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Mai N, Abuhadra N, Jhaveri K. Molecularly Targeted Therapies for Triple Negative Breast Cancer: History, Advances, and Future Directions. Clin Breast Cancer 2023; 23:784-799. [PMID: 37336650 DOI: 10.1016/j.clbc.2023.05.012] [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: 04/10/2023] [Revised: 05/16/2023] [Accepted: 05/21/2023] [Indexed: 06/21/2023]
Abstract
Triple negative breast cancer (TNBC) remains the subtype with poorest prognosis. Despite the subtype's heterogeneity, there is still a paucity in effective targeted therapeutics that offer both good efficacy and tolerability, and chemotherapy remains the backbone of modern TNBC therapy. In the past few years, immunotherapy as well as novel therapeutic modalities like antibody-drug conjugates (ADCs) have shown clinical benefit and have been FDA approved in various clinical stages of unselected TNBC. However, there has not been similar advancement in molecularly targeted therapies, especially when compared to advancements seen in hormone receptor (HR)-positive or HER2-positive breast cancer. PARP inhibitors have been approved for BRCA-mutated TNBC, but responses are short-lived, and resistance remains a barrier for current treatment. PI3K pathway inhibitors approved in HR+ breast cancer has not worked for TNBC and continue to have significant dose-limiting adverse effects. EGFR inhibition has been thoroughly explored in TNBC, but all trials so far have shown minimal efficacy. Nevertheless, despite these setbacks, current research in targeted therapy for TNBC holds great promise in overcoming the barriers of the past and developing novel therapeutic approaches for the future. In this review, we describe molecular targets both identified and validated in the treatment of TNBC, discuss the historical efforts towards development of targeted agents and current areas of improvement, and address promising advances that have the potential to improve outcomes in this heterogenous and aggressive breast cancer subtype. Immunotherapy, ADCs, and AR targeting will be discussed in separate reviews of this edition.
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Affiliation(s)
- Nicholas Mai
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nour Abuhadra
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Komal Jhaveri
- Memorial Sloan Kettering Cancer Center, New York, NY.
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2
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Abuhadra N, Sun R, Yam C, Rauch GM, Ding Q, Lim B, Thompson AM, Mittendorf EA, Adrada BE, Damodaran S, Virani K, White J, Ravenberg E, Sun J, Choi J, Candelaria R, Arun B, Ueno NT, Santiago L, Saleem S, Abouharb S, Murthy RK, Ibrahim N, Sahin A, Valero V, Symmans WF, Litton JK, Tripathy D, Moulder S, Huo L. Predictive Roles of Baseline Stromal Tumor-Infiltrating Lymphocytes and Ki-67 in Pathologic Complete Response in an Early-Stage Triple-Negative Breast Cancer Prospective Trial. Cancers (Basel) 2023; 15:3275. [PMID: 37444385 DOI: 10.3390/cancers15133275] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/11/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
High stromal tumor-infiltrating lymphocytes (sTILs) are associated with improved pathologic complete response (pCR) in triple-negative breast cancer (TNBC). We hypothesize that integrating high sTILs and additional clinicopathologic features associated with pCR could enhance our ability to predict the group of patients on whom treatment de-escalation strategies could be tested. In this prospective early-stage TNBC neoadjuvant chemotherapy study, pretreatment biopsies from 408 patients were evaluated for their clinical and demographic features, as well as biomarkers including sTILs, Ki-67, PD-L1 and androgen receptor. Multivariate logistic regression models were developed to generate a computed response score to predict pCR. The pCR rate for the entire cohort was 41%. Recursive partitioning analysis identified ≥20% as the optimal cutoff for sTILs to denote 35% (143/408) of patients as having high sTILs, with a pCR rate of 59%, and 65% (265/408) of patients as having low sTILs, with a pCR rate of 31%. High Ki-67 (cutoff > 35%) was identified as the only predictor of pCR in addition to sTILs in the training set. This finding was verified in the testing set, where the highest computed response score encompassing both high sTILa and high Ki-67 predicted a pCR rate of 65%. Integrating Ki67 and sTIL may refine the selection of early stage TNBC patients for neoadjuvant clinical trials evaluating de-escalation strategies.
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Affiliation(s)
- Nour Abuhadra
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ryan Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Clinton Yam
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Gaiane M Rauch
- Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Qingqing Ding
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Bora Lim
- Department of Oncology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Alastair M Thompson
- Division of Surgical Oncology, Section of Breast Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Beatriz E Adrada
- Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Senthil Damodaran
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kiran Virani
- Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jason White
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Elizabeth Ravenberg
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jia Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jaihee Choi
- Department of Statistics, Rice University, Houston, TX 77005, USA
| | - Rosalind Candelaria
- Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Banu Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Naoto T Ueno
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lumarie Santiago
- Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sadia Saleem
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sausan Abouharb
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Rashmi K Murthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Nuhad Ibrahim
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Aysegul Sahin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Vicente Valero
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - William Fraser Symmans
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jennifer K Litton
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Debu Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Stacy Moulder
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lei Huo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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3
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Abuhadra N, Sun R, Bassett RL, Huo L, Chang JT, Teshome M, Clayborn AR, White JB, Ravenberg EE, Adrada BE, Candelaria RP, Yang W, Ding Q, Symmans WF, Arun B, Damodaran S, Koenig KB, Layman RM, Lim B, Litton JK, Thompson A, Ueno NT, Piwnica-Worms H, Hortobagyi GN, Valero V, Tripathy D, Rauch GM, Moulder S, Yam C. Targeting chemotherapy resistance in mesenchymal triple-negative breast cancer: a phase II trial of neoadjuvant angiogenic and mTOR inhibition with chemotherapy. Invest New Drugs 2023:10.1007/s10637-023-01357-4. [PMID: 37043123 DOI: 10.1007/s10637-023-01357-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/27/2023] [Indexed: 04/13/2023]
Affiliation(s)
- Nour Abuhadra
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Ryan Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roland L Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lei Huo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey T Chang
- Department of Integrative Biology and Pharmacology, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mediget Teshome
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alyson R Clayborn
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Jason B White
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Elizabeth E Ravenberg
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Beatriz E Adrada
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rosalind P Candelaria
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei Yang
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Qingqing Ding
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - W Fraser Symmans
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Banu Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Senthil Damodaran
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Kimberly B Koenig
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Rachel M Layman
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Bora Lim
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Jennifer K Litton
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Alastair Thompson
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naoto T Ueno
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Helen Piwnica-Worms
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel N Hortobagyi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Vicente Valero
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Debu Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Gaiane M Rauch
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stacy Moulder
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Clinton Yam
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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Hamilton E, Chaudhry A, Spira AI, Adams S, Abuhadra N, Giordano A, Parajuli R, Han HS, Weise A, Marchesani A, Josephs K, Shin CR, Kalinsky K. Abstract OT1-03-01: XMT-1660: A Phase 1b trial of a B7-H4 targeted Antibody Drug Conjugate (ADC) in Breast, Endometrial, and Ovarian Cancers. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-ot1-03-01] [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: Breast cancer (BC) is the most commonly diagnosed cancer and one of the leading causes of cancer death in women. Despite significant therapeutic advances, the majority of patients with unresectable or recurrent/metastatic disease eventually develop resistance to available standard of care (SOC) therapies. B7-H4 is a poor prognostic factor and is overexpressed in several cancers including endometrial, ovarian, and breast. As a member of the CD28/B7 family of cell surface proteins, it promotes tumorigenesis by suppressing anti-tumor immunity. XMT-1660 is a B7-H4-targeted Dolasynthen antibody drug conjugate with a precise, optimized drug-to-antibody ratio and a DolaLock microtubule inhibitor payload with controlled bystander effect. In the preclinical setting, XMT-1660 has demonstrated anti-tumor activity in TNBC and ER+/HER2- patient-derived xenograft mouse models, which included tumors from heavily pre-treated patients (Collins et al, AACR 2022). Increased anti-tumor activity tended to be more frequent in models with higher B7-H4 expression, providing rationale for a Ph1 clinical trial. Methods: The Ph1 trial includes a first-in-human open-label dose escalation (DES) portion followed by dose expansion (EXP) evaluating XMT-1660 in patients with BC, EC, and OC following progression on SOC as applicable (i.e., CDK4/6i + ET; platinum-based chemotherapy). In the DES, Bayesian Optimal Interval (BOIN) design will be used to determine the MTD. Patients will receive XMT-1660 IV Q3 weeks. Primary endpoints in DES are to assess safety and determine a recommended phase 2 dose (RP2D) and assessment of preliminary efficacy as a secondary endpoint. In the EXP portion, cohorts enrolling TNBC, ER+/HER2- BC, EC/OC are planned and additional patients may be enrolled based on emerging data. The primary endpoint of EXP is to assess safety and tolerability, overall response rate, disease control rate, and duration of response. Secondary endpoints include pharmacokinetic analysis and antidrug antibodies. Patients are not selected by B7-H4 status, but baseline tumors samples are collected for retrospective tumor tissue evaluation. The trial is currently enrolling patients. NCT05377996
Citation Format: Erika Hamilton, Arvind Chaudhry, Alexander I. Spira, Sylvia Adams, Nour Abuhadra, Antonio Giordano, Ritesh Parajuli, Hyo S. Han, Amy Weise, Aubri Marchesani, Kate Josephs, Chu Ri Shin, Kevin Kalinsky. XMT-1660: A Phase 1b trial of a B7-H4 targeted Antibody Drug Conjugate (ADC) in Breast, Endometrial, and Ovarian Cancers [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 OT1-03-01.
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Affiliation(s)
| | | | | | - Sylvia Adams
- 4NYU Perlmutter Cancer Center, NYU Langone Health
| | | | | | - Ritesh Parajuli
- 7University of California, Irvine Medical Center, Orange, California
| | - Hyo S. Han
- 8H. Lee Moffitt Cancer Center, Tampa, FL
| | | | | | | | | | - Kevin Kalinsky
- 13Winship Cancer Institute at Emory University, Atlanta, GA
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Drago JZ, Ferraro E, Abuhadra N, Modi S. Beyond HER2: Targeting the ErbB receptor family in breast cancer. Cancer Treat Rev 2022; 109:102436. [PMID: 35870237 PMCID: PMC10478787 DOI: 10.1016/j.ctrv.2022.102436] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 05/17/2022] [Revised: 07/07/2022] [Accepted: 07/10/2022] [Indexed: 11/28/2022]
Abstract
Targeting the HER2 oncogene represents one of the greatest advances in the treatment of breast cancer. HER2 is one member of the ERBB-receptor family, which includes EGFR (HER1), HER3 and HER4. In the presence or absence of underling genomic aberrations such as mutations or amplification events, intricate interactions between these proteins on the cell membrane lead to downstream signaling that encourages cancer growth and proliferation. In this Review, we contextualize efforts to pharmacologically target the ErbB receptor family beyond HER2, with a focus on EGFR and HER3. Preclinical and clinical efforts are synthesized. We discuss successes and failures of this approach to date, summarize lessons learned, and propose a way forward that invokes new therapeutic modalities such as antibody drug conjugates (ADCs), combination strategies, and patient selection through rational biomarkers.
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Affiliation(s)
- Joshua Z Drago
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weil Cornell Medicine, New York, NY, USA.
| | - Emanuela Ferraro
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nour Abuhadra
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weil Cornell Medicine, New York, NY, USA
| | - Shanu Modi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weil Cornell Medicine, New York, NY, USA
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Yam C, Abuhadra N, Sun R, Adrada BE, Ding QQ, White JB, Ravenberg EE, Clayborn AR, Valero V, Tripathy D, Damodaran S, Arun BK, Litton JK, Ueno NT, Murthy RK, Lim B, Baez L, Li X, Buzdar AU, Hortobagyi GN, Thompson AM, Mittendorf EA, Rauch GM, Candelaria RP, Huo L, Moulder SL, Chang JT. Molecular Characterization and Prospective Evaluation of Pathologic Response and Outcomes with Neoadjuvant Therapy in Metaplastic Triple-Negative Breast Cancer. Clin Cancer Res 2022; 28:2878-2889. [PMID: 35507014 PMCID: PMC9250637 DOI: 10.1158/1078-0432.ccr-21-3100] [Citation(s) in RCA: 8] [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: 08/26/2021] [Revised: 02/28/2022] [Accepted: 04/29/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE Metaplastic breast cancer (MpBC) is a rare subtype of breast cancer that is commonly triple-negative and poorly responsive to neoadjuvant therapy in retrospective studies. EXPERIMENTAL DESIGN To better define clinical outcomes and correlates of response, we analyzed the rate of pathologic complete response (pCR) to neoadjuvant therapy, survival outcomes, and genomic and transcriptomic profiles of the pretreatment tumors in a prospective clinical trial (NCT02276443). A total of 211 patients with triple-negative breast cancer (TNBC), including 39 with MpBC, received doxorubicin-cyclophosphamide-based neoadjuvant therapy. RESULTS Although not meeting the threshold for statistical significance, patients with MpBCs were less likely to experience a pCR (23% vs. 40%; P = 0.07), had shorter event-free survival (29.4 vs. 32.2 months, P = 0.15), metastasis-free survival (30.3 vs. 32.4 months, P = 0.22); and overall survival (32.6 vs. 34.3 months, P = 0.21). This heterogeneity is mirrored in the molecular profiling. Mutations in PI3KCA (23% vs. 9%, P = 0.07) and its pathway (41% vs. 18%, P = 0.02) were frequently observed and enriched in MpBCs. The gene expression profiles of each histologically defined subtype were distinguishable and characterized by distinctive gene signatures. Among nonmetaplastic (non-Mp) TNBCs, 10% possessed a metaplastic-like gene expression signature and had pCR rates and survival outcomes similar to MpBC. CONCLUSIONS Further investigations will determine if metaplastic-like tumors should be treated more similarly to MpBC in the clinic. The 23% pCR rate in this study suggests that patients with MpBC should be considered for NAT. To improve this rate, a pathway analysis predicted enrichment of histone deacetylase (HDAC) and RTK/MAPK pathways in MpBC, which may serve as new targetable vulnerabilities.
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Affiliation(s)
- Clinton Yam
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nour Abuhadra
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Beatriz E. Adrada
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Qing-Qing Ding
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason B. White
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth E. Ravenberg
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alyson R. Clayborn
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vicente Valero
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debu Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Senthilkumar Damodaran
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Banu K. Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer K. Litton
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naoto T. Ueno
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi K. Murthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bora Lim
- Department of Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Luis Baez
- PROncology (Private Practice), University of Puerto Rico. San Juan, Puerto Rico
| | - Xiaoxian Li
- Department of Pathology & Laboratory Medicine, Winship Cancer Institute - Emory University Hospital, Atlanta, GA, USA
| | - Aman U. Buzdar
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel N. Hortobagyi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alistair M. Thompson
- Division of Surgical Oncology, Section of Breast Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Elizabeth A. Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MD, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, USA
| | - Gaiane M. Rauch
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rosalind P. Candelaria
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lei Huo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stacy L. Moulder
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey T. Chang
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Integrative Biology and Pharmacology, The University of Texas Health Science Center at Houston, TX, USA
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Abstract
Triple-negative breast cancer (TNBC) accounts for approximately 15%-20% of breast cancers diagnosed worldwide, which amounts to almost 200 000 cases each year. Although historically TNBC is considered difficult to treat with a poor prognosis, there is emerging evidence showing excellent response rates in a subset of TNBC patients. Attempts to de-escalate chemotherapy in hormone-receptor-positive (HR+) and HER2-neu amplified breast cancer subtypes have been successful. At present, robust strategies to personalize therapy in early-stage TNBC do not exist, and despite excellent response rates in a subset of patients, all patients are exposed to the same several cycles of cytotoxic chemotherapy. Personalizing therapy in TNBC represents a challenge due to the scarcity of treatment options outside of cytotoxic chemotherapy and limited predictive and prognostic biomarkers to tailor treatment. Recent developments in understanding TNBC biology have sparked interest in exploring treatment optimization and personalization with the goal of achieving excellent response rates and long-term clinical outcomes, while simultaneously reducing physical, psychological, and financial toxicities for select patients. Here, we provide an update on the current evidence to support future studies examining de-escalating chemotherapy in patients with low-risk TNBC and adjuvant intensification strategies to improve outcomes for patients who are at high risk for systemic failure despite current standard-of-care treatments.
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Affiliation(s)
- Nour Abuhadra
- Breast Medicine Service, Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Corresponding author: Nour Abuhadra, MD, Breast Medicine Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Shane Stecklein
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Priyanka Sharma
- Division of Medical Oncology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Stacy Moulder
- Eli Lilly and Company. Lilly Corporate Center, Indianapolis, IN, USA
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8
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Abuhadra N, Chang CC, Yam C, White JB, Ravenberg E, Lim B, Ueno NT, Litton JK, Arun B, Damodaran S, Murthy RK, Ibrahim NK, Hortobagyi GN, Valero V, Tripathy D, Thompson AM, Mittendorf EA, Huo L, Moulder SL, Jenq RR. The impact of gut microbial composition on response to neoadjuvant chemotherapy (NACT) in early-stage triple negative breast cancer (TNBC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.590] [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: 11/20/2022] Open
Abstract
590 Background: The impact of gut microbiome on tumor biology, progression and response to immunotherapy has been shown across cancer types. However, there is little known about the impact of gut microbial composition on response to chemotherapy. We have previously shown that the gut microbiome remains unaltered during NACT in a cohort of 32 patients. Here we investigate the association between gut microbiome and response to NACT in a larger cohort of early-stage TNBC. Methods: Longitudinal fecal samples were collected from 85 patients with newly-diagnosed, early-stage TNBC patients enrolled in the ARTEMIS trial (NCT02276443). Patients all received standard NACT with adriamycin/cyclophosphamide (AC); volumetric change was assessed using ultrasound and patients with < 70% volumetric reduction (VR) after 4 cycles of AC were recommended to receive targeted therapy in addition to standard NACT to improve response rates. We performed 16S sequencing on bacterial genomic DNA extracted from 85 pre-AC fecal samples using the 2x250 bp paired-end read protocol. Quality-filtered sequences were clustered into Operational Taxonomic Units and classified using Mothur method with the Silva database version 138. For differential taxa-based univariate analysis, abundant microbiome taxa at species, genus, family, class, and order levels were analyzed using DESeq2 after logit transformation. Alpha-diversity indices within group categories were calculated using phyloseq. Microbial alpha diversity (within-sample diversity) was measured by Simpson's reciprocal index. β-diversity was measured using weighted UniFrac distances between the groups. The association between microbiota abundance and pathologic complete response (pCR) or residual disease (RD) was assessed using DESeq2 analysis. Results: Pre-AC fecal samples from 85 patients were available for analysis. Amongst them, there were 46 patients with pCR and 39 patients with RD. There was no significant difference in alpha diversity (p = 0.8) or beta-diversity (p = 0.7) between the pCR and RD groups. However, relative to patients with RD, the gut microbiome in patients with pCR was enriched for the Bifidobacterium longum species (p = 0.03). The gut microbiome in patients with RD was enriched for Lachnospiraceae (p = 0.03) at the genus level and the Bacteroides thetaiotaomicron species (p = 0.02). Conclusions: We have demonstrated significant differences in the gut microbial composition in patients with pCR as compared to patients with RD. Further investigation in larger studies is needed to support therapeutic exploration of gut microbiome modulation in TNBC patients receiving chemotherapy such as probiotic supplementation or fecal microbiota transplant.
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Affiliation(s)
- Nour Abuhadra
- MD Anderson Hematology/Oncology Fellowship, Houston, TX
| | - Chia-Chi Chang
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Clinton Yam
- Woodlands Health Campus, Singapore, Singapore
| | - Jason B White
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Bora Lim
- Baylor College of Medicine, Houston, TX
| | - Naoto T. Ueno
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Banu Arun
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Vicente Valero
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Debu Tripathy
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Lei Huo
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Al-Awadhi A, Abuhadra N, Liu DD, Barrera AMG, Corredor J, Strong LC, Arun BK. Abstract PS8-04: Clinical and pathological characteristics and screening outcome for secondary cancers in breast cancer patients with li-fraumeni syndrome attending the MD anderson li-fraumeni education and early detection program clinic. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps8-04] [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: 11/16/2022]
Abstract
Abstract
Background: Germline TP53 mutations predispose to early onset breast cancer (BC) and are associated with Li-Fraumeni syndrome (LFS) Published data on the clinical and pathological characteristics and screening outcome for secondary cancers among women with BC and TP53 mutations is limited. The UTMD Anderson's Li-Fraumeni Education and Early Detection (LEAD) program conducts comprehensive cancer screening for patients with LFS. Here we report characteristics and screening outcome of patients with BC and LFS who were referred to the LEAD program.
Methods: Patients with BC and LFS were identified from a prospective BC database between 2001 to 2018. Patients had genetic testing at The University of Texas MD Anderson Cancer Center (MDACC) Clinical Cancer Genetics (CCG) program and confirmed to have germline TP53 mutations. Data reviewed included clinical and pathological characteristics of their BC, the pattern of referral to the LEAD program, adherence to screening recommendation and rate of secondary cancer detection in the LEAD program.
Results: A total of 78 female patients with positive germline TP53 mutation and BC diagnosis were identified. The clinical and pathological characteristics of these patients are provided in table 1. Out of the 78 patients, 62 patients were referred and followed at the LEAD clinic. 50 were referred after BC diagnosis and 12 were referred to LEAD clinic before BC diagnosis. A total of 137 cancers were diagnosed in the total population. The cancers were further grouped into diagnosed before or after BC diagnosis. (table 2). 24 cancers were diagnosed in LEAD clinic including 12 breast cancers, 2 soft tissue tumors, 2 thyroid cancers, 2 acute myeloid leukemia, 1 brain tumor, 1 lung cancer, 1 pancreatic cancer, 1 melanoma, 1 parotid cancer and 1 Merkel cell cancer. Adherence to follow up and recommended screening in the first year was 77%, second year 75% and third year 65%. 6 patients, who were diagnosed with leukemia, had received adjuvant chemotherapy with anthracycline and/or cyclophosphamide-based therapy for breast cancer with median time from chemotherapy to leukemia diagnosis of 9 years (5-10yrs). 8 patients developed chest wall sarcoma in the same location of prior radiation therapy for breast cancer with median time from radiation therapy to chest wall sarcoma diagnosis of 7 years (3-11yrs).
Conclusion: Patients with LFS associated breast cancer are at significant increased risk to develop secondary cancers. Increased surveillance for secondary cancers in a dedicated program can increase adherence to screening, lead to early detection that could potentially lead to improved outcomes. Patient outcome of this cohort will be presented at the meeting.
Table 1: Clinical and Pathological Characteristics of Women with Breast cancer and LFSN(%)N(%)Median Age (Range)33 (20, 63)——Hormonal receptor/HER-2 status+/+22(31.4%)RaceAsian/Pacific islander7(9%)+/-27(38.6%)Black8(10.3%)-/+14(20%)Hispanic12(15.4%)-/-7(10%)White51(65.4%)Menopausal status at the time of BC diagnosis.Pre-menopausal(72%)Stage013(16.9%)Post-menopausal(28%)I21(27.3%)HistologyDCIS12(15.6%)II31(40.3%)IDC49(63.6%)III9(11.7%)ILC3(3.9%)IV3(3.9%)LCIS1(1.3%)Breast cancer diagnosisMRI4(5.2%)Mixed8(10.4%)Palpated lesion51(66.2%)Mucinous2(2.6%)Screening mammogram22(28.6%)Phyllodes2(2.6%)
Table 2: Cancer diagnosed in the total population N=78 grouped into before and after to BC diagnosisCancer diagnosed before BC diagnosisNCancer diagnosed after BC diagnosisNSoft tissue sarcoma13Soft tissue sarcoma18CNS1Lung2Thyroid3Thyroid3leukemia2Merkel cell1Adrenal2Leukemia6Uterus1CNS3Renal1pancreas1Melanoma1Parotid1
Citation Format: Aydah Al-Awadhi, Nour Abuhadra, Diane D Liu, Angelica M Gutierrez Barrera, Jessica Corredor, Louise C Strong, Banu K Arun. Clinical and pathological characteristics and screening outcome for secondary cancers in breast cancer patients with li-fraumeni syndrome attending the MD anderson li-fraumeni education and early detection program clinic [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS8-04.
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Affiliation(s)
| | - Nour Abuhadra
- 2The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Diane D Liu
- 2The University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Jessica Corredor
- 2The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Louise C Strong
- 2The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Banu K Arun
- 2The University of Texas, MD Anderson Cancer Center, Houston, TX
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Abuhadra N, Chang CC, Yam C, Sun R, Huo L, White J, Ravenberg EE, Litton J, Lim B, Ueno NT, Arun B, Tripathy D, Damodaran S, Murthy R, Valero V, Hortobagyi G, Ibrahim N, Thompson A, Mittendorf E, Moulder S, Jenq R. Abstract PS4-05: Prospective evaluation of the gut microbiome and response to neoadjuvant therapy (NAT) in early-stage triple negative breast cancer (TNBC). Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps4-05] [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: 11/16/2022]
Abstract
Abstract
Introduction: Emerging data suggest that the gut microbial composition influences responses to chemotherapy and immunotherapy. However, similar data in patients with TNBC receiving NAT remains limited. Thus, we investigated the association between the gut microbial composition in patients with newly-diagnosed, early-stage TNBC and response to NAT in a cohort of patients enrolled in the ARTEMIS trial (NCT02276443). Methods: We performed 16S sequencing on bacterial genomic DNA extracted from pre-NAT fecal samples using the 2x250 bp paired-end read protocol. Quality-filtered sequences were clustered into Operational Taxonomic Units and classified using Mothur method with the Silva database version 128. Associations between abundance and pathologic response to NAT were assessed using the Mann Whitney U Test. A cohort of 32 patients had longitudinal samples collected. Mann-Whitney U Test and Fishers exact were used to compare clinical variables as appropriate between the pCR and non-pCR groups. Results: There was no significant difference in age, race or stage between the pCR and non-pCR groups (Table 1). As expected, the pCR group was enriched for high TIL (p=0.026). There was no difference in alpha-diversity of the gut microbiome between patients with NAT-sensitive (pCR) and NAT-resistant disease (non-pCR) (p=0.5). Relative to patients with NAT-sensitive disease (pCR), the gut microbiome in patients with NAT-resistant disease was enriched for Fusobacterium (p=0.009), Intestinimonas (p=0.01) and Lachnospiraceae (p=0.003) at the genus level; the median abundances between pCR and non-pCR are provided in Table 1. Longitudinal samples collected during NAT demonstrated no substantial impact of NAT on the gut microbiome.
Conclusions: Taken together, these data suggest that response to NAT may be influenced by the gut microbial composition, which remains unaltered during NAT. Research efforts to modulate the gut microbiome should be further explored as a potential therapeutic strategy in TNBC.
Table 1: Median Microbial Abundance and Clinicopathological Variables (N=43)pCR (n=18)Non-pCR (n=25)p- valueMicrobial AbundanceFusobacterium1 x 10-61.02 x 10-50.009Intestinimonas6.4 x 10-54.8 x 10-40.01Lachnospiraceae6.2 x 10-31.0 x 10-20.003Age median, interquartile range (n=44)45 (38-59)53 (46-58)0.61n (%)Race/EthnicityWhite, non-Hispanic11 (61.1)14 (56.0)0.53White, Hispanic4 (22.2)3 (12.0)Black2 (11.1)7 (28.0)Asian1 (5.6)1 (4.0)T categoryT15 (27.8)4 (16.0)0.15T213 (72.2)17 (68.0)T304 (16.0)T400Nodal statusNegative12 (66.7)14 (56.0)0.54Positive6 (33.3)11 (44.0)StageI3 (16.7)3 (12.0)0.91II11 (61.1)15 (60.0)III4 (22.2)7 (28.0)TIL<20%7 (38.9)19 (76.0)0.026>20%11 (61.1)6 (24.0)
Citation Format: Nour Abuhadra, Chia-Chi Chang, Clinton Yam, Ryan Sun, Lei Huo, Jason White, Elizabeth E Ravenberg, Jennifer Litton, Bora Lim, Naoto T Ueno, Banu Arun, Debu Tripathy, Senthil Damodaran, Rashmi Murthy, Vicente Valero, Gabriel Hortobagyi, Nuhad Ibrahim, Alastair Thompson, Elizabeth Mittendorf, Stacy Moulder, Robert Jenq. Prospective evaluation of the gut microbiome and response to neoadjuvant therapy (NAT) in early-stage triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-05.
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Affiliation(s)
- Nour Abuhadra
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Chia-Chi Chang
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Clinton Yam
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Ryan Sun
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Lei Huo
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Jason White
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | - Jennifer Litton
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Bora Lim
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Naoto T Ueno
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Banu Arun
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Debu Tripathy
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | - Rashmi Murthy
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Vicente Valero
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | - Nuhad Ibrahim
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | | | - Stacy Moulder
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Robert Jenq
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
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Abuhadra N, Sun R, Litton JK, Rauch GM, Thompson AM, Lim B, Adrada BE, Mittendorf EA, White JB, Ravenberg E, Damodaran S, Candelaria RP, Arun B, Ueno NT, Santiago L, Murthy RK, Ibrahim NK, Symmans WF, Moulder SL, Huo L. Prognostic impact of high stromal tumor-infiltrating lymphocytes (sTIL) in the absence of pathologic complete response (pCR) to neoadjuvant therapy (NAT) in early stage triple negative breast cancer (TNBC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
583 Background: Pathologic complete response is an excellent surrogate for disease-free survival (DFS) and overall survival (OS) in TNBC. High sTIL is associated with improved pCR rates in TNBC. Recent data suggest that high sTIL is also associated with improved outcomes in patients who received no chemotherapy for early stage TNBC (Park, Annals of Oncology, 2019). Thus, we hypothesized that high sTIL may have prognostic impact in patients who do not achieve pCR to NAT. Methods: Pretreatment core biopsies from 182 patients with early-stage TNBC enrolled on the ARTEMIS trial (NCT02276443) were evaluated for sTIL by H&E. Patients were stratified according to sTIL (low < 30%, and high > 30%) and pCR (patients with pCR vs. no pCR). The primary outcome measure was DFS, defined from the date of diagnosis to the first local recurrence, distant metastases or death. Cox proportional hazards regression model was used. During follow-up 33 events for DFS were observed. Results: Among subjects who achieve pCR, DFS was excellent regardless of sTIL status and significantly better than those without pCR (p < 0.05). However, patients with high sTIL and no pCR demonstrated significantly worse DFS compared to all subjects having pCR (HR 0.18, 95% CI 0.04-0.76, p = 0.02). Additionally, we did not find a significant difference between high and low sTIL patients who did not achieve pCR. Conclusions: In early TNBC receiving NAT, for patients failing to achieve pCR, high sTIL was not associated with improved DFS; outcomes were comparable to those with low sTIL without pCR. Thus, high sTIL at baseline does not appear to confer an intrinsic prognostic benefit in the absence of pCR.
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Affiliation(s)
- Nour Abuhadra
- MD Anderson Hematology/Oncology Fellowship, Houston, TX
| | - Ryan Sun
- MD Anderson Cancer Center, Houston, TX
| | | | - Gaiane M Rauch
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Bora Lim
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Jason B White
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Senthil Damodaran
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Banu Arun
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naoto T. Ueno
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | - Lei Huo
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Abuhadra N, Sun R, Litton J, Rauch G, Thompson A, Lim B, Adrada B, Mittendorf E, Damodaran S, Pitpitan R, Arun B, White J, Ravenberg E, Santiago L, Sahin A, Murthy R, Ueno N, Ibrahim N, Moulder S, Huo L. 98O The immunomodulatory (IM) signature enhances prediction of pathologic complete response (pCR) to neoadjuvant therapy (NAT) in triple negative breast cancers (TNBC) with moderate stromal tumour infiltrating lymphocytes (sTIL). Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.03.038] [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] [Indexed: 10/24/2022] Open
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Abuhadra N, Hess K, Litton J, Rauch G, Thompson A, Lim B, Adrada B, Mittendorf E, Damodaran S, Candelaria R, Arun B, Yang WT, Ueno N, Santiago L, Murthy R, Ibrahim N, Aysegul S, Symmans W, Huo L, Moulder S. Abstract P1-10-20: Serial TILs: Evaluating the role of mid-treatment tumor infiltrating lymphocytes (TIL) in predicting pathologic complete response (pCR) in early-stage triple negative breast cancer (TNBC). Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p1-10-20] [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: 11/16/2022]
Abstract
Abstract
Introduction High levels of TIL at baseline are associated with higher pCR rates and better overall survival in TNBC. Recent studies have also indicated that higher TIL in post-NACT residual disease in TNBC are an important independent predictor of improved survival. We evaluated the role of mid-treatment (post-AC; Adriamycin/Cyclophosphamide) TIL in predicting pCR rates in early-stage TNBC. Methods Of 242 patients with stage I-III TNBC enrolled in the ARTEMIS trial (NCT02276443), 156 patients had pre-AC TIL and pCR status available for this analysis. Both pre-and post-AC TIL counts were available in 29 patients. Post-AC TIL counts for the remaining patients were imputed using linear regression with age, race, stage III, vimentin >50% and post-AC tumor volume reduction. Using these imputed TIL counts we evaluated the association of post-AC TIL with pCR. We also evaluated the change in TIL before and after treatment with AC. Results At baseline the median TIL count was 10% (n=156). In the post-AC samples, the median TIL count was 5%. Using imputed TIL counts, we did not conclude that post-AC TIL was associated with pCR (p= 0.28). Using a cut-point of 15% TIL, our analysis showed that baseline TIL is more strongly correlated with pCR than post-AC TIL (Table 1). In our univariable logistic regression, both baseline TIL and the difference in TIL pre-and post- treatment were significantly associated with pCR (p= 0.0015 and p=0.0068, respectively), however in the multivariable analysis only baseline TIL was significant. Our analysis did show that a decrease in TIL from pre- to post-treatment was significantly associated with pCR (p=0.022). However, this measure was not significant in our logistic regression model when pre-TIL was also included. Conclusion Higher pre-treatment TIL correlated more strongly with pCR rate when compared to post-AC TIL. Pre-treatment high TIL was associated with pCR regardless of changes in TIL pre and post treatment.
Table 1. Changes in TIL before and after treatmentBaseline TILPost-AC TILN#pCR (%)LowLow6217 (27%)LowHigh4012 (30%)HighLow2513 (52%)HighHigh2916 (55%)TIL; Low: <15, High >15
Citation Format: Nour Abuhadra, Kenneth Hess, Jennifer Litton, Gaiane Rauch, Alastair Thompson, Bora Lim, Beatriz Adrada, Elizabeth Mittendorf, Senthil Damodaran, Rosalind Candelaria, Banu Arun, Wei Tse Yang, Naoto Ueno, Lumarie Santiago, Rashmi Murthy, Nuhad Ibrahim, Sahin Aysegul, William Symmans, Lei Huo, Stacy Moulder. Serial TILs: Evaluating the role of mid-treatment tumor infiltrating lymphocytes (TIL) in predicting pathologic complete response (pCR) in early-stage triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-10-20.
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Affiliation(s)
- Nour Abuhadra
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Kenneth Hess
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Jennifer Litton
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Gaiane Rauch
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | - Bora Lim
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Beatriz Adrada
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Banu Arun
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Wei Tse Yang
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Naoto Ueno
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | | | - Rashmi Murthy
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Nuhad Ibrahim
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Sahin Aysegul
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - William Symmans
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Lei Huo
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Stacy Moulder
- 1University of Texas - MD Anderson Cancer Center, Houston, TX
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Abuhadra N, Seth S, Moulder S. Clinical features of early-stage (I-III) triple-negative breast cancer (TNBC) patients with tumours exhibiting low-overall change in molecular profile after neoadjuvant therapy. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz240.076] [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] [Indexed: 11/13/2022] Open
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Abuhadra N, Hess KR, Litton JK, Rauch GM, Thompson AM, Lim B, Adrada BE, Mittendorf EA, Damodaran S, Candelaria RP, Arun B, Yang WT, Ueno NT, Santiago L, Murthy RK, Ibrahim NK, Sahin AA, Symmans WF, Moulder SL, Huo L. Beyond TILs: Predictors of pathologic complete response (pCR) in triple-negative breast cancer (TNBC) patients with moderate tumor-infiltrating lymphocytes (TIL) receiving neoadjuvant therapy. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.572] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
572 Background: Increased TIL in TNBC is associated with higher rates of pCR. High TIL is also associated with improved disease free survival and overall survival. The aim of this study is to identify data cut-points of pre-treatment low, moderate and high TIL count based on pCR and to identify clinical and pathological predictors of pCR in patients with moderate TIL. Methods: We evaluated the relationship between pCR and TIL in 180 patients with stage I-III TNBC enrolled in the ARTEMIS trial (NCT02276443). Recursive portioning was used to identify cut-points. Clinical and pathological variables such as age at diagnosis, stage, race, histology as well as Ki-67, vimentin, and androgen receptor (AR) by immunohistochemistry, were evaluated in pts with moderate TIL. A multivariable logistic regression model identified variables independently, significantly associated with pCR. Results: Four TIL groups were identified with pCR rates of 23%, 31%, 48% and 78% respectively (p < 0.0001) (Table A). In the two combined moderate TIL groups, 90 (97%) pts were evaluable for the multivariate model. Stage I-II disease, high Ki-67 and low AR were associated with increased probability of pCR (Table B). The multivariable logistic regression model area under the ROC curve was 0.78 (95% CI=0.68-0.88; p<0.0001). A model of computed risk score [ Stage I-II (score 2)+Ki-67≥ 50% (score 1)+AR<10% (score 1)] predicted a probability of 67% for pCR when all three variables were favorable (Table). Conclusions: Four TIL groups were identified. In pts with moderate TIL levels, early stage disease, high Ki-67 and low AR were associated with increased probability of pCR with neoadjuvant therapy. [Table: see text]
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Affiliation(s)
- Nour Abuhadra
- MD Anderson Hematology/Oncology Fellowship, Houston, TX
| | - Kenneth R. Hess
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Gaiane M Rauch
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Bora Lim
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Banu Arun
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wei Tse Yang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naoto T. Ueno
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Nuhad K. Ibrahim
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Lei Huo
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Abuhadra N, Mukherjee S, Al-Issa K, Adema V, Hirsch CM, Advani A, Przychodzen B, Makhoul A, Awada H, Maciejewski JP, Sekeres MA, Nazha A. BCOR and BCORL1 mutations in myelodysplastic syndromes (MDS): clonal architecture and impact on outcomes. Leuk Lymphoma 2019; 60:1587-1590. [PMID: 30618304 DOI: 10.1080/10428194.2018.1543885] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Nour Abuhadra
- a Department of Hematology and Medical Oncology , Leukemia Program, Cleveland Clinic , Cleveland , OH , USA
| | - Sudipto Mukherjee
- a Department of Hematology and Medical Oncology , Leukemia Program, Cleveland Clinic , Cleveland , OH , USA
| | - Karam Al-Issa
- a Department of Hematology and Medical Oncology , Leukemia Program, Cleveland Clinic , Cleveland , OH , USA
| | - Vera Adema
- b Translational Hematology and Oncology Research Department , Cleveland Clinic, Taussig Cancer Institute , Cleveland , OH , USA
| | - Cassandra M Hirsch
- b Translational Hematology and Oncology Research Department , Cleveland Clinic, Taussig Cancer Institute , Cleveland , OH , USA
| | - Anjali Advani
- a Department of Hematology and Medical Oncology , Leukemia Program, Cleveland Clinic , Cleveland , OH , USA
| | - Bartlomiej Przychodzen
- b Translational Hematology and Oncology Research Department , Cleveland Clinic, Taussig Cancer Institute , Cleveland , OH , USA
| | - Ahed Makhoul
- a Department of Hematology and Medical Oncology , Leukemia Program, Cleveland Clinic , Cleveland , OH , USA
| | - Hassan Awada
- b Translational Hematology and Oncology Research Department , Cleveland Clinic, Taussig Cancer Institute , Cleveland , OH , USA
| | - Jaroslaw P Maciejewski
- b Translational Hematology and Oncology Research Department , Cleveland Clinic, Taussig Cancer Institute , Cleveland , OH , USA
| | - Mikkael A Sekeres
- a Department of Hematology and Medical Oncology , Leukemia Program, Cleveland Clinic , Cleveland , OH , USA
| | - Aziz Nazha
- a Department of Hematology and Medical Oncology , Leukemia Program, Cleveland Clinic , Cleveland , OH , USA
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Abuhadra N, Majhail NS, Nazha A. Impact of social media for the hematologist/oncologist. Semin Hematol 2017; 54:193-197. [DOI: 10.1053/j.seminhematol.2017.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/11/2022]
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Nazha A, Al-Issa K, Przychodzen B, Abuhadra N, Hirsch C, Maciejewski JP, Sekeres MA. Differences in genomic patterns and clinical outcomes between African-American and White patients with myelodysplastic syndromes. Blood Cancer J 2017; 7:e602. [PMID: 28862700 PMCID: PMC5709751 DOI: 10.1038/bcj.2017.82] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- A Nazha
- Department of Translation Hematology and Oncology Research, Leukemia Program, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - K Al-Issa
- Department of Translation Hematology and Oncology Research, Leukemia Program, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - B Przychodzen
- Department of Translation Hematology and Oncology Research, Leukemia Program, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - N Abuhadra
- Department of Translation Hematology and Oncology Research, Leukemia Program, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - C Hirsch
- Department of Translation Hematology and Oncology Research, Leukemia Program, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - J P Maciejewski
- Department of Translation Hematology and Oncology Research, Leukemia Program, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - M A Sekeres
- Department of Translation Hematology and Oncology Research, Leukemia Program, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
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Nazha A, Al-Issa K, Hamilton BK, Radivoyevitch T, Gerds AT, Mukherjee S, Adema V, Zarzour A, Abuhadra N, Patel BJ, Hirsch CM, Advani A, Przychodzen B, Carraway HE, Maciejewski JP, Sekeres MA. Adding molecular data to prognostic models can improve predictive power in treated patients with myelodysplastic syndromes. Leukemia 2017; 31:2848-2850. [DOI: 10.1038/leu.2017.266] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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20
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Haddad N, Melikyan G, Al Hail H, Al Jurdi A, Aqeel F, Elzafarany A, Abuhadra N, Laswi M, Alsamman Y, Uthman B, Deleu D, Mesraoua B, Alarcon G, Azar N, Streletz L, Mahfoud Z. Epilepsy in Qatar: Causes, treatment, and outcome. Epilepsy Behav 2016; 63:98-102. [PMID: 27588359 DOI: 10.1016/j.yebeh.2016.07.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/29/2016] [Accepted: 07/30/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Qatar is a small country on the Eastern coast of the Arabian Peninsula. Its population is a unique mixture of native citizens and immigrants. We aimed to describe the features of epilepsy in Qatar as such information is virtually lacking from the current literature. METHODS We summarized information retrospectively collected from 468 patients with epilepsy seen through the national health system adult neurology clinic. RESULTS Epilepsy was classified as focal in 65.5% of the cases and generalized in 23%. Common causes of epilepsy were as follows: stroke (9%), hippocampal sclerosis (7%), infections (6%), and trauma (6%). Sixty-six percent of patients were receiving a single antiepileptic drug, with levetiracetam being the most frequently prescribed drug (41% of subjects). When the patients were divided by geographical background, remote infections caused the epilepsy in 15% of Asian patients (with neurocysticercosis accounting for 10%) but only in 1% of Qatari and 3% of Middle East/North African subjects (with no reported neurocysticercosis) (p<0.001). Cerebrovascular and neurodegenerative etiologies were the most prominent in Qataris, accounting for 14% (p=0.005) and 4% (p=0.03) of cases, respectively. The choice of antiepileptic drugs varied also according to the regional background, but the seizure freedom rate did not, averaging at 54% on the last clinic visit. SIGNIFICANCE To our knowledge, this is the first detailed information about epilepsy in Qatar. The geographical origin of patients adds to the heterogeneity of this disorder. Neurocysticercosis should be in the etiological differential diagnosis of epilepsy in patients coming from Southeast Asian countries, despite the fact that it is not endemic to Qatar. The choice of antiepileptic drugs is influenced by the availability of individual agents in the patients' native countries but had no bearing on the final seizure outcome.
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Affiliation(s)
- Naim Haddad
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Gayane Melikyan
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Hassan Al Hail
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Ayman Al Jurdi
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar.
| | - Faten Aqeel
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar.
| | | | - Nour Abuhadra
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar.
| | - Mujahed Laswi
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar.
| | - Yasser Alsamman
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar.
| | - Basim Uthman
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Dirk Deleu
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Boulenouar Mesraoua
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Gonzalo Alarcon
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Nabil Azar
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Leopold Streletz
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar; Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
| | - Ziyad Mahfoud
- Weill Cornell Medicine-Qatar, PO Box 24144, Education City, Doha, Qatar.
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Chellapandian D, Shaikh F, van den Bos C, Somers GR, Astigarraga I, Jubran R, Degar B, Carret AS, Mandel K, Belletrutti M, Dix D, Visser J, Abuhadra N, Chang T, Rollins B, Whitlock J, Weitzman S, Abla O. Management and Outcome of Patients With Langerhans Cell Histiocytosis and Single-Bone CNS-Risk Lesions: A Multi-Institutional Retrospective Study. Pediatr Blood Cancer 2015; 62:2162-6. [PMID: 26179251 DOI: 10.1002/pbc.25645] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/29/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Children with Langerhans cell histiocytosis (LCH) and single-bone CNS-risk lesions have been reported to be at increased risk of diabetes insipidus (DI), central nervous system neurodegeneration (CNS-ND), and recurrence of disease. However, it is unknown whether the addition of chemotherapy or radiotherapy changes outcomes in these patients. METHODS Ten pediatric institutions across North America and Europe contributed data of their patients with LCH and single-bone CNS-risk lesions. Clinical information on age, sex, specific craniofacial site involvement, and intracranial extension at diagnosis, therapy, and disease course was collected for all eligible patients. RESULTS The final analysis included 93 eligible children who were either treated with systemic therapy (chemotherapy, chemo-radiotherapy, or radiotherapy) or local therapy (biopsy, curettage, and/or intralesional steroids). Fifty-nine patients had systemic and 34 had local therapy. The 5-year event-free survival (EFS) and overall survival (OS) were 80 ± 5% and 98 ± 2% in the systemic therapy group versus 85 ± 6% and 95 ± 5% in the local therapy group. There was no statistically significant difference between either group with regard to EFS (P = 0.26) and OS (P = 0.78). On multivariable analysis, there was no significant difference among the two treatment groups after adjusting for site and intracranial soft tissue extension, nor any trend favoring systemic therapy (HR = 2.26, 95% CI = 0.77-6.70; P = 0.14). CONCLUSION Systemic therapy may not reduce the risk of recurrence or late sequelae in children with LCH and single-bone CNS-risk lesions as compared to local treatment.
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Affiliation(s)
- Deepak Chellapandian
- Department of Pediatrics, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Furqan Shaikh
- Department of Pediatrics, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cor van den Bos
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Gino R Somers
- Division of Pathology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Itziar Astigarraga
- Servicio de Pediatria, Bio Cruces Health Research Institute, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain.,Departamento de Pediatria, Universidad del Pais Vasco UPV/EHU, Vizcaya, Spain
| | - Rima Jubran
- Children's Hospital of Los Angeles, Los Angeles, California
| | - Barbara Degar
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anne-Sophie Carret
- Division of Hematology-Oncology, Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Karen Mandel
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Belletrutti
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - David Dix
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Nour Abuhadra
- Department of Pediatrics, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tiffany Chang
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Barret Rollins
- Department of Medical Oncology, Harvard Medical School, Boston, Massachusetts
| | - James Whitlock
- Department of Pediatrics, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sheila Weitzman
- Department of Pediatrics, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Oussama Abla
- Department of Pediatrics, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
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