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Tang X, Prodduturi N, Thompson KJ, Weinshilboum RM, O'Sullivan CC, Boughey JC, Tizhoosh H, Klee EW, Wang L, Goetz MP, Suman V, Kalari KR. OmicsFootPrint: a framework to integrate and interpret multi-omics data using circular images and deep neural networks. bioRxiv 2024:2024.03.21.586001. [PMID: 38585820 PMCID: PMC10996492 DOI: 10.1101/2024.03.21.586001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
The OmicsFootPrint framework addresses the need for advanced multi-omics data analysis methodologies by transforming data into intuitive two-dimensional circular images and facilitating the interpretation of complex diseases. Utilizing Deep Neural Networks and incorporating the SHapley Additive exPlanations (SHAP) algorithm, the framework enhances model interpretability. Tested with The Cancer Genome Atlas (TCGA) data, OmicsFootPrint effectively classified lung and breast cancer subtypes, achieving high Area Under Curve (AUC) scores - 0.98±0.02 for lung cancer subtype differentiation, 0.83±0.07 for breast cancer PAM50 subtypes, and successfully distinguishe between invasive lobular and ductal carcinomas in breast cancer, showcasing its robustness. It also demonstrated notable performance in predicting drug responses in cancer cell lines, with a median AUC of 0.74, surpassing existing algorithms. Furthermore, its effectiveness persists even with reduced training sample sizes. OmicsFootPrint marks an enhancement in multi-omics research, offering a novel, efficient, and interpretable approach that contributes to a deeper understanding of disease mechanisms.
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Montagna G, Mrdutt MM, Sun SX, Hlavin C, Diego EJ, Wong SM, Barrio AV, van den Bruele AB, Cabioglu N, Sevilimedu V, Rosenberger LH, Hwang ES, Ingham A, Papassotiropoulos B, Nguyen-Sträuli BD, Kurzeder C, Aybar DD, Vorburger D, Matlac DM, Ostapenko E, Riedel F, Fitzal F, Meani F, Fick F, Sagasser J, Heil J, Karanlık H, Dedes KJ, Romics L, Banys-Paluchowski M, Muslumanoglu M, Perez MDRC, Díaz MC, Heidinger M, Fehr MK, Reinisch M, Tukenmez M, Maggi N, Rocco N, Ditsch N, Gentilini OD, Paulinelli RR, Zarhi SS, Kuemmel S, Bruzas S, di Lascio S, Parissenti TK, Hoskin TL, Güth U, Ovalle V, Tausch C, Kuerer HM, Caudle AS, Boileau JF, Boughey JC, Kühn T, Morrow M, Weber WP. Omission of Axillary Dissection Following Nodal Downstaging With Neoadjuvant Chemotherapy. JAMA Oncol 2024:2817953. [PMID: 38662396 PMCID: PMC11046400 DOI: 10.1001/jamaoncol.2024.0578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/07/2023] [Indexed: 04/26/2024]
Abstract
Importance Data on oncological outcomes after omission of axillary lymph node dissection (ALND) in patients with breast cancer that downstages from node positive to negative with neoadjuvant chemotherapy are sparse. Additionally, the best axillary surgical staging technique in this scenario is unknown. Objective To investigate oncological outcomes after sentinel lymph node biopsy (SLNB) with dual-tracer mapping or targeted axillary dissection (TAD), which combines SLNB with localization and retrieval of the clipped lymph node. Design, Setting, and Participants In this multicenter retrospective cohort study that was conducted at 25 centers in 11 countries, 1144 patients with consecutive stage II to III biopsy-proven node-positive breast cancer were included between April 2013 and December 2020. The cumulative incidence rates of axillary, locoregional, and any invasive (locoregional or distant) recurrence were determined by competing risk analysis. Exposure Omission of ALND after SLNB or TAD. Main Outcomes and Measures The primary end points were the 3-year and 5-year rates of any axillary recurrence. Secondary end points included locoregional recurrence, any invasive (locoregional and distant) recurrence, and the number of lymph nodes removed. Results A total of 1144 patients (median [IQR] age, 50 [41-59] years; 78 [6.8%] Asian, 105 [9.2%] Black, 102 [8.9%] Hispanic, and 816 [71.0%] White individuals; 666 SLNB [58.2%] and 478 TAD [41.8%]) were included. A total of 1060 patients (93%) had N1 disease, 619 (54%) had ERBB2 (formerly HER2)-positive illness, and 758 (66%) had a breast pathologic complete response. TAD patients were more likely to receive nodal radiation therapy (85% vs 78%; P = .01). The clipped node was successfully retrieved in 97% of TAD cases and 86% of SLNB cases (without localization). The mean (SD) number of sentinel lymph nodes retrieved was 3 (2) vs 4 (2) (P < .001), and the mean (SD) number of total lymph nodes removed was 3.95 (1.97) vs 4.44 (2.04) (P < .001) in the TAD and SLNB groups, respectively. The 5-year rates of any axillary, locoregional, and any invasive recurrence in the entire cohort were 1.0% (95% CI, 0.49%-2.0%), 2.7% (95% CI, 1.6%-4.1%), and 10% (95% CI, 8.3%-13%), respectively. The 3-year cumulative incidence of axillary recurrence did not differ between TAD and SLNB (0.5% vs 0.8%; P = .55). Conclusions and Relevance The results of this cohort study showed that axillary recurrence was rare in this setting and was not significantly lower after TAD vs SLNB. These results support omission of ALND in this population.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary M. Mrdutt
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Susie X. Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Callie Hlavin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Emilia J. Diego
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie M. Wong
- Department of Surgery, McGill University Medical School, Montreal, Quebec, Canada
- Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Andrea V. Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Neslihan Cabioglu
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | - Varadan Sevilimedu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - E. Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Abigail Ingham
- University of Glasgow and National Health Service Greater Glasgow and Clyde, Department of Academic Surgery, Glasgow, Scotland
| | | | | | - Christian Kurzeder
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Danilo Díaz Aybar
- Breast Service, Department of Surgery, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - Denise Vorburger
- Breast Cancer Unit, Comprehensive Cancer Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Dieter Michael Matlac
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Edvin Ostapenko
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Fabian Riedel
- Department of Gynecology and Obstetrics, Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Fitzal
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - Francesco Meani
- Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Gruppo Ospedaliero Moncucco, Ticino, Switzerland
| | - Franziska Fick
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Jacqueline Sagasser
- Department of Obstetrics and Gynecology, University Hospital of Augsburg, Augsburg, Germany
| | - Jörg Heil
- Department of Gynecology and Obstetrics, Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Hasan Karanlık
- Division of Surgical Oncology, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | | | - Laszlo Romics
- University of Glasgow and National Health Service Greater Glasgow and Clyde, Department of Academic Surgery, Glasgow, Scotland
| | - Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Mahmut Muslumanoglu
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | | | - Marcelo Chávez Díaz
- Breast Service, Department of Surgery, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - Martin Heidinger
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Mattea Reinisch
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
- Charité–Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Mustafa Tukenmez
- Department of General Surgery, Istanbul Medical Faculty, Breast Surgery Service, Istanbul University, Istanbul, Turkey
| | - Nadia Maggi
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Nicola Rocco
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Nina Ditsch
- Department of Obstetrics and Gynecology, University Hospital of Augsburg, Augsburg, Germany
| | | | | | - Sebastián Solé Zarhi
- Department of Radiation Oncology, IRAM–Universidad Diego Portales, Santiago, Chile
| | - Sherko Kuemmel
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
- Charité–Universitätsmedizin Berlin, Department of Gynecology with Breast Center, Berlin, Germany
| | - Simona Bruzas
- Interdisciplinary Breast Cancer Center/Breast Unit, Kliniken Essen-Mitte, Germany
| | - Simona di Lascio
- Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Service of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Tanya L. Hoskin
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Uwe Güth
- Breast-Center Zurich AG, Zurich, Switzerland
| | - Valentina Ovalle
- Department of Radiation Oncology, IRAM–Universidad Diego Portales, Santiago, Chile
| | - Christoph Tausch
- Breast-Center Zurich AG, Zurich, Switzerland
- University of Basel, Basel, Switzerland
| | - Henry M. Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Abigail S. Caudle
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jean-Francois Boileau
- Department of Surgery, McGill University Medical School, Montreal, Quebec, Canada
- Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Judy C. Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Thorsten Kühn
- Department of Gynecology, Klinikum Esslingen, Esslingen, Germany
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Walter P. Weber
- Breast Center, University Hospital of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Leon-Ferre RA, Carter JM, Zahrieh D, Sinnwell JP, Salgado R, Suman VJ, Hillman DW, Boughey JC, Kalari KR, Couch FJ, Ingle JN, Balkenhol M, Ciompi F, van der Laak J, Goetz MP. Automated mitotic spindle hotspot counts are highly associated with clinical outcomes in systemically untreated early-stage triple-negative breast cancer. NPJ Breast Cancer 2024; 10:25. [PMID: 38553444 PMCID: PMC10980681 DOI: 10.1038/s41523-024-00629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 03/08/2024] [Indexed: 04/02/2024] Open
Abstract
Operable triple-negative breast cancer (TNBC) has a higher risk of recurrence and death compared to other subtypes. Tumor size and nodal status are the primary clinical factors used to guide systemic treatment, while biomarkers of proliferation have not demonstrated value. Recent studies suggest that subsets of TNBC have a favorable prognosis, even without systemic therapy. We evaluated the association of fully automated mitotic spindle hotspot (AMSH) counts with recurrence-free (RFS) and overall survival (OS) in two separate cohorts of patients with early-stage TNBC who did not receive systemic therapy. AMSH counts were obtained from areas with the highest mitotic density in digitized whole slide images processed with a convolutional neural network trained to detect mitoses. In 140 patients from the Mayo Clinic TNBC cohort, AMSH counts were significantly associated with RFS and OS in a multivariable model controlling for nodal status, tumor size, and tumor-infiltrating lymphocytes (TILs) (p < 0.0001). For every 10-point increase in AMSH counts, there was a 16% increase in the risk of an RFS event (HR 1.16, 95% CI 1.08-1.25), and a 7% increase in the risk of death (HR 1.07, 95% CI 1.00-1.14). We corroborated these findings in a separate cohort of systemically untreated TNBC patients from Radboud UMC in the Netherlands. Our findings suggest that AMSH counts offer valuable prognostic information in patients with early-stage TNBC who did not receive systemic therapy, independent of tumor size, nodal status, and TILs. If further validated, AMSH counts could help inform future systemic therapy de-escalation strategies.
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Affiliation(s)
| | | | | | | | - Roberto Salgado
- GZA-ZNA-Hospitals, Antwerp, Belgium
- Peter Mac Callum Cancer Centre, Melbourne, Australia
| | | | | | | | | | | | | | | | | | - Jeroen van der Laak
- Radboud University Medical Center, Nijmegen, Netherlands
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
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Steadman JA, Hoskin TL, Klassen C, Boughey JC, Degnim AC, Piltin MA, Mrdutt MM, Johnson JE, Hieken TJ. Assessment of the effect of the American Society of Breast Surgery guidelines on contralateral prophylactic mastectomy rates for unilateral breast cancer. Surgery 2024; 175:677-686. [PMID: 37863697 DOI: 10.1016/j.surg.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/31/2023] [Accepted: 09/05/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND In July 2016, the American Society of Breast Surgeons published guidelines discouraging contralateral prophylactic mastectomy for average-risk women with unilateral breast cancer. We incorporated these into practice with structured patient counseling and aimed to assess the effect of this initiative on contralateral prophylactic mastectomy rates. METHODS We evaluated female patients with unilateral breast cancer undergoing mastectomy at our institution from January 2011 to November 2022. Variables associated with contralateral prophylactic mastectomy and trends over time were analyzed using the Wilcoxon rank sum test or χ2 analysis as appropriate. RESULTS Among 3,208 patients, (median age 54 years) 1,366 (43%) had a unilateral mastectomy, and 1,842 (57%) also had a concomitant contralateral prophylactic mastectomy. Across all patients, contralateral prophylactic mastectomy rates significantly decreased post-implementation from 2017 to 2019 (55%) vs 2015 to 2016 (62%) (P = .01) but increased from 2020 to 2022 (61%). Immediate breast reconstruction rate was 70% overall (81% with contralateral prophylactic mastectomy and 56% without contralateral prophylactic mastectomy, P < .001). Younger age, White race, mutation status, and earlier stage were also associated with contralateral prophylactic mastectomy. Genetic testing increased from 27% pre-guideline to 74% 2020 to 2022, as did the proportion of patients with a pathogenic variant (4% pre-guideline vs 11% from 2020-2022, P < .001), of whom 91% had a contralateral prophylactic mastectomy. Among tested patients without a pathogenic variant and patients not tested, contralateral prophylactic mastectomy rates declined from 78% to 67% and 48% to 38% pre -and post-guidelines, respectively, P < .001. CONCLUSION Implementation of specific patient counseling was effective in decreasing contralateral prophylactic mastectomy rates. While recognizing that patient choice plays a significant role in the decision for contralateral prophylactic mastectomy, further educational efforts are warranted to affect contralateral prophylactic mastectomy rates, particularly in the setting of negative genetic testing.
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Affiliation(s)
- Jessica A Steadman
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Tanya L Hoskin
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Amy C Degnim
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Mara A Piltin
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Mary M Mrdutt
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Jeffrey E Johnson
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Tina J Hieken
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN.
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Albain KS, Yau C, Petricoin EF, Wolf DM, Lang JE, Chien AJ, Haddad T, Forero-Torres A, Wallace AM, Kaplan H, Pusztai L, Euhus D, Nanda R, Elias AD, Clark AS, Godellas C, Boughey JC, Isaacs C, Tripathy D, Lu J, Yung RL, Gallagher RI, Wulfkuhle JD, Brown-Swigart L, Krings G, Chen YY, Potter DA, Stringer-Reasor E, Blair S, Asare SM, Wilson A, Hirst GL, Singhrao R, Buxton M, Clennell JL, Sanil A, Berry S, Asare AL, Matthews JB, DeMichele AM, Hylton NM, Melisko M, Perlmutter J, Rugo HS, Symmans WF, van’t Veer LJ, Yee D, Berry DA, Esserman LJ. Neoadjuvant Trebananib plus Paclitaxel-based Chemotherapy for Stage II/III Breast Cancer in the Adaptively Randomized I-SPY2 Trial-Efficacy and Biomarker Discovery. Clin Cancer Res 2024; 30:729-740. [PMID: 38109213 PMCID: PMC10956403 DOI: 10.1158/1078-0432.ccr-22-2256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 10/11/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Abstract
PURPOSE The neutralizing peptibody trebananib prevents angiopoietin-1 and angiopoietin-2 from binding with Tie2 receptors, inhibiting angiogenesis and proliferation. Trebananib was combined with paclitaxel±trastuzumab in the I-SPY2 breast cancer trial. PATIENTS AND METHODS I-SPY2, a phase II neoadjuvant trial, adaptively randomizes patients with high-risk, early-stage breast cancer to one of several experimental therapies or control based on receptor subtypes as defined by hormone receptor (HR) and HER2 status and MammaPrint risk (MP1, MP2). The primary endpoint is pathologic complete response (pCR). A therapy "graduates" if/when it achieves 85% Bayesian probability of success in a phase III trial within a given subtype. Patients received weekly paclitaxel (plus trastuzumab if HER2-positive) without (control) or with weekly intravenous trebananib, followed by doxorubicin/cyclophosphamide and surgery. Pathway-specific biomarkers were assessed for response prediction. RESULTS There were 134 participants randomized to trebananib and 133 to control. Although trebananib did not graduate in any signature [phase III probabilities: Hazard ratio (HR)-negative (78%), HR-negative/HER2-positive (74%), HR-negative/HER2-negative (77%), and MP2 (79%)], it demonstrated high probability of superior pCR rates over control (92%-99%) among these subtypes. Trebananib improved 3-year event-free survival (HR 0.67), with no significant increase in adverse events. Activation levels of the Tie2 receptor and downstream signaling partners predicted trebananib response in HER2-positive disease; high expression of a CD8 T-cell gene signature predicted response in HR-negative/HER2-negative disease. CONCLUSIONS The angiopoietin (Ang)/Tie2 axis inhibitor trebananib combined with standard neoadjuvant therapy increased estimated pCR rates across HR-negative and MP2 subtypes, with probabilities of superiority >90%. Further study of Ang/Tie2 receptor axis inhibitors in validated, biomarker-predicted sensitive subtypes is warranted.
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Affiliation(s)
- Kathy S. Albain
- Loyola University Chicago Stritch School of Medicine, Chicago, IL
| | - Christina Yau
- University of California San Francisco, San Francisco, CA
| | | | - Denise M. Wolf
- University of California San Francisco, San Francisco, CA
| | | | - A. Jo Chien
- University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Debu Tripathy
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Janice Lu
- University of Southern California, Los Angeles, CA
| | | | | | | | | | - Gregor Krings
- University of California San Francisco, San Francisco, CA
| | - Yunn Yi Chen
- University of California San Francisco, San Francisco, CA
| | | | | | - Sarah Blair
- University of California San Diego, La Jolla, CA
| | - Smita M. Asare
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | - Ruby Singhrao
- University of California San Francisco, San Francisco, CA
| | | | | | | | | | - Adam L. Asare
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | | | - Nola M. Hylton
- University of California San Francisco, San Francisco, CA
| | | | | | - Hope S. Rugo
- University of California San Francisco, San Francisco, CA
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6
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Bedrosian I, Somerfield MR, Achatz MI, Boughey JC, Curigliano G, Friedman S, Kohlmann WK, Kurian AW, Laronga C, Lynce F, Norquist BS, Plichta JK, Rodriguez P, Shah PD, Tischkowitz M, Wood M, Yadav S, Yao K, Robson ME. Germline Testing in Patients With Breast Cancer: ASCO-Society of Surgical Oncology Guideline. J Clin Oncol 2024; 42:584-604. [PMID: 38175972 DOI: 10.1200/jco.23.02225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 01/06/2024] Open
Abstract
PURPOSE To develop recommendations for germline mutation testing for patients with breast cancer. METHODS An ASCO-Society of Surgical Oncology (SSO) panel convened to develop recommendations based on a systematic review and formal consensus process. RESULTS Forty-seven articles met eligibility criteria for the germline mutation testing recommendations; 18 for the genetic counseling recommendations. RECOMMENDATIONS BRCA1/2 mutation testing should be offered to all newly diagnosed patients with breast cancer ≤65 years and select patients >65 years based on personal history, family history, ancestry, or eligibility for poly(ADP-ribose) polymerase (PARP) inhibitor therapy. All patients with recurrent breast cancer who are candidates for PARP inhibitor therapy should be offered BRCA1/2 testing, regardless of family history. BRCA1/2 testing should be offered to women who develop a second primary cancer in the ipsilateral or contralateral breast. For patients with prior history of breast cancer and without active disease, testing should be offered to patients diagnosed ≤65 years and selectively in patients diagnosed after 65 years, if it will inform personal and family risk. Testing for high-penetrance cancer susceptibility genes beyond BRCA1/2 should be offered to those with supportive family histories; testing for moderate-penetrance genes may be offered if necessary to inform personal and family cancer risk. Patients should be provided enough pretest information for informed consent; those with pathogenic variants should receive individualized post-test counseling. Variants of uncertain significance should not impact management, and patients with such variants should be followed for reclassification. Referral to providers experienced in clinical cancer genetics may help facilitate patient selection and interpretation of expanded testing, and provide counseling of individuals without pathogenic germline variants but with significant family history.Additional information is available at www.asco.org/breast-cancer-guidelines.
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Affiliation(s)
| | | | | | | | - Giuseppe Curigliano
- University of Milan, Italy
- European Institute of Oncology, IRCCS, Milano, Italy
| | - Sue Friedman
- FORCE (Facing Our Risk of Cancer Empowered), Tampa, FL
| | - Wendy K Kohlmann
- University of Utah Huntsman Cancer Institute, Salt Lake City, UT
| | | | | | | | | | | | - Patricia Rodriguez
- Hereditary Cancer Risk Assessment Program, Virginia Cancer Specialists, Arlington, VA
| | - Payal D Shah
- Basser Center for BRCA & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Marc Tischkowitz
- Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | | | | | - Katherine Yao
- Division of Surgical Oncology at NorthShore University Health System, Evanston, IL
| | - Mark E Robson
- Memorial Sloan Kettering Cancer Center, New York, NY
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7
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Moldoveanu D, Hoskin TL, Day CN, Schulze AK, Goetz MP, Boughey JC. Nodal pCR and overall survival following neoadjuvant chemotherapy for node positive ER+/Her2- breast cancer. Breast Cancer Res Treat 2024; 203:419-428. [PMID: 37878154 DOI: 10.1007/s10549-023-07152-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/29/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE The role of neoadjuvant chemotherapy (NAC) in node-positive (N+) ER+/HER2- breast cancer (BC) is debated, given low total pathologic complete response (pCR) rates. However, the rate and impact of nodal pCR is unknown. We sought to evaluate nodal pCR rates and the impact on overall survival (OS). Further, we sought to validate the association between nodal pCR with age and Ki67. METHODS We queried the National Cancer Database for cN + ER+/HER2- BC patients treated with NAC and surgery. Data from 2010 to 2018 were used to evaluate nodal pCR and OS, with multivariable Cox proportional hazards modeling for OS, as well as Ki67 for the years 2018-2019. RESULTS From 2010 to 2018, we identified 19,611 cN + ER+/HER2- BC patients treated with NAC. While total pCR occurred in only 7.4%, nodal pCR rates were nearly double (14.3%). Nodal pCR (+/- breast pCR) was seen in 21.7% and associated with 5-year OS rate of 86.1% (95% CI: 84.9-87.4%) versus 77.1% (95% CI: 76.3-77.9%) in patients without nodal pCR (p < 0.001). On multivariable analysis, nodal pCR had better OS (adjusted HR 0.57, 95% CI 0.52-0.63, p < 0.001) across all age groups. Of 2,444 patients with available Ki67, those with age < 50 and Ki67 ≥ 20% had the highest nodal pCR at 31.6%. CONCLUSION In cN + ER+/HER2- BC treated with NAC, nodal pCR is common, associated with age and Ki67, and prognostic for OS. These data strongly suggest that for cN + patients, eradication of nodal disease is critical for OS, and total pCR may not be the optimal measure of NAC benefit.
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Affiliation(s)
- Dan Moldoveanu
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tanya L Hoskin
- Department of Quantitative Health Sciences , Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Quantitative Health Sciences , Mayo Clinic, Rochester, MN, USA
| | - Amy K Schulze
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Matthew P Goetz
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Lohani KR, Hoskin TL, Day CN, Yasir S, Boughey JC, Degnim AC. Lobular-Like Features and Outcomes of Mixed Invasive Ductolobular Breast Cancer (MIDLC): Insights from 54,403 Stage I-III MIDLC Patients. Ann Surg Oncol 2024; 31:936-946. [PMID: 37872454 DOI: 10.1245/s10434-023-14455-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Mixed invasive ductolobular breast cancer (MIDLC) is a rare histological subtype of breast cancer (BC), with components of both invasive ductal cancer (IDC) and invasive lobular cancer (ILC). Its clinicopathological features and outcomes have not been well characterized. METHOD The National Cancer Database 2010-2017 was reviewed to identify women with stage I-III BCs. Univariate analysis was performed using Chi-square or Wilcoxon rank-sum tests and multivariable analysis with logistic regression to predict surgical decisions. Survival was assessed using multivariable Cox proportional hazards regression analysis. RESULTS We identified 955,828 women with stage I-III BCs (5.7% MIDLC, 10.3% ILC, and 84.0% IDC). MIDLC was more like ILC than IDC in terms of multicentricity (14.2% MIDLC, 13.0% ILC, 10.0% IDC), hormone receptor positivity (96.6% MIDLC, 98.2% ILC, 81.2% IDC), and use of neoadjuvant chemotherapy (NAC; 5.8% MIDLC, 5.2% ILC, 10.8% IDC). 744,607 women underwent upfront surgery. The mastectomy rates were 42.3% for MIDLC, 46.5% for ILC, and 33.3% for IDC (all p < 0.001). With 5.5 years of median follow-up, the adjusted overall survival in the upfront surgery hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) biological subgroup was better in MIDLC (hazard ratio 0.88, p < 0.001) and ILC (hazard ratio 0.91, p < 0.001) than in IDC. Like ILC, MIDLC also had a lower pathological complete response to NAC than IDC (12.3% MIDLC, 7.3% ILC, 28.6% IDC). CONCLUSIONS MIDLC displays a mixed pattern of characteristics favoring features of ILC compared with IDC, with favorable 5-year overall survival compared with IDC within the HR+/HER2- subtype who underwent upfront surgery.
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Affiliation(s)
- Kush R Lohani
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Saba Yasir
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Schulze AK, Hoskin TL, Moldoveanu D, Sturz JL, Boughey JC. Tumor Characteristics of Bilateral Breast Cancer Compared with Unilateral Breast Cancer. Ann Surg Oncol 2024; 31:947-956. [PMID: 37906382 DOI: 10.1245/s10434-023-14451-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Bilateral breast cancer (BC) has an incidence of 1 to 3 %. This study aimed to describe the clinicopathologic characteristics and management of bilateral BC, estimate disease-free survival (DFS), and compare DFS with unilateral BC. METHODS A retrospective analysis was performed for patients who had bilateral invasive BC or unilateral invasive BC and contralateral ductal carcinoma in situ (DCIS) treated at Mayo Clinic Rochester from 2008 to 2022. A 4:1 matched cohort of patients with unilateral invasive BC was used for comparison. The groups were compared using Wilcoxon rank-sum or chi-square tests. Disease-free survival was analyzed using the Kaplan-Meier method and log-rank test, with Cox proportional hazards regression used for multivariable analysis. RESULTS The study identified 278 cases of bilateral breast cancer (177 cases of bilateral invasive cancer and 101 cases of unilateral invasive cancer with contralateral DCIS), representing 4.1 % of invasive BCs. Biologic subtype was concordant between sides in 79.8 % of the patients. Initial surgery was bilateral mastectomy for 76.6 %, bilateral lumpectomy for 20.5 %, and unilateral mastectomy with unilateral lumpectomy for 2.9 % of the patients. Pathogenic variants in breast cancer predisposition genes were present in 21.7 % of those tested. The patients who had bilateral BC presented with a higher cT category than the patients who had unilateral BC (p = 0.02), and a higher proportion presented with ILC (17.3 % vs 10.9 %; p = 0.004), estrogen receptor-positive (ER+) disease (89.2 % vs 84.2 %; p = 0.04), multicentric/multifocal disease (37.1 % vs 24.3 %; p < 0.001), breast cancer pathogenic variant (21.7 % vs 12.4 %; p = 0.02), and palpable presentation (48.2 % vs 40.8 %; p = 0.03). The patients with bilateral BC showed DFS similar to that for the unilateral BC cohort (p = 0.71). CONCLUSIONS Bilateral BCs most commonly are biologically concordant between sides. Bilateral BC presented more commonly with larger tumors, lobular histology, ER+ status, multicentricity or multifocality, pathogenic variant, and palpable disease. Bilateral BC is not associated with worse DFS than unilateral BC.
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Affiliation(s)
- Amy K Schulze
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Dan Moldoveanu
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jenna L Sturz
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Lohani KR, Hoskin TL, Day CN, Yasir S, Boughey JC, Degnim AC. ASO Visual Abstract: Lobular-Like Features and Outcomes of Mixed Invasive Ductolobular Breast Cancer (MIDLC): Insights from 54,403 Stage I-III MIDLC Patients. Ann Surg Oncol 2024; 31:1027-1028. [PMID: 37985529 DOI: 10.1245/s10434-023-14589-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Affiliation(s)
- Kush R Lohani
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Saba Yasir
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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11
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Schulze AK, Hoskin TL, Moldoveanu D, Sturz JL, Boughey JC. ASO Visual Abstract: Tumor Characteristics of Bilateral Breast Cancer Compared with Unilateral Breast Cancer. Ann Surg Oncol 2024; 31:1025-1026. [PMID: 38006525 DOI: 10.1245/s10434-023-14588-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Affiliation(s)
- Amy K Schulze
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Dan Moldoveanu
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jenna L Sturz
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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12
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Lohani KR, Hoskin TL, Day CN, Yasir S, Boughey JC, Degnim AC. ASO Author Reflections: Toward Individualized Management of Heterogenous Mixed Invasive Ductolobular Breast Cancers. Ann Surg Oncol 2024; 31:1008-1009. [PMID: 37952218 DOI: 10.1245/s10434-023-14568-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023]
Abstract
Mixed invasive ductolobular breast cancer (MIDLC) is a rare breast cancer with varying lobular and ductal components. Characteristics, management, and outcomes of MIDLC are not well understood due to the rarity of the cancer and the lack of uniform diagnostic criteria and reporting. There is a need for better understanding and individualized management of this heterogeneous spectrum of breast cancers.
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Affiliation(s)
- Kush R Lohani
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Saba Yasir
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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13
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Alkhatib H, Conage-Pough J, Roy Chowdhury S, Shian D, Zaid D, Rubinstein AM, Sonnenblick A, Peretz-Yablonsky T, Granit A, Carmon E, Kohale IN, Boughey JC, Goetz MP, Wang L, White FM, Kravchenko-Balasha N. Patient-specific signaling signatures predict optimal therapeutic combinations for triple negative breast cancer. Mol Cancer 2024; 23:17. [PMID: 38229082 PMCID: PMC10790458 DOI: 10.1186/s12943-023-01921-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/20/2023] [Indexed: 01/18/2024] Open
Abstract
Triple negative breast cancer (TNBC) is a heterogeneous group of tumors which lack estrogen receptor, progesterone receptor, and HER2 expression. Targeted therapies have limited success in treating TNBC, thus a strategy enabling effective targeted combinations is an unmet need. To tackle these challenges and discover individualized targeted combination therapies for TNBC, we integrated phosphoproteomic analysis of altered signaling networks with patient-specific signaling signature (PaSSS) analysis using an information-theoretic, thermodynamic-based approach. Using this method on a large number of TNBC patient-derived tumors (PDX), we were able to thoroughly characterize each PDX by computing a patient-specific set of unbalanced signaling processes and assigning a personalized therapy based on them. We discovered that each tumor has an average of two separate processes, and that, consistent with prior research, EGFR is a major core target in at least one of them in half of the tumors analyzed. However, anti-EGFR monotherapies were predicted to be ineffective, thus we developed personalized combination treatments based on PaSSS. These were predicted to induce anti-EGFR responses or to be used to develop an alternative therapy if EGFR was not present.In-vivo experimental validation of the predicted therapy showed that PaSSS predictions were more accurate than other therapies. Thus, we suggest that a detailed identification of molecular imbalances is necessary to tailor therapy for each TNBC. In summary, we propose a new strategy to design personalized therapy for TNBC using pY proteomics and PaSSS analysis. This method can be applied to different cancer types to improve response to the biomarker-based treatment.
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Affiliation(s)
- Heba Alkhatib
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, 9103401, Jerusalem, Israel
| | - Jason Conage-Pough
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Sangita Roy Chowdhury
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, 9103401, Jerusalem, Israel
| | - Denen Shian
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, 9103401, Jerusalem, Israel
| | - Deema Zaid
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, 9103401, Jerusalem, Israel
| | - Ariel M Rubinstein
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, 9103401, Jerusalem, Israel
| | - Amir Sonnenblick
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Peretz-Yablonsky
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, 9103401, Jerusalem, Israel
| | - Avital Granit
- Sharett Institute of Oncology, Hebrew University-Hadassah Medical Center, 9103401, Jerusalem, Israel
| | - Einat Carmon
- Department of Surgery, Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | - Ishwar N Kohale
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Judy C Boughey
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Matthew P Goetz
- Department of Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Forest M White
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA.
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA.
| | - Nataly Kravchenko-Balasha
- The Institute of Biomedical and Oral Research, The Hebrew University of Jerusalem, 9103401, Jerusalem, Israel.
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14
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Kyalwazi B, Yau C, Campbell MJ, Yoshimatsu TF, Chien AJ, Wallace AM, Forero-Torres A, Pusztai L, Ellis ED, Albain KS, Blaes AH, Haley BB, Boughey JC, Elias AD, Clark AS, Isaacs CJ, Nanda R, Han HS, Yung RL, Tripathy D, Edmiston KK, Viscusi RK, Northfelt DW, Khan QJ, Asare SM, Wilson A, Hirst GL, Lu R, Symmans WF, Yee D, DeMichele AM, van ’t Veer LJ, Esserman LJ, Olopade OI. Race, Gene Expression Signatures, and Clinical Outcomes of Patients With High-Risk Early Breast Cancer. JAMA Netw Open 2023; 6:e2349646. [PMID: 38153734 PMCID: PMC10755617 DOI: 10.1001/jamanetworkopen.2023.49646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/26/2023] [Indexed: 12/29/2023] Open
Abstract
Importance There has been little consideration of genomic risk of recurrence by breast cancer subtype despite evidence of racial disparities in breast cancer outcomes. Objective To evaluate associations between clinical trial end points, namely pathologic complete response (pCR) and distant recurrence-free survival (DRFS), and race and examine whether gene expression signatures are associated with outcomes by race. Design, Setting, and Participants This retrospective cohort study used data from the Investigation of Serial Studies to Predict Your Therapeutic Response With Imaging and Molecular Analysis 2 (I-SPY 2) multicenter clinical trial of neoadjuvant chemotherapy with novel agents and combinations for patients with previously untreated stage II/III breast cancer. Analyses were conducted of associations between race and short- and long-term outcomes, overall and by receptor subtypes, and their association with 28 expression biomarkers. The trial enrolled 990 female patients between March 30, 2010, and November 5, 2016, with a primary tumor size of 2.5 cm or greater and clinical or molecular high risk based on MammaPrint or hormone receptor (HR)-negative/ERBB2 (formerly HER2 or HER2/neu)-positive subtyping across 9 arms. This data analysis was performed between June 10, 2021, and October 20, 2022. Exposure Race, tumor receptor subtypes, and genomic biomarker expression of early breast cancer. Main Outcomes and Measures The primary outcomes were pCR and DRFS assessed by race, overall, and by tumor subtype using logistic regression and Cox proportional hazards regression models. The interaction between 28 expression biomarkers and race, considering pCR and DRFS overall and within subtypes, was also evaluated. Results The analytic sample included 974 participants (excluding 16 self-reporting as American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or multiple races due to small sample sizes), including 68 Asian (7%), 120 Black (12%), and 786 White (81%) patients. Median (range) age at diagnosis was 47 (25-71) years for Asian, 49 (25-77) for Black, and 49 (23-73) years for White patients. The pCR rates were 32% (n = 22) for Asian, 30% for Black (n = 36), and 32% for White (n = 255) patients (P = .87). Black patients with HR-positive/ERBB2-negative tumors not achieving pCR had significantly worse DRFS than their White counterparts (hazard ratio, 2.28; 95% CI, 1.24-4.21; P = .01), with 5-year DRFS rates of 55% (n = 32) and 77% (n = 247), respectively. Black patients with HR-positive/ERBB2-negative tumors, compared with White patients, had higher expression of an interferon signature (mean [SD], 0.39 [0.87] and -0.10 [0.99]; P = .007) and, compared with Asian patients, had a higher mitotic score (mean [SD], 0.07 [1.08] and -0.69 [1.06]; P = .01) and lower estrogen receptor/progesterone receptor signature (mean [SD], 0.31 [0.90] and 1.08 [0.95]; P = .008). A transforming growth factor β signature had a significant association with race relative to pCR and DRFS, with a higher signature associated with lower pCR and worse DRFS outcomes among Black patients only. Conclusions and Relevance The findings show that women with early high-risk breast cancer who achieve pCR have similarly good outcomes regardless of race, but Black women with HR-positive/ERBB2-negative tumors without pCR may have worse DRFS than White women, highlighting the need to develop and test novel biomarker-informed therapies in diverse populations.
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Affiliation(s)
- Beverly Kyalwazi
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Christina Yau
- Department of Surgery, University of California, San Francisco
| | | | - Toshio F. Yoshimatsu
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
| | - A. Jo Chien
- Department of Hematology Oncology and Surgery, University of California, San Francisco Helen Diller Comprehensive Cancer Center, San Francisco
| | - Anne M. Wallace
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla
| | | | - Lajos Pusztai
- Department of Medical Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | | | - Kathy S. Albain
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Anne H. Blaes
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Barbara B. Haley
- Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas
| | | | | | - Amy S. Clark
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | | | - Rita Nanda
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
| | - Hyo S. Han
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Rachel L. Yung
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - Debasish Tripathy
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Rebecca K. Viscusi
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | | | - Qamar J. Khan
- Division of Medical Oncology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City
| | - Smita M. Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | | | - Ruixiao Lu
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - William Fraser Symmans
- Division of Pathology and Laboratory Medicine, Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Douglas Yee
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Angela M. DeMichele
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Laura J. van ’t Veer
- Department of Laboratory Medicine, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco
| | | | - Olufunmilayo I. Olopade
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
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15
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Gao RW, Mullikin TC, Aziz KA, Afzal A, Smith NL, Routman DM, Gergelis KR, Harmsen WS, Remmes NB, Tseung HSWC, Shiraishi SS, Boughey JC, Ruddy KJ, Harless CA, Garda AE, Waddle MR, Park SS, Shumway DA, Corbin KS, Mutter RW. Postmastectomy Intensity Modulated Proton Therapy: 5-Year Oncologic and Patient-Reported Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:846-856. [PMID: 37244627 DOI: 10.1016/j.ijrobp.2023.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE To report oncologic, physician-assessed, and patient-reported outcomes (PROs) for a group of women homogeneously treated with modern, skin-sparing multifield optimized pencil-beam scanning proton (intensity modulated proton therapy [IMPT]) postmastectomy radiation therapy (PMRT). METHODS AND MATERIALS We reviewed consecutive patients who received unilateral, curative-intent, conventionally fractionated IMPT PMRT between 2015 and 2019. Strict constraints were applied to limit the dose to the skin and other organs at risk. Five-year oncologic outcomes were analyzed. Patient-reported outcomes were evaluated as part of a prospective registry at baseline, completion of PMRT, and 3 and 12 months after PMRT. RESULTS A total of 127 patients were included. One hundred nine (86%) received chemotherapy, among whom 82 (65%) received neoadjuvant chemotherapy. The median follow-up was 4.1 years. Five-year locoregional control was 98.4% (95% CI, 93.6-99.6), and overall survival was 87.9% (95% CI, 78.7-96.5). Acute grade 2 and 3 dermatitis was seen in 45% and 4% of patients, respectively. Three patients (2%) experienced acute grade 3 infection, all of whom had breast reconstruction. Three late grade 3 adverse events occurred: morphea (n = 1), infection (n = 1), and seroma (n = 1). There were no cardiac or pulmonary adverse events. Among the 73 patients at risk for PMRT-associated reconstruction complications, 7 (10%) experienced reconstruction failure. Ninety-five patients (75%) enrolled in the prospective PRO registry. The only metrics to increase by >1 point were skin color (mean change: 5) and itchiness (2) at treatment completion and tightness/pulling/stretching (2) and skin color (2) at 12 months. There was no significant change in the following PROs: bleeding/leaking fluid, blistering, telangiectasia, lifting, arm extension, or bending/straightening the arm. CONCLUSIONS With strict dose constraints to skin and organs at risk, postmastectomy IMPT was associated with excellent oncologic outcomes and PROs. Rates of skin, chest wall, and reconstruction complications compared favorably to previous proton and photon series. Postmastectomy IMPT warrants further investigation in a multi-institutional setting with careful attention to planning techniques.
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Affiliation(s)
- Robert W Gao
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Trey C Mullikin
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Khaled A Aziz
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arslan Afzal
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Na L Smith
- Sanford Cancer Center, Sioux Falls, South Dakota
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Allison E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
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16
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Lenz L, Neff C, Solimeno C, Cogan ES, Abramson VG, Boughey JC, Falkson C, Goetz MP, Ford JM, Gradishar WJ, Jankowitz RC, Kaklamani VG, Marcom PK, Richardson AL, Storniolo AM, Tung NM, Vinayak S, Hodgson DR, Lai Z, Dearden S, Hennessy BT, Mayer EL, Mills GB, Slavin TP, Gutin A, Connolly RM, Telli ML, Stearns V, Lanchbury JS, Timms KM. Identifying homologous recombination deficiency in breast cancer: genomic instability score distributions differ among breast cancer subtypes. Breast Cancer Res Treat 2023; 202:191-201. [PMID: 37589839 PMCID: PMC10504389 DOI: 10.1007/s10549-023-07046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/07/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE A 3-biomarker homologous recombination deficiency (HRD) score is a key component of a currently FDA-approved companion diagnostic assay to identify HRD in patients with ovarian cancer using a threshold score of ≥ 42, though recent studies have explored the utility of a lower threshold (GIS ≥ 33). The present study evaluated whether the ovarian cancer thresholds may also be appropriate for major breast cancer subtypes by comparing the genomic instability score (GIS) distributions of BRCA1/2-deficient estrogen receptor-positive breast cancer (ER + BC) and triple-negative breast cancer (TNBC) to the GIS distribution of BRCA1/2-deficient ovarian cancer. METHODS Ovarian cancer and breast cancer (ER + BC and TNBC) tumors from ten study cohorts were sequenced to identify pathogenic BRCA1/2 mutations, and GIS was calculated using a previously described algorithm. Pathologic complete response (pCR) to platinum therapy was evaluated in a subset of TNBC samples. For TNBC, a threshold was set and threshold validity was assessed relative to clinical outcomes. RESULTS A total of 560 ovarian cancer, 805 ER + BC, and 443 TNBC tumors were included. Compared to ovarian cancer, the GIS distribution of BRCA1/2-deficient samples was shifted lower for ER + BC (p = 0.015), but not TNBC (p = 0.35). In the subset of TNBC samples, univariable logistic regression models revealed that GIS status using thresholds of ≥ 42 and ≥ 33 were significant predictors of response to platinum therapy. CONCLUSIONS This study demonstrated that the GIS thresholds used for ovarian cancer may also be appropriate for TNBC, but not ER + BC. GIS thresholds in TNBC were validated using clinical response data to platinum therapy.
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Affiliation(s)
- Lauren Lenz
- Myriad Genetics, Inc, 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Chris Neff
- Myriad Genetics, Inc, 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Cara Solimeno
- Myriad Genetics, Inc, 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Elizabeth S Cogan
- Myriad Genetics, Inc, 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | | | | | - Carla Falkson
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - James M Ford
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | - Andrea L Richardson
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Anna Maria Storniolo
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nadine M Tung
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Shaveta Vinayak
- University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, 15. AstraZeneca, Seattle, WA, USA
| | | | | | | | | | - Erica L Mayer
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Thomas P Slavin
- Myriad Genetics, Inc, 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Alexander Gutin
- Myriad Genetics, Inc, 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | | | | | - Vered Stearns
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jerry S Lanchbury
- Myriad Genetics, Inc, 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Kirsten M Timms
- Myriad Genetics, Inc, 320 Wakara Way, Salt Lake City, UT, 84108, USA.
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17
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Boughey JC, Yu H, Dugan CL, Piltin MA, Postlewait L, Son JD, Edmiston KK, Godellas C, Lee MC, Carr MJ, Tonneson JE, Crown A, Lancaster RB, Woriax HE, Ewing CA, Chau HS, Patterson AK, Wong JM, Alvarado MD, Yang RL, Chan TW, Sheade JB, Ahrendt GM, Larson KE, Switalla K, Tuttle TM, Tchou JC, Rao R, Tamirisa N, Singh P, Gould RE, Terando A, Sauder C, Hewitt K, Chiba A, Esserman LJ, Mukhtar R. ASO Visual Abstract: Changes in Surgical Management of the Axilla Over 11 Years-Report on Over 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial. Ann Surg Oncol 2023; 30:6411-6412. [PMID: 37537482 DOI: 10.1245/s10434-023-14017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Affiliation(s)
- Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Hongmei Yu
- Quantum Leap Healthcare Collaborative, San Francisco, CA, USA
| | | | - Mara A Piltin
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lauren Postlewait
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer D Son
- Ourisman Breast Center, MedStar Georgetown University, Washington, DC, USA
| | - Kirsten K Edmiston
- Department of Surgery, University of Virginia, Inova Campus, Fairfax, VA, USA
| | | | - Marie C Lee
- Division of Breast Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Michael J Carr
- Department of Breast Surgery, Moffitt Cancer Center, Tampa, FL, USA
| | - Jennifer E Tonneson
- Division of Surgical Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Angelena Crown
- True Family Women's Cancer Center, Swedish Cancer Institute, Seattle, WA, USA
| | - Rachel B Lancaster
- Division of Surgical Oncology, The University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Hannah E Woriax
- Division of Surgical Oncology, Duke University of School of Medicine, Durham, NC, USA
| | - Cheryl A Ewing
- Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | | | - Anne K Patterson
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Jasmine M Wong
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael D Alvarado
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Rachel L Yang
- Department of Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Theresa W Chan
- Department of Breast Surgical Oncology, Ironwood Cancer and Research Centers, Scottsdale, AZ, USA
| | - Jori B Sheade
- Division of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Gretchen M Ahrendt
- Division of Surgical Oncology, University of Colorado Denver - Anschutz Medical Campus, Boulder, CO, USA
| | - Kelsey E Larson
- Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Kayla Switalla
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Julia C Tchou
- Department of Breast Surgery Research, Penn Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Roshni Rao
- Division of Breast Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Puneet Singh
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebekah E Gould
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alicia Terando
- Division of Surgical Oncology, Department of Surgery, Huntington Cancer Center/Cedars Sinai Cancer, Pasadena, CA, USA
| | - Candice Sauder
- Department of Surgery, UC Davis Health Comprehensive Cancer Center, Sacramento, CA, USA
| | - Kelly Hewitt
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Akiko Chiba
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Laura J Esserman
- Departments of Surgery and Radiology, UCSF, San Francisco, CA, USA
| | - Rita Mukhtar
- Department of Surgery, UCSF, San Francisco, CA, USA
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18
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Sturz JL, Boughey JC. Lasting Impacts of the COVID-19 Pandemic on Breast Cancer Diagnosis and Treatment in the United States. Surg Oncol Clin N Am 2023; 32:811-819. [PMID: 37714645 PMCID: PMC10169575 DOI: 10.1016/j.soc.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
The COVID-19 pandemic was an unprecedented time that placed unique challenges on the screening and treatment of breast cancer in the United States. Collaboration among medical disciplines and societies provided guidelines and strategies to mitigate the exposure of patients and medical providers to the virus and provide optimal care. We discuss the changes that the pandemic had on the multidisciplinary management of breast cancer.
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Affiliation(s)
- Jenna L Sturz
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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19
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Moldoveanu D, Goetz MP, Boughey JC. ASO Author Reflections: Low Estrogen Receptor (ER) Expression Breast Cancer Behaves More like ER Negative Disease and Influences Management. Ann Surg Oncol 2023; 30:6484-6485. [PMID: 37488395 DOI: 10.1245/s10434-023-13985-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Dan Moldoveanu
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Matthew P Goetz
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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20
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Moldoveanu D, Hoskin TL, Day CN, Schulze AK, Goetz MP, Boughey JC. Clinical Behavior, Management, and Treatment Response of Estrogen Receptor Low (1-10%) Breast Cancer. Ann Surg Oncol 2023; 30:6475-6483. [PMID: 37460743 DOI: 10.1245/s10434-023-13846-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/19/2023] [Indexed: 09/20/2023]
Abstract
INTRODUCTION Estrogen receptor (ER) and progesterone receptor (PR) guide management and impact outcomes of breast cancer (BC). This study compares ER-low (1-10%) with ER-negative (< 1%) and ER-positive (>10%) BC and investigates the significance of PR expression within ER-low disease. PATIENTS AND METHODS All patients with HER2-negative invasive BC were identified from the National Cancer Database 2018-2019. Treatment and outcomes were compared using chi-squared tests and multivariable logistic regression. RESULTS Of 232,762 patients, ER expression was: negative (13.8%), low (2.0%), and > 10% (84.2%). Chemotherapy was given in 83.9% of ER- disease, 82.4% of ER-low/PR- disease, 58.9% of ER-low/PR+ disease, and only in 22.9% of ER+ disease. Within the ER-low subgroup, adjuvant endocrine therapy, recurrence score, and Ki67 varied by PR status (all < 0.01). Patients with ER-low disease selected for neoadjuvant chemotherapy (NAC) were younger and had higher T and N category, tumor grade, and Ki67. With NAC, pathological complete response (pCR) rates were similar between ER-low/PR- and ER-low/PR+ (39.5% and 38.1%, respectively, p = 0.67), and were closer to the ER- group (39.7%) than the ER+ group (8.4%). On multivariable analysis, the adjusted effect of ER status (1-10% versus > 10%) on chemotherapy administration was odds ratio (OR) 8.2 (95% CI 7.3-9.2, p < 0.001) for PR-negative, and OR 3.3 (95% CI 7.3-9.2, p < 0.001) for PR-positive. CONCLUSIONS This study suggests that the tumor features and clinical management of ER-low tumors vary significantly by PR expression. Within ER-low tumors, PR- tumors more closely resemble ER- BC, while PR+ tumors exhibit less aggressive characteristics. In ER-low disease selected for treatment with NAC, response is similar to ER- regardless of PR status.
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Affiliation(s)
- Dan Moldoveanu
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Amy K Schulze
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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21
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Ioakeim-Ioannidou M, Gao RW, Dunn SA, Harmsen WS, Smith N, Mullikin TC, Harless C, Connoly J, Keenan JC, Boughey JC, Liu L, Shumway D, MacDonald SM, Corbin KS, Mutter RW, Ho AY. Proton vs. Photons for Breast Cancer Patients with Immediate, Implant-Based Reconstruction Receiving Postmastectomy Radiotherapy: A Multicenter Pooled Analysis. Int J Radiat Oncol Biol Phys 2023; 117:S175. [PMID: 37784435 DOI: 10.1016/j.ijrobp.2023.06.644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Proton therapy improves postmastectomy radiotherapy (PMRT) normal tissue sparing compared with photon techniques. However, little is understood about its effect on reconstruction outcomes. The primary objective was to evaluate complication rates in breast cancer patients treated with proton (PRO) versus photon (PHO) PMRT following immediate, implant-based breast reconstruction. MATERIALS/METHODS Consecutive patients with breast cancer who underwent mastectomy and immediate reconstruction with a tissue expander (TE) or permanent implant (PI) and PRO or PHO PMRT between 2011 and 2022 were included from two institutions. Complication rate was defined as the sum of reconstruction failure (explantation without replacement), unplanned prosthesis exchange, and other unplanned revisional surgery. Each complication type was analyzed as an independent endpoint. RESULTS Among 733 patients, median follow-up was 4.4 years; 36.5% (267) were treated with PRO and 63.5% (466) with PHO. There was no difference in age, BMI, or comorbidities between the two groups. PRO was more likely to have had, two-stage reconstruction and pre-pectoral implant placement (p<.01). Median dose was 50-50.4 Gy in 25-28 fractions, with only 50 receiving hypofractionation. Bolus was used in all PHO patients. Regional nodes were more likely to be included in PRO (99.6% v. 83.7% PHO, p<.01). Although there was no difference in the use of chest wall boost between groups, the axillary nodes were more frequently boosted in PRO (25.1% vs 2.8% PHO, p<.01). The overall rate of complications at 4 years was 26.7% (95% CI = 23.3-30.5). The 4-year rate of reconstruction failure, unplanned exchange, and other surgery was 8.2% (95% CI = 6.3-10.7), 17.4% (95% CI = 14.6-20.8), and 12.5% (95% CI = 10.1-15.5), respectively. On MVA, PRO did not confer an increased risk of reconstruction complications compared to PHO. Significant risk factors for reconstruction failure included TE-to-autologous approach [HR versus direct-to-implant reference: 4.05 (95% CI = 1.60-10.22)], TE-to-permanent implant approach [HR = 2.06 (95% CI = 1.12-3.79)], chest wall boost [HR = 2.20 (95% CI = 1.21-4.02)], and any lymph node boost [HR = 2.33 (95% CI = 1.10-4.97)]. Compared to direct-to-implant, two-stage reconstruction was also associated with a higher rate of unplanned exchange [HR for TE/PI = 1.49 (95% CI = 1.01-2.20)] and revisional surgery [HR for TE-to-autologous = 3.95 (95% CI = 1.64-9.52)]. Prepectoral implant placement was correlated with reduced risk of revisional surgery, relative to subpectoral placement [HR = 0.42 (95% CI = 0.22-0.81)]. CONCLUSION This represents the largest combined series to date comparing PRO and PHO PMRT. Despite a higher rate of two-stage reconstruction, nodal irradiation, and nodal boost in PRO, there was no significant difference in the risk of complications between protons and photons. Differences in PRO delivery techniques between institutions and dosimetric details such as skin dose will be presented in person.
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Affiliation(s)
- M Ioakeim-Ioannidou
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - R W Gao
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - S A Dunn
- Massachusetts General Hospital, Boston, MA
| | - W S Harmsen
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN
| | - N Smith
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - T C Mullikin
- Department of Radiation Oncology, Duke University, Rochester, MN
| | - C Harless
- Department of Plastic Surgery, Mayo Clinic, Rochester, MN
| | - J Connoly
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, Boston, MA
| | - J C Keenan
- Massachusetts General Hospital, Boston, MA
| | - J C Boughey
- Department of Breast Surgery, Mayo Clinic, Rochester, MN
| | - L Liu
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, Boston, MA
| | - D Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - S M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - K S Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - R W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - A Y Ho
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
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22
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Boughey JC, Yu H, Dugan CL, Piltin MA, Postlewait L, Son JD, Edmiston KK, Godellas CV, Lee MC, Carr MJ, Tonneson JE, Crown A, Lancaster RB, Woriax HE, Ewing CA, Chau HS, Patterson AK, Wong JM, Alvarado MD, Yang RL, Chan TW, Sheade JB, Ahrendt GM, Larson KE, Switalla K, Tuttle TM, Tchou JC, Rao R, Tamirisa N, Singh P, Gould RE, Terando A, Sauder C, Hewitt K, Chiba A, Esserman LJ, Mukhtar RA. Changes in Surgical Management of the Axilla Over 11 Years - Report on More Than 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial. Ann Surg Oncol 2023; 30:6401-6410. [PMID: 37380911 DOI: 10.1245/s10434-023-13759-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/01/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Axillary surgery after neoadjuvant chemotherapy (NAC) is becoming less extensive. We evaluated the evolution of axillary surgery after NAC on the multi-institutional I-SPY2 prospective trial. METHODS We examined annual rates of sentinel lymph node (SLN) surgery with resection of clipped node, if present), axillary lymph node dissection (ALND), and SLN and ALND in patients enrolled in I-SPY2 from January 1, 2011 to December 31, 2021 by clinical N status at diagnosis and pathologic N status at surgery. Cochran-Armitage trend tests were calculated to evaluate patterns over time. RESULTS Of 1578 patients, 973 patients (61.7%) had SLN-only, 136 (8.6%) had SLN and ALND, and 469 (29.7%) had ALND-only. In the cN0 group, ALND-only decreased from 20% in 2011 to 6.25% in 2021 (p = 0.0078) and SLN-only increased from 70.0% to 87.5% (p = 0.0020). This was even more striking in patients with clinically node-positive (cN+) disease at diagnosis, where ALND-only decreased from 70.7% to 29.4% (p < 0.0001) and SLN-only significantly increased from 14.6% to 56.5% (p < 0.0001). This change was significant across subtypes (HR-/HER2-, HR+/HER2-, and HER2+). Among pathologically node-positive (pN+) patients after NAC (n = 525) ALND-only decreased from 69.0% to 39.2% (p < 0.0001) and SLN-only increased from 6.9% to 39.2% (p < 0.0001). CONCLUSIONS Use of ALND after NAC has significantly decreased over the past decade. This is most pronounced in cN+ disease at diagnosis with an increase in the use of SLN surgery after NAC. Additionally, in pN+ disease after NAC, there has been a decrease in use of completion ALND, a practice pattern change that precedes results from clinical trials.
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Affiliation(s)
- Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Hongmei Yu
- Quantum Leap Healthcare Collaborative, San Francisco, CA, USA
| | | | - Mara A Piltin
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lauren Postlewait
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer D Son
- Ourisman Breast Center, MedStar Georgetown University, Washington, DC, USA
| | - Kirsten K Edmiston
- Department of Surgery, University of Virginia, Inova Campus, Fairfax, VA, USA
| | | | - Marie C Lee
- Division of Breast Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Michael J Carr
- Department of Breast Surgery, Moffitt Cancer Center, Tampa, FL, USA
| | - Jennifer E Tonneson
- Division of Surgical Oncology, Oregon Health and Science University, Portland, OR, USA
| | - Angelena Crown
- True Family Women's Cancer Center, Swedish Cancer Institute, Seattle, WA, USA
| | - Rachel B Lancaster
- Division of Surgical Oncology, The University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Hannah E Woriax
- Division of Surgical Oncology, Duke University of School of Medicine, Durham, NC, USA
| | - Cheryl A Ewing
- Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | | | - Anne K Patterson
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Jasmine M Wong
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael D Alvarado
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Rachel L Yang
- Department of Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Theresa W Chan
- Department of Breast Surgical Oncology, Ironwood Cancer and Research Centers, Scottsdale, AZ, USA
| | - Jori B Sheade
- Division of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Gretchen M Ahrendt
- Division of Surgical Oncology, University of Colorado Denver - Anschutz Medical Campus, Boulder, CO, USA
| | - Kelsey E Larson
- Department of Surgery, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Kayla Switalla
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Julia C Tchou
- Department of Breast Surgery Research, Penn Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Roshni Rao
- Division of Breast Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Puneet Singh
- Department of Breast Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebekah E Gould
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alicia Terando
- Division of Surgical Oncology, Department of Surgery, Huntington Cancer Center/Cedars Sinai Cancer, Pasadena, CA, USA
| | - Candice Sauder
- Department of Surgery, UC Davis Health Comprehensive Cancer Center, Sacramento, CA, USA
| | - Kelly Hewitt
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Akiko Chiba
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Laura J Esserman
- Departments of Surgery and Radiology, UCSF, San Francisco, CA, USA
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23
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Moldoveanu D, Hoskin TL, Day CN, Schulze AK, Goetz MP, Boughey JC. ASO Visual Abstract: Clinical Behavior, Management, and Treatment Response of Estrogen Receptor-Low (1-10%) Breast Cancer. Ann Surg Oncol 2023; 30:6486-6487. [PMID: 37516725 DOI: 10.1245/s10434-023-13998-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Affiliation(s)
- Dan Moldoveanu
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Amy K Schulze
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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24
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Mutter RW, Giri S, Fruth BF, Remmes NB, Boughey JC, Harless CA, Ruddy KJ, McGee LA, Afzal A, Gao RW, Shumway DA, Vern-Gross TZ, Villarraga HR, Kenison SL, Kang Y, Wong WW, Stish BJ, Merrell KW, Yan ES, Park SS, Corbin KS, Vargas CE. Conventional versus hypofractionated postmastectomy proton radiotherapy in the USA (MC1631): a randomised phase 2 trial. Lancet Oncol 2023; 24:1083-1093. [PMID: 37696281 PMCID: PMC10591844 DOI: 10.1016/s1470-2045(23)00388-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Proton therapy is under investigation in breast cancer as a strategy to reduce radiation exposure to the heart and lungs. So far, studies investigating proton postmastectomy radiotherapy (PMRT) have used conventional fractionation over 25-28 days, but whether hypofractionated proton PMRT is feasible is unclear. We aimed to compare conventional fractionation and hypofractionation in patients with indications for PMRT, including those with immediate breast reconstruction. METHODS We did a randomised phase 2 trial (MC1631) at Mayo Clinic in Rochester (MN, USA) and Mayo Clinic in Arizona (Phoenix, AZ, USA) comparing conventional fractionated (50 Gy in 25 fractions of 2 Gy [relative biological effectiveness of 1·1]) and hypofractionated (40·05 Gy in 15 fractions of 2·67 Gy [relative biological effectiveness of 1·1]) proton PMRT. All patients were treated with pencil-beam scanning. Eligibility criteria included age 18 years or older, an Eastern Cooperative Oncology Group performance status of 0-2, and breast cancer resected by mastectomy with or without immediate reconstruction with indications for PMRT. Patients were randomly assigned (1:1) to either conventional fractionation or hypofractionation, with presence of immediate reconstruction (yes vs no) as a stratification factor, using a biased-coin minimisation algorithm. Any patient who received at least one fraction of protocol treatment was evaluable for the primary endpoint and safety analyses. The primary endpoint was 24-month complication rate from the date of first radiotherapy, defined as grade 3 or worse adverse events occurring from 90 days after last radiotherapy or unplanned surgical interventions in patients with immediate reconstruction. The inferiority of hypofractionation would not be ruled out if the upper bound of the one-sided 95% CI for the difference in 24-month complication rate between the two groups was greater than 10%. This trial is registered with ClinicalTrials.gov, NCT02783690, and is closed to accrual. FINDINGS Between June 2, 2016, and Aug 23, 2018, 88 patients were randomly assigned (44 to each group), of whom 82 received protocol treatment (41 in the conventional fractionation group and 41 in the hypofractionation group; median age of 52 years [IQR 44-64], 79 [96%] patients were White, two [2%] were Black or African American, one [1%] was Asian, and 79 [96%] were not of Hispanic ethnicity). As of data cutoff (Jan 30, 2023), the median follow-up was 39·3 months (IQR 37·5-61·2). The median mean heart dose was 0·54 Gy (IQR 0·30-0·72) for the conventional fractionation group and 0·49 Gy (0·25-0·64) for the hypofractionation group. Within 24 months of first radiotherapy, 14 protocol-defined complications occurred in six (15%) patients in the conventional fractionation group and in eight (20%) patients in the hypofractionation group (absolute difference 4·9% [one-sided 95% CI 18·5], p=0·27). The complications in the conventionally fractionated group were contracture (five [12%] of 41 patients]) and fat necrosis (one [2%] patient) requiring surgical intervention. All eight protocol-defined complications in the hypofractionation group were due to infections, three of which were acute infections that required surgical intervention, and five were late infections, four of which required surgical intervention. All 14 complications were in patients with immediate expander or implant-based reconstruction. INTERPRETATION After a median follow-up of 39·3 months, non-inferiority of the hypofractionation group could not be established. However, given similar tolerability, hypofractionated proton PMRT appears to be worthy of further study in patients with and without immediate reconstruction. FUNDING The Department of Radiation Oncology, Mayo Clinic, Rochester, MN, the Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA, and the US National Cancer Institute.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
| | - Sharmila Giri
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Briant F Fruth
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Arslan Afzal
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert W Gao
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth S Yan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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25
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Johnson HM, Lin H, Shen Y, Diego EJ, Krishnamurthy S, Yang WT, Smith BD, Valero V, Lucci A, Sun SX, Shaitelman SF, Mitchell MP, Boughey JC, White RL, Rauch GM, Kuerer HM. Patient-Reported Outcomes of Omission of Breast Surgery Following Neoadjuvant Systemic Therapy: A Nonrandomized Clinical Trial. JAMA Netw Open 2023; 6:e2333933. [PMID: 37707811 PMCID: PMC10502524 DOI: 10.1001/jamanetworkopen.2023.33933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 09/15/2023] Open
Abstract
Importance Patients should have an active role in decisions about pursuing or forgoing specific therapies in treatment de-escalation trials. Objective To evaluate longitudinal patient-reported outcomes (PROs) encompassing decisional comfort and health-related quality of life (HRQOL) among patients who elected to enroll in a clinical trial evaluating radiotherapy alone, without breast surgery, for invasive breast cancers with exceptional response to neoadjuvant systemic therapy (NST). Design, Setting, and Participants Prospective, single-group, phase 2 clinical trial at 7 US medical centers. Women aged 40 years or older with invasive cT1-2 N0-1 M0 triple-negative or human epidermal growth factor receptor 2 (ERBB2)-positive breast cancer with no pathologic evidence of residual disease following standard NST enrolled from March 6, 2017, to November 9, 2021. Validated PRO measures were administered at baseline and 6, 12, and 36 months post-radiotherapy. Data were analyzed from January to February 2023. Interventions PRO measures included the Decision Regret Scale (DRS), Functional Assessment of Cancer Therapy-Lymphedema (FACT-B+4), and Breast Cancer Treatment Outcomes Scale (BCTOS). Main Outcomes and Measures Changes in PRO measure scores and subscores over time. Results Among 31 patients, the median (IQR) age was 61 (56-66) years, 26 (84%) were White, and 26 (84%) were non-Hispanic. A total of 15 (48%) had triple-negative disease and 16 (52%) had ERBB2-positive disease. Decisional comfort was high at baseline (median [IQR] DRS score 10 [0-25] on a 0-100 scale, with higher scores indicating higher decisional regret) and significantly increased over time (median [IQR] DRS score at 36 months, 0 [0-20]; P < .001). HRQOL was relatively high at baseline (median [IQR] FACT-B composite score 121 [111-134] on a 0-148 scale, with higher scores indicating higher HRQOL) and significantly increased over time (median [IQR] FACT-B score at 36 months, 128 [116-137]; P = .04). Perceived differences between the affected breast and contralateral breast were minimal at baseline (median [IQR] BCTOS score 1.05 [1.00-1.23] on a 1-4 scale, with higher scores indicating greater differences) and increased significantly over time (median [IQR] BCTOS score at 36 months, 1.36 [1.18-1.64]; P < .001). At 36 months postradiotherapy, the cosmetic subscore was 0.45 points higher than baseline (95% CI, 0.16-0.74; P = .001), whereas function, pain, and edema subscores were not significantly different than baseline. Conclusions and Relevance In this nonrandomized phase 2 clinical trial, analysis of PROs demonstrated an overall positive experience for trial participants, with longitudinal improvements in decisional comfort and overall HRQOL over time and minimal lasting adverse effects of therapy. Trial Registration ClinicalTrials.gov Identifier: NCT02945579.
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Affiliation(s)
- Helen M. Johnson
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Emilia J. Diego
- Division of Breast Surgery, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | | | - Wei T. Yang
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin D. Smith
- Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Vicente Valero
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Susie X. Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Simona F. Shaitelman
- Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Melissa P. Mitchell
- Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Judy C. Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Richard L. White
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Gaiane M. Rauch
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston
| | - Henry M. Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
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26
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Blair SL, Boughey JC. First steps into synoptic operative reporting in breast cancer surgery: A journey to improve quality cancer care. Surgery 2023; 174:715-716. [PMID: 37277309 DOI: 10.1016/j.surg.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 06/07/2023]
Affiliation(s)
- Sarah L Blair
- Department of Surgery University of California San Diego, San Diego, CA.
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN
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27
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Mukhtar RA, Chau H, Woriax H, Piltin M, Ahrendt G, Tchou J, Yu H, Ding Q, Dugan CL, Sheade J, Crown A, Carr M, Wong J, Son J, Yang R, Chan T, Terando A, Alvarado M, Ewing C, Tonneson J, Tamirisa N, Gould R, Singh P, Godellas C, Larson K, Chiba A, Rao R, Sauder C, Postlewait L, Lee MC, Symmans WF, Esserman LJ, Boughey JC. Breast Conservation Surgery and Mastectomy Have Similar Locoregional Recurrence After Neoadjuvant Chemotherapy: Results From 1462 Patients on the Prospective, Randomized I-SPY2 Trial. Ann Surg 2023; 278:320-327. [PMID: 37325931 DOI: 10.1097/sla.0000000000005968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Neoadjuvant chemotherapy (NAC) increases rates of successful breast-conserving surgery (BCS) in patients with breast cancer. However, some studies suggest that BCS after NAC may confer an increased risk of locoregional recurrence (LRR). We assessed LRR rates and locoregional recurrence-free survival (LRFS) in patients enrolled on I-SPY2 (NCT01042379), a prospective NAC trial for patients with clinical stage II to III, molecularly high-risk breast cancer. Cox proportional hazards models were used to evaluate associations between surgical procedure (BCS vs mastectomy) and LRFS adjusted for age, tumor receptor subtype, clinical T category, clinical nodal status, and residual cancer burden (RCB). In 1462 patients, surgical procedure was not associated with LRR or LRFS on either univariate or multivariate analysis. The unadjusted incidence of LRR was 5.4% after BCS and 7.0% after mastectomy, at a median follow-up time of 3.5 years. The strongest predictor of LRR was RCB class, with each increasing RCB class having a significantly higher hazard ratio for LRR compared with RCB 0 on multivariate analysis. Triple-negative receptor subtype was also associated with an increased risk of LRR (hazard ratio: 2.91, 95% CI: 1.8-4.6, P < 0.0001), regardless of the type of operation. In this large multi-institutional prospective trial of patients completing NAC, we found no increased risk of LRR or differences in LRFS after BCS compared with mastectomy. Tumor receptor subtype and extent of residual disease after NAC were significantly associated with recurrence. These data demonstrate that BCS can be an excellent surgical option after NAC for appropriately selected patients.
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Affiliation(s)
- Rita A Mukhtar
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Harrison Chau
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Hannah Woriax
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mara Piltin
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Julia Tchou
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Hongmei Yu
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | - Qian Ding
- Quantum Leap Healthcare Collaborative, San Francisco, CA
| | - Catherine Lu Dugan
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Jori Sheade
- Department of Surgery, Northwestern University, Chicago, IL
| | - Angelena Crown
- Department of Surgery, Swedish Cancer Institute, Seattle, WA
| | - Michael Carr
- Department of Surgery, University of Louisville, Louisville, KY
| | - Jasmine Wong
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Jennifer Son
- Department of Surgery, Georgetown University, Washington, D.C
| | - Rachel Yang
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Theresa Chan
- Department of Surgery, Ironwood Cancer and Research Centers, Phoenix, AZ
| | - Alicia Terando
- Department of Surgery, Cedars-Sinai Cancer at Huntington Hospital Cancer Center, Pasadena, CA
| | - Michael Alvarado
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Cheryl Ewing
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Jennifer Tonneson
- Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Nina Tamirisa
- Department of Surgery and Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rebekah Gould
- Department of Surgery and Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Puneet Singh
- Department of Surgery and Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Kelsey Larson
- Department of Surgery, University of Kansas, Kansas City, KS
| | - Akiko Chiba
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Roshni Rao
- Department of Surgery, Columbia University, New York, NY
| | - Candice Sauder
- Department of Surgery, University of California Davis, Davis, CA
| | | | | | - William Fraser Symmans
- Department of Surgery and Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Laura J Esserman
- Department of Surgery, University of California San Francisco, San Francisco, CA
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28
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Kim H, Hieken TJ, Abraha F, Jakub JW, Corbin KS, Furutani KM, Boughey JC, Stish BJ, Deufel CL, Degnim AC, Shumway DA, Ahmed SK, Piltin MA, Sandhu NP, Conners AL, Ruddy KJ, Mutter RW, Park SS. Long-term outcomes of intraoperatively-placed applicator brachytherapy for rapid completion of breast conserving treatment: An analysis of a prospective registry data. Clin Transl Radiat Oncol 2023; 41:100639. [PMID: 37251618 PMCID: PMC10212787 DOI: 10.1016/j.ctro.2023.100639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/09/2023] [Accepted: 05/07/2023] [Indexed: 05/31/2023] Open
Abstract
Background and purpose To evaluate the long-term outcome of accelerated partial breast irradiation utilizing intraoperatively placed applicator-based brachytherapy (ABB) in early-stage breast cancer. Materials and methods From our prospective registry, 223 patients with pTis-T2, pN0/pN1mic breast cancer were treated with ABB. The median treatment duration including surgery and ABB was 7 days. The prescribed doses were 32 Gy/8 fx BID (n = 25), 34 Gy/10 fx BID (n = 99), and 21 Gy/3 fx QD (n = 99). Endocrine therapy (ET) adherence was defined as completion of planned ET or ≥ 80% of the follow-up (FU) period. Cumulative incidence of ipsilateral breast tumor recurrence (IBTR) was estimated and influencing factors for IBTR-free survival rate (IBTRFS) were analyzed. Results 218/223 patients had hormone receptor-positive tumors, including 38 (17.0%) with Tis and 185 (83.0%) with invasive cancer. After a median FU of 63 months, 19 (8.5%) patients had recurrence [17 (7.6%) with an IBTR]. Rates of 5-year IBTRFS and DFS were 92.2% and 91.1%, respectively. The 5-year IBTRFS rates were significantly higher for post-menopausal women (93.6% vs. 66.4%, p = 0.04), BMI < 30 kg/m2 (97.4% vs. 88.1%, p = 0.02), and ET-adherence (97.5% vs. 88.6%, p = 0.02). IBTRFS did not differ with dose regimens. Conclusions Postmenopausal status, BMI < 30 kg/m2, and ET- adherence predicted favorable IBTRFS. Our results highlight the importance of careful patient selection for ABB and encouragement of ET compliance.
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Affiliation(s)
- Haeyoung Kim
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University of School of Medicine, Seoul, South Korea
| | | | - Feven Abraha
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - James W. Jakub
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | - Bradley J. Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Amy C. Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dean A. Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Mara A. Piltin
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nicole P. Sandhu
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amy L. Conners
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Robert W. Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Sean S. Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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29
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Joshi U, Budhathoki P, Gaire S, Yadav SK, Shah A, Adhikari A, Choong G, Couzi R, Giridhar KV, Leon-Ferre RA, Boughey JC, Hieken TJ, Mutter R, Ruddy KJ, Haddad TC, Goetz MP, Couch FJ, Yadav S. Clinical outcomes and prognostic factors in triple-negative invasive lobular carcinoma of the breast. Breast Cancer Res Treat 2023; 200:217-224. [PMID: 37210429 PMCID: PMC10782581 DOI: 10.1007/s10549-023-06959-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/21/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE Triple-negative invasive lobular carcinoma (TN-ILC) of breast cancer is a rare disease and the clinical outcomes and prognostic factors are not well-defined. METHODS Women with stage I-III TN-ILC or triple-negative invasive ductal carcinoma (TN-IDC) of the breast undergoing mastectomy or breast-conserving surgery between 2010 and 2018 in the National Cancer Database were included. Kaplan-Meier curves and multivariate Cox proportional hazard regression were used to compare overall survival (OS) and evaluate prognostic factors. Multivariate logistic regression was performed to analyze the factors associated with pathological response to neoadjuvant chemotherapy. RESULTS The median age at diagnosis for women with TN-ILC was 67 years compared to 58 years in TN-IDC (p < 0.001). There was no significant difference in the OS between TN-ILC and TN-IDC in multivariate analysis (HR 0.96, p = 0.44). Black race and higher TNM stage were associated with worse OS, whereas receipt of chemotherapy or radiation was associated with better OS in TN-ILC. Among women with TN-ILC receiving neoadjuvant chemotherapy, the 5-year OS was 77.3% in women with a complete pathological response (pCR) compared to 39.8% in women without any response. The odds of achieving pCR following neoadjuvant chemotherapy were significantly lower in women with TN-ILC compared to TN-IDC (OR 0.53, p < 0.001). CONCLUSION Women with TN-ILC are older at diagnosis but have similar OS compared to TN-IDC after adjusting for tumor and demographic characteristics. Administration of chemotherapy was associated with improved OS in TN-ILC, but women with TN-ILC were less likely to achieve complete response to neoadjuvant therapy compared to TN-IDC.
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Affiliation(s)
- Utsav Joshi
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, 14621, USA
| | - Pravash Budhathoki
- Department of Internal Medicine, Bronxcare Health System, Bronx, NY, 10457, USA
| | - Suman Gaire
- Department of Internal Medicine, Mount Sinai Hospital Chicago, Chicago, IL, 60608, USA
| | - Sumeet K Yadav
- Department of Hospital Internal Medicine, Mayo Clinic, Mankato, MN, 56001, USA
| | - Anish Shah
- Department of Internal Medicine, Bronxcare Health System, Bronx, NY, 10457, USA
| | - Anurag Adhikari
- Department of Internal Medicine, Jacobi Medical Center, New York, NY, 10461, USA
| | - Grace Choong
- Department of Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Rima Couzi
- Department of Oncology, Johns Hopkins Hospital, Baltimore, MD, 21231, USA
| | | | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Tina J Hieken
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Robert Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kathryn J Ruddy
- Department of Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Tufia C Haddad
- Department of Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Matthew P Goetz
- Department of Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Fergus J Couch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
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30
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Boughey JC, Rosenkranz KM, Ballman KV, McCall L, Haffty BG, Cuttino LW, Kubicky CD, Le-Petross HT, Giuliano AE, Van Zee KJ, Hunt KK, Hahn OM, Carey LA, Partridge AH. Local Recurrence After Breast-Conserving Therapy in Patients With Multiple Ipsilateral Breast Cancer: Results From ACOSOG Z11102 (Alliance). J Clin Oncol 2023; 41:3184-3193. [PMID: 36977292 PMCID: PMC10256355 DOI: 10.1200/jco.22.02553] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/11/2023] [Accepted: 02/17/2023] [Indexed: 03/30/2023] Open
Abstract
PURPOSE Breast-conserving therapy (BCT) is the preferred treatment for unifocal breast cancer (BC). The oncologic safety of BCT for multiple ipsilateral breast cancer (MIBC) has not been demonstrated in a prospective study. ACOSOG Z11102 (Alliance) is a phase II, single-arm, prospective trial designed to evaluate oncologic outcomes in patients undergoing BCT for MIBC. PATIENTS AND METHODS Women age 40 years and older with two to three foci of biopsy-proven cN0-1 BC were eligible. Patients underwent lumpectomies with negative margins followed by whole breast radiation with boost to all lumpectomy beds. The primary end point was cumulative incidence of local recurrence (LR) at 5 years with an a priori rate of clinical acceptability of <8%. RESULTS Among 270 women enrolled between November 2012 and August 2016, there were 204 eligible patients who underwent protocol-directed BCT. The median age was 61 years (range, 40-87 years). At a median follow-up of 66.4 months (range, 1.3-90.6 months), six patients developed LR for an estimated 5-year cumulative incidence of LR of 3.1% (95% CI, 1.3 to 6.4). Patient age, number of sites of preoperative biopsy-proven BC, estrogen receptor status and human epidermal growth factor receptor 2 status, and pathologic T and N categories were not associated with LR risk. Exploratory analysis showed that the 5-year LR rate in patients without preoperative magnetic resonance imaging (MRI; n = 15) was 22.6% compared with 1.7% in patients with a preoperative MRI (n = 189; P = .002). CONCLUSION The Z11102 clinical trial demonstrates that breast-conserving surgery with adjuvant radiation that includes lumpectomy site boosts yields an acceptably low 5-year LR rate for MIBC. This evidence supports BCT as a reasonable surgical option for women with two to three ipsilateral foci, particularly among patients with disease evaluated with preoperative breast MRI.
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Affiliation(s)
| | - Kari M. Rosenkranz
- Dartmouth Hitchcock Medical Center, Dartmouth College—Norris Cotton Cancer Center, Lebanon, NH
| | - Karla V. Ballman
- Alliance Statistics and Data Management Center, Weill Cornell Medicine, New York, NY
| | - Linda McCall
- Alliance Statistics and Data Management Center, Duke University, Durham, NC
| | | | | | - Charlotte D. Kubicky
- Oregon Health and Science University, Legacy Good Samaritan Hospital and Medical Center, Portland, OR
| | | | | | | | - Kelly K. Hunt
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olwen M. Hahn
- Alliance for Clinical Trials in Oncology Operations Office, Chicago, IL
| | - Lisa A. Carey
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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31
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Tang X, Thompson KJ, Kalari KR, Sinnwell JP, Suman VJ, Vedell PT, McLaughlin SA, Northfelt DW, Aspitia AM, Gray RJ, Carter JM, Weinshilboum R, Wang L, Boughey JC, Goetz MP. Integration of multiomics data shows down regulation of mismatch repair and tubulin pathways in triple-negative chemotherapy-resistant breast tumors. Breast Cancer Res 2023; 25:57. [PMID: 37226243 PMCID: PMC10207800 DOI: 10.1186/s13058-023-01656-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/09/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Triple-negative breast cancer (TNBC) is the most aggressive breast cancer subtype. Patients with TNBC are primarily treated with neoadjuvant chemotherapy (NAC). The response to NAC is prognostic, with reductions in overall survival and disease-free survival rates in those patients who do not achieve a pathological complete response (pCR). Based on this premise, we hypothesized that paired analysis of primary and residual TNBC tumors following NAC could identify unique biomarkers associated with post-NAC recurrence. METHODS AND RESULTS We investigated 24 samples from 12 non-LAR TNBC patients with paired pre- and post-NAC data, including four patients with recurrence shortly after surgery (< 24 months) and eight who remained recurrence-free (> 48 months). These tumors were collected from a prospective NAC breast cancer study (BEAUTY) conducted at the Mayo Clinic. Differential expression analysis of pre-NAC biopsies showed minimal gene expression differences between early recurrent and nonrecurrent TNBC tumors; however, post-NAC samples demonstrated significant alterations in expression patterns in response to intervention. Topological-level differences associated with early recurrence were implicated in 251 gene sets, and an independent assessment of microarray gene expression data from the 9 paired non-LAR samples available in the NAC I-SPY1 trial confirmed 56 gene sets. Within these 56 gene sets, 113 genes were observed to be differentially expressed in the I-SPY1 and BEAUTY post-NAC studies. An independent (n = 392) breast cancer dataset with relapse-free survival (RFS) data was used to refine our gene list to a 17-gene signature. A threefold cross-validation analysis of the gene signature with the combined BEAUTY and I-SPY1 data yielded an average AUC of 0.88 for six machine-learning models. Due to the limited number of studies with pre- and post-NAC TNBC tumor data, further validation of the signature is needed. CONCLUSION Analysis of multiomics data from post-NAC TNBC chemoresistant tumors showed down regulation of mismatch repair and tubulin pathways. Additionally, we identified a 17-gene signature in TNBC associated with post-NAC recurrence enriched with down-regulated immune genes.
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Affiliation(s)
- Xiaojia Tang
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Thompson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Krishna R Kalari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.
| | - Jason P Sinnwell
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Vera J Suman
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Peter T Vedell
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | - Jodi M Carter
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | - Richard Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | | | - Matthew P Goetz
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA.
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Carter JM, Chumsri S, Hinerfeld DA, Ma Y, Wang X, Zahrieh D, Hillman DW, Tenner KS, Kachergus JM, Brauer HA, Warren SE, Henderson D, Shi J, Liu Y, Joensuu H, Lindman H, Leon-Ferre RA, Boughey JC, Liu MC, Ingle JN, Kalari KR, Couch FJ, Knutson KL, Goetz MP, Perez EA, Thompson EA. Distinct spatial immune microlandscapes are independently associated with outcomes in triple-negative breast cancer. Nat Commun 2023; 14:2215. [PMID: 37072398 PMCID: PMC10113250 DOI: 10.1038/s41467-023-37806-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 03/30/2023] [Indexed: 04/20/2023] Open
Abstract
The utility of spatial immunobiomarker quantitation in prognostication and therapeutic prediction is actively being investigated in triple-negative breast cancer (TNBC). Here, with high-plex quantitative digital spatial profiling, we map and quantitate intraepithelial and adjacent stromal tumor immune protein microenvironments in systemic treatment-naïve (female only) TNBC to assess the spatial context in immunobiomarker-based prediction of outcome. Immune protein profiles of CD45-rich and CD68-rich stromal microenvironments differ significantly. While they typically mirror adjacent, intraepithelial microenvironments, this is not uniformly true. In two TNBC cohorts, intraepithelial CD40 or HLA-DR enrichment associates with better outcomes, independently of stromal immune protein profiles or stromal TILs and other established prognostic variables. In contrast, intraepithelial or stromal microenvironment enrichment with IDO1 associates with improved survival irrespective of its spatial location. Antigen-presenting and T-cell activation states are inferred from eigenprotein scores. Such scores within the intraepithelial compartment interact with PD-L1 and IDO1 in ways that suggest prognostic and/or therapeutic potential. This characterization of the intrinsic spatial immunobiology of treatment-naïve TNBC highlights the importance of spatial microenvironments for biomarker quantitation to resolve intrinsic prognostic and predictive immune features and ultimately inform therapeutic strategies for clinically actionable immune biomarkers.
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Affiliation(s)
- Jodi M Carter
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | - Saranya Chumsri
- Department of Medicine, Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Yaohua Ma
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Xue Wang
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - David Zahrieh
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - David W Hillman
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kathleen S Tenner
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | - Ji Shi
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
| | - Yi Liu
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
| | - Heikki Joensuu
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Henrik Lindman
- Department of Oncology, University of Uppsala, Uppsala, Sweden
| | - Roberto A Leon-Ferre
- Department of Oncology, Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | - James N Ingle
- Department of Oncology, Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Krishna R Kalari
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Fergus J Couch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Keith L Knutson
- Department of Immunology, Mayo Clinic, Jacksonville, FL, USA
| | - Matthew P Goetz
- Department of Oncology, Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Edith A Perez
- Department of Medicine, Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
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Magbanua MJM, van ‘t Veer L, Clark AS, Chien AJ, Boughey JC, Han HS, Wallace A, Beckwith H, Liu MC, Yau C, Wileyto EP, Ordonez A, Solanki T, Hsiao F, Lee JC, Basu A, Swigart LB, Perlmutter J, Delson AL, Bayne L, Deluca S, Yee SS, Carpenter EL, Esserman LJ, Park JW, Chodosh LA, DeMichele A. Outcomes and clinicopathologic characteristics associated with disseminated tumor cells in bone marrow after neoadjuvant chemotherapy in high-risk early stage breast cancer: the I-SPY SURMOUNT study. Breast Cancer Res Treat 2023; 198:383-390. [PMID: 36689092 PMCID: PMC10290540 DOI: 10.1007/s10549-022-06803-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/03/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE Disseminated tumor cells (DTCs) expressing epithelial markers in the bone marrow are associated with recurrence and death, but little is known about risk factors predicting their occurrence. We detected EPCAM+/CD45- cells in bone marrow from early stage breast cancer patients after neoadjuvant chemotherapy (NAC) in the I-SPY 2 Trial and examined clinicopathologic factors and outcomes. METHODS Patients who signed consent for SURMOUNT, a sub-study of the I-SPY 2 Trial (NCT01042379), had bone marrow collected after NAC at the time of surgery. EPCAM+CD45- cells in 4 mLs of bone marrow aspirate were enumerated using immunomagnetic enrichment/flow cytometry (IE/FC). Patients with > 4.16 EPCAM+CD45- cells per mL of bone marrow were classified as DTC-positive. Tumor response was assessed using the residual cancer burden (RCB), a standardized approach to quantitate the extent of residual invasive cancer present in the breast and the axillary lymph nodes after NAC. Association of DTC-positivity with clinicopathologic variables and survival was examined. RESULTS A total of 73 patients were enrolled, 51 of whom had successful EPCAM+CD45- cell enumeration. Twenty-four of 51 (47.1%) were DTC-positive. The DTC-positivity rate was similar across receptor subtypes, but DTC-positive patients were significantly younger (p = 0.0239) and had larger pretreatment tumors compared to DTC-negative patients (p = 0.0319). Twenty of 51 (39.2%) achieved a pathologic complete response (pCR). While DTC-positivity was not associated with achieving pCR, it was significantly associated with higher RCB class (RCB-II/III, 62.5% vs. RCB-0/I; 33.3%; Chi-squared p = 0.0373). No significant correlation was observed between DTC-positivity and distant recurrence-free survival (p = 0.38, median follow-up = 3.2 years). CONCLUSION DTC-positivity at surgery after NAC was higher in younger patients, those with larger tumors, and those with residual disease at surgery.
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Affiliation(s)
| | | | | | - A. Jo Chien
- University of California San Francisco, San Francisco, CA
| | | | | | - Anne Wallace
- University of California San Diego, San Diego, CA
| | | | | | - Christina Yau
- University of California San Francisco, San Francisco, CA
| | | | - Andrea Ordonez
- University of California San Francisco, San Francisco, CA
| | - Tulasi Solanki
- University of California San Francisco, San Francisco, CA
| | - Feng Hsiao
- University of California San Francisco, San Francisco, CA
| | - Jen Chieh Lee
- University of California San Francisco, San Francisco, CA
| | - Amrita Basu
- University of California San Francisco, San Francisco, CA
| | | | | | - Amy L. Delson
- University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | - John W. Park
- University of California San Francisco, San Francisco, CA
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Hunt KK, Suman VJ, Wingate HF, Leitch AM, Unzeitig G, Boughey JC, Meric-Bernstam F, Ellis MJ, Olson J. Local-Regional Recurrence After Neoadjuvant Endocrine Therapy: Data from ACOSOG Z1031 (Alliance), a Randomized Phase 2 Neoadjuvant Comparison Between Letrozole, Anastrozole, and Exemestane for Postmenopausal Women with Estrogen Receptor-Positive Clinical Stage 2 or 3 Breast Cancer. Ann Surg Oncol 2023; 30:2111-2118. [PMID: 36653664 PMCID: PMC10373661 DOI: 10.1245/s10434-022-12972-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/26/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND The ACOSOG Z1031 trial addressed the ability of three neoadjuvant aromatase inhibitors (NAIs) to reduce residual disease (cohort A) and to assess whether switching to neoadjuvant chemotherapy (NCT) after 4 weeks of receiving NAI with Ki67 greater than 10% increases pathologic complete response (pCR) in postmenopausal women with estrogen receptor-enriched (Allred score 6-8) breast cancer (BC). METHODS The study enrolled 622 women with clinical stage 2 or 3 estrogen receptor-positive (ER+) BC. Cohort A comprised 377 patients, and cohort B had 245 patients. The analysis cohort consisted of 509 patients after exclusion of patients who did not meet the trial eligibility criteria, switched to NCT or surgery due to 4-week Ki67 greater than 10%, or withdrew before surgery. Distribution of time to local-regional recurrence (LRR) was estimated using the competing-risk approach, in which distant recurrence and second primaries were considered to be competing-risk events. Patients who died without LRR, distant recurrence, or a second primary were censored at the last evaluation. RESULTS Of the 509 patients, 342 (67.2%) had breast-conserving surgery (BCS). Of 221 patients thought to require mastectomy at presentation, 50% were able to have BCS. Five (1%) patients had no residual disease in the breast or nodes at surgery. Among 382 women alive at this writing, 90% have been followed longer than 5 years. The 5-year cumulative incidence rate for LRR is estimated to be 1.53% (95% confidence interval 0.7-3.0%). CONCLUSIONS Rarely does NAI result in pCR for patients with stage 2 or 3 ER+ BC. However, a significant proportion will have downstaged to allow for BCS. Local-regional recurrence after surgery is uncommon (1.5% at 5 years), supporting the use of BCS after NAI.
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Affiliation(s)
- Kelly K Hunt
- Breast Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA.
| | - Vera J Suman
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Hannah F Wingate
- Breast Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX, USA
| | - A Marilyn Leitch
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Matthew J Ellis
- Lester and Sue Smith Breast Center, Baylor College of Medicine, Houston, TX, USA
| | - John Olson
- Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA
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Hunt KK, Suman VJ, Wingate HF, Leitch AM, Unzeitig G, Boughey JC, Meric-Bernstam F, Ellis MJ, Olson JA. ASO Visual Abstract: Local-Regional Recurrence Following Neoadjuvant Endocrine Therapy - Data from ACOSOG Z1031 (Alliance), a Randomized Phase II Neoadjuvant Comparison Between Letrozole, Anastrozole, and Exemestane for Postmenopausal Women with Estrogen Receptor-Positive Clinical Stage 2-3 Breast Cancer. Ann Surg Oncol 2023; 30:2119-2120. [PMID: 36745260 DOI: 10.1245/s10434-023-13149-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kelly K Hunt
- Breast Surgical Oncology, UT MD Anderson Cancer Center, 1400 Pressler St. Unit 1434, Houston, TX, 77030, USA.
| | - Vera J Suman
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Hannah F Wingate
- Breast Surgical Oncology, UT MD Anderson Cancer Center, 1400 Pressler St. Unit 1434, Houston, TX, 77030, USA
| | - A Marilyn Leitch
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Funda Meric-Bernstam
- Breast Surgical Oncology, UT MD Anderson Cancer Center, 1400 Pressler St. Unit 1434, Houston, TX, 77030, USA
| | - Matthew J Ellis
- Lester and Sue Smith Breast Center, Baylor College of Medicine, Houston, TX, USA
| | - John A Olson
- Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA
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Ballman KV, McCall L, Boughey JC, Rosenkranz KM. Reply to: “The Feasibility of Breast-Conserving Surgery for Multiple Ipsilateral Breast Cancer: An Initial Report from ACOSOG Z11102 (Alliance) Trial: A Comment” by Alser, Osaid. Ann Surg Oncol 2023; 30:3282-3283. [PMID: 36971986 DOI: 10.1245/s10434-023-13375-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
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Joshi U, Budhathoki P, Gaire S, Yadav SK, Shah A, Adhikari A, Choong G, Couzi R, Giridhar K, Leon-Ferre R, Boughey JC, Hieken TJ, Mutter R, Ruddy KJ, Haddad TC, Goetz MP, Couch FJ, Yadav S. Clinical Outcomes and Prognostic Factors in Triple-Negative Invasive Lobular Carcinoma of the Breast. Res Sq 2023:rs.3.rs-2658909. [PMID: 36993608 PMCID: PMC10055567 DOI: 10.21203/rs.3.rs-2658909/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Purpose: Triple-negative invasive lobular carcinoma (TN-ILC) of breast cancer is a rare disease and the clinical outcomes and prognostic factors are not well-defined. Methods: Women with stage I-III TN-ILC or triple-negative invasive ductal carcinoma (TN-IDC) of the breast undergoing mastectomy or breast-conserving surgery between 2010 and 2018 in the National Cancer Database were included. Kaplan-Meier curves and multivariate Cox proportional hazard regression were used to compare overall survival (OS) and evaluate prognostic factors. Multivariate logistic regression was performed to analyze the factors associated with pathological response to neoadjuvant chemotherapy. Results: The median age at diagnosis for women with TN-ILC was 67 years compared to 58 years in TN-IDC (p<0.001). There was no significant difference in the OS between TN-ILC and TN-IDC in multivariate analysis (HR 0.96, p=0.44). Black race and higher TNM stage were associated with worse OS, whereas receipt of chemotherapy or radiation was associated with better OS in TN-ILC. Among women with TN-ILC receiving neoadjuvant chemotherapy, the 5-year OS was 77.3% in women with a complete pathological response (pCR) compared to 39.8% in women without any response. The odds of achieving pCR following neoadjuvant chemotherapy were significantly lower in women with TN-ILC compared to TN-IDC (OR 0.53, p<0.001). Conclusion: Women with TN-ILC are older at diagnosis but have similar OS compared to TN-IDC after adjusting for tumor and demographic characteristics. Administration of chemotherapy was associated with improved OS in TN-ILC, but women with TN-ILC were less likely to achieve complete response to neoadjuvant therapy compared to TN-IDC.
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Affiliation(s)
| | | | | | | | | | | | | | - Rima Couzi
- Johns Hopkins School of Medicine Department of Oncology: Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center
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Leon-Ferre RA, Carter JM, Zahrieh D, Sinnwell JP, Salgado R, Suman V, Hillman D, Boughey JC, Kalari KR, Couch FJ, Ingle JN, Balkenkohl M, Ciompi F, van der Laak J, Goetz MP. Abstract P2-11-34: Mitotic spindle hotspot counting using deep learning networks is highly associated with clinical outcomes in patients with early-stage triple-negative breast cancer who did not receive systemic therapy. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p2-11-34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: Triple-negative breast cancers (TNBC) exhibit high rates of recurrence and mortality. However, recent studies suggest that a subset of patients (pts) with early-stage TNBC enriched in tumor-infiltrating lymphocytes (TILs) have excellent clinical outcomes even in the absence of systemic therapy. Additional histological biomarkers that could identify pts for future systemic therapy escalation/de-escalation strategies are of great interest. TNBC are frequently highly proliferative with abundant mitoses. However, classic markers of proliferation (manual mitosis counting and Ki-67) appear to offer no prognostic value. Here, we evaluated the prognostic effects of automated mitotic spindle hotspot (AMSH) counting on RFS in independent cohorts of systemically untreated early-stage TNBC.
Methods: AMSH counting was conducted with a state-of-the-art deep learning algorithm trained on the detection of mitoses within 2 mm2 areas with the highest mitotic density (i.e. hotspots) in digital H&E images. Details of the development, training and validation of the algorithm were published previously [1] in a cohort of unselected TNBC. We obtained AMSH counts in a centrally confirmed TNBC cohort from Mayo Clinic [2] and focused our analysis on pts who received locoregional therapy but no systemic therapy. Using a fractional polynomial analysis with a multivariable proportional hazards regression model, we confirmed the assumption of linearity in the log hazard for the continuous variable AMSH and evaluated whether AMSH counts were prognostic of RFS. We corroborated our findings in an independent cohort of systemically untreated TNBC pts from the Radboud University Medical Center in the Netherlands (Radboud Cohort). Results are reported at a median follow-up of 8.1 and 6.7 years for the Mayo and Netherlands cohorts, respectively.
Results: Among 182 pts with who did not receive systemic therapy in the Mayo Cohort, 140 (77%) with available AMSH counts were included. The mean age was 61 (range: 31-94), 71% were postmenopausal, 67% had tumors ≤ 2cm, and 83% were node-negative. As expected, most tumors were Nottingham grade 3 (84%) and had a high Ki-67 proliferation index (54% with Ki-67 >30%). Most tumors (73%) had stromal TILs ≤ 30%. The median AMSH count was 18 (IQR: 8, 42). AMSH counts were linearly associated with grade and tumor size, with the proportion of pts with grade 3 tumors and size > 2 cm increasing as the AMSH counts increased (p=0.007 and p=0.059, respectively). In a multivariate model controlling for nodal status, tumor size, and stromal TILs, AMSH counts were independently associated with RFS (p< 0.0001). For every 10-point increase in the AMSH count, we observed a 17% increase in the risk of experiencing an RFS event (HR 1.17, 95% CI 1.08-1.26). We corroborated our findings in the Radboud Cohort (n=126). The mean age was 68 (range: 40-96), and 81% were node-negative. While the median AMSH count was 36 (IQR: 16-63), higher than in the Mayo Cohort (p=0.004), the prognostic impact was similar, with a significant association between AMSH count and RFS (p=0.028) in a multivariate model corrected for nodal status, tumor size, and stromal TILs. For every 10-point increase in the AMSH count in the Netherlands cohort, we observed a 9% increase in the risk of experiencing an RFS event (HR 1.09, 95% CI 1.01-1.17). RFS rates according to AMSH counts for both cohorts are shown in the Table.
Conclusions: AMSH counting is a new proliferation biomarker that provides prognostic value independent of nodal status, tumor size, and stromal TILs in systemically untreated early-stage TNBC. Plans are underway to evaluate AMSH counts in additional cohorts of systemically untreated TNBC, and in other disease settings such as prior to neoadjuvant systemic therapy. If validated, this biomarker should be prospectively evaluated as a potential selection biomarker in clinical trials of systemic therapy de-escalation.
References:
1. PMID: 29994086
2. PMID: 28913760
Table RFS according to AMSH counts in the Mayo and Radboud Cohorts
Citation Format: Roberto A. Leon-Ferre, Jodi M. Carter, David Zahrieh, Jason P. Sinnwell, Roberto Salgado, Vera Suman, David Hillman, Judy C. Boughey, Krishna R. Kalari, Fergus J. Couch, James N. Ingle, Maschenka Balkenkohl, Francesco Ciompi, Jeroen van der Laak, Matthew P. Goetz. Mitotic spindle hotspot counting using deep learning networks is highly associated with clinical outcomes in patients with early-stage triple-negative breast cancer who did not receive systemic therapy [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 P2-11-34.
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Affiliation(s)
| | | | | | | | - Roberto Salgado
- 5GZA-ZNA-Hospitals, Antwerp, Belgium; Peter Mac Callum Cancer Centre, Melbourne, Australia
| | | | | | - Judy C. Boughey
- 8Division of Breast and Melanoma Surgical Oncology, Department of Surgery,Mayo Clinic, Rochester, Minnesota, USA
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Choong GM, Boughey JC, Hoskin TL, Day CN, Goetz MP. Abstract P2-03-12: Impact of adjuvant endocrine therapy (ET) omission in ER+ breast cancer (BC) treated with neoadjuvant chemotherapy (NAC). Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p2-03-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: Adjuvant endocrine therapy (ET) in ER+ breast cancer (BC) reduces local, distant, and contralateral BC events and improves overall survival (OS). Furthermore, decreased adherence or omission of ET increases the risk of death. However, in ER+ pts with early-stage BC treated with NAC who have a pathologic complete response (pCR), the importance of adjuvant ET may be called into question. We sought to examine the impact of ET omission on the survival of pts with ER+ BC treated with NAC, according to pCR vs residual disease.
Methods: We queried the National Cancer Database (NCDB) 2010-2018 for female pts with stage I-III ER+ BC treated with NAC followed by surgery. pCR was defined as ypT0/ypTis, ypN0. The percent receiving adjuvant ET and the impact of adjuvant ET omission on overall survival (OS) in patients with and without pCR were assessed separately based on HER2 expression. OS was analyzed with adjuvant ET as a time-dependent covariate using Cox proportional hazards regression.
Results: We identified 34,394 pts treated with NAC for ER+ BC (28,434 ER+/HER2-, 5960 ER+/HER2+). Pts with ER+/HER2+ BC were less likely than pts with ER+/HER2- BC to have received adjuvant ET (61.6% vs 88.8%, p< 0.001). Overall, 4505 (13.1%) had pCR (9.1% of ER+/HER2- and 32.0% of ER+/HER2+). Within each subtype, pts with pCR were significantly less likely to start adjuvant ET after surgery than pts with residual disease (78.4% vs 89.8% for ER+/HER2- and 46.5% vs 68.7% for ER+/HER2+, each p< 0.001), Table 1. Regarding those with residual disease, pts with ER+/HER2+ BC were less likely than ER+/HER2- BC to receive adjuvant ET (68.7% vs 89.8%, p< 0.001). Median follow-up was 4.4 years. Among pts with pCR, 5-year OS was 93.2% (95% CI: 92.1-94.4%) for ER+/HER2- BC and 94.3% (95% CI: 93.1-95.5%) for ER+/HER2+ BC (p=0.08), while among patients with residual disease 5-year OS was 81.7% (95% CI: 81.1-82.2%) and 85.7% (95% CI: 84.5-86.9%) for the two subtypes respectively (p< 0.001). On multivariable analysis, omission of adjuvant ET was significantly associated with poorer OS in patients with residual disease for both ER+/HER2- BC (adjusted HR 1.72, p< 0.001) and ER+/HER2+ BC (adjusted HR 1.63, p< 0.001). In contrast, omission of adjuvant ET was not significantly associated with OS in patients with pCR, regardless of HER2 status (ER+/HER2- adjusted HR 1.28, p=0.20; ER+/HER2+ adjusted HR 1.13, p=0.54), Table 1.
Conclusions: In pts receiving NAC for ER+ BC, those with ER+/HER2+ disease were less likely to have received adjuvant ET compared to ER+/HER2- patients, regardless of pCR. In pts with residual disease after NAC, omission of adjuvant ET was associated with significantly higher risk of death. These data provide strong support for interventions to increase utilization of ET, especially for patients with residual disease following NAC. The observation that ET omission did not impact OS in pts with ER+ BC who achieve pCR following NAC is hypothesis generating and may have implications for future de-escalation trials for this subset of patients.
Table 1. Differential use of adjuvant endocrine therapy by subtype and pCR and the impact on overall survival
Citation Format: Grace M. Choong, Judy C. Boughey, Tanya L. Hoskin, Courtney N. Day, Matthew P. Goetz. Impact of adjuvant endocrine therapy (ET) omission in ER+ breast cancer (BC) treated with neoadjuvant chemotherapy (NAC) [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 P2-03-12.
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Affiliation(s)
| | - Judy C. Boughey
- 2Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L. Hoskin
- 3Department of Surgery, Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
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Stringer-Reasor E, Shatsky RA, Chien J, Wallace A, Boughey JC, Albain KS, Han HS, Nanda R, Isaacs C, Kalinsky K, Mitri Z, Clark AS, Vaklavas C, Thomas A, Trivedi MS, Lu J, Asare S, Lu R, Pitsouni M, Wilson A, Perlmutter J, Rugo H, Schwab R, Symmans WF, Hylton NM, Van ’t Veer L, Yee D, DeMichele A, Berry D, Esserman LJ, Investigators ISPY. Abstract PD11-01: PD11-01 Evaluation of the PD-1 Inhibitor Cemiplimab in early-stage, high-risk HER2-negative breast cancer: Results from the neoadjuvant I-SPY 2 TRIAL. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-pd11-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: I-SPY2 is a multicenter, phase 2 trial using response-adaptive randomization within biomarker subtypes defined by hormone-receptor (HR), HER2, and MammaPrint (MP) status to evaluate novel agents as neoadjuvant therapy for high-risk breast cancer. The primary endpoint is pathologic complete response (pCR). Cemiplimab (Cemi) is a PD-1 inhibitor approved for the treatment of NSCLC, cutaneous basal, and squamous cell cancer. Here, we report current efficacy rates of Cemi in combination with paclitaxel followed by AC.
Methods: Women with tumors ≥ 2.5cm were eligible for screening. Only HER2 negative (HER2-) patients were eligible for this treatment; HR positive (HR+) patients had to be MP high risk. Treatment included paclitaxel 80 mg/m2 IV weekly x 12 and Cemi 350 mg IV given q3weeks x 4, followed by doxorubicin/cyclophosphamide (AC) every 2 weeks x 4. The control arm was weekly paclitaxel x 12 followed by AC every 2-3 weeks x 4. All patients undergo serial MRI imaging; and imaging response (at 3 weeks, 12 weeks and prior to surgery) were used along with accumulating pCR data to continuously update and estimate pCR rates for trial arms. Analysis was modified intent to treat. Patients who switched to non-protocol therapy count as non-pCR. The goal is to identify (graduate) regimens with ≥85% Bayesian predictive probability of success (i.e. demonstrating superiority to control) in a future 300-patient phase 3 neoadjuvant trial with a pCR endpoint within responsive signatures. Cemi was eligible to graduate in 3 pre-defined signatures: HER2-, HR-HER2-, and HR+HER2-. To adapt to changing standard of care, we constructed “dynamic controls” comprising ‘best’ alternative therapies using I-SPY 2 and external data and estimated the probability of Cemi being superior to the dynamic control.
Results: 60 HER2- patients (28 HR+ and 32 HR-) received Cemi arm treatment. The control group included 357 patients with HER2- tumors (201 HR+ and 156 HR-) enrolled since March 2010. Cemi graduated in HR-/HER2- signature. Estimated pCR rates (as of June 2022) are summarized in the table.
Immune-related endocrine disorders include: hypothyroid (14.5%), adrenal insufficiency (10%), hyperthyroid (4.8%),) and thyroiditis (3.2%). Only one grade 3 adrenal insufficiency was observed. All immune related AE’s were manageable. Additional biomarker analyses are ongoing and will be presented at the meeting. Response predictive subtypes (Immune+ vs Immune-) and additional predictive biomarkers were assessed. Associations with pCR will be presented at SABCS.
Conclusion: The I-SPY 2 study aims to assess the probability that investigational regimens will be successful in a phase 3 neoadjuvant trial. Anti-PD-1 therapy with Cemi resulted in a higher predicted pCR rate in HR-/HER2- 55 rate% disease compared to control at 29%. Immune-mediated AE’s were observed. This data is consistent with previously published data using check point inhibitors in early-stage HR-/HER2- breast cancer.
Estimated pCR rates
Citation Format: Erica Stringer-Reasor, Rebecca A. Shatsky, Jo Chien, Anne Wallace, Judy C. Boughey, Kathy S. Albain, Hyo S. Han, Rita Nanda, Claudine Isaacs, Kevin Kalinsky, Zahi Mitri, Amy S. Clark, Christos Vaklavas, Alexandra Thomas, Meghna S. Trivedi, Janice Lu, Smita Asare, Ruixiao Lu, Maria Pitsouni, Amy Wilson, Jane Perlmutter, Hope Rugo, Richard Schwab, W. Fraser Symmans, Nola M. Hylton, Laura Van ’t Veer, Douglas Yee, Angela DeMichele, Donald Berry, Laura J. Esserman, I-SPY Investigators. PD11-01 Evaluation of the PD-1 Inhibitor Cemiplimab in early-stage, high-risk HER2-negative breast cancer: Results from the neoadjuvant I-SPY 2 TRIAL [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 PD11-01.
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Affiliation(s)
| | | | - Jo Chien
- 3University of California, San Francisco
| | | | - Judy C. Boughey
- 5Division of Breast and Melanoma Surgical Oncology, Department of Surgery,Mayo Clinic, Rochester, Minnesota
| | - Kathy S. Albain
- 6Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center
| | - Hyo S. Han
- 7H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Rita Nanda
- 8University of Chicago, Chicago, Illinois
| | | | - Kevin Kalinsky
- 10Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Hope Rugo
- 22University of California San Francisco, San Francisco, CA
| | | | | | | | | | - Douglas Yee
- 27Masonic Cancer Center, University of Minnesota, Minnesota
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Moldoveanu D, Goetz MP, Hoskin TL, Day CN, Boughey JC. Abstract P6-01-22: Age, Ki-67, Nodal pCR and overall survival following Neoadjuvant Chemotherapy for Node Positive ER+/Her2- Breast Cancer. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p6-01-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: The role of chemotherapy in node positive (N+) luminal breast cancer (BC) is often debated, given low total pathologic complete response (pCR) rates following neoadjuvant chemotherapy (NAC) and discrepancy in adjuvant chemotherapy benefit. A prior single institution study of cN+ luminal BC showed that pts age < 50 and tumor Ki-67 ≥ 20% had high nodal pCR (> 35%). This study’s goals were 1) to validate Ki-67 and age in relation to nodal pCR and 2) evaluate the prognostic impact of nodal pCR on overall survival (OS).
Methods: We queried the National Cancer Database 2010-2019 for pts with cN+ ER+/HER2- BC treated with NAC and surgery. Breast pCR was defined as ypT0/ypTis and nodal pCR as ypN0/ypN0i+. Ki-67 was available in 2018 & 2019 only and was used to evaluate Ki-67 and nodal pCR. 2010-2018 data were used to evaluate nodal pCR and OS. OS was analyzed using multivariable Cox proportional hazards regression.
Results: In 2018-2019, 4,801 pts were identified and 2,473 (51.5%) had Ki-67 available. Nodal pCR was 23.7% and was higher in pts < 50 years old (28.1% vs 21.1%) and in those with Ki67 ≥ 20% (28.4% vs 12.7%), both p < 0.001. Pts < 50 with Ki67 ≥ 20% had the highest nodal pCR at 31.7%, followed by age ≥ 50 with Ki67 ≥ 20% at 26.3%. With Ki67 < 20%, nodal pCR was 15.4% (in age < 50) and 11.3% (in age ≥ 50).
From 2010-2018, we identified 20,084 cN+ ER+/HER2- BC pts treated with NAC. Total pCR was 7.4%, 14.3% had nodal pCR only, 3.8% had breast pCR only, and 74.5% had residual disease in breast and nodes. OS at 5 years was 79.1% and varied by NAC response: 90.8% with total pCR, 83.8% with nodal pCR only, 80.7% with breast pCR only, and 76.9% with residual disease in breast and nodes. Specifically nodal pCR (with or without breast pCR) was seen in 22.0% and was associated with 5-year OS rate of 86.4% compared to 77.1% without nodal pCR, p < 0.001. On multivariable analysis adjusted for other clinical and treatment factors, nodal pCR was associated with better OS (adjusted HR 0.56, 95% CI: 0.50-0.61, p < 0.001) in all ages combined and within both the age < 50 and age ≥ 50 subgroups (see Table).
In a subgroup of pts approximating RxPonder entry criteria (defined as cT1-3, N1, Grade I or II, ER+/PR+), results were consistent with the overall cohort: nodal pCR varied by both age (17.5% in age < 50 and 13.6% in age ≥ 50, p < 0.001) and by Ki67 ≥ 20% vs < 20% (16.8% vs 7.9%, p < 0.001) and nodal pCR remained prognostic for OS with adjusted HR 0.63 (95% CI: 0.50-0.81, p < 0.001).
Conclusion: In cN+ ER+/HER2- BC treated with NAC, nodal pCR is more common in pts< 50 and those with high Ki-67 and is highly prognostic for OS. These data strongly suggest that NAC chemotherapy benefit should not be evaluated using total pCR rates in isolation, but for N+ pts to also consider nodal response. Given that nodal pCR is highly prognostic for OS, future neoadjuvant strategies should consider nodal pCR as a potential intermediate biomarker for long term survival.
Multivariable analysis of factors associated with overall survival, including the adjusted effect of nodal pCR
Citation Format: Dan Moldoveanu, Matthew P. Goetz, Tanya L. Hoskin, Courtney N. Day, Judy C. Boughey. Age, Ki-67, Nodal pCR and overall survival following Neoadjuvant Chemotherapy for Node Positive ER+/Her2- 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 P6-01-22.
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Affiliation(s)
| | | | - Tanya L. Hoskin
- 3Department of Surgery, Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN
| | | | - Judy C. Boughey
- 5Division of Breast and Melanoma Surgical Oncology, Department of Surgery,Mayo Clinic, Rochester, Minnesota
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Isaacs C, Nanda R, Chien J, Trivedi MS, Stringer-Reasor E, Vaklavas C, Boughey JC, Sanford A, Wallace A, Clark AS, Thomas A, Albain KS, Kennedy LC, Sanft TB, Kalinsky K, Han HS, Williams N, Arora M, Elias A, Falkson C, Asare S, Lu R, Pitsouni M, Wilson A, Perlmutter J, Rugo H, Schwab R, Symmans WF, Hylton NM, Veer LV, Yee D, DeMichele A, Berry D, Esserman LJ, I-SPY Investigators. Abstract GS5-03: Evaluation of anti-PD-1 Cemiplimab plus anti-LAG-3 REGN3767 in early-stage, high-risk HER2-negative breast cancer: Results from the neoadjuvant I-SPY 2 TRIAL. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-gs5-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: I-SPY2 is a multicenter, phase 2 trial using response-adaptive randomization within biomarker subtypes defined by hormone-receptor (HR), HER2, and MammaPrint (MP) status to evaluate novel agents as neoadjuvant therapy for high-risk breast cancer. The primary endpoint is pathologic complete response (pCR). Cemiplimab is an anti-PD-1 inhibitor approved for the treatment of NSCLC and cutaneous basal and squamous cell CA. Lymphocyte activation gene 3 (LAG-3) binds MHC class II leading to inhibition of T-cell proliferation and activation and is often co-expressed with PD-1. REGN3767 is a fully humanized mAb that binds to LAG-3 and blocks inhibitory T-cell signaling. Concurrent blockade of LAG-3 with an anti-PD-1 may enhance efficacy of an anti-PD-1.
Methods: Women with tumors ≥ 2.5cm were eligible for screening. Only HER2 negative (HER2-) patients were eligible for this treatment; HR positive (HR+) patients had to be MP high risk. Treatment included Paclitaxel 80 mg/m2 IV weekly x 12 and Cemiplimab 350 mg and REGN3767 1600 mg both given q3weeks x 4, followed by doxorubicin/cyclophosphamide (AC) every 2 weeks x 4. The control arm was weekly paclitaxel x 12 followed by AC every 2-3 weeks x 4. Cemiplimab/REGN3767 was eligible to graduate in 3 of 10 pre-defined signatures: HER2-, HR-HER2-, and HR+HER2-. The statistical methods for evaluating I-SPY 2 agents has been previously described. To adapt to changing standard of care, we constructed “dynamic controls” comprising ‘best’ alternative therapies using I-SPY 2 and external data and estimated the probability of Cemiplimab/REGN3767 being superior to the dynamic control. Response predictive subtypes (Immune+ vs Immune-) were assessed using pre-treatment gene expression data and the ImPrint signature.
Results: 73 HER2- patients (40 HR+ and 33 HR-) received Cemiplimab/REGN3767 treatment. The control group included [357 patients with HER2- tumors (201 HR+ and 156 HR-) enrolled since March 2010. Cemiplimab/REGN3767 graduated in both HR-/HER2- and HR+/HER2- groups; estimated pCR rates (as of June 2022) are summarized in the table. Safety events of note for Cemiplimab/REGN3767 include hypothyroidism 30.8%, adrenal insufficiency (AI) 19.2%, hyperthyroidism 14.1%, pneumonitis 1.3%, and hepatitis 3.8%. All were G1/2 except for 6 (7.7%) G3 AI and 3 (3.8%) G3 colitis. Rash occurred in 62.8%, 9% G3 and 2 pts (2.6%) had pulmonary embolism. X% of adrenal insufficiency cases required replacement therapy. 40 patients (11 HR+ and 29 HR-) in Cemiplimab/REGN3767 were predicted Immune+; 32 (29 HR+ and 3 HR-) were predicted Immune-. In the HR+ group pCR was achieved in 10/11 (91%) patients with Immune+ subtype compared with 8/29 (28%) with Immune- subtype. Additional biomarker analyses are ongoing and will be presented at the meeting.
Conclusion: The I-SPY 2 study aims to assess the probability that investigational regimens will be successful in a phase 3 neoadjuvant trial. Dual immune blockade with a LAG-3 inhibitor and anti-PD1 therapy resulted in a high predicted pCR rate both in HR-/HER2- (60%) and HR+/HER2- (37%) disease. The novel Imprint signature identified a group of HR+ patients most likely to benefit from this active regimen.
Table 1: Estimated pCR rates
Citation Format: Claudine Isaacs, Rita Nanda, Jo Chien, Meghna S. Trivedi, Erica Stringer-Reasor, Christos Vaklavas, Judy C. Boughey, Amy Sanford, Anne Wallace, Amy S. Clark, Alexandra Thomas, Kathy S. Albain, Laura C. Kennedy, Tara B. Sanft, Kevin Kalinsky, Hyo S. Han, Nicole Williams, Mili Arora, Anthony Elias, Carla Falkson, Smita Asare, Ruixiao Lu, Maria Pitsouni, Amy Wilson, Jane Perlmutter, Hope Rugo, Richard Schwab, W. Fraser Symmans, Nola M. Hylton, Laura Van’t Veer, Douglas Yee, Angela DeMichele, Donald Berry, Laura J. Esserman, I-SPY Investigators. Evaluation of anti-PD-1 Cemiplimab plus anti-LAG-3 REGN3767 in early-stage, high-risk HER2-negative breast cancer: Results from the neoadjuvant I-SPY 2 TRIAL [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 GS5-03.
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Affiliation(s)
| | - Rita Nanda
- 2University of Chicago, Chicago, Illinois
| | - Jo Chien
- 3University of California, San Francisco
| | | | | | | | - Judy C. Boughey
- 7Division of Breast and Melanoma Surgical Oncology, Department of Surgery,Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Kathy S. Albain
- 12Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center
| | | | | | - Kevin Kalinsky
- 15Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Hyo S. Han
- 16H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | | | | | | | - Carla Falkson
- 20Wilmot Cancer Institute, University of Rochester Medical Center
| | | | | | | | | | | | - Hope Rugo
- 26University of California San Francisco, San Francisco, CA
| | | | | | | | | | - Douglas Yee
- 31Masonic Cancer Center, University of Minnesota, Minnesota
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Montagna G, Mrdutt M, Botty A, Barrio AV, Sevilimedu V, Boughey JC, Hoskin TL, Rosenberger LH, Hwang ES, Ingham A, Papassotiropoulos B, Nguyen-Sträuli BD, Kurzeder C, Aybar DD, Vorburger D, Matlac DM, Ostapenko E, Riedel F, Fitzal F, Meani F, Fick F, Sagasser J, Heil J, Dedes KJ, Romics L, Banys-Paluchowski M, Perez MDRC, Diaz MC, Heidinger M, Fehr MK, Reinisch M, Maggi N, Rocco N, Ditsch N, Gentilini OD, Paulinelli RR, Zarhi SS, Küemmel S, Bruzas S, Lascio SD, Parissenti T, Güth U, Ovalle V, Tausch C, Morrow M, Kühn T, Weber WP. Abstract GS4-02: Oncological Outcomes Following Omission of Axillary Lymph Node Dissection in Node Positive Patients Downstaging To Node Negative with Neoadjuvant Chemotherapy: the OPBC-04/EUBREAST-06/OMA study. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-gs4-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: Data on the oncologic safety of omission of axillary lymph node dissection (ALND) in node positive (N+) patients who downstage to ypN0 with neoadjuvant chemotherapy (NAC) is sparse. Additionally, there is no consensus on which axillary staging procedure should be used in this setting, sentinel lymph node biopsy (SLNB) alone or in combination with localization and retrieval of the clipped positive node, also known as targeted axillary dissection (TAD). Whether the reduction in the false negative rate observed with TAD translates into a significant reduction in the rate of axillary recurrence is unknown. We sought to evaluate oncologic outcomes after omission of ALND in a large, real-world cohort of breast cancer (BC) patients and to compare rates of axillary recurrence after SLNB with dual tracer mapping vs. TAD.
Methods: Data were collected from 19 centers in the Oncoplastic Breast Consortium (OPBC) and EUBREAST networks. Patients with T1-4 biopsy-proven N1-3 BC who underwent NAC followed by axillary staging with either SLNB with dual tracer mapping or TAD and who were pathologically node negative (ypN0) were included. ypN0 was defined as the absence of any tumor or isolated tumor cells. Competing risk analysis was performed to assess the cumulative incidence rates of axillary recurrence, locoregional recurrence, and any invasive (locoregional or distant) recurrence. Two-year cumulative incidence rates were compared between TAD and SLNB using the Gray’s test. Type I error rate was set to 0.05 (α).
Results: We included 785 patients (565 treated with SLNB and 220 with TAD) treated with NAC followed by surgery from 01/2014-12/2020. Median patient age was 50 years. The majority (57%) of patients had clinical T2 tumors, and 95% had N1 disease. Most (55%) were HER2+, and 21% were triple negative. Most patients (81%) received anthracycline and taxane-based chemotherapy regimens, but NAC regimens differed between patients treated with TAD and those treated with SLNB (Table 1). All patients with HER2+ tumors received anti HER2 therapy. Nodal radiotherapy was administered to 76% of patients, and was more common in patients who underwent TAD (82% TAD vs 74% SLNB, p=0.017). Breast pathologic complete response (ypT0/is) was more frequent among those patients that had TAD (80% TAD vs. 66% SLNB, p< 0.001). TAD localization was with wire in 46%, radioactive seed in 40%, ultrasound in 5%, tattoo in 2%, and with a combination of these techniques in 7%. The clipped node was successfully retrieved in 94% of TAD cases. The median number of lymph nodes removed was lower in the TAD group compared to the SLNB group [3 (IQR 3-5) vs 4 IQR 3-5), p< 0.001], as was the median number of sentinel lymph nodes [3 (IQR 2-4) vs 4 IQR 3-5), p< 0.001] (Table 1). The 5-year rates of any axillary recurrence, locoregional recurrence, and any invasive recurrence in the entire cohort were 1.1% (95%CI 0.39-2.4%), 3.1% (95%CI 1.6-5.3%) and 10% (95%CI 7.6-13%), respectively. The two-year cumulative incidence of axillary recurrence did not differ between patients treated with TAD compared to SLNB (0% vs 0.9%, p=0.19).
Conclusion: Early axillary recurrence after omission of ALND in patients who successfully downstage from N+ to ypN0 with NAC is a rare event following both SLNB or TAD, and was not significantly lower in TAD than SLNB. Although longer follow-up is needed to confirm these findings, the main advantage of TAD seems to be a reduction in the number of lymph nodes removed. Overall, these results support omission of ALND in patients who successfully downstage to node negative disease after NAC.
Table 1: Clinicopathological Features of the Study Cohort, Stratified by Axillary Staging Technique
Citation Format: Giacomo Montagna, Mary Mrdutt, Astrid Botty, Andrea V. Barrio, Varadan Sevilimedu, Judy C. Boughey, Tanya L. Hoskin, Laura H. Rosenberger, E Shelley Hwang, Abigail Ingham, Bärbel Papassotiropoulos, Bich Doan Nguyen-Sträuli, Christian Kurzeder, Danilo Diaz Aybar, Denise Vorburger, Dieter Michael Matlac, Edvin Ostapenko, Fabian Riedel, Florian Fitzal, Francesco Meani, Franziska Fick, Jacqueline Sagasser, Jörg Heil, Konstantin J. Dedes, Laszlo Romics, Maggie Banys-Paluchowski, Maria Del Rosario Cueva Perez, Marcelo Chavez Diaz, Martin Heidinger, Mathias K. Fehr, Mattea Reinisch, Nadia Maggi, Nicola Rocco, Nina Ditsch, Oreste Davide Gentilini, Regis Resende Paulinelli, Sebastian Sole Zarhi, Sherko Küemmel, Simona Bruzas, Simona Di Lascio, Tamara Parissenti, Uwe Güth, Valentina Ovalle, Christoph Tausch, Monica Morrow, Thorsten Kühn, Walter P. Weber. Oncological Outcomes Following Omission of Axillary Lymph Node Dissection in Node Positive Patients Downstaging To Node Negative with Neoadjuvant Chemotherapy: the OPBC-04/EUBREAST-06/OMA 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 GS4-02.
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Affiliation(s)
- Giacomo Montagna
- 1Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary Mrdutt
- 2Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Astrid Botty
- 3Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | | | - Judy C. Boughey
- 6Division of Breast and Melanoma Surgical Oncology, Department of Surgery,Mayo Clinic, Rochester, Minnesota
| | - Tanya L. Hoskin
- 7Department of Surgery, Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Abigail Ingham
- 10University of Glasgow and NHS Greater Glasgow and Clyde,Department of Academic Surgery, Glasgow, UK
| | | | | | - Christian Kurzeder
- 13Breast Center, University Hospital of Basel, Basel, Switzerland, Basel-Stadt, Switzerland
| | | | - Denise Vorburger
- 15Breast Cancer Unit, Comprehensive Cancer Center Zurich, University Hospital Zurich, Zurich,Switzerland
| | - Dieter Michael Matlac
- 16Department of Gynecology and Obstetrics, University of Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Edvin Ostapenko
- 17Department of General Surgery and Breast Health Center, Medical University of Vienna, Vienna, Austria; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Fabian Riedel
- 18Department of Gynecology and Obstetrics, Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Fitzal
- 19Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Meani
- 20Centro di Senologia della Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Franziska Fick
- 21Department of Gynecology and Obstetrics, University of Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Jacqueline Sagasser
- 22Department of Obstetrics and Gynecology, University Hospital of Augsburg, Augsburg, Germany
| | - Jörg Heil
- 23Department of Gynecology and Obstetrics, Breast Unit, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Laszlo Romics
- 25Department of Academic Surgery, Gartnavel General Hospital Glasgow,University of Glasgow, Glasgow, UK
| | - Maggie Banys-Paluchowski
- 26Department of Gynecology and Obstetrics, University of Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | | | | | - Martin Heidinger
- 29Breast Center, University Hospital of Basel, Basel, Switzerland
| | | | - Mattea Reinisch
- 31Interdisciplinary Breast Cancer Center/Breast Unit, Essen, Germany
| | - Nadia Maggi
- 32Breast Center, University Hospital of Basel, Basel, Switzerland
| | - Nicola Rocco
- 33Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Nina Ditsch
- 34Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg,Germany
| | | | | | - Sebastian Sole Zarhi
- 37Department of Radiation Oncology, University Diego Portales – IRAM, Santiago, Chile
| | | | | | - Simona Di Lascio
- 40Service of medical oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | | | - Uwe Güth
- 42Breast Center Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Valentina Ovalle
- 43Department of Radiation Oncology, University Diego Portales – IRAM, Santiago, Chile
| | | | | | - Thorsten Kühn
- 46Department of Gynecology, Hospital Esslingen, Esslingen, Germany
| | - Walter P. Weber
- 47Breast Center, University Hospital of Basel, Basel, Switzerland, Basel-Stadt, Basel-Stadt, Switzerland
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Mutter R, Giri S, Fruth B, Remmes N, Anand A, Ruddy K, Villarraga H, Patarroyo SS, Yan E, Merrell K, McGee L, Vern-Gross T, Stish B, Gao R, Boughey JC, Park S, Corbin K, Vargas C. Abstract GS4-05: Phase II randomized trial of conventional versus hypofractionated post-mastectomy proton radiotherapy. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-gs4-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Purpose/Objectives: Proton therapy is under investigation in breast cancer as a strategy to reduce heart and lung exposure, which is associated with late cardiopulmonary adverse events and secondary malignancy. To date, studies investigating postmastectomy radiotherapy (PMRT) with protons have used conventional fractionation. We hypothesized that condensing treatment to 15 fractions would be safe based on evidence that breast cancer is more sensitive to higher dose fractions than surrounding normal tissues. Materials/Methods: We conducted a randomized non-inferiority phase II trial comparing conventional and hypofractionated proton PMRT with primary endpoint of 24-month complication rate (defined as grade 3 or higher late adverse events using CTCAE, v 4.0 and/or unplanned surgical intervention in patients undergoing mastectomy with reconstruction). With a 10% non-inferiority margin the study ensured 80% power and had a one sided-type I error rate of 0.05. Cardiotoxicity was assessed with serial transthoracic conventional and 2-dimensional speckle tracking echocardiography (2D-STE). Eligibility included age ≥ 18 years with non-inflammatory breast cancer resected by mastectomy with indications for PMRT. Assignment of treatments was balanced with respect to immediate breast reconstruction (IBR). Conventional fractionation group received 50 Gy in 25 fractions of 2 Gy, and hypofractionation group received 40.05 Gy in 15 fractions of 2.67 Gy (RBE 1.1). Target volume included the chest wall and axillary, supraclavicular, and internal mammary lymph nodes. All patients were treated with multi-field optimized pencil beam scanning (intensity modulated proton therapy). Results: Between 2016 and 2018, 82 patients were enrolled and randomized (41 conventional, 41 hypofractionation). Median patient age was 52 years. 32.9% were staged T3-T4 and 79.3% node positive at diagnosis. 57 of 82 patients (69.5%) elected IBR. The median mean heart dose was 0.49 Gy and the median ipsilateral lung volume receiving 40% of prescription or greater (V40%) was 13.6%. No significant changes on conventional or 2D-STE at end-of-treatment or 3-month follow-up compared to baseline were observed. The rate of ≥ grade 2 acute dermatitis was lower with hypofractionation (44% vs 15%, p = 0.006). Other ≥ grade 2 acute adverse events including esophagitis (0 vs 5%), infection (5% vs 2.4%) and skin hyperpigmentation (7.3% vs 4.8%) were not significantly different between the two arms. With a median follow-up of 38.3 months, the 24-month complication rate was conventional 14.6% vs hypofractionation 17.1% (absolute difference 2.4%, p=0.17, 95% CI [-, 15.7%]). In patients with IBR, 6 of 28 (21.4%) conventional and 7 of 29 (24.1%) hypofractionated patients developed complications (p =0.80). There was no significant difference in 3-year disease-free survival between the conventional (89.4%; 95% CI 80.0 – 99.8%) and hypofractionated (92.4%, 95% CI 84.5 – 100.0%) arms (p = 0.91). One local recurrence occurred in the hypofractionated arm simultaneous with regional and distant relapse. The remaining 6 recurrences were isolated distant events. Conclusions: Proton PMRT provided excellent locoregional control and normal tissue sparing. There were no subclinical echocardiographic changes indicative of radiation-induced cardiac dysfunction. Hypofractionation resulted in comparable disease control, tolerability and reconstruction outcomes as conventional fractionation. Although non-inferiority of hypofractionation could not be established based on the upper bound of the 95% confidence interval for complication rate being greater than 10%, both conventional and hypofractionation may be considered appropriate regimens for ongoing phase 3 randomized trials comparing photon and proton radiotherapy.
Citation Format: Robert Mutter, Sharmila Giri, Briant Fruth, Nicholas Remmes, Aman Anand, Kathryn Ruddy, Hector Villarraga, Sebastian Santos Patarroyo, Elizabeth Yan, Kenneth Merrell, Lisa McGee, Tamara Vern-Gross, Bradley Stish, Robert Gao, Judy C. Boughey, Sean Park, Kimberly Corbin, Carlos Vargas. Phase II randomized trial of conventional versus hypofractionated post-mastectomy proton radiotherapy [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 GS4-05.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Judy C. Boughey
- 15Division of Breast and Melanoma Surgical Oncology, Department of Surgery,Mayo Clinic, Rochester, Minnesota
| | | | - Kimberly Corbin
- 17Department of Radiation Oncology, Mayo Clinic Rochester Campus
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De la Cruz-Ku G, Chambergo-Michilot D, Perez A, Valcarcel B, Pamen L, Linshaw D, Chatterjee A, LaFemina J, Boughey JC. Outcomes of robotic nipple-sparing mastectomy versus conventional nipple-sparing mastectomy in women with breast cancer: a systematic review and meta-analysis. J Robot Surg 2023:10.1007/s11701-023-01547-5. [PMID: 36808041 DOI: 10.1007/s11701-023-01547-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/10/2023] [Indexed: 02/23/2023]
Abstract
The promising results of the robotic approach for multiple cancer operations has led to interest in the potential of robotic nipple-sparing mastectomy (R-NSM); however, further studies are required to compare the benefits and complications of this approach with those of conventional open nipple-sparing mastectomy (C-NSM). We performed a meta-analysis to compare surgical complications of R-NSM versus C-NSM. We performed a review of literature through June 2022 in PubMed, Scopus, and EMBASE. We included randomized controlled trials (RCTs), cohorts, case-control studies, and case series with > 50 patients comparing the two techniques. Separate meta-analyses were conducted according to study design. From 80 publications, we identified six studies. The sample size ranged from 63 to 311 mastectomies from 63 to 275 patients. The tumor size and disease stage were similar between groups. The positive margin rate was 0-4.6% in the R-NSM arm and 0-2.9% in the C-NSM arm. Four studies reported early recurrence data, which were similar between groups (R-NSM: 0%, C-NSM: 0-8%). The R-NSM group had a lower rate of overall complications compared to the C-NSM group in cohorts/RCTs (RR = 0.68, 95%CI 0.49-0.96). In case-control studies, rate of necrosis was lower with R-NSM. Operative time was significantly longer in the R-NSM group in cohort/RCTs. In early experience with R-NSM, R-NSM had a lower overall complication rate compared to C-NSM in cohorts/RCTs. While these data are promising, our results show variability and heterogeneity limiting definitive conclusions. Additional trials are needed to guide the role of R-NSM and its oncologic outcomes.
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Affiliation(s)
- Gabriel De la Cruz-Ku
- Department of Surgery, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA. .,Universidad Científica del Sur, Lima, Perú.
| | | | - Armando Perez
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bryan Valcarcel
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Larissa Pamen
- Department of Surgery, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - David Linshaw
- Department of Surgery, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Abhishek Chatterjee
- Division of Surgical Oncology, Division of Plastic Surgery, Tufts Medical Center/Tufts School of Medicine, Boston, MA, USA
| | - Jennifer LaFemina
- Department of Surgery, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
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Wei L, Gao H, Yu J, Zhang H, Nguyen TTL, Gu Y, Passow MR, Carter JM, Qin B, Boughey JC, Goetz MP, Weinshilboum RM, Ingle JN, Wang L. Pharmacological Targeting of Androgen Receptor Elicits Context-Specific Effects in Estrogen Receptor-Positive Breast Cancer. Cancer Res 2023; 83:456-470. [PMID: 36469363 PMCID: PMC9896025 DOI: 10.1158/0008-5472.can-22-1016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/04/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Androgen receptor (AR) is expressed in 80% to 90% of estrogen receptor α-positive (ER+) breast cancers. Accumulated evidence has shown that AR is a tumor suppressor and that its expression is associated with improved prognosis in ER+ breast cancer. However, both a selective AR agonist (RAD140) and an AR inhibitor (enzalutamide, ENZ) have shown a therapeutic effect on ER+ breast cancer, so the potential for clinical application of AR-targeting therapy for ER+ breast cancer is still in dispute. In this study, we evaluated the efficacy of ENZ and RAD140 in vivo and in vitro in AR+/ER+ breast cancer models, characterizing the relationship of AR and ER levels to response to AR-targeting drugs and investigating the alterations of global gene expression and chromatin binding of AR and ERα after ENZ treatment. In the AR-low setting, ENZ directly functioned as an ERα antagonist. Cell growth inhibition by ENZ in breast cancer with low AR expression was independent of AR and instead dependent on ER. In AR-high breast cancer models, AR repressed ERα signaling and ENZ promoted ERα signaling by antagonizing AR. In contrast, RAD140 activated AR signaling and suppressed AR-high tumor growth by deregulating ERα expression and blocking ERα function. Overall, analysis of the dynamic efficacies and outcomes of AR agonist, and antagonist in the presence of different AR and ERα levels reveals regulators of response and supports the clinical investigation of ENZ in selected ER+ tumors with a low AR/ER ratio and AR agonists in tumors with a high AR/ER ratio. SIGNIFICANCE The ratio of androgen receptor to estrogen receptor in breast cancer dictates the response to AR-targeted therapies, providing guidelines for developing AR-directed treatment strategies for patients with breast cancer.
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Affiliation(s)
- Lixuan Wei
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Huanyao Gao
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Jia Yu
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Huan Zhang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Thanh Thanh L. Nguyen
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Yayun Gu
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Marie R. Passow
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jodi M. Carter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Bo Qin
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Matthew P. Goetz
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Richard M. Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - James N. Ingle
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
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Jakub JW, Zhang W, Solanki M, Yonkus J, Boughey JC, Harmsen S, Giridhar KV. Response Rates of Invasive Lobular Cancer in Patients Undergoing Neoadjuvant Endocrine or Chemotherapy. Am Surg 2023; 89:230-237. [PMID: 36305029 DOI: 10.1177/00031348221135778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND A gap remains in the role of neoadjuvant therapy for patients with ILC. METHOD Single-institution retrospective review of patients with ILC who received neoadjuvant therapy between 2008 and 2019. RESULTS 141 patients met inclusion criteria: 71 neoadjuvant chemotherapy (NACT) and 70 neoadjuvant endocrine therapy (NET). 7/71 (9.9%) patients had a pCR following NACT compared to 1/70 (1.4%) with NET (P = .063). pCR was observed in 5/18 (27.8%) patients with Her2Neu-positive disease following NACT, compared to 2/53 (3.8%) with Her2Neu-negative disease (P = .01).For luminal B tumors, median Ki-67 decrease was similar following NACT and NET (18.3 vs 16.3, P = .26).T category decreased in 59 (42.1%) patients following neoadjuvant therapy, increased in 9 (6.4%), and was unchanged in 72 (51.4%). More patients had an increase (28.6%) than decrease (12.1%) in their N category, including 13/60 (21.7%) who were clinically node-negative at diagnosis and identified to have node-positive disease following neoadjuvant therapy, at definitive surgery. CONCLUSION In Her2Neu-negative ILC, the potential of a pCR with NACT or NET is low. Most patients' nodal status and tumor size remain unchanged. There is a potential for pathologic stage to be higher at surgery compared to the clinical stage prior to neoadjuvant therapy.
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Affiliation(s)
- James W Jakub
- Division of Surgical Oncology, 156400Mayo Clinic, Jacksonville, FL, USA
| | - Wenexia Zhang
- Department of Breast Surgery, Shenzhen Maternity & Child Healthcare Hospital, 248258Nanfang Medical University, Shen Zhen Shi, Guangdong, China
| | - Malvika Solanki
- Department of Laboratory Medicine and Pathology, 4352Mayo Clinic, Rochester, MN, USA
| | | | - Judy C Boughey
- Division of Breast & Melanoma Surgical Oncology, 4352Mayo Clinic, Rochester, MN, USA
| | - Scott Harmsen
- Department of Biostatistics, 4352Mayo Clinic, Rochester, MN, USA
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Robbins T, Hoskin TL, Day CN, Mrdutt MM, Hieken TJ, Jakub JW, Glazebrook K, Boughey JC, Degnim AC. ASO Visual Abstract: Node Positivity Among Sonographically Suspicious but FNA-Negative Axillary Nodes. Ann Surg Oncol 2022; 29:622-623. [PMID: 36109410 DOI: 10.1245/s10434-022-12474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Affiliation(s)
- Thomas Robbins
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Mary M Mrdutt
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Tina J Hieken
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - James W Jakub
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MN, USA.
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Lang JE, Forero-Torres A, Yee D, Yau C, Wolf D, Park J, Parker BA, Chien AJ, Wallace AM, Murthy R, Albain KS, Ellis ED, Beckwith H, Haley BB, Elias AD, Boughey JC, Yung RL, Isaacs C, Clark AS, Han HS, Nanda R, Khan QJ, Edmiston KK, Stringer-Reasor E, Price E, Joe B, Liu MC, Brown-Swigart L, Petricoin EF, Wulfkuhle JD, Buxton M, Clennell JL, Sanil A, Berry S, Asare SM, Wilson A, Hirst GL, Singhrao R, Asare AL, Matthews JB, Melisko M, Perlmutter J, Rugo HS, Symmans WF, van 't Veer LJ, Hylton NM, DeMichele AM, Berry DA, Esserman LJ. Safety and efficacy of HSP90 inhibitor ganetespib for neoadjuvant treatment of stage II/III breast cancer. NPJ Breast Cancer 2022; 8:128. [PMID: 36456573 PMCID: PMC9715670 DOI: 10.1038/s41523-022-00493-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/10/2022] [Indexed: 12/03/2022] Open
Abstract
HSP90 inhibitors destabilize oncoproteins associated with cell cycle, angiogenesis, RAS-MAPK activity, histone modification, kinases and growth factors. We evaluated the HSP90-inhibitor ganetespib in combination with standard chemotherapy in patients with high-risk early-stage breast cancer. I-SPY2 is a multicenter, phase II adaptively randomized neoadjuvant (NAC) clinical trial enrolling patients with stage II-III breast cancer with tumors 2.5 cm or larger on the basis of hormone receptors (HR), HER2 and Mammaprint status. Multiple novel investigational agents plus standard chemotherapy are evaluated in parallel for the primary endpoint of pathologic complete response (pCR). Patients with HER2-negative breast cancer were eligible for randomization to ganetespib from October 2014 to October 2015. Of 233 women included in the final analysis, 140 were randomized to the standard NAC control; 93 were randomized to receive 150 mg/m2 ganetespib every 3 weeks with weekly paclitaxel over 12 weeks, followed by AC. Arms were balanced for hormone receptor status (51-52% HR-positive). Ganetespib did not graduate in any of the biomarker signatures studied before reaching maximum enrollment. Final estimated pCR rates were 26% vs. 18% HER2-negative, 38% vs. 22% HR-negative/HER2-negative, and 15% vs. 14% HR-positive/HER2-negative for ganetespib vs control, respectively. The predicted probability of success in phase 3 testing was 47% HER2-negative, 72% HR-negative/HER2-negative, and 19% HR-positive/HER2-negative. Ganetespib added to standard therapy is unlikely to yield substantially higher pCR rates in HER2-negative breast cancer compared to standard NAC, and neither HSP90 pathway nor replicative stress expression markers predicted response. HSP90 inhibitors remain of limited clinical interest in breast cancer, potentially in other clinical settings such as HER2-positive disease or in combination with anti-PD1 neoadjuvant chemotherapy in triple negative breast cancer.Trial registration: www.clinicaltrials.gov/ct2/show/NCT01042379.
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Affiliation(s)
- Julie E Lang
- University of Southern California, Los Angeles, USA.
| | | | | | - Christina Yau
- University of California San Francisco, San Francisco, USA
| | - Denise Wolf
- University of California San Francisco, San Francisco, USA
| | - John Park
- University of California San Francisco, San Francisco, USA
| | | | - A Jo Chien
- University of California San Francisco, San Francisco, USA
| | - Anne M Wallace
- University of California San Francisco, San Francisco, USA
| | - Rashmi Murthy
- University of Texas MD Anderson Cancer Center, Houston, USA
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | | | | | | | | | | | | | | | - Amy S Clark
- University of Pennsylvania, Philadelphia, USA
| | | | | | | | | | | | - Elissa Price
- University of California San Francisco, San Francisco, USA
| | - Bonnie Joe
- University of California San Francisco, San Francisco, USA
| | | | | | | | | | | | | | | | | | - Smita M Asare
- Quantum Leap Healthcare Collaborative, San Francisco, USA
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, USA
| | | | - Ruby Singhrao
- University of California San Francisco, San Francisco, USA
| | - Adam L Asare
- Quantum Leap Healthcare Collaborative, San Francisco, USA
| | | | | | | | - Hope S Rugo
- University of California San Francisco, San Francisco, USA
| | | | | | - Nola M Hylton
- University of California San Francisco, San Francisco, USA
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Osdoit M, Yau C, Symmans WF, Boughey JC, Ewing CA, Balassanian R, Chen YY, Krings G, Wallace AM, Zare S, Fadare O, Lancaster R, Wei S, Godellas CV, Tang P, Tuttle TM, Klein M, Sahoo S, Hieken TJ, Carter JM, Chen B, Ahrendt G, Tchou J, Feldman M, Tousimis E, Zeck J, Jaskowiak N, Sattar H, Naik AM, Lee MC, Rosa M, Khazai L, Rendi MH, Lang JE, Lu J, Tawfik O, Asare SM, Esserman LJ, Mukhtar RA. Association of Residual Ductal Carcinoma In Situ With Breast Cancer Recurrence in the Neoadjuvant I-SPY2 Trial. JAMA Surg 2022; 157:1034-1041. [PMID: 36069821 PMCID: PMC9453630 DOI: 10.1001/jamasurg.2022.4118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
Importance Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer strongly correlates with overall survival and has become the standard end point in neoadjuvant trials. However, there is controversy regarding whether the definition of pCR should exclude or permit the presence of residual ductal carcinoma in situ (DCIS). Objective To examine the association of residual DCIS in surgical specimens after neoadjuvant chemotherapy for breast cancer with survival end points to inform standards for the assessment of pathologic complete response. Design, Setting, and Participants The study team analyzed the association of residual DCIS after NAC with 3-year event-free survival (EFS), distant recurrence-free survival (DRFS), and local-regional recurrence (LRR) in the I-SPY2 trial, an adaptive neoadjuvant platform trial for patients with breast cancer at high risk of recurrence. This is a retrospective analysis of clinical specimens and data from the ongoing I-SPY2 adaptive platform trial of novel therapeutics on a background of standard of care for early breast cancer. I-SPY2 participants are adult women diagnosed with stage II/III breast cancer at high risk of recurrence. Interventions Participants were randomized to receive taxane and anthracycline-based neoadjuvant therapy with or without 1 of 10 investigational agents, followed by definitive surgery. Main Outcomes and Measures The presence of DCIS and EFS, DRFS, and LRR. Results The study team identified 933 I-SPY2 participants (aged 24 to 77 years) with complete pathology and follow-up data. Median follow-up time was 3.9 years; 337 participants (36%) had no residual invasive disease (residual cancer burden 0, or pCR). Of the 337 participants with pCR, 70 (21%) had residual DCIS, which varied significantly by tumor-receptor subtype; residual DCIS was present in 8.5% of triple negative tumors, 15.6% of hormone-receptor positive tumors, and 36.6% of ERBB2-positive tumors. Among those participants with pCR, there was no significant difference in EFS, DRFS, or LRR based on presence or absence of residual DCIS. Conclusions and Relevance The analysis supports the definition of pCR as the absence of invasive disease after NAC regardless of the presence or absence of DCIS. Trial Registration ClinicalTrials.gov Identifier NCT01042379.
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MESH Headings
- Adult
- Female
- Humans
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Neoadjuvant Therapy
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm, Residual/drug therapy
- Receptor, ErbB-2
- Retrospective Studies
- Young Adult
- Middle Aged
- Aged
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Affiliation(s)
- Marie Osdoit
- Department of Surgery, University of California San Francisco, San Francisco
| | - Christina Yau
- Department of Surgery, University of California San Francisco, San Francisco
| | - W. Fraser Symmans
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston
| | | | - Cheryl A. Ewing
- Department of Surgery, University of California San Francisco, San Francisco
| | - Ron Balassanian
- Department of Pathology, University of California San Francisco, San Francisco
| | - Yunn-Yi Chen
- Department of Pathology, University of California San Francisco, San Francisco
| | - Gregor Krings
- Department of Pathology, University of California San Francisco, San Francisco
| | - Anne M Wallace
- Department of Surgery, University of California San Diego, La Jolla
| | - Somaye Zare
- Department of Pathology, University of California San Diego, La Jolla
| | - Oluwole Fadare
- Department of Pathology, University of California San Diego, La Jolla
| | - Rachael Lancaster
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Shi Wei
- Department of Pathology, University of Alabama at Birmingham
| | - Constantine V. Godellas
- Department of Surgery, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Ping Tang
- Department of Pathology, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota, Minneapolis
| | - Molly Klein
- Laboratory Medicine and Pathology, Masonic Cancer Center, Minneapolis, Minnesota
| | - Sunati Sahoo
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Tina J. Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jodi M. Carter
- Laboratory Medicine and Pathology, May Clinic, Rochester, Minnesota
| | - Beiyun Chen
- Laboratory Medicine and Pathology, May Clinic, Rochester, Minnesota
| | | | - Julia Tchou
- Department of Surgery, University of Pennsylvania, Philadelphia
| | - Michael Feldman
- Pathology & Laboratory Medicine, University of Pennsylvania, Philadelphia
| | - Eleni Tousimis
- Department of Surgery, Georgetown University, Washington, DC
| | - Jay Zeck
- Pathology and Laboratory Medicine, Georgetown University, Washington, DC
| | | | - Husain Sattar
- Department of Pathology, University of Chicago, Illinois
| | - Arpana M. Naik
- Department of Surgery, Oregon Health & Science University, Portland
| | | | - Marilin Rosa
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Laila Khazai
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Mara H. Rendi
- Department of Pathology, University of Washington, Seattle
| | - Julie E. Lang
- Department of Surgery, University of Southern California, Los Angeles
| | - Janice Lu
- Department of Medicine, University of Southern California, Los Angeles
| | - Ossama Tawfik
- Department of Pathology, University of Kansas, Kansas City
| | | | - Laura J. Esserman
- Department of Surgery, University of California San Francisco, San Francisco
| | - Rita A. Mukhtar
- Department of Surgery, University of California San Francisco, San Francisco
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