Abstract P3-13-03: NEOS: A randomized, open label, phase 3 trial of adjuvant chemotherapy for postmenopausal breast cancer patients who responded to neoadjuvant letrozole: First report of long-term outcome and prognostic value of response to neoadjuvant endocrine therapy

Background: Whether adjuvant chemotherapy is required for patients (pts) with intermediate-risk endocrine-responsive postmenopausal breast cancer (BC) remains unknown. Sufficient data have not been available about the long-term prognosis of patients with neoadjuvant endocrine therapy (ET). NEOS is a randomized phase III study that assessed the long-term prognosis of estrogen receptor positive (ER+) primary breast cancer (PBC) pts who received neoadjuvant ET with/without adjuvant chemotherapy.

Methods: Postmenopausal BC pts with ER +/HER2 negative, T1c-2, clinically node negative, under 76 years old were enrolled at primary registration. Pts were treated by leterozole (LET) in weeks 24-28 after primary enrollment. Pts experienced progression (PD) during neoadjuvant phase were excluded at randomization and received any systemic therapy driven by investigators before or after surgery. The long-term prognosis was followed in all registered pts including PD pts. Response to neoadjuvant ET was evaluated as complete response (CR), partial response (PR) or stable disease (SD) using calipers, ultrasound and MRI (or CT) at the baseline and end of treatment before surgery. Pts who met eligibility criteria were randomized 1:1 to LET for 4.5-5 years after chemotherapy or LET alone for 4.5-5 years without chemotherapy after surgery. Pts excluded at second registration were treated any systemic therapies driven by investigators. The primary endpoint was disease-free survival (DFS) and secondary endpoints included overall survival (OS), clinical response rate in neoadjuvant phase, pathological response, and breast-conserving surgery rate. The randomization code have been blinded to the investigators.

Results: Between May 2008 and June 2013, 904 patients were enrolled at primary registration from 100 institutions in Japan (median follow-up: 4.0 years) and 24 pts were withdrawn during neoadjuvant phase. The median age was 63 years, T1c:37%, T2:63%, and PgR+:78%. Clinical response rates (CR, PR, SD and PD) were2% (16pts), 48% (421pts), 45% (400pts) and 5% (43pts), respectively and, in each response category, 0% (0/16), 5.5% (23/421), 7.8% (31/400), and 20.9% (9/43) experienced DFS events. DFS in PD pts to neoadjuvant ET were statistically significantly worse than CR, PR, SD pts (p<0.0001, hazard ratio 4.7 (95% CI:2.3-9.5). The prognosis after surgery in 669 randomized pts was good regardless with/without chemotherapy, forty four pts (6.6%) experienced DFS events after surgery. The predictive markers of PD for neoadjuvant ET were yet unclear among evaluated clinical factors.

Conclusion: This is the first report of DFS in the largest neoadjuvant ET trial (NEOS). The DFS of postmenopausal, ER+/HER2-, PBC pts excluding PD pts to neoadjuvant ET is highly good regardless with/without chemotherapy. Neoadjuvant ET with utilization of PD response as a prognostic marker can be considered as a standard treatment option for these patients. Clinical trial information: UMIN000001090.

Citation Format: Iwata H, Masuda N, Fujisawa T, Toyama T, Ohtani S, Yamamoto Y, Kashiwaba M, Taira N, Sakai T, Hasegawa Y, Nakamura R, Akabane H, Shibahara Y, Sasano H, Yamaguchi T, Ohashi Y. NEOS: A randomized, open label, phase 3 trial of adjuvant chemotherapy for postmenopausal breast cancer patients who responded to neoadjuvant letrozole: First report of long-term outcome and prognostic value of response to neoadjuvant endocrine therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-13-03.

Abstract PD5-03: TransNEOS: Validation of the oncotype DX recurrence score (RS) testing core needle biopsy samples from NEOS as predictor of clinical response to neoadjuvant endocrine therapy for postmenopausal estrogen receptor positive (ER+), HER2 negative (HER2-) breast cancer patients

Background: Neoadjuvant therapy for locally advanced breast cancer has the potential to improve surgical therapeutic outcomes without sacrificing the survival advantages of adjuvant therapy. However, determining whether ER+ patients (pts) will respond to neoadjuvant (NA) chemotherapy (CT) or hormone therapy (HT) can be difficult. Not all ER+ pts respond to NACT, while response to NAHT can vary across ER+ pts. Thus, the ability to select pts more likely to benefit from NAHT would represent progress in clinical management of breast cancer. NEOS is a randomized phase III study assessinglong-term prognosis of ER+ primary breast cancer with/without adjuvant CT following NAHT (UMIN 000001090, http://www.umin.ac.jp/). We used archived core biopsy tumor samples from the NEOS study to validate the RS result as a predictor of clinical response and its association with successful breast conserving surgery (BCS) in pts treated with 6 months of NAHT.

Methods: NEOS enrolled 904 postmenopausal pts with ER+, HER2-, clinically node negative (cN0) breast cancer to evaluate whether adjuvant CT was necessary for pts who responded to NAHT. In this current study, we enrolled pts with tumors ≥2cm from the NEOS study. Biopsy samples of 333 pts were assessed for the Oncotype DX assay. Response to NAHT was recorded as complete/partial response (CR/PR), or stable/progressive disease (SD/PD).

Primary endpoint of this study was to evaluate clinical response (CR/PR) to NA letrozole between pts with low (<18) and high (≥31) RS result. Secondary endpoints include evaluating the relationships between clinical response and continuous RS results, and other covariates including age, tumor size, grade, Ki67 by IHC, ER and PR single gene scores, and ER and proliferation gene group scores by RT-PCR.

Results: The analysis included 294 pts with median age of 63 yrs, median tumor size of 25mm, and 66% were nuclear grade 1. 156 (53.0%), 83 (28.6%) and 54(18.4%) cases were low, intermediate, and high RS groups by Oncotype DX, respectively. Six (2%), 126 (42.8%), 149 (50.3%), 13 (4.4%) cases experienced CR, PR, SD, PD as clinical response, respectively, similar to that of all NEOS pts. Clinical response rate was 54%, 42% and 22% in low, intermediate, and high RS groups, respectively. The proportion of pts with clinical response was significantly higher in the low RS group vs the high RS group (p<0.001). In univariate analyses, continuous RS was significantly associated with clinical response (p<0.001), along with ER (p=.02), PR (p<0.001), and ER gene group score (p<0.001). Other covariates were not associated with clinical response.

Conclusion: The Oncotype DX RS test in core biopsy samples is validated as a predictive assay for clinical response of NAHT in postmenopausal, ER+/HER2-, cN0, primary early breast cancer pts. Further results on the association of RS results with BCS outcomes following NAHT will be presented. These results when combined with previously published data on RS in NACT studies help guide pts with ER+, HER2- breast cancer with NAHT vs NACT treatment options to maximize clinical response.

Citation Format: Yamamoto Y, Iwata H, Masuda N, Fujisawa T, Toyama T, Kashiwaba M, Ohtani S, Taira N, Sakai T, Hasegawa Y, Nakamura R, Akabane H, Shibahara Y, Sasano H, Yamaguchi T, Sakamaki K, Chao C, McCullough D, Sugiyama N, Ohashi Y. TransNEOS: Validation of the oncotype DX recurrence score (RS) testing core needle biopsy samples from NEOS as predictor of clinical response to neoadjuvant endocrine therapy for postmenopausal estrogen receptor positive (ER+), HER2 negative (HER2-) breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD5-03.

Abstract P5-21-07: Phase II study of eribulin in combination with pertuzumab plus trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive advanced or metastatic breast cancer

Background: Pertuzumab provided overall and progression-free survival (PFS) benefits in HER2-positive metastatic breast cancer patients (pts) in the CLEOPATRA (Clinical evaluation of docetaxel, pertuzumab and trastuzumab) study. However, few studies have described the efficacy of other drugs in combination with pertuzumab plus trastuzumab. Here, we present a pre-specified analysis of eribulin in combination with pertuzumab plus trastuzumab as first- and second-line therapy for advanced or metastatic breast cancer (AMBC) in a multicenter, open-label phase II study (UMIN000012232, JBCRG-M03).

Methods: HER2-positive AMBC with no or single prior chemotherapy for AMBC were enrolled. All pts were administered trastuzumab and taxane as adjuvant or first-line chemotherapy. Treatment consisted of eribulin 1.4 mg/m2 on days 1 and 8 of a 21-day cycle and trastuzumab (8 mg/kg loading dose, then 6 mg/kg) plus pertuzumab (840 mg/body loading dose, then 420 mg/ body) once every 3 weeks, all administered intravenously. The primary endpoint was PFS, and secondary endpoints included overall response rate (ORR) and safety. PFS was determined using Kaplan–Meier analysis. Tumor response was assessed according to RECIST ver. 1.1.

Results: Fifty pts were enrolled from November 2013 to April 2016. Forty-nine pts were eligible for safety analysis and the full analysis set (FAS) included 46 pts. The median age was 56 years (23–70), and 8 (16%) and 41 (84%) pts were treated in first- and second-line settings, respectively. Eleven pts (23.9%) were de-novo Stage 4, and 35 pts (76.1%) had progressed in metastatic disease after completion of local therapy. Median PFS was 9.3 months (M) (95% confidence interval [CI]: 6.4–12.3). Table 1 shows the efficacy data for each treatment line and includes ORR, complete response rate (CR), partial response rate (PR), stable disease rate (SD), progressive disease rate (PD), not evaluable rate (NE) and PFS in the FAS. The median relative dose intensities of eribulin, trastuzumab, and pertuzumab were 93.3% (77.0%–100%), 100% (96.0%–100%), and 100% (89.7%–100%), respectively, in the FAS. The grade 3/4 adverse events (AE) were neutropenia in 5 pts (10.2%), including 2 pts (4.1%) with febrile neutropenia; hypertension in 3 pts (6.1%), and other AEs in only one patient. The average of the ejection fraction did not decrease significantly. Symptomatic left ventricular systolic dysfunction was not observed.

Conclusion: In pts with HER2-positive AMBC, first- and second-line therapy of eribulin in combination with pertuzumab plus trastuzumab demonstrated substantial antitumor activity with an acceptable safety profile. We are planning a phase III study comparing eribulin with taxanes in combination with pertuzumab plus trastuzumab for the treatment of HER2-positive AMBC.

Efficacy data for each treatment lineTreatment LineTotal (n=46)First line (n=8)Second line (n=38)PFS (95% CI), months9.3 (6.4-12.3)20.8 (2.8-38.7)8.7 (7.2-10.2)ORR (%)28 (60.9)7 (87.5)21 (55.3)CR (%)8 (17.4)3 (37.5)5 (13.2)PR (%)20 (43.5)4 (50.0)16 (42.1)SD (%)11 (23.9)1 (12.5)10 (26.3)PD (%)5 (10.9)05 (13.2)NE (%)2 (4.3)02 (5.3)

Citation Format: Kawaguchi H, Yamashita T, Masuda N, Kitada M, Narui K, Hattori M, Yoshinami T, Matsunami N, Yanagihara K, Kawasoe T, Nagashima T, Bando H, Yano H, Hasegawa Y, Nakamura R, Kashiwaba M, Morita S, Ohno S, Toi M. Phase II study of eribulin in combination with pertuzumab plus trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive advanced or metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-07.

Long-term health status as measured by EQ-5D among patients with metastatic breast cancer: comparison of first-line oral S-1 and taxane therapies in the randomized phase III SELECT BC trial

Purpose

The goal of chemotherapy for metastatic breast cancer (MBC) is to prolong survival and maintain health-related quality of life. This study aimed to evaluate long-term health status of patients with MBC who participated in the phase III randomized SELECT BC trial.

Methods

In the SELECT BC trial, patients were randomly allocated to the S-1 or taxane (paclitaxel or docetaxel) arm. Health status was assessed by EQ-5D at pre-treatment, 3 and 6 months after randomization, and every 6 months thereafter to the extent possible. Least square mean scores were assessed to compare EQ-5D index values between groups. Time to deterioration analysis was also performed by defining the minimally important difference of EQ-5D as 0.05 or 0.1.

Results

The number of patients for EQ-5D analysis was 175 and 208 in the taxane and S-1 arms, respectively. Least square mean EQ-5D index values up to 60 months were 0.741 (95 % CI [0.713–0.769]) in the taxane arm and 0.748 [0.722–0.775] in the S-1 arm. The EQ-5D index value during PFS up to 12 months in the S-1 was superior to the corresponding index value in the taxane (0.812 [0.789–0.834] vs. 0.772 [0.751–0.792], P = 0.009). Time to deterioration analysis also revealed that S-1 significantly delayed the deterioration of EQ-5D index value during the period before progression (P = 0.002 and 0.003).

Conclusions

Our findings suggest that the EQ-5D index value was higher in patients treated with S-1 during first-line chemotherapy. Considering non-inferiority of S-1 in terms of OS, obtained quality-adjusted life years may be greater in the S-1 arm.

Abstract P5-18-01: A randomized clinical trial of postoperative adjuvant therapy for elderly breast cancer patients: Conditions of obtaining informed consent and reasons for declining participation

Background: There are few randomized clinical trials examining adjuvant treatment in elderly breast cancer patients. While obtaining informed consent is essential for participation in clinical studies, there is little information on the frequency of agreement to participate among elderly patients. Furthermore, elderly patients might have specific reasons to decline participation.

Patients and Method: The National Surgical Adjuvant Study of Breast Cancer 07 (N-SAS BC 07) is a randomized clinical trial in women over 70 years with HER2-positive primary breast cancer. The primary aim was to investigate the benefit of trastuzumab monotherapy compared with the combination of trastuzumab and chemotherapy. Key inclusion criteria were as follows: women between 70 and 80 years old with HER2-positive breast cancer; underwent curative operation; stage I to IIIA; with sufficient organ function. Patients were randomized to receive either trastuzumab plus chemotherapy or trastuzumab monotherapy. The primary endpoint was disease-free survival, and the secondary endpoints were overall survival, relapse-free survival, safety, health-related quality of life, and cost effectiveness (NCT01104935). It was not possible to predict the number of patients who would agree to participate. In order to comprehensively assess the effect of postoperative adjuvant therapy, we evaluated the reasons why eligible patients declined to participate. The patients were registered in a cohort study to prospectively evaluate the subsequent treatment options and prognosis (07-Cohort). This study examined the obtaining of informed consent for N-SAS BC 07 and the reasons for declining participation, and compared the clinicopathological backgrounds between the N-SAS BC 07 and 07-Cohort groups.

Results: 398 eligible patients have been recruited. Informed consent to participate in N-SAS BC 07 has been obtained from 275 patients (69%) and 123 patients (31%) who declined to participate in the RCT have been registered in the 07-Cohort. The common reasons to decline participation in the RCT were "cannot choose the treatment option (55%)", "refused chemotherapy (16%)", "wanted chemotherapy (9%)", "anxious about clinical studies (9%)" and "family opposition (8%)". The mean ages of the patients in N-SAS BC 07 and 07-Cohort were 73.9 and 74.6 years old, respectively. There were no differences in stage, surgical procedure, lymph node metastasis, or co-morbidities between the groups. ER-positive rate was higher in 07-Cohort group compared with N-SAS BC 07 group (53% vs. 37%, p=0.017, χ2 test).

Conclusion: While we expected the number of registrants to be small, since N-SAS BC 07 investigated whether elderly patients with HER2-positive breast cancer should undergo chemotherapy, almost 70% of the patients accepted informed consent. The most common reason to decline participation in N-SAS BC 07 was "cannot choose the treatment option" and the majority refused chemotherapy. Furthermore, ER-positivity was higher in the 07-Cohort group, which suggested that ER expression in the patients with HER2-positive breast cancer might influence their decision to participate in the study or to choose the treatment option.

Citation Format: Sagara Y, Sawaki M, Taira N, Saito T, Kashiwaba M, Iwata H, Kobayashi K, Nakayama T, Bando H, Mizuno T, Yamamoto Y, Tsuneizumi M, Takahashi M, Yamaguchi M, Kawashima H, Takashima T, Uemura Y, Hozumi Y, Sagawa N, Mukai H, Ohashi Y. A randomized clinical trial of postoperative adjuvant therapy for elderly breast cancer patients: Conditions of obtaining informed consent and reasons for declining participation. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-18-01.

Abstract P4-11-02: Endocrine-related symptoms during neoadjuvant endocrine therapy for breast cancer: Agreement between patient and physician reporting in a prospective clinical trial

Background: There is a high risk of under-reporting subjective toxicities by physicians, even when collected prospectively in clinical trials. It has been recommended to include patient reported measures regarding symptoms in prospective clinical comparative effectiveness trials. However, there have been few reports of agreement in endocrine related symptoms between patient and physician reporting.

Patients and Method: The National Surgical Adjuvant Study of Breast Cancer 06 (N-SAS BC 06) is a multicenter, randomized clinical trial of postmenopausal, hormone receptor-positive breast cancer patients, with a two-stage (preoperative and postoperative) enrollment, and intervention. The primary aim was to evaluate the need for adjuvant chemotherapy in the treatment of postmenopausal breast cancer patients who responded to neoadjuvant treatment with Letrozole (LET) for 24-28 weeks. After surgery, responders were randomized into two arms receiving either chemotherapy plus LET, or LET alone. The primary endpoint was disease-free survival, and the secondary endpoints included adverse events, quality of life and health economic evaluation. This study enrolled 497 subjects from the N-SAS BC 06 who were evaluated by Patient Reported Outcomes (PROs). The concordance rate between Clinician Reported Outcomes (CROs) and PROs in their endocrine symptoms during neoadjuvant endocrine therapy was examined. Symptoms were collected prospectively by physicians using the Common Toxicity Criteria for Adverse Events at enrollment, i.e., baseline, and 4 and 16 weeks after starting neoadjuvant LET. Patients also completed the FACT-G (General), B (Breast), ES (Endocrine Symptoms), and HADS. The endocrine symptoms according to the PROs, included nausea, hot flushes, cold sweats, headaches, and HADS-Depression score. In FACT, "Not at all" was used to express the absence of the symptoms, and "A little bit", "Some-what", "Quite a bit", and "Very much" were used to express the presence of symptoms. The HADS-Depression score threshold was 10/11. According to the CROs, grade 0 was defined as the absence of symptoms and grade 1 or more was defined as the presence of symptoms. Cohen's kappa was used to determine the concordance between CROs and PROs. The sensitivity of CROs was also calculated.

Results: The calculated point estimates of Cohen's kappa at Weeks 4 and 16 after starting neoadjuvant LET were 0.12 and 0.01 for nausea, 0.16 and 0.18 for hot flushes, 0.12 and 0.09 for cold sweats, 0.03 and 0.02 for headaches, and 0.11 and 0.11 for dysthymia/depression, respectively; the concordance was quite low. The sensitivity of CROs at Weeks 4 and 16 after starting neoadjuvant LET was 0.07 and 0.03 for nausea, 0.16 and 0.17 for hot flushes, 0.1 and 0.08 for cold sweats, 0.03 and 0.03 for headaches, and 0.11 and 0.1 for dysthymia/depression, respectively; the sensitivity was quite low.

Conclusion: This study showed that there were big differences between CROs and PROs in endocrine symptoms associated with endocrine therapy for breast cancer and that physicians could not obtain sufficient information on the endocrine symptoms. It is recommended that PROs be used to evaluate adverse events caused by endocrine therapy.

Citation Format: Fujisawa T, Iwata H, Sakai T, Nakamura R, Hasegawa Y, Ohtani S, Kashiwaba M, Taira N, Toyama T, Masuda N, Yamamoto Y, Kihara K, Shimozuma K, Ohashi Y, Mukai H. Endocrine-related symptoms during neoadjuvant endocrine therapy for breast cancer: Agreement between patient and physician reporting in a prospective clinical trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-11-02.

Abstract P4-11-09: A randomized controlled trial of postoperative adjuvant therapy for elderly breast cancer patients: Comparison of health-related quality of life between clinical trial participants and decliners

Background: Health-related quality of life (HRQoL) is one of the important outcomes in cancer control trials and has increasingly become the one of the primary foci. Obtaining informed consent from participants is essential for participation in randomized controlled trials (RCTs), but the participation in these RCTs may directly influence HRQoL, because treatment options are determined according to the allocation schedule. To date, only a few studies have compared HRQoL between clinical trial participants and decliners.

Patients and Method: The National Surgical Adjuvant Study of Breast Cancer 07 (N-SAS BC 07) is a randomized controlled trial in women with HER2-positive primary breast cancer who are over 70 years of age. The primary aim was to investigate the benefit of trastuzumab monotherapy compared with combination therapy using trastuzumab and chemotherapy. The study concept and design were published in concept paper (Sawaki M. et al., Jpn J Clin Oncol. 2011). In this study, patients were randomized to receive either trastuzumab plus chemotherapy or trastuzumab monotherapy. The primary endpoint was disease-free survival, and the secondary endpoints were overall survival, relapse-free survival, safety, HRQoL, comprehensive geriatric assessment (CGA) and cost effectiveness (protocol ID; NCT01104935).

HRQoL and CGA were assessed at registration (baseline), 2 month, 1 year, and 3 years after the start of protocol treatments using the Functional Assessment of Cancer Therapy-General (FACT-G), Hospital Anxiety and Depression Scale (HADS), EuroQol 5 Dimension (EQ-5D), Tokyo Metropolitan Institute of Gerontology (TMIG) index of competence, and the Philadelphia Geriatric Center (PGC) Morale Scale.

The patients who declined to participate in N-SAS BC 07 were registered in a cohort study to prospectively evaluate the subsequent treatment options and prognosis (07-Cohort). The same questionnaire that was used in N-SAS BC 07 was used in 07-Cohort to evaluate HRQoL and CGA at entry.

Results: Patients were enrolled from October 2012 to October 2016. During this period, 275 and 123 patients were registered in N-SAS BC 07 and 07-Cohort, respectively. The mean age at entry of the patients in the N-SAS BC 07 and 07-Cohort groups was 73.9 and 74.6 years, respectively. The questionnaire response rates at baseline in the patients in N-SAS BC 07 and 07-Cohort groups were 89% and 82%, respectively. There were no significant differences in FACT-G, HADS, EQ-5D, or TMIG index of competence at baseline between the groups, but the mean (standard deviation) scores of PGC Morale Scale in N-SAS BC 07 and 07-Cohort groups were 10.8 (3.3) and 9.9 (3.7), respectively, with the scores being significantly greater in the N-SAS BC 07 group (p=0.020, t-test).

Conclusion: The PGC Morale Scale provides a multidimensional approach to assess the psychological state of older people. This study indicated that participation in the RCT did not affect the baseline QoL of elderly patients but suggested that the baseline QoL of the RCT participants was better than decliners.

Citation Format: Saito T, Sawaki M, Hozumi Y, Sagawa N, Iwata H, Kashiwaba M, Kawashima H, Kobayashi K, Taira N, Takashima T, Takahashi M, Tsuneizumi M, Nakayama T, Baba S, Bando H, Mizuno T, Yamaguchi M, Yamamoto Y, Uemura Y, Ohashi Y, Mukai H. A randomized controlled trial of postoperative adjuvant therapy for elderly breast cancer patients: Comparison of health-related quality of life between clinical trial participants and decliners. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-11-09.

Randomized trial of preoperative docetaxel with or without capecitabine after 4 cycles of 5-fluorouracil– epirubicin–cyclophosphamide (FEC) in early-stage breast cancer: exploratory analyses identify Ki67 as a predictive biomarker for response to neoadjuvant chemotherapy

This randomized, multicenter study compared the efficacy of docetaxel with or without capecitabine following fluorouracil/epirubicin/cyclophosphamide (FEC) therapy in operable breast cancer and investigated the role of Ki67 as a predictive biomarker. Patients were randomized to 4 cycles of docetaxel/capecitabine (docetaxel: 75 mg/m² on day 1; capecitabine: 1,650 mg/m² on days 1–14 every 3 weeks) or docetaxel alone (75 mg/m² on day 1 every 3 weeks) after completion of 4 cycles of FEC (5-fluorouracil 500 mg/m², epirubicin 100 mg/m² and cyclophosphamide 500 mg/m² on day 1 every 3 weeks). The primary endpoint was the pathological complete response (pCR) rate. Predictive factor analysis was conducted using clinicopathological markers, including hormone receptors and Ki67 labeling index (Ki67LI). A total of 477 patients were randomized; the overall response in the docetaxel/capecitabine and docetaxel groups was 88.3 and 87.4 %, respectively. There were no significant differences in the pCR rate (docetaxel/capecitabine: 23 %; docetaxel: 24 %; p = 0.748), disease-free survival, or overall survival. However, patients with mid-range Ki67LI (10–20 %) showed a trend towards improved pCR rate with docetaxel/capecitabine compared to docetaxel alone. Furthermore, multivariate logistic regression analysis showed pre-treatment Ki67LI (odds ratio 1.031; 95 % CI 1.014–1.048; p = 0.0004) to be a significant predictor of pCR in this neoadjuvant treatment setting. Docetaxel/capecitabine (after 4 cycles of FEC) did not generate significant improvement in pCR compared to docetaxel alone. However, exploratory analyses suggested that assessment of pre-treatment Ki67LI may be a useful tool in the identification of responders to preoperative docetaxel/capecitabine in early-stage breast cancer.

Abstract P1-14-02: Preoperative docetaxel (T) with or without capecitabine (X) following epirubicin, 5-fluorouracil and cyclophosphamide (FEC) in patients with operable breast cancer (OOTR N003): Results of comparative study and predictive marker analysis

Objective: This preoperative study aimed to evaluate the efficacy of 4 cycles of TX compared with 4 cycles of T, following 4 cycles of FEC in operable breast cancer patients.

Methods: Women with operable breast cancer (T1C-3N0M0/T1-3N1M0) were randomly assigned to receive either T (75 mg/m2, q3) plus X (825 mg/m2 bid, days 1 to 14) or T alone (75 mg/m2, q3) after completion of FEC (5-fluorouracil 500 mg/m2, epirubicin 100 mg/m2, cyclophosphamide 500 mg/m2, q3). Patients who had disease progression on FEC were excluded from randomization. The primary endpoint was pathological complete response (pCR). Predictive factor analysis was conducted using clinicopathological markers such as hormone receptors, Ki67 labeling index (Ki67LI) and thymidine phosphorylase (TP).

Results: From November 2005 to October 2009, 504 patients were enrolled and 239 and 238 patients were assigned to TX and T group, respectively (median age 49 years, median tumor size 3.5 cm and node positive rate 56%). Treatment discontinuation was observed in 22% of TX group and 5% in T group (p < 0.0001). The major reasons for discontinuation were toxicity, refusal/ consent withdrawal and several others. No significant difference in pCR rate was shown between the two groups (TX 23% and T 24%, p = 0.748). Neither clinical response nor surgical outcome differed between TX and T. The pCR rate in patients who had therapy discontinuation or dose-reduction on TX was 23%, whereas pCR rate in those on T was 11%. A subpopulation treatment effect pattern plots method indicated a trend that TX may improve the pCR rate in patients having a middle range of pretreatment Ki67LI, such as 10%–20%. In the median follow-up time of 3.7 years, disease-free survival (DFS) was not different between TX and T (3-year DFS: 92% in TX and 91% in T; hazard ratio 0.907, 95%CI 0.528–1.557, p = 0.723). The frequency of major grade 3 or greater adverse events of TX and T were leukopenia, 36% and 34%, febrile neutropenia 8% and 5%, and hand-foot syndrome 15% and 2%, respectively.

According to the analysis for evaluating predictive values of biomarkers, a multivariate logistic regression analysis showed that HER2 (+/−: odds ratio 4.107, p < 0.0001), Ki67LI (continuous variables: 1.029, p = 0.003), hormone receptor status (+/−: 0.457, p = 0.009), stroma TP status (0.523, p = 0.02) and grade (1/3: 0.387, 2/3: 0.532, p = 0.047) had statistical significant values for predicting pCR. A multiple Cox model in landmark analysis showed that tumor size (p < 0.0001), cancer cell TP status (p = 0.005), pCR and posttreatment Ki67LI (p = 0.016), and age (p = 0.049) were associated with DFS significantly.

Conclusions: Addition of X to T showed no superiority to T alone following FEC in neoadjuvant treatment of these patients with operable breast cancer. Treatment discontinuation rate was significantly higher in TX than T group, however the pCR rate in patients in TX group who required treatment discontinuation or dose-reduction was similar to that in patients who completed as scheduled, which was different from T group. Determination of pre-/ post-treatment Ki67LI looks useful for predicting pCR and DFS.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-02.

Abstract P1-14-08: A prospective multicenter randomized phase II neo-adjuvant study of 5-fluorouracil, epirubicin and cyclophosphamide (FEC) followed by docetaxel, cyclophosphamide and trastuzumab (TCH) versus TCH followed by FEC versus TCH alone, in patients (pts) with operable HER2 positive breast cancer: JBCRG-10 study

Background: The current standard treatment of primary systemic therapy (PST) in HER2 positive breast cancer is anthracyclines (A) and/or taxanes combined with trastuzumab (H) which demonstrates high pathological complete response (pCR). The pCR is considered as a predictive marker of prognosis although results are slightly different depending on the hormone receptor status. We conducted a randomized phase II study to examine sequence of treatments and necessity of A in the treatments using TCH to improve outcome and reduce cardiac toxicity in Japanese HER2 positive pts.

Methods: Pts were treated with FEC (5FU 500 mg/m2, epirubicin 100 mg/m2, cyclophosphamide 500 mg/m2) and/or TCH (docetaxel 75 mg/m2, cyclophosphamide 600 mg/m2, H 6 mg/kg, loading by 8 mg) in 3 groups: 4 cycles of FEC followed by 4 cycles of TCH (A-TCH); 4 cycles of TCH followed by 4 cycles of FEC (TCH-A) or 6 cycles of TCH. An unplanned interim analysis was conducted due to one death by interstitial lung disease (ILD) in the A-TCH after completion of 8 cycles. The pCR results suggested A containing regimens did not exceed benefit from the current standard regimen. The study was continued by limiting allocation only to the TCH group considering efficacy and safety. The primary endpoint was pCR and secondary endpoints were overall response rate (ORR) and safety.

Results: A total of 103 pts were enrolled between Sep. 2009 and Sep. 2011; 21 pts in the A-TCH, 22 pts in the TCH-A and 60 pts in the TCH including pts enrolled after termination of random allocation. Characteristics of the 103 pts were; median age of 54 (range, 33–70), median tumor size of 35 mm (range, 12–80), 42 pts with N(+) (40.8%) and 62 ER positive pts (60.2%). Characteristics of pts in the TCH were; median age of 54.5 (range, 33–67), median tumor size of 35.5 mm (range, 12–80), 25 pts with N(+) (41.7%) and 34 ER positive pts (56.7%). No major difference was reported between groups treated with or without A. Per protocol population was 59 pts in the TCH and its pCR rate was 45.8% (95% CI, 32.2–59.3: ER negative, 61.5%; ER positive, 33.3%). ORR was 86.4% assessed by MRI or CT. Although it is an exploratory analysis, the pCR rate of A containing regimens was 39.0% (ER negative, 57.1%; ER positive, 29.6%). Adverse events ≥grade 3 were reported in 50 pts (48.5%). Reported ILD was in 5 pts (A-TCH, 1; TCH-A, 1; TCH, 3). The mean left ventricular ejection fraction (LVEF) decreased from 70.0% to 69.0% after treatment (A-TCH, 65.9%; TCH-A, 70.4%; TCH, 69.0%). Decrease of LVEF in the A-TCH was significant (p < 0.01).

Conclusion: The pCR rate of the TCH group was similar to previous reports on A including regimens. Although ILD had been occurred during the treatment containing the TCH, no other new safety issues were reported. We were not able to conclude preferable sequence of A and T since statistical power was not sufficient. However, the result of LVEF suggested TCH followed by A or TCH were preferable. Six cycles of TCH could be one of treatment options as a PST in HER2 positive breast cancer to exclude A. (UMIN000002365)

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-08.

Laparoscopy-assisted appendectomy through an umbilical port in children

INTRODUCTION

We report surgical techniques for single-incision laparoscopy-assisted surgery (SILAS) in the treatment of pediatric acute appendicitis.

METHODS

We performed SILAS in 15 cases of acute appendicitis between January and September of 2009. SILAS is a surgical method that involves making the incision at the umbilicus, inserting a wound retractor XS, suspending the abdominal wall with a hook, and appendectomy with the same procedures as conventional appendectomy.

RESULTS

SILAS appendectomy was performed in all 15 cases with the exception of one case where one 3-mm port was added. Compared to open appendectomy, blood loss was significantly lower and postoperative hospitalization time was shorter, although there was no significant decrease in operative time, or postoperative fasting time. No postoperative complications, such as wound infection, intestinal obstruction, intra-abdominal abscess, or bleeding, were encountered.

CONCLUSION

SILAS was safely performed and is superior to open appendectomy with regard to cosmetic outcome.

Phase II trial of neoadjuvant 5-fluorouracil, epirubicin and cyclophosphamide (FEC100) followed by weekly paclitaxel and trastuzumab (PH) for HER2 positive breast cancer (Kinki Multidisciplinary Breast Oncology Group; KMBOG-0402)

Abstract #3160

Background: Achievement of pathological complete response (pCR) by primary systemic chemotherapy (PST) correlates with improved disease-free survival in operable breast cancer patients. Based on data of the higher pCR rate with concomitant chemotherapy and trastuzumab (H) presented by the randomized prospective trial (Buzdar AU, et al: JCO 23:3676-85; 2005), we performed a multi-center, prospective phase II study to assess the addition of H to primary systemic chemotherapy in HER2+ pts in Japan.
 Methods: Generally, the concomitant combination therapy with anthracycline-containing regimens and H is not recommended because of the increasing rate of cardiac toxicity. This study was designed to evaluate the efficacy and safety of PST for the operable breast cancer with HER2+ phenotype. PST is the sequential chemotherapy with 4 cycles of FEC100 followed by 12 times in combination with weekly paclitaxel (P) 80mg/m2 and H 2mg/kg (PH x 12).. The inclusion criteria is pts with histopathologically confirmed invasive breast carcinoma, T1-3N+M0/T2-3N0M0, HER2 positive by FISH or immunohistochemistry (IHC) 3+, PS=0-1, adequate hematologic, renal, hepatic and cardiac function and a written informed consent. The study was designed to detect a pCR rate of >43% in at least 42 pts. The evaluation of pathological response was carried out on all the surgical specimens sliced every 5 mm interval.
 Results: From Dec 2004 to Dec 2007, 43 pts were enrolled. Pre-reviewed data is now available for all pts: median age 56 [26-75 years]; 15 (35%) pre-menopausal; median clinical tumor size 40 mm [15-80]; 14 (33%) were ER-positive phenotype. All pts had a normal cardiac function before entry and after FEC→PH. No episodes of serious adverse events were reported. Febrile neutropenia was observed on 5 pts (12%). Grade 2 or 3 neuropathy was limited to 4 pts (9%). Other grade 3 non-hematological toxicities were not observed. Two pts requested to stop the treatment with P after 6 times of infusion because of neuropathy, edema and hyperpigmentation on the face, however, they had completed 12 times of H infusion. After PST, breast conservative surgery was done in 38 patients (88%) and mastectomy in 5 (12%). The overall pCR rate was 60% (26/43), and 6 of 26 pts had only component of DICS.
 Conclusions: In HER2+ pts, PST with FEC100x4 followed by PHx12 was active and promising, achieving high pathological complete response without significant toxicity.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3160.

Exploratory study of clonality determined by expression of tumor markers in intrinsic subtypes of breast cancers

Abstract #5060

[Background] However expression profile-based intrinsic subtypes revealed heterogeneity of breast cancer, several biological issues are not clarified yet, especially in tumor development. [Objectives] In order to clarify the relationship between intrinsic subtypes and positivity of tumor markers (TMs), CEA, CA15-3, BCA225 and NCC-ST439 were measured from sera taken from patients at the relapse retrospectively. In addition to the analysis of positivity of TMs, migration of TMs were analyzed in each intrinsic subtype, especially focused on changes of CA15-3 (equivalent to soluble MUC1) to identify the heterogeneity and development to other subtypes in the meaning of TMs expression. [Methods] Sera were collected from seventy five patients of newly diagnosed metastatic breast cancer. Intrinsic subtypes were simply determined by immunohistochemical staining as Luminal A (LA) ,B (LB), HER2 and TN. The positivity of TM was defined if it elevated 20% higher than normal upper limit. [Results] The positive rate of any TMs were higher in order of LA, LB, HER2 and TN. There was significant difference between Luminal (LA+LB) and TN in positive rate of TMs(p<0.05). If focused on mammary epithelium development marker MUC1 (CA15-3 as a soluble form), it was significantly elevated in Luminal (LA+LB) than HER2 and TN(p<0.05). Interestingly, 18 of 23 (72.3%) TN tumors showed all TMs negative at the relapse, although 4 of 18 (22.2%) TN tumors developed to TMs positive after palliative chemotherapies. [Conclusion] Luminal type showed higher expression of TMs at the relapse. It might be explained by the fact that common TMs were selected as responsive serum proteins to the tumor volume of dominant population of breast cancer by chance. But if we integrate the idea that CA15-3 as a development marker, luminal cancer was developed from ER+ highly developed progenitor and HER2 and TN might be developed from ER- progenitor lineage. The migration of TMs of TN after palliative chemotherapies might be illustrated with clonal selection by chemosensitivity. These phenomenon will be understood by further biological experiments and prospective clinical trials to improve the outcome of metastatic breast cancer.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5060.

Early results of a phase I clinical trial of capecitabine in combination with CPT-11 for metastatic breast cancer (MBC) pre-treated with anthracycline and taxane

10750

Background: Capecitabine (C) is administrated with other drugs to improve response rate of single agent and to extend time to progression for MBC expecting up-regulation of thymidine phosphorylase activity. Conversely, administration of CPT-11 (TOP) against MBC is less common while superiority of combination therapy C and TOP is established in metastatic setting of colorectal cancer. Therefore a phase I clinical trial was conducted to determine the recommended dose (RD) of TOP administrated with fixed dose of C (1,657 mg/m2/day) against MBC pre-treated with antracycline and taxane. Methods: Five dose level of CPT-11 (80, 90, 100,110 and 120 mg/m2) on Day 1 and 15 and C (1,657 mg/m2/day) on Day 1–21 were given every 28 days. A standard “3+3” design is used and dose limiting toxicity is defined in cycle 1. Results: To date, five patients were enrolled from October 2005 to January 2006 and 8 cycles were administrated without grade 3–4 toxicities as followed: 3 pts in Level I (TOP: 80 mg/m2), 2 pts in Level II (TOP: 90mg/m2). 5 pts have archived a response: PR in 1, SD in 2. Conclusions: Combination therapy C and TOP against MBC pre-treated antracycline and taxane is well-tolerated. Enrollment will continue until the RD is identified for further phase II clinical trial.

No significant financial relationships to disclose.

[Novel biodegradable materials for drug delivery systems (DDS)]

The authors provide three new and different types of fibrin gels (FCs) and a chitosan sheet (BC) using an ultraviolet (UV)-crosslinking method. They are 1) FC-UV, 2) gelatin entrapped FC; FC (Gp)-UV, 3) chitosan entrapped FC; FC (Cs)-UV and 4) BC-UV. Each material was loaded with aqueous cis-platinum (CDDP), and both the degradation of the drug carriers and the release profile of the CDDP were examined in vitro. The FCs, 1)-3), gradually degraded and dissolved within 10-12 days. The BC, 4), maintained its original weight for more than 30 days. Each FC showed a sustained release of CDDP for 10 days, while BC provided an initial bursting of the loaded drug. New materials 2) and 3) show great potential as drug carriers for DDS and further in vivo studies are now proceeding.

Adenomatous polyposis coli (APC) gene promoter hypermethylation in primary breast cancers

Similar to findings in colorectal cancers, it has been suggested that disruption of the adenomatous polyposis coli (APC)/beta-catenin pathway may be involved in breast carcinogenesis. However, somatic mutations of APC and beta- catenin are infrequently reported in breast cancers, in contrast to findings in colorectal cancers. To further explore the role of the APC/beta-catenin pathway in breast carcinogenesis, we investigated the status of APC gene promoter methylation in primary breast cancers and in their non-cancerous breast tissue counterparts, as well as mutations of the APC and beta- catenin genes. Hypermethylation of the APC promoter CpG island was detected in 18 of 50 (36%) primary breast cancers and in none of 21 non-cancerous breast tissue samples, although no mutations of the APC and beta- catenin were found. No significant associations between APC promoter hypermethylation and patient age, lymph node metastasis, oestrogen and progesterone receptor status, size, stage or histological type of tumour were observed. These results indicate that APC promoter CpG island hypermethylation is a cancer-specific change and may be a more common mechanism of inactivation of this tumour suppressor gene in primary breast cancers than previously suspected.

Induction of antitumor immunity by vaccination of dendritic cells transfected with MUC1 RNA

Dendritic cells (DC) are potent APCs. In this study, murine bone marrow-derived DC were transfected with RNA encoding the MUC1 Ag that is aberrantly overexpressed in human breast and other carcinomas. The MUC1 RNA-transfected DC exhibited cell surface expression of MUC1 and costimulatory molecules. After injection at the base of the tail, the transfected DC were detectable in inguinal lymph nodes by dual immunochemical staining. Vaccination of wild-type mice with MUC1 RNA-transfected DC induced anti-MUC1 immune responses against MUC1-positive MC38/MUC1, but not MUC1-negative, tumor cells. Mice immunized with the transfected DC were protected against challenge with MC38/MUC1 tumor cells. Furthermore, mice with established MC38/MUC1 tumors were eliminated after receiving the vaccination. CTLs isolated from mice immunized with the transfected DC exhibited specific cytolytic activity against MC38/MUC1 tumor cells. In contrast to these findings, there was little if any anti-MUC1 immunity induced with the transfected DC in MUC1 transgenic (MUC1.Tg) mice. However, coadministration of the transfected DC and IL-12 reversed the unresponsiveness to MUC1 Ag in MUC1.Tg mice and induced MUC1-specific immune responses. These findings demonstrate that vaccination of DC transfected with MUC1 RNA and IL-12 reverses tolerance to MUC1 and induces immunity against MUC1-positive tumors.

[A novel fibrin clot with a sustained release of cis-platinum (CDDP)]

The authors devised a novel fibrin clot (FC) using an ultra-violet (UV)-crosslinking method. CDDP was impregnated into FCs, and the release profiles of the CDDP were examined in vitro. The microstructures of the FCs were studied with scanning electron microscopy (SEM). The release of CDDP from the FC-UV-CDDP was maintained for 10 days, while that from the FC-CDDP showed initial bursting with a following plateau of CDDP concentrations. SEM of UV-crosslinked FCs revealed highly organized, close and homogeneous micropore structures. Native FCs and non-crosslinked FCs showed rough fibrin networks with entangling fibrin fibers. These microstructural differences may play important roles in the release profiles of CDDP. Our newly devised UV-crosslinked material is promising as a drug carrier for sustained release.

Activation of antitumor cytotoxic T lymphocytes by fusions of human dendritic cells and breast carcinoma cells

We have reported that fusions of murine dendritic cells (DCs) and murine carcinoma cells reverse unresponsiveness to tumor-associated antigens and induce the rejection of established metastases. In the present study, fusions were generated with primary human breast carcinoma cells and autologous DCs. Fusion cells coexpressed tumor-associated antigens and DC-derived costimulatory molecules. The fusion cells also retained the functional potency of DCs and stimulated autologous T cell proliferation. Significantly, the results show that autologous T cells are primed by the fusion cells to induce MHC class I-dependent lysis of autologous breast tumor cells. These findings demonstrate that fusions of human breast cancer cells and DCs activate T cell responses against autologous tumors.

Reversal of tolerance to human MUC1 antigen in MUC1 transgenic mice immunized with fusions of dendritic and carcinoma cells

Immunological unresponsiveness established by the elimination or anergy of self-reactive lymphocyte clones is of importance to immunization against tumor-associated antigens. In this study, we have investigated induction of immunity against the human MUC1 carcinoma-associated antigen in MUC1 transgenic mice unresponsive to MUC1 antigen. Immunization of adult MUC1 transgenic mice with irradiated MUC1-positive tumor cells was unsuccessful in reversing unresponsiveness to MUC1. By contrast, fusions of dendritic cells with MUC1-positive tumor cells induced cellular and humoral immunity against MUC1. Immunization with the dendritic cell fusions that express MUC1 resulted in the rejection of established metastases and no apparent autoimmunity against normal tissues. These findings demonstrate that unresponsiveness to the MUC1 tumor-associated antigen is reversible by immunization with heterokaryons of dendritic cells and MUC1-positive carcinoma cells.

Establishment and characterization of a new human extrahepatic bile duct carcinoma cell line (ICBD-1)

A new human extrahepatic bile duct carcinoma cell line (ICBD-1) was established from surgically resected tumor of a 71-year-old Japanese male patient. ICBD-1 cells proliferate in a layer with a population doubling time of 31.5 h and secrete tissue polypeptide antigen. ICBD-1 cells have a tetraploid pattern with a DNA index of 1.83 and chromosome counts showed equally distribution in a range from 65 to 69. IC50 values for ICBD-1 cells were 200 ng/ml for adriamycin, 400 ng/ml for mitomycin C, 2 microg/ml for cisplatin and 300 ng/ml for 5-fluorouracil. ICBD-1 cells were successfully transplanted to male nude mice, inducing progressive tumor growth. Histologically, nude mouse tumors were less differentiated than the original human tumor. Tumor cells showed alveolar structures with thin fibrous stroma, classified as poorly-differentiated adenocarcinoma. ICBD-1 is the fourth established cell line that originate from extrahepatic bile duct carcinoma and it will be applicable for the experimental studies of this disease.

Induction of antigen-specific antitumor immunity with adenovirus-transduced dendritic cells

Transduction of dendritic cells (DC) can result in presentation of tumor-associated antigens and induction of immunity against undefined epitopes. The present studies demonstrate adenovirus (Ad)-mediated transduction of the beta-galactosidase gene in mouse DC. Similar transductions have been obtained with the gene encoding the DF3/MUC1 tumor-associated antigen. We show that the Ad-transduced DC are functional in primary allogeneic mixed lymphocyte reactions. Mice immunized with Ad-transduced DC develop cytotoxic T lymphocytes that are specific for the beta-galactosidase or DF3/MUC1 antigens. The results also demonstrate that Ad MUC1-transduced DC induce a specific response which inhibits the growth of DF3/MUC1-positive tumors. These findings support the usefulness of Ad-transduced DC for in vivo immunization against tumor-associated antigens.

Induction of antitumor activity by immunization with fusions of dendritic and carcinoma cells

Dendritic cells (DCs) are potent antigen-presenting cells that prime naive cytotoxic T-cells (CTLs). In this study, we have fused DCs with MC38 carcinoma cells. The fusion cells were positive for major histocompatibility (MHC) class I and II, costimulating molecules and intercellular cell adhesion molecule-1 (ICAM-1). The results show that the fusion cells stimulate naive T cells in the primary mixed lymphocyte reaction (MLR) and induce MC38 tumor-specific CTLs in vivo. Antibody-mediated depletion experiments demonstrate that induction of CD4+ and CD8+ CTLs protects against challenge with tumor cells. We also show that immunization with the fusion cells induces rejection of established metastases. These findings represent the first demonstration that fusions of DCs and tumor cells can be used in the treatment of cancer.

Epithelial-cadherin gene is not mutated in ductal carcinomas of the breast

We investigated mutations of the epithelial (E)-cadherin gene and loss of heterozygosity (LOH) at flanking loci using three microsatellite markers on the long arm of chromosome 16 in 25 ductal carcinomas of the breast. Expression of E-cadherin was also investigated immunohistochemically. No mutations were detected in exons 6 through 9 of the E-cadherin gene. LOH was observed more frequently (42%) at D16S402 (16q-ter) than at D16S421 (16q22.3-q23.1) (17%), which is located near the E-cadherin gene. Expression of E-cadherin was observed at the cell borders in 92% (11/12) of the tumors examined. The absence of mutations in the E-cadherin gene and its conserved expression suggest that inactivation of E-cadherin does not contribute significantly to the invasion or metastatic potential of ductal carcinomas of the breast. Furthermore, the high frequency of LOH at 16q-ter suggests the existence of another tumor suppressor gene which may play a crucial role in the genesis of ductal carcinomas of the breast.

The sequential accumulation of genetic alterations characteristic of the colorectal adenoma-carcinoma sequence does not occur between gastric adenoma and adenocarcinoma

We screened 30 gastric adenomas and 72 gastric adenocarcinomas for four genetic alterations (mutations of the K-ras, APC, and p53 genes and loss of heterozygosity at the DCC genetic locus) which are known to occur during colorectal tumourigenesis. We used polymerase chain reaction (PCR) single-strand conformation polymorphism analysis to detect mutations. Loss of heterozygosity (LOH) at the DCC locus was ascertained directly by performing PCR on the variable number of tandem repeats within the gene. Mutations of the K-ras gene were not detected in any gastric adenoma or carcinoma. APC mutations were detected in 20 per cent (6/30) of the adenomas but in only 1.4 per cent (1/72) of the carcinomas. In contrast, the p53 gene was frequently mutated in carcinomas (35 per cent; 25/72), but not in adenomas. LOH at the DCC locus was a frequent occurrence in carcinomas (58 per cent; 11/19 informative cases) but was infrequent in adenomas (14 per cent; 1/7). Alterations of the p53 and DCC genes occurred frequently both in differentiated and in undifferentiated gastric carcinomas. The considerable differences in the incidences of genetic alterations between gastric adenoma and carcinoma indicate that the sequential development of gastric carcinoma from adenoma is uncommon in gastric carcinogenesis.

A point mutation, C to T, in exon 8 of the porphobilinogen deaminase gene in a Japanese family with acute intermittent porphyria

Acute intermittent porphyria (AIP) is an autosomal dominant disease characterized by a deficiency of porphobilinogen deaminase (PBGD). To date, only two mutations have been reported in Japanese patients. We report here another mutation of the gene in a Japanese patient. Analysis of the PCR amplified DNA fragments of the gene by direct-sequencing method revealed the gene abnormality responsible for the disease. The mutation found was a point mutation, C to T, in exon 8 of the gene at position 346 of the housekeeping cDNA from the translation codon ATG. This mutation resulted in an Arg116 to Trp substitution. Four carriers in the family were successfully diagnosed by detecting the mutation using restriction analysis of PCR products.

Frequent loss of heterozygosity at the deleted in colorectal carcinoma gene locus and its association with histologic phenotypes in breast carcinoma

Loss of heterozygosity (LOH) at the deleted in colorectal carcinoma gene (DCC), a tumour suppressor gene that encodes a protein with high homology to the neural cell adhesion molecule, was investigated in 42 surgical specimens of primary breast carcinoma. LOH was analysed in breast carcinoma by amplifying the DNA, spanning a variable number of tandem repeats site and a restriction fragment length polymorphism site within DCC, using the polymerase chain reaction (PCR). Cell sorting was used to enrich carcinoma cells. The expression of the DCC gene was also investigated using a reverse transcription-PCR method followed by Southern blot hybridization. LOH at the DCC locus was detected in 15 (51.7%) of 29 informative cases and 10 of 13 cases having DCC-LOH showed distinct reduction or loss of DCC expression. The DCC-LOH was closely associated with certain histological phenotypes: DCC-LOH was more frequent in scirrhous carcinomas than in solid-tubular ones (P < 0.05), and was also more frequent in carcinomas with infiltration into fat tissue over the mammary gland than in those without infiltration (P < 0.05). DCC-LOH was detected in invasive lobular carcinomas (2/2), but in none of the noninvasive ductal carcinomas (0/2). These observations suggest that malignant histological phenotypes are associated with DCC-LOH.

Aberrations of the APC gene in primary breast carcinoma

Aberrations of the APC gene, which plays an important role in the genesis of familial adenomatous polyposis and colorectal carcinoma, were investigated in 31 surgical specimens of primary breast carcinoma. These studies utilized the polymerase chain reaction followed by restriction-fragment-length polymorphism and single-strand-conformation polymorphism analyses combined with tumor cell enrichment by cell sorting. Loss of heterozygosity at the APC locus was detected in 8 (38%) of 21 informative cases, but only 2 (6%) of 31 tumors carried a mutated APC gene. Direct DNA sequencing analysis confirmed mutations at codon 1081 (AGC to ATC) resulting in an amino acid substitution of serine for isoleucine, and at codon 1096 (CAG to CAT) resulting in a substitution of glutamine for histidine. There were no significant correlations between the loss of heterozygosity or mutation at the APC locus and any clinicopathological characteristics. Our present observations suggest that the mutations of the APC gene may play an important role in the genesis of certain breast carcinomas, and that another tumor-suppressor gene, which is the true target of frequent loss of heterozygosity, may exist near the APC gene.

Mutations of the APC gene occur during early stages of gastric adenoma development

Mutations of the adenomatous polyposis coli (APC) gene have recently been shown to play an important role in colorectal tumorigenesis. We investigated mutations of the APC gene in 30 gastric adenomas obtained endoscopically. Mutations of the APC gene were examined by polymerase chain reaction-single-strand conformation polymorphism analysis followed by sequencing of the polymerase chain reaction products. Mutations were detected in 20% (6 of 30) of gastric adenomas. In addition, deletion of the remaining allele that subsequently led to complete inactivation of the APC gene was confirmed in one-half (3 of 6) of the tumors with APC gene mutations. Sequencing analysis confirmed that the mutations resulted in truncation of the gene products or in an amino acid change. The incidences of mutations of the APC gene remained constant regardless of the size or degree of histological atypia. Our observations suggest that mutations of the APC gene, similarly to those in colorectal tumorigenesis, occur during the early stages of gastric adenoma development.

Improved detection of loss of heterozygosity at retinoblastoma gene locus in human breast carcinoma

Loss of heterozygosity (LOH) at the retinoblastoma (Rb) gene locus was investigated in 33 breast carcinomas by polymerase chain reaction single-strand conformation polymorphism (PCR-SSCP) analysis after tumor cell enrichment by cell sorting. The efficacy of cell sorting was evaluated by comparing the results of PCR-SSCP with and without cell sorting. Ten of 17 (59%) informative cases showed LOH at this locus by cell sorting combined with PCR-SSCP, although LOH was detectable in six (35%) cases without cell sorting. Flow cytometry and histologic examination revealed that this underestimation may occur when the tumor cell population is less than 50% in the specimens analyzed. It is concluded that LOH of the Rb gene occurs more frequently in human breast carcinoma than previously thought, and thus may contribute significantly to the development and/or progression of this tumor.

[Long-term oral administration of etoposide (VP-16) for the patients with refractory or relapsed acute non-lymphocytic leukemia]

We investigated the efficacy of oral etoposide (VP-16) for the patients with acute non-lymphocytic leukemia (ANLL) in relapse or refractory to the standard chemotherapy. Patients were given etoposide orally at the dose of 50 mg/body/day on consecutive days until the leukemic cells in the bone marrow were reduced less than 5%. The duration of administration of oral etoposide ranged from 16 days to 50 days (average 30 days). Seven patients were given very low dose cytosine arabinoside (5 approximately 10 mg X 2/day i.s.c.) combination with oral etoposide. Six patients (66.7%) out of 9 achieved complete remission (CR) and 3 patients had no response. Adverse effects such as abdominal discomfort and appetite loss were observed in 3 patients, but they were mild and tolerable. The duration of CR ranged from 2 to 24 (+) months, and the median CR duration is 7 months. The over all CR rate (66.7%) in this group of patients with refractory or relapsed ANLL were encouraging. Further studies, however, are needed to evaluate the efficacy of long term oral administration of etoposide for the patients with leukemia.