficiency was detected in 136 (70.5%) of 193 triple-negative tumors, of which 82 (60.3%) showed high HRD score without tmBRCA. HR deficiency independently predicted pCR (ypT0 ypN0) [odds ratio (OR) 2.60, 95% CI 1.26-5.37, P = 0.008]. Adding carboplatin to PM significantly increased the pCR rate from 33.9% to 63.5% in HR deficient tumors (P = 0.001), but only marginally in HR nondeficient tumors (from 20.0% to 29.6%, P = 0.540; test for interaction P = 0.327). pCR rates with carboplatin were also higher (63.2%) than without carboplatin (31.7%; OR 3.69, 1.46-9.37, P = 0.005) in patients with high HRD score but no tmBRCA. DFS rates were improved with addition of carboplatin, both in HR nondeficient (hazard ratio 0.44, 0.17-1.17, P = 0.086) and HR deficient tumors (hazard ratio 0.49, 0.23-1.04, P = 0.059).

Conclusions

The addition of carboplatin to neoadjuvant PM improved DFS significantly in TNBC. Long-term survival analyses support the neoadjuvant use of carboplatin in TNBC. HR deficiency in TNBC and HRD score in non-tmBRCA TNBC are predictors of response. HRD does not predict for carboplatin benefit.

Abstract P6-15-03: Outcome after neoadjuvant chemotherapy in elderly breast cancer patients – a pooled analysis of individual patient data from eight prospectively randomized controlled trials

Introduction: Recent studies showed the high and independent impact of age (<40 years) on pathologic complete remission (pCR) and prognosis for patients undergoing neoadjuvant chemotherapy (NACT). Some physicians might not consider elderly patients (>65 years) for NACT due to poor prognosis or higher toxicity. The aim of this analysis is to help selecting appropriately elderly women who would benefit from NACT. Secondly, survival parameters will be investigated in several clinical and histological subgroups.

Methods: From 1998 to 2010, eight prospectively randomized German Breast Group (GBG) trials of anthracycline- and taxane-based NACT were performed and analyzed in this study.

Results: Compared to the overall average, women older than 65 years had significant larger tumors and more overall lymph node involvement. Also, compared to patients younger than 51 years, they had more lobular invasive tumors. Histologically, they had more G2 tumors, more estrogen-receptor positive tumors. PCR (ypT0 ypN0) was strongly associated with age: >65y: 11.7%; 51-65y: 14.1%; 40-50y: 17.3%; <40y: 20.9%. The multivariable logistic regression analysis of clinical parameters showed that young age, clinical stage T4, invasive ductal cancer and poor differentiated breast cancer are predictive for high pCR. The multivariate analyses of molecular subgroups also showed that age >65years is a predictor of significant (p<0.05) lower pCR in TNBC and HR positive/HER2- breast cancers. Nonetheless, in this cohort, HER2+ patients showed pCR rates as high - and for HR+/HER2+ even higher - pCR rates compared to younger patients.

Discussion: This study underlines the unfavorable impact of higher age on pCR, but it shows nevertheless a realistic chance for pCR if NACT is applied - especially for HER2+ patients. Furthermore, elderly patients in this analysis with non-TNBC have a good prognosis (comparable to younger patients) regarding OS, even if they do not have pCR.

Citation Format: von Waldenfels G, Loibl S, Furlanetto J, Anna M, Lederer B, Denkert C, Hanusch C, Huober J, Jackisch C, Kümmel S, von Minckwitz G, Schneeweiss A, Untch M, Rhiem K, Fasching PA, Blohmer JU. Outcome after neoadjuvant chemotherapy in elderly breast cancer patients – a pooled analysis of individual patient data from eight prospectively randomized controlled trials [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 P6-15-03.

Abstract P6-15-01: Withdrawn

This abstract was withdrawn by the authors.

Abstract P1-01-07: Clinical and histological characteristics of peritoneal metastases of invasive lobular breast cancer

Introduction: In previously reported autopsy series, peritoneal metastases have been detected in up to 40% of patients with invasive lobular breast cancer (ILC). Despite modern diagnostic techniques such as high-resolution ultrasound, it remains a challenge to differentiate ovarian cancer from metastatic breast cancer with peritoneal manifestation before or during surgery. The goal of this analysis was to determine typical clinical and immunohistological features of peritoneal metastasis of ILC. Specifically, we asked the question whether there are predictive factors in primary breast cancer associated with subsequent development of peritoneal metastasis. Patients and methods: We identified 58 patients with ovarian metastases in the Charité cancer register (4,792 breast cancer patients from 2003 to 2015). We looked for clinical and pathological differences between breast cancer patients with (N=58) and without (N=4734) peritoneal metastases and between ILC and non-ILC breast cancer subtypes. Imaging and surgical reports of these 58 patients with ILC intraperitoneal metastases were reviewed. Results: The majority (84.7%) of primary breast cancers consisted of subtypes other than ILC and only 15.3% were histologically characterized as ILC. In contrast, 63.6% of patients with peritoneal metastases had histologically proven ILC in the metastatic tissue. Other subtypes where found in the 36.4% of the metastatic tissue (p<0.001). The Odds ratio for peritoneal metastases for ILC was 2.35 (95% CI 1.655-3.332) and for Non-ILC 0.23 (0.185-0.284). There were no significant differences in receptor status between primary and peritoneal metastatic ILC. Comparing ER/PR expressions levels on primary tumor versus metastasis, while statistically not significant (p= 0.805), showed a rise in ER expression in 42.95% in the metastatic tissue while PR expression remained stable with no difference in 53.3% and a rise in the metastatic site in only 26.7% (p= 0.715). Median age of all patients with primary breast cancer was 60 years (10%-90%: 41-75). There was a significant difference in age at diagnosis of metastasis between patients with (50.5 years) and without peritoneal metastases (59 years) (p= 0.002). Median time to development of peritoneal metastases for all patients was 48.5 months (10%-90%: 0-191.7), for ILC 44 months (0-198.2) and for Non-ILC 56.5 months (6.7-206.4) (p= 0.487). Median survival time for patients with ILC and peritoneal metastases was 56 months, for Non-ILC 53 months (p=0.759). 33 of 58 patients had radiologic evidence of disease, 26 with ILC and 7 with Non-ILC. An ovarian mass was detected by imaging in 15/26 patients with ILC and 4/7 patients with non-ILC. Ascites and diffuse peritoneal metastases were seen in 18/26 patients with detectable ILC and in 4/7 patients with Non-ILC.

Conclusion: This is the first comprehensive analysis of clinical and pathological characteristics of peritoneal metastases showing ILC is more frequent than other histologic subtypes. Patients with peritoneal metastasis are significantly younger (median 50.5y.) than patients without. The clinical signs are similar to those of ovarian cancer except and therefore the diagnosis of metastatic ILC must be taken into consideration as a differential diagnosis.

Citation Format: Karsten MM, Ingold-Heppner B, Oesterreich S, Sander S, Machleidt A, von Waldenfels G, Denkert C, Blohmer JU. Clinical and histological characteristics of peritoneal metastases of invasive lobular breast cancer [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 P1-01-07.

Abstract P3-01-16: Can sentinel node staging be performed using a minimally invasive needle-biopsy? Results of German multicentric pilot study

AIM

Evaluate within a pilot setup feasibility and safety of minimally invasive needle-biopsy of sentinel nodes guided by SPECT/US as compared to surgical removal while defining optimal needle for follow-up trial.

METHOD AND MATERIALS

As pretrial test phase of the MinimalSNB study, 38 breast cancer patients (6 centers) were taken a needle-biopsy of their sentinel lymph nodes (SLNs) under guidance of SPECT/US (SentiGuide by SurgicEye, Munich, DE). All patients were indicated for a surgical SLN biopsy which was performed immediately after the needle-biopsy. For the test phase, 4 different biopsy systems were tested: HistoCore 14G (BIP, Tuerkenfeld, DE), elite 10G and 13G (Mammotome, Cincinnati, OH, US) and CASSI II 10G (Scion Medical Technologies, Boston, MA, US). Histopathological examination (H&E, step-sectioning) of needle-biopsies and surgically removed SLNs were compared.

RESULTS

No single complication was reported. Occasionally, small hematomas could be found close to the SLN during surgery. Duration of complete procedure (imaging, needle placement, biopsy) took in average 17min. A learning curve was observed in duration (average after 5 biopsies 12min). 1-14 samples were taken of each SLN (average 5 samples). Final pathological examination of material harvested with both methods matched in 34 cases (33 negatives, 1 positive). The needle biopsy failed to detect metastases in 2 pN1 SLNs. In 1 case, the surgically resected tissue did not contain lymph nodes and the needle biopsy remained the only information on nodal status. In 1 case a metastasis found in needle-biopsy motivated a second reading of an originally negative SLN which resulted in the upstaging of the patient. In both cases a metastases was missed by needle-biopsy, the retrieved lymph tissue was minimal (1x 14G sample, 1x 10G sample tangential to node).

CONCLUSION

SPECT/US showed to be a valid method for percutaneous detection of SLNs and needle-guidance. Sampling SLNs with a needle seems safe and feasible. However it requires proper training and user experienced with axillary needle-biopsies. Retrieving more tissue (more cores and larger lumen needles) improves diagnostic power of needle-biopsy. These considerations will be taken within the upcoming MinimalSNB trial.

CLINICAL RELEVANCE

Sentinel lymph biopsy today is a surgical diagnostic procedure with an nonzero morbidity. Moving it out of the operating theatre to a needle-based intervention has a huge impact on the burden of this procedure for the patient as well as relevant improvements in logistics, workflow and radiation burden.

Citation Format: Paepke S, Pfob CH, Ohlinger R, Gruber I, Thill M, Blohmer JU, Kuehn T, Hahn M, Kiechle M, Wendler T. Can sentinel node staging be performed using a minimally invasive needle-biopsy? Results of German multicentric pilot study. [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 P3-01-16.

Prognostic Factors for Local, Loco-regional and Systemic Recurrence in Early-stage Breast Cancer

Aim: The risk of recurrence in breast cancer depends on factors such as treatment but also on the intrinsic subtype. We analyzed the risk factors for local, loco-regional and systemic recurrence, evaluated the differences and analyzed the risk of recurrence for different molecular subtypes. Material and Methods: A total of 3054 breast cancer patients who underwent surgery followed by adjuvant treatment at HSK hospital or Essen Mitte Hospital between 1998 and 2011 were analyzed. Based on immunohistochemical parameters, cancers were divided into the following subgroups: luminal A, luminal B (HER2-), luminal B (HER2+), HER2+ and TNBC (triple negative breast cancer). Results: 67 % of tumors were classified as luminal A, 13 % as luminal B (HER2-), 6 % as luminal B (HER2+), 3 % as HER2+ and 11 % as TNBC. After a median follow-up time of 6.6 years there were 100 local (3.3 %), 32 loco-regional (1 %) and 248 distant recurrences (8 %). Five-year recurrence-free survival for the overall patient collective was 92 %. On multivariate analysis, positive nodal status, TNBC subtype and absence of radiation therapy were found to be independent risk factors for all forms of recurrence. Age < 50 years, tumor size, luminal B (HER2-) subtype and breast-conserving therapy were additional risk factors for local recurrence. Compared to the luminal A subtype, the risk of systemic recurrence was higher for all other subtypes; additional risk factors for systemic recurrence were lymphatic invasion, absence of systemic therapy and mastectomy. Conclusion: Overall, the risk of local and loco-regional recurrence was low. In addition to nodal status, subgroup classification was found to be an important factor affecting the risk of recurrence.

Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.

Abstract S5-05: Postneoadjuvant treatment with zoledronate in patients with tumor residuals after anthracyclines-taxane-based chemotherapy for primary breast cancer – The phase III NATAN study (GBG 36/ABCSG XX)

Background: Patients with residual disease after neoadjuvant chemotherapy (NACT) are considered to have chemoresistant breast cancer. Adjuvant treatment with bisphosphonates is considered to reduce the relapse risk predominantly in estrogen-deprivated patients.

Methods: Patients who had invasive tumor residuals (ypT1-4 or ypN+) after a minimum of 4 cycles of anthracycline-taxane-containing NACT were eligible to the NATAN study. Patients were randomized within 3 years after surgery to receive zoledronate 4 mg i.v. (plus 1000 mg Ca2+ and 880 I.U. vitamin D daily) for 5 years vs. observation. Zoledronate was given q 4 weeks for the first 6 months, q 3 months the following 2 years, and q 6 months for the last 2.5 years. Patients with hormone receptor (HR)-positive disease received letrozole for 5 years if postmenopausal, or tamoxifen, if premenopausal. Adjuvant trastuzumab for HER2-positive disease was allowed since an amendment in 2007. Stratification factors were HR, time since surgery, age, and center. Primary objective was event-free survival (EFS). 654 patients and 316 events were required to observe an increase of 5yr EFS from 58% to 67.2% (hazard ratio 0.73). Secondary objectives were to determine overall survival, EFS with respect to the interval between surgery and randomization, bone-metastasis-free-survival, toxicity of and compliance to zoledronate, the predictive value of breast tumor response to NACT on the effect of postoperative treatment and the prognostic impact of chemotherapy induced amenorrhea in premenopausal patients. An interim analysis for high efficacy at 158 observed events was planned in the protocol; in agreement with study IDMC a Bayesian analysis for futility with futility boundary of 15% will be performed at the same time.

Results: Between 2/2005 and 5/2009 693 patients were enrolled. Time between surgery and randomization was &lt;4 months in 48.4%, 4-12 months in 34.5%, and 13-36 months in 17.1% of patients. The median age was 50.9 yrs (range 33.7-88.2), 72.3% of patients were postmenopausal. 82% had HR-positive and 19% HER2-positive disease. During a median follow up of 48 months 154 events were observed so far.

Conclusion: This is the first post-neoadjuvant phase III study. Analysis of the primary endpoint will be presented in case the IDMC will release of the results of the futility analysis.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S5-05.

Survival after adding capecitabine and trastuzumab to neoadjuvant anthracycline-taxane-based chemotherapy for primary breast cancer (GBG 40--GeparQuattro)

BACKGROUND

The GeparQuattro study showed that adding capecitabine or prolonging the duration of anthracycline-taxane-based neoadjuvant chemotherapy from 24 to 36 weeks did not increase pathological complete response (pCR) rates. Trastuzumab-treated patients with HER2-positive disease showed a higher pCR rate than patients with HER2-negative disease treated with chemotherapy alone. We here present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1495) with cT ≥ 3 tumors, or negative hormone-receptor status, or positive hormone-receptor and clinically node-positive disease received four times epirubicin/cyclophosphamide and were thereafter randomly assigned to four times docetaxel (Taxotere), or four times docetaxel/capecitabine over 24 weeks, or four times docetaxel followed by capecitabine over 36 weeks. Patients with HER2-positive tumors received 1 year of trastuzumab, starting with the first chemotherapy cycle. Follow-up was available for a median of 5.4 years.

RESULTS

Outcome was not improved for patients receiving capecitabine (HR 0.92; P = 0.463 for DFS and HR 93; P = 0.618 for OS) as well as for patients receiving 36 weeks of chemotherapy (HR 0.97; P = 0.818 for DFS and HR 0.97; P = 0.825 for OS). Trastuzumab-treated patients with HER2-positive disease showed similar DFS (P = 0.305) but a significantly better adjusted OS (P = 0.040) when compared with patients with HER2-negative disease treated with chemotherapy alone. Recorded long-term cardiac toxicity was low.

CONCLUSIONS

Long-term results, similar to the results of pCR, do not support the use of capecitabine in the neoadjuvant setting in addition to an anthracycline-taxane-based chemotherapy. However, the results support previous data showing a benefit of trastuzumab as predicted by higher pCR rates.

Neoadjuvant bevacizumab and anthracycline-taxane-based chemotherapy in 678 triple-negative primary breast cancers; results from the geparquinto study (GBG 44)

BACKGROUND

We evaluated the pathological complete response (pCR) rate after neoadjuvant epirubicin, (E) cyclophosphamide (C) and docetaxel containing chemotherapy with and without the addition of bevacizumab in patients with triple-negative breast cancer (TNBC).

PATIENTS AND METHODS

Patients with untreated cT1c-4d TNBC represented a stratified subset of the 1948 participants of the HER2-negative part of the GeparQuinto trial. Patients were randomized to receive four cycles EC (90/600 mg/m(2); q3w) followed by four cycles docetaxel (100 mg/m(2); q3w) each with or without bevacizumab (15 mg/kg; q3w) added to chemotherapy.

RESULTS

TNBC patients were randomized to chemotherapy without (n = 340) or with bevacizumab (n = 323). pCR (ypT0 ypN0, primary end point) rates were 27.9% without and 39.3% with bevacizumab (P = 0.003). According to other pCR definitions, the addition of bevacizumab increased the pCR rate from 30.9% to 41.8% (ypT0 ypN0/+; P = 0.004), 36.2% to 46.4% (ypT0/is ypN0/+; P = 0.009) and 32.9% to 43.3% (ypT0/is ypN0; P = 0.007). Bevacizumab treatment [OR 1.73, 95% confidence interval (CI) 1.23-2.42; P = 0.002], lower tumor stage (OR 2.38, 95% CI 1.24-4.54; P = 0.009) and grade 3 tumors (OR 1.68, 95% CI 1.14-2.48; P = 0.009) were confirmed as independent predictors of higher pCR in multivariate logistic regression analysis.

CONCLUSIONS

The addition of bevacizumab to chemotherapy in TNBC significantly increases pCR rates.

Ki67 levels as predictive and prognostic parameters in pretherapeutic breast cancer core biopsies: a translational investigation in the neoadjuvant GeparTrio trial

BACKGROUND

The proliferation marker Ki67 has been suggested as a promising cancer biomarker. As Ki67 needs an exact quantification, this marker is a prototype of a new generation of tissue-based biomarkers. In this study, we have systematically evaluated different cut points for Ki67 using three different clinical end points in a large neoadjuvant study cohort.

PATIENTS AND METHODS

We have evaluated pretherapeutic Ki67 levels by immunohistochemistry in 1166 breast cancer core biopsies from the neoadjuvant GeparTrio trial. We used the standardized cutoff-finder algorithm for three end points [response to neoadjuvant chemotherapy (pCR), disease-free (DFS) and overall-survival (OS)]. The analyses were stratified for hormone receptor (HR) and HER2 status by molecular subtype radar diagrams (MSRDs).

RESULTS

A wide range of Ki67 cut points between 3%-94% (for pCR), 6%-46% (for DFS) and 4%-58% (for OS) were significant. The three groups of Ki67 ≤ 15% versus 15.1%-35% versus >35% had pCR-rates of 4.2%, 12.8%, and 29.0% (P < 0.0005), this effect was also present in six of eight molecular subtypes. In MSRD, Ki67 was significantly linked to prognosis in uni- and multivariate analysis in the complete cohort and in HR-positive, but not triple-negative tumors.

CONCLUSIONS

Ki67 is a significant predictive and prognostic marker over a wide range of cut points suggesting that data-derived cut point optimization might not be possible. Ki67 could be used as a continuous marker; in addition, the scientific community could define standardized cut points for Ki67. Our analysis explains the variability observed for Ki67 cut points in previous studies; however, this should not be seen as weakness, but as strength of this marker. MSRDs are an easy new approach for visualization of biomarker effects on outcome across molecular subtypes in breast cancer. The experience with Ki67 could provide important information regarding the development and implementation of other quantitative biomarkers.

Using the 21-gene assay to guide adjuvant chemotherapy decision-making in early-stage breast cancer: a cost-effectiveness evaluation in the German setting

OBJECTIVE

The 21-gene assay (Oncotype DX Breast Cancer Test (Genomic Health Inc., Redwood City, CA)) is a well validated test that predicts the likelihood of adjuvant chemotherapy benefit and the 10-year risk of distant recurrence in patients with ER+, HER2- early-stage breast cancer. The aim of this analysis was to evaluate the cost-effectiveness of using the assay to inform adjuvant chemotherapy decisions in Germany.

METHODS

A Markov model was developed to make long-term projections of distant recurrence, survival, quality-adjusted life expectancy, and direct costs for patients with ER+, HER2-, node-negative, or up to 3 node-positive early-stage breast cancer. Scenarios using conventional diagnostic procedures or the 21-gene assay to inform treatment recommendations for adjuvant chemotherapy were modeled based on a prospective, multi-center trial in 366 patients. Transition probabilities and risk adjustment were based on published landmark trials. Costs (2011 Euros (€)) were estimated from a sick fund perspective based on resource use in patients receiving chemotherapy. Future costs and clinical benefits were discounted at 3% annually.

RESULTS

The 21-gene assay was projected to increase mean life expectancy by 0.06 years and quality-adjusted life expectancy by 0.06 quality-adjusted life years (QALYs) compared with current clinical practice over a 30-year time horizon. Clinical benefits were driven by optimized allocation of adjuvant chemotherapy. Costs from a healthcare payer perspective were lower with the 21-gene assay by ∼€561 vs standard of care. Probabilistic sensitivity analysis indicated that there was an 87% probability that the 21-gene assay would be dominant (cost and life saving) to standard of care.

LIMITATIONS

Country-specific data on the risk of distant recurrence and quality-of-life were not available.

CONCLUSIONS

Guiding decision-making on adjuvant chemotherapy using the 21-gene assay was projected to improve survival, quality-adjusted life expectancy, and be cost saving vs the current standard of care women with ER+, HER2- early-stage breast cancer.

Abstract S4-5: Ki67 levels in pretherapeutic core biopsies as predictive and prognostic parameters in the neoadjuvant GeparTrio trial

Background: Ki67 has been suggested as a marker for definition of luminal A and luminal B tumors by the 2011 St. Gallen consensus panel. However, the cutoffs for Ki67 are still under debate. In particular, it is not clear if one single cutoff is useful for prognostic and predictive information in the different molecular subtypes. It is an advantage of the neoadjuvant approach that predictive and prognostic outcome measurements can be separated in the same cohort. In this study, we evaluated a large cohort of core biopsies from the neoadjuvant GeparTrio trial to investigate the impact of pretherapeutic Ki67 levels as a predictive marker for response to neoadjuvant chemotherapy as well as a prognostic marker for progression-free and overall survival. The analysis was stratified for hormone-receptor positive and negative tumors as well as HER2 status.

Methods: A total of 1166 pretherapeutic core biopsies from the neoadjuvant Gepartrio trial were evaluated for Ki67 by immunohistochemistry, a total of 200 cells were counted in each sample. Ki67 cutoffs were evaluated using web-based software Cutoff Finder (http://molpath.charite.de/cutoff/). The details of the GeparTrio study design have been described before (von Minckwitz, JNCI 2008). We compared pCR rate as well as the overall and disease free survival in the complete cohort as well as subgroups of patients based on hormone receptor and HER2 expression.

Results: Using Ki67 as a continuous parameter, a wide range of cutoffs between 10% and 80% for Ki67 were predictive for pCR. For DFS and OS, a wide range of cutoffs between 10% and 45% was significant. For further analysis, the three groups of Ki67 0–15% vs. Ki67 15.1%–35% vs. Ki67 &gt;35 were defined and were compared for different outcome parameters. The pCR rates in these three groups of Ki67 expression were 4.2%, 12.9% and 29.0% (p &lt; 0.0005). For DFS and OS, the groups were significantly linked to prognosis in univariate and multivariate analysis. A detailed subgroup analysis was performed showing that Ki67 was significantly predictive for pCR in all molecular subgroups. However, in subgroup survival analysis, Ki67 was prognostic in luminal, but not in triple-negative tumors.

Conclusion: Ki67 is a valid predictive and prognostic marker in breast cancer. This marker is significant over a wide range of different cutoffs, which explains the different results of Ki67 cutoffs in different previous studies. Therefore, the variability observed in different studies evaluating Ki67 might reflect A) the wide range of valid cutoffs B) the different clinical endpoints of the studies and C) the different contribution of the molecular subtypes in the study cohorts. Based on our results we suggest three subgroups for Ki67 (0–15% vs. 15.1–35 vs. &gt;35%) as a reasonable approach for further standardization of this marker.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S4-5.

PD07-05: Local Recurrence Risk in 6377 Patients with Early Breast Cancer Receiving Neoadjuvant Anthracycline-Taxane +/− Trastuzumab Containing Chemotherapy

Background: Locoregional recurrence (LRR; defined according to Hudis C, JCO 2007) risk after neoadjuvant systemic treatment is considered as a possible hazard of this treatment approach. However, few data exist on the incidence and risk factors for LRR after anthracycline-taxane+/−trastuzumab (AT+/−H) containing neoadjuvant treatment. We analyzed individual data of 7 prospective neoadjuvant trials conducted by the German Breast Group and the AGO Breast Group.

Patients (Pts) and methods: 6377 Pts with operable or locally advanced, non-metastatic breast cancer were analyzed (for details see von Minckwitz G et al, BCRT 2010). Postsurgical radiotherapy was indicated after breast conservation for all patients and after mastectomy for patients with cT3/4 or cN+ disease. Endocrine treatment was given to ER− and/or PgR-positive patients. 485 LRR were observed during a median follow up of 46.2 (0-127) months.

Results: LRR was similar for patients treated by tumorectomy (7.2% of N=1123), segmentectomy (6.8% of N=1121), quadrantectomy (7% of 557), or breast conservation (BCT) (not otherwise specified) (7.7% of N=819), but higher in patients treated by mastectomy (ME) (12.1% of N=1670) (p&lt;0.001). Rate of breast conservation decreased by increasing initial tumor size (cT1(N=198): 77.7%, cT2(N=3675): 78.1%, cT3(N=795): 49.4%, cT4a-c(N=348): 35.9%, cT4d(N=235):19.1%). LRR in patients treated by BCT or ME were 9.1% vs 9.1% for cT1 (p=0.9); 6.9% vs. 9.8% for cT2 (p=0.001); 9.7% vs 14.2% for cT3 (p=0.04); 3.2% vs. 11.7% for cT4a-c (p=0.004; and 22.2% vs 18.9% for cT4d (p=0.4). LRR increased with surgical yT-stage from 4.7% for ypT0 (N=990), 11.8% for ypTis (N=340), 9.1% for ypT1 (N=1555), 8.2% for ypT2 (N=926), 13.8% for ypT3 (N=232), 20% ypT4a-c (N=80), to 31.2% for ypT4d (N=16) (p&lt;0.001). Comparable results were obtained for cN and ypN stages. Patients with a pathological complete response (pCR = ypT0 ypN0) showed a lower LRR of 3.7% compared to patients not achieving a pCR (3.7% vs 9.9% (HR 0.36 p&lt;0.001). Patients with a pCR showed low LRR in all intrinsic subtypes except Luminal B/HER2+ -like tumors (Luminal A-like tumors (N=105; 3.8%), Luminal B/HER2− -like (N=40; 0%), Luminal B/Her2+ -like (N=124; 8.1%), HER2+(non-luminal)-like (N=158; 1.9%), triple-negative (N=276; 2.5%) (p=0.016). Patients without a pCR showed an excessive LRR for HER2+(non-luminal) and triple-negative tumors (Luminal A-like tumors (N=1498; 5.1%), Luminal B/HER2− -like (N=304; 11.9%), Luminal B/HER2+ -like (N=602; 8.5%), HER2+(non-luminal)-like (N=367; 18%) and triple-negative (N=276; 17.8%) (p&lt;0.001). cT, cN, ypN, intrinsic subtype, but not ypT stage and type of surgery were independent predictors of LRR for patients without pCR in a Cox regression model. None of these factors except Luminal B/HER2+ (p=0.012) were significant in patients with pCR.

Conclusions: LRR in this large pooled analysis after AT+/−H containing neoadjuvant treatment appears to be low, especially in all patients with a pCR except Luminal B/HER2+ disease. In patients without a pCR low cT, cN, ypN and Luminal tumor type predict a low LRR. Other stages and subtypes without pCR should be carefully followed up irrespective of type of surgery.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD07-05.

[Imatinib--a possible therapeutic option for cervical carcinoma: results of a preclinical phase I study]

BACKGROUND

In the last few years, the therapy of cervical carcinoma has progressed substantially due to the use of simultaneous platinum- containing radiochemotherapy. However, there are no data which evaluate an individualized treatment adapted to tumor biology, in spite of the fact that patients show remarkably different responses to chemotherapy. Therefore this preclinical phase I study aims at finding therapeutic alternatives to the current cytostatic drugs to treat cervical carcinoma.

MATERIAL AND METHODS

In a tumor chemosensitivity assay, 8 drugs were tested on freshly isolated tumor cells of 16 patients [carbo- and cisplatin, topotecan, paclitaxel as well as the 2 tyrosine kinase inhibitors imatinib (Glivec) and gefitinib (Iressa (R) ) and the 2 monoclonal antibodies cetuximab (Erbitux) and trastuzumab (Herceptin (R) )].

RESULTS

Overall the test was evaluable for 16 specimens (100%). Ten of 15 tumor samples (66.6%) were sensitive to imatinib. A sensitive therapeutic response could be demonstrated in all tested FIGO stages. An interindividual comparison could establish sensitivity to cetuximab in 12.5% of cases, to gefitinib in 6.25%, to trastuzumab in 6.6%, to cisplatin in 13.3%, to carboplatin in 7.6%, to paclitaxel in 93.8% and to topotecan in 25%.

CONCLUSION

Imatinib seems to be an efficacious therapeutic option for patients with cervical carcinoma, independently of tumor subtype.

Docetaxel and carboplatin as first-line chemotherapy in patients with advanced gynecological tumors. A phase I/II trial of the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO-OVAR) Ovarian Cancer Study Group

OBJECTIVES

We performed a phase I-II study in patients with ovarian and other gynecological cancers to determine the dose-limiting toxicities, maximum tolerated dose (MTD) and efficacy of docetaxel/carboplatin.

METHODS

Thirty patients were treated in three cohorts with carboplatin (AUC 5) and escalating docetaxel (60, 75 and 90 mg/m2), administered intravenously on day 1, repeated every 3 weeks. Premedication consisted of 16 mg dexamethasone per os on day -1, and +1 and 4 mg intravenously before docetaxel.

RESULTS

A total of 6, 11 and 12 patients were eligible and treated on dose levels 1, 2 and 3, respectively. At docetaxel 90 mg/m2, febrile and prolonged neutropenia were dose-limiting, and 75 mg/m2 with carboplatin AUC 5 was considered the MTD. Prolonged neutropenia occurred in two, four and nine patients of dose levels 1-3, respectively, and febrile neutropenia in 2, 1, and 2 patients of dose level 1-3. Thrombocytopenia grade 4 was observed in one patient of dose level 1. Non-hematological toxicity including neuropathy was usually mild across all dose levels. Overall response rate was 73%. Median time to progression was 18.0 months, and median overall survival will exceed 24.4 months.

CONCLUSIONS

Docetaxel/carboplatin can be safely administered to patients with gynecological cancer despite substantial myelotoxicity and appears to be active in the treatment of ovarian cancer. Low neurotoxicity offers an option for comparison with paclitaxel-containing regimens.

[Chemoprevention of breast cancer: a literature review and report on the current status in Germany]

The prevention of breast cancer is increasingly of focus in health-politics policies and has gained a valid position in the area of medical intervention. Data from a current meta-analysis of all four randomised Tamoxifen prevention studies illustrate a reduction of 38 % (Odds ratio 0.62; 95 % CI 0.42-0.89) in the incidence of breast cancer. This observation lead to registration of this drug in the USA for the prevention of breast cancer in women with a calculated 5-year risk of > 1.66 %. In addition to Tamoxifen, further substances are currently being tested with the aim of improving the therapeutic index whilst reducing incidence and mortality rates. These are primarily substances which have proven efficacy in the treatment of breast cancer (other antioestrogens, aromatase inhibitors and GnRH-analogues) or those whose mechanism of action predict a preventative effect (retinoids, phytooestrogens, substitution preparations e. g. Tibolone). In Germany, chemoprevention is currently only to be recommended within study protocols, as to date no substance is approved in the indication 'prevention of breast cancer'. A essential contribution to the accrual of valid data is the conduct of breast cancer prevention trials. The participation of women with high risk of breast cancer in Germany is, in contrast to comparable international studies, problematic. Data on the current knowledge and attitude of the female population towards such trials (gathered via a questionnaire of the DACH in 7 000 women) show that only 19.5 % of the women questioned during a consultation with a gynaecologist were aware of the possibility of active chemoprevention. However, 55.3 % stated that they would be prepared to take such a substance, were chemoprevention possible. Studies for both pre- and post-menopausal women with increased risk of breast cancer are currently active in Germany (GISS and IBIS-II of the study group GABG - German Adjuvant Breast cancer Group). An intensive information campaign to raise public awareness of breast cancer risk amongst women and their physicians is planned in conjunction with the IBIS-II study (www.brustkrebsvorbeugen.de). Latest literature recommendations for prevention of breast cancer (Chlebowski et al.) have been assessed.

[Comparing the visualization of microcalcifications with direct magnification in digital full-field mammography vs. film-screen mammography]

PURPOSE

To evaluate the conspicuity of microcalcifications in magnified mammographic views of preparations obtained with full field digital mammography (FFDM), film-screen mammography (FSM), and the DIMA technique.

MATERIAL AND METHODS

Twelve preparations were examined by FFDM and FSM using 1.8 x magnification and DIMA using 7 x magnification. Parameter settings were identical for all three techniques. The number of visible microcalcifications was then determined for each modality by three radiologists. As far as possible, all preparations were X-rayed at 22 kV and 10 mAS.

RESULTS

Altogether 9705 calcifications were counted (DIMA: 1609/1542/1534; FFDM: 1020/753/881; FSM: 901/643/822). The total number of microcalcifications identified with the DIMA technique was 4685 as compared to 2654 with FFDM and 2366 with FSM. The calcifications counted with FFDM and FSM thus corresponded to 56.6 % and 50.5 %, respectively, of those identified with DIMA. The differences between the groups were statistically significant (F-Test, p < 0.05).

CONCLUSION

Significantly more calcifications are identified when magnified mammographic views of preparations containing microcalcifications are obtained with the DIMA technique compared to FFDM or FSM. FFDM depicts markedly more calcifications than FSM. This means one should increase spatial resolution. Digital mammography offers the potential for improved visualization of microcalcifications with advanced applications.

Magnetic Resonance Female Breast Imaging (MRFBI) - Evaluation of the Changes in Signal Intensity over Time Pre- and Post-administration of 0.2 mmol/kg Gd-DTPA

PURPOSE

We are looking for a threshold value to discriminate between benign and malign breast lesions in MRI of female breast after administration of 0.2 mmol Gadolinum-DTPA/kg bw.

MATERIALS AND METHODS

Double coil breast MRI (1.5 Tesla) were performed in 65 patients with an suspicious lesion for malignancy in an anteriorly examination. 57 patients could be evaluated in our study design. Histopathological 35 patients had an invasive carcinoma, 3 patients had an in-situ-carcinoma and in 27 patients benign changes were found.

RESULTS

For different carcinoma diameters we found a different increase of signal intensity (SI): small carcinoma (< 10 mm) had an maximum increase of SI of 102 %, medium sized (10 to 20 mm) 222 % and carcinomas over 20 mm showed an increase of 271 %. We did not find a significant difference between SI in benign and malign lesions. The sensitivity was 94.6 % the specificity 65 %.

CONCLUSION

A threshold value to distinguish between malign and benign in MRI could not be defined. With the double normal Gd-DTPA dose we do not have better specificity and sensitivity than for normal dose (0.1 mmol/kg bw) is described.

[Preoperative chemotherapy in primary operable breast cancer with a dose-dense combination of doxorubicin and docetaxel (ADoc) - Experience of the GEPARDO-GABG study group]

OBJECTIVE

The German Adjuvant Breast Cancer Study Group (GABG) conducts trials of preoperative chemotherapy in patients with primary breast cancer using a combination of doxorubicin and docetaxel (ADoc). -

PATIENTS AND METHODS

We conducted a parallel-grouped phase IIa-study with 42 patients with a conventionally dosed and a dose-dense ADoc-schedule (4 cycles of Doxorubicin 50 mg/m(2), Docetaxel 75 mg/m(2) i. v. day 1, q day 15 or 22; G-CSF day 3-15 only for the dose-dense schedule) and a randomized phase IIb-study (GEPARDO-Study) with 250 patients with ADoc +/- Tamoxifen. Biological factors were determined immunohistochemically on 197 core biopsies before treatment. A comparison to a sequential AC-Doc regimen including 913 patients has been completed recently. -

RESULTS

ADoc can be applicated on schedule in 93 % of all patients. The dose-dense regimen shows a tendency to more toxicity but also to more efficacy. The rate of complete pathological remissions (pCR) was 9.7 %. No difference was found between chemo- and chemoendocrine treatment. Clinically negative lymphnodes and a negative estrogen receptor status is predictive for a higher pCR-rate. To date no differences in toxicity could be found between ADoc and AC-Doc. -

CONCLUSIONS

The dose-dense ADoc regimen is well tolerated and highly effective as preoperative therapy of breast cancer.

Dose-dense doxorubicin, docetaxel, and granulocyte colony-stimulating factor support with or without tamoxifen as preoperative therapy in patients with operable carcinoma of the breast: a randomized, controlled, open phase IIb study

PURPOSE

To investigate the effect of adding tamoxifen to a preoperative dose-dense doxorubicin and docetaxel regimen on the pathologic response of primary operable breast cancer.

PATIENTS AND METHODS

Patients (tumor size > or = 3 cm, N0 to 2, M0) were prospectively randomized to receive every 14 days a total of four cycles of doxorubicin 50 mg/m2 and docetaxel 75 mg/m(2), either with (ADocT) or without (ADoc) simultaneous tamoxifen. Granulocyte colony-stimulating factor (G-CSF) was routinely given on days 5 to 10. Surgery followed 8 to 10 weeks after the start of treatment.

RESULTS

Within 14 months, 250 patients were included in the study at 56 centers. Of 992 planned cycles, 97.9% were administered. Pathologically complete remission (pCR) with no detectable viable tumor cells was achieved in 9.7%. There was a nonsignificant difference of -1.2% in favor of ADoc, with a 95% confidence interval of -8.6% to 6.2%. A further 2.4% had only noninvasive tumor residues, and 13.8% had focal invasive residues. Complete and partial responses detected by palpation were observed in 28.9% and 52.4%, respectively. The response rates (complete and partial) by best appropriate imaging methods were 77.5% and 67.5% for ADocT and ADoc, respectively. Breast conservation was possible in 68.8% of the patients. A tendency toward more frequent toxic events was observed with ADocT treatment. Significant predictors of pCR to chemotherapy were negative lymph node and negative estrogen receptor status.

CONCLUSION

A dose-dense regimen of ADoc with G-CSF offers high compliance, moderate toxicity, and rapid efficacy as a form of preoperative chemotherapy in operable breast cancer. Concurrent treatment with tamoxifen for 8 weeks could not improve the pathologic response rate.

Second-line carboplatin and gemcitabine in platinum sensitive ovarian cancer--a dose-finding study by the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO) Ovarian Cancer Study Group

BACKGROUND

Despite the progress that has been achieved in the last years, recurrence rates in ovarian cancer patients are still considerably high and the majority of patients ultimately become candidates for second-line treatment. Carboplatin reinduction is a broadly adopted regimen in patients with recurrences occurring six months or later after first-line treatment. Gemcitabine is among the candidates as combination partner in second-line regimens.

PATIENTS AND METHODS

We performed a study with escalating doses of gemcitabine combined with carboplatin in 26 platinum-pretreated patients with recurrent ovarian cancer and a treatment-free interval of 6+ months. Dose-limiting toxicity (DLT) and a maximum tolerable dose (MTD) recommendable for further trials was evaluated.

RESULTS

The DLT was myelosuppression, mainly thrombocytopenia. No dose limiting non-hematological toxicities were observed. The MTD of gemcitabine was 1,000 mg/m2 given on days 1 + 8 of a three-week schedule combined with carboplatin AUC 4 given on day 1. The majority of evaluable patients showed an objective response (62.5%), and median progression-free and overall survival were 10 and 18+ months, respectively.

CONCLUSION

Gemcitabine-carboplatin given according to the MTD is well tolerated and active against recurrent platinum-sensitive disease. A randomized trial comparing carboplatin with or without gemcitabine in platinum-sensitive ovarian cancer has already been initiated.

[Adjuvant chemotherapy of cervix carcinoma--results of a phase II study]

OBJECTIVE

Therapies involving a radical operation and radiation treatment for cervical carcinoma in stages I and II are not sufficiently effective in patient subgroups with high risk for recurrence. In recent publications, patients with high risk cervical cancer had with adjuvant simultaneous radio-chemotherapy a better disease free and overall survival but a higher toxicity compared with patients received an adjuvant radiotherapy alone.

MATERIAL AND METHODS

34 patients with at least 2 risk factors for recurrence of cervical cancer were treated with adjuvant chemotherapy after radical hysterectomy. The protocol consisted of 3 cycles of ifosfamide 1.6 g/m2 (d 1-3) and carboplatin (AUC 4, d1) every three weeks. For cell protection 21 patients received amifostine 740 mg/m2 d1-3; this was followed by standard radiation therapy (50.4 Gy percutaneous and high-dose-rate-after-loading for 21 patients, 2 x 5 Gy). The dose determination of the substances and their toxicity were investigated.

RESULTS

Patient (p) data: Median age 43 years (range: 25-70); pT1b-2a: n = 22; pT2b: n = 12; pN1: n = 28; pN0: n = 6; G3: n = 10; adeno- and adenosquamous carcinoma: n = 9, G3: n = 10, R1-resection: n = 5. 70.6% of these high-risk patients were disease-free after a median observation time of 40 (18-62) months. Median number of cycles of chemotherapy: 2.8. There was no more dose escalation than carboplatin according to AUC 4 possible. Hematologic toxicity (CTC grading, % of 96 documented cycles): anemia-grade 3-4: 30; -grade 1-2: 10.4; leukopenia-grade 3-4: 13, -grade 1-2: 21.7; alopecia-grade 3: all p.; cerebral neurotoxicity-grade 3-4: 8.3, -grade 1-2; 17.7; diarrhea under radiotherapy-grade 3-4: 2 p., -grade 1-2: 6 p.

CONCLUSION

This combined sequential adjuvant therapy was effective and had an acceptable level of toxicity. A phase III study comparing adjuvant sequential chemo-radiotherapy with and without Erythropoeitin to counteract the negative effects of anemia started in Germany in 1999 and had randomized now about 270 patients.

Detection of HMGI-C in the peripheral blood of breast cancer patients

The human high mobility group (HMG) protein (HMGI-C) belongs to the HMG family of architectural transcription factors which are expressed only during embryonic development, and not in normal adult tissues. Considerable interest has recently been shown in HMGI-C and its expression in a variety of neoplastic tissues, whereas no expression could be found in normal tissue adjacent to the tumour. So far, no data is available on the expression of HMGI-C in the peripheral blood of patients with solid tumours. In this study we analysed the expression of HMGI-C in peripheral blood samples of 61 patients with breast cancer and 35 healthy donors using a haemi-nested reverse transcriptase-polymerase chain reaction (RT-PCR) technique. No HMGI-C could be detected in any of the healthy donors' samples. In the three prognostic groups according to the Nottingham Prognostic Score, the proportion of patients expressing HMGI-C differed significantly (P=0.001). The worse the prognosis was, the more patients expressed HMGI-C. This is the first report on the expression of HMGI-C in the peripheral blood of patients with breast cancer and our data suggest that this expression is correlated with a poor prognosis.

Pre-operative staging of cervical cancer: comparison of magnetic resonance imaging (MRI) and computed tomography (CT) with histologic results

Thirty-two patients with histologically confirmed cervical carcinoma were preoperatively investigated using MRI; in addition, a CAT-scan was performed on 15 of these patients. The diagnostic results using both modalities were compared with the histological findings (after hysterectomy according to Wertheim-Meigs, including lymph node dissection in the pelvic and, in part, in para-aortal regions). Determination of tumour volume was possible with high accuracy using MRI. Accuracy in assessing the parametria was 86%, vagina 90%, bladder and rectum 97%. The shortcoming of MRI is still the detection of infiltrated lymph nodes. The accuracy of 69% achieved for lymph nodes is equal to results with computed tomography. The general accuracy for our patients in staging was 81% for MRI versus 47% for CT. MRI-based diagnosis enables us to determine a correct tumour staging preoperatively, and is therefore very helpful in planning an adequate therapy. If MRI were used more widely it would contribute to simplification and shortening of the preoperative diagnostic procedure in patients with cervical carcinoma.

Dose- intensified, preoperative and adjuvant chemotherapy in patients with T3- and T4- breast cancer: toxicity, clinical and pathological remission

OBJECTIVE

The aim of the study was to investigate a dose-intensified, preoperative chemotherapy with 3 cycles (cy) of epirubicin 60 mg/m2, ifosfamide 5 g/m2 with mesna 5 g/m2, biweekly with G-CSF 5 micrograms/kg (filgrastim), in terms of toxicity, clinical and pathological remission rates and changes of immunohistochemical characteristics (ER, PR, c-erbB2, p53) during chemotherapy of inoperable patients (pt) with poor prognosis (locally advanced (LABC, 9 pt), inflammatory breast cancer (IBC, 12 pt) and M0.

PATIENTS AND METHODS

Following preoperative chemotherapy (63 cy) and mastectomy patients received adjuvant 3 cy of epirubicin 60 mg/m2 and paclitaxel 175 mg/m2 (biweekly) with G-CSF (54 cy), and subsequently radiation of the thoracic wall and tamoxifen 20 mg/day.

RESULTS

Primary toxicity (T): grade 3 alopecia (21 pt), grade 3-4 leucopenia (7 cy), grade 1-2 leucopenia (26 cy), grade 1-2 anemia (61 cy), grade 1-2 neurocortical T (13 cy), grade 1-2 neurosensory T (7 cy), grade 1 cardiac toxicity (1 pt). ORR: 65% (CR: 0 pt, PR: 13 pt, NC: 8 pt). The grades of histological regression were: 0: 14 pt, 1: 6 pt, 2: 0 pt, 3: 1 pt. No significant correlation was observed between the clinical response and the histological regression (Fischer's exact test). The immunohistochemical expression of tumor characteristics did not change significantly during preoperative chemotherapy (Wilcoxon test). 81% of the pt were disease-free after a median follow-up of 20 months (7-26).

CONCLUSION

This therapy is safe, feasible and effective, both as primary and adjuvant chemotherapy in women with LABC and IBC.

CD99 positivity and EWS-FLI1 gene rearrangement identify a breast tumor in a 60-year-old patient with attributes of the Ewing family of neoplasms

Rearrangements of the EWS gene with ETS transcription factor genes as a result of chromosomal translocation and high expression levels of CD99MIC2 characterize the Ewing family of tumors (EFT). This group of rather undifferentiated neoplasms affects bone and soft tissue in children and young adults mostly between 5 and 30 years of age (median, 15 years). This study reports a case of a CD99MIC2 positive small round cell tumor in the breast of a 60-year-old woman in whom a t(11;22)(q24;q12) chromosomal aberration was identified by cytogenetic analysis. Reverse transcriptase (RT)-polymerase chain reaction (PCR) followed by sequence analysis revealed expression of a chimera transcript in which EWS exon 10 was fused to FLI1 exon 6. Previously, this gene fusion has been reported to occur in approximately 3% of EFT. The specific gene rearrangement of EWS intron 10 was confirmed on Southern blot of genomic DNA. This study further contributes to the growing list of unusual neoplasms in adults that carry genotypic and phenotypic traits of the EFT.

Maximized reduction of primary breast tumor size using preoperative chemotherapy with doxorubicin and docetaxel

PURPOSE

To assess the toxicity and efficacy of preoperative chemotherapy with doxorubicin and docetaxel in patients with primary operable breast cancer.

PATIENTS AND METHODS

Forty-two patients with histologically confirmed primary breast cancer tumors of at least 2 cm in diameter received doxorubicin (50 mg/m(2) intravenously [IV] over 15 minutes) and docetaxel (75 mg/m(2) IV over 1 hour) every 14 (24 patients) or 21 (18 patients) days for four cycles.

RESULTS

The median size of the primary tumor decreased significantly, from 4 cm (range, 2 to 10 cm) to 2 cm (range, 0 to 5 cm) on physical examination and from 3.4 cm (range, 1 to 8 cm) to 1. 8 cm (range, 0 to 4 cm) on sonography (P <.001). The overall response rate as assessed by physical examination was 93%, and complete remission of the primary tumor occurred in 33% of patients. The remission rate as assessed by sonographic measurement was 67%. Two patients (5%) had histologically confirmed complete responses. Sonography was more reliable than palpation in predicting histologically determined response. No grade 4 toxicity was noted, and grade 3 toxicity was reported with alopecia (95%), lethargy (17%), loss of appetite (10%), stomatitis (7%), leukopenia (5%), skin desquamation (5%), infection (5%), motor neuropathy (2%), and nausea (2%). The 3-week schedule was associated with less toxicity than the 2-week schedule.

CONCLUSION

Preoperative combination chemotherapy with doxorubicin and docetaxel is highly effective and feasible in primary operable breast cancer.

The role of docetaxel (Taxotere) in neoadjuvant chemotherapy of breast cancer

Neoadjuvant chemotherapy has become standard therapy in the management of breast cancer patients with locally advanced disease with inoperable tumors and inflammatory breast cancer. Patients with earlier stage breast cancer and operable tumors may also benefit from treatment with neoadjuvant chemotherapy. Docetaxel (Taxotere; Rhône-Poulenc Rorer, Collegeville, PA) is thought to be one of the most potent agents in the treatment of metastatic breast cancer and is therefore being investigated for its likely benefit in preoperative, neoadjuvant regimens. Several large phase II and randomized phase III trials are evaluating docetaxel as a single agent, in combination, and/or sequentially in the preoperative setting. Preliminary findings demonstrate high complete and partial response rates and a tolerable toxicity profile. These results are consistent with the view that incorporation of docetaxel in neoadjuvant chemotherapy regimens will contribute to improved patient outcome. Ongoing studies will provide important information regarding the most appropriate regimens and schedules of docetaxel to use in the preoperative, neoadjuvant setting.

Comparison of various imaging methods with particular evaluation of color Doppler sonography for planning surgery for breast tumors

OBJECTIVE

Color Doppler sonography (CD) was compared with other diagnostic imaging methods [mammography (MG), breast ultrasound (US) and magnetic resonance imaging (MRI)] in the planning of surgery for breast tumors.

MATERIALS AND METHODS

99 patients with breast cancer and 101 with ultimately benign breast lesions were examined preoperatively. The specificity and sensitivity were calculated, as well as the predictive values. Various qualitative and semiquantitative CD parameters were also analysed for their diagnostic value.

RESULTS

The sensitivity/specificity of the various methods (in %) was: MG 85/77; US 95/80; CD 82/75; MRI 90/63. The positive predictive value (ppv)/negative predictive value (npv) (in %) was: MG 79/83; US 81/94; CD 72/84; MRI 79/63. The median maximum systolic flow velocity and the resistance index (RI) were significantly higher in breast cancer vessels than in benign lesions. The number of pulsating color pixels detected by CD was significantly higher for breast cancer. In cases of breast cancer significantly more blood flows were detected in the body of the tumor than at its periphery.

CONCLUSION

Color Doppler sonography was not superior to other diagnostic methods for preoperative assessment of a breast lesion. The combination of all diagnostic procedures gave a correct classification rate of 93.3% and is much better than the correct classification of any single diagnostic imaging procedure.

[Optimal use of MRI mammography from the economic viewpoint]

With the introduction of the contrast agent gadolinum DTPA there were hopes that "MRM" would prove to be the investigatory technique that would largely solve the problems of breast diagnostics. However, after the early years of acceptance, the new method of investigation became a subject of controversy. Nonetheless, MRM today occupies a recognized place in diagnostics for certain indications. It is still true, however, that reliable use of this procedure requires a great deal of experience, since there is a relatively large area of overlap between benign and malignant tumors. Further, the costs are significantly higher than those for conventional methods of investigation. New studies that have been conducted at the Charité, Campus Virchow Medical Center in Berlin, suggest that, if one takes the relevant indications into account, MRM can be economic and contribute significantly to cost reduction. Application of a newly developed software package has shown that the good discrimination in a suspect area resulting from contrast agent enhancement makes possible a reliable differentiation between malignant and benign tissue changes. A further result was that, when certain boundary conditions are satisfied, a contrast agent bolus of 0.1 mmol/kg BW is sufficient, making a double dose (0.2 mmol/kg BW) unnecessary.