Sensitivity and specificity of strain rate for the early detection of left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with adriamycin with or without trastuzumab

Background

Medical literature states that a global longitudinal strain rate (GLS) <−19% and further reductions in relation with baseline GLS may predict long term left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with Adriamycin (A) with or without trastuzumab (T). However, there is not strong evidence to support the use of this technique in daily clinical practice.

Purpose

To analyze the sensitivity (S) and specificity (Sp) of GLS <−19% or its relative 10, 15 and 20% reduction form baseline, for the early detection of left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with A with or without T.

Methods

Patients were prospectively assessed with a cardiac echoDoppler + GLS at baseline, every 3 months during the first year and every 4 months thereafter. We assessed the S and Sp of GLS <−19% or its relative >10%, >15% and >20% reduction form baseline after treatment with A with or without T as predictors of cardiotoxicity (defined as a >10 percentage points decrease of left ventricular ejection fraction to a value below the lower normal limit with respect to baseline).

Results

136 out of 884 patients (16%) had GLS measured at each visit: 83 patients (60%) and 53 patients (40%) treated with A or A+T respectively. Patients were followed up to 31±6 months. Mean age was 51±12 years. The table shows the baseline characteristics of both groups. 10 out of 83 patients in group A (12%) and 18 out of 53 P in group A+T (34%) developed cardiotoxicity. Baseline left ventricular ejection fraction and GLS were 61±4,7% and −20,18±2,6% in group A, and 58,7±5,8% and −19,5±2,6 post treatment. In this group, GLS S and Sp were 50 and 80%, respectively. In the group A+T, the best GLS cutoff was −19%, with a 60% sensitivity and 78% specificity.

Conclusions

In our non-selected cohort of patients, nor GLS or its percentage reductions along follow up predicted the reduction of left ventricular ejection fraction and the developing of cardiotoxic ventricular dysfunction in breast cancer patients receiving adjuvant treatment with A with or without T. The systematic use of this tool should be further investigated and validated at each center to help establish its usefulness in daily practice.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristics

Phase II Trial of 4′-Epi-Doxorubicin in Locally Advanced or Metastatic Gastric Cancer

Patients with locally advanced or metastatic gastric adenocarcinoma received an i.v. bolus of 4′-epi-doxorubicin, 75/mg/m2/cycle, every 21 days. Partial responses were observed in 5 of 23 evaluable patients (21.7%). Treatment was generally well tolerated and toxicity was mild. The response rate to epirubicin appears to be very similar to that reported for doxorubicin. Larger doses of epirubicin could be safely used in future studies, and further evaluation of epirubicin in phase III trials is indicated.

Abstract P6-09-09: Meta-analysis of ESR1 mutation prevalence in metastatic breast cancer

Introduction: ESR1 mutations were described for the first time in 1996 when different tyrosine 537 mutations were found to confer constitutive activation of the receptor, describing this region as a key factor in the ligand regulation of ER transcriptional activity. However, due to the low prevalence of this mutation in primary breast tumors its clinical significance maintained unknown. With the advent of large scale genomic analysis, a new understanding of breast cancer molecular characteristics has gained relevance. The low prevalence of ESR1 mutations in primary breast cancer has been confirmed but mutations in metastatic ER-positive breast cancers has been proved to be a completely different scenario. Nevertheless, information regarding real prevalence of ESR1 mutation in metastatic breast cancer is not known as selection of patients and molecular technique used are heterogeneous.

Sources: Search was carried by corresponding clinical oncologists of the Breast Cancer Unit of Alexander Fleming Institute. In March 2017, key words “ESR1 mutations”, “Estrogen receptor mutations” and “Breast cancer” were used as search strategy for the present meta-analysis in PubMed. Furthermore, abstracts from congress presentations were analyzed and hand searching from reference list of obtained articles was executed. Online search retrieved 60 articles published, 3 abstracts related were found and 3 further studies were detected by hand search. Articles were excluded if they only included primary tumors and not metastatic cases and if they were undertaken before 2000 due to important technical differences of mutation detection, including finally 23 cohorts.

Study Selection: Studies considered were prospective or retrospective cohorts of metastatic breast cancer patients with mutation analysis of tissue or circulating DNA. A data form was used by the primary reviewer to extract equivalent information from each article. Information extracted included population sampled, prevalence estimates, clinical characteristics of cohort, sample analyzed and technical procedure for mutation detection. A second reviewer blinded to the primary reviewer's decisions checked the article selection and data extraction. Any differences of opinion were discussed, and a third reviewer was available to arbitrate any issues.

Meta-analysis was undertaken using a random-effects model conducted using the metaprop function in Meta package of R studio Version 1.0.136 (© 2009-2016 RStudio, Inc.). PRISMA guidelines were followed in conducting and reporting the results.

Results and Discussion: Results show a prevalence of ESR1 mutation of 24% (CI95% 19-30%) in the 3607 patients included. Nevertheless, important heterogeneity (I2 =90%) is observed due to great differences in the articles published of this topic. This heterogeneity is attributed to the type of cohorts presented, the selection of patients, the technique used and type of sample studied, but another source of heterogeneity must be present as it still persists after grouping studies according to this variables. The importance of this analysis resides in the fact that it is the most complete information of the prevalence of this mutation that may have future importance in therapeutic decisions in metastatic breast cancer.

Citation Format: Mandó P, Rizzo MM, Perez de la Puente C, Costanzo MV, Nervo A, Nadal J, Colo F, Loza CM, Loza J, Fabiano V, Ponce C, Chacon R. Meta-analysis of ESR1 mutation prevalence in 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 P6-09-09.

Breast cancer care in Latin America and the Caribbean (LAC)

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Background: This study was designed to evaluate breast cancer care (BCC) in LAC trough a survey of 65 questions. Methods: We surveyed 96 opinion leaders (OL) from 12 countries that were first contacted by a researcher explaining the project and methodology. A phone interview was done by a specialist in epidemiology surveys. Answers were analyzed by center or country with Intercooled State 8 software (State Corp.) Results: 92 % OL confirm that there is no country law or guidelines making mandatory mammographyc screening. Nearly 75% of the OL stated that some type of cancer registry was available. The first consultation is done by gynecologists or breast cancer surgeons (83%), clinicians (13%) and surgeons (4%).Time lapsed from consultation until pathologic diagnosis was less than 3 months in 62% (country) and 91% (centers). Accessibility for hormone receptor and molecular markers is very good in specialized centers: 90% and 83% respectively but it is only available to 52% and 5% of country patients. Conservative surgery is widely accepted (87%) and 71% OL are able to perform sentinel node biopsies (centers). Systemic treatment is mainly based in Anthracyclines and Tamoxifen. The treatment coverage at centers is through medical insurance companies (53%), government (28%) and patient (19%) while 67% of country patients are government covered. Radiation treatment is mainly indicated by oncologists and 62% consider that radiotherapy centers in their countries are insufficient. There is adequate availability of morphine for 93% (centers) and 82% (countries).The choice of the chemotherapy or hormonal adjuvant treatment is free for 74% of those surveyed at their centers and in 23% is pre-established by the coverage. Majority of opinions are that all types of research are deficient. It is mainly organized in public institutions and sponsored by pharmaceutical companies (76%). Full results will be presented. Conclusions: We obtained data about the reality of BCC in the region. There is a general lack of prevention plans. Time to diagnosis and first treatment is similar to developed countries. Treatment according to stage is similar to international standards. Radiotherapy availability is poor. Based on this data a strategic plan for BCC in LAC will be developed. Supported by a grant from The Breast Cancer Research Foundation

No significant financial relationships to disclose.

A prospective, randomized Phase III trial comparing combination chemotherapy with cyclophosphamide, doxorubicin, and 5-fluorouracil with vinorelbine plus doxorubicin in the treatment of advanced breast carcinoma

BACKGROUND

A prospective, multicenter, randomized, Phase III trial comparing the efficacy of combination chemotherapy with 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) with a combination of vinorelbine and doxorubicin (NA) in the treatment of patients with advanced breast carcinoma was undertaken.

METHODS

One hundred and seventy-seven patients who previously were untreated for recurrent or metastatic breast carcinoma were entered into the study; 7 patients could not be assessed. The final analysis relates to 85 patients who were treated with FAC and 85 patients who were treated with NA, of whom 21 (25%) and 44 (52%), respectively, had received prior adjuvant chemotherapy.

RESULTS

The overall response rates were similar for the two treatments and were unaffected by prior exposure to adjuvant therapy; overall response rate (ORR) for FAC was 74% (95% confidence interval [95% CI], 65-83%), and the ORR for NA was 75% (95% CI, 66-84%). The activity of NA in patients with liver involvement was greater than that of FAC in terms of survival. Overall survivals were similar, with a median of 17.3 months for patients receiving FAC and 17.8 months for patients receiving NA. Severe toxicity was uncommon with World Health Organization Grade 3-4 neutropenia affecting only 7% of patients in each arm of the study. NA was associated with a higher incidence of mild to moderate constipation, neurotoxicity, and phlebitis, whereas FAC produced a slight excess of mild cardiotoxicity.

CONCLUSIONS

The efficacy of these two regimens is very similar, although NA may be more active in a subset of patients with visceral metastatic disease, particularly liver involvement. It is clear that, in a direct comparison with an established three-drug regimen, the newer two-drug combination of NA demonstrated equivalent activity with no significant excess of Grade 3-4 toxicity.

Less efficacy with alternating regimen as adjuvant chemotherapy in stage II node-positive breast cancer: results at 8 years (Pronacam 85)

A randomized trial to compare adjuvant treatment with an alternating regimen with conventional chemotherapy was performed. A total of 589 node-positive patients were included and stratified according to number of positive nodes (N1-3 and N > 4) and menopausal status. Premenopausal N1-3 patients were randomized to cyclophosphamide, methotrexate and fluorouracil (CMF) or CMF/4'-epirubicin, cyclophosphamide (EC), post-menopausal N1-3 patients to fluorouracil, 4 epirubicin, cyclophosphamide (FEC) or CMF/EC and pre- and post-menopausal patients with N > or = 4 to fluorouracil, 4' epirubicin, cyclophosphamide, methotrexate, prednisone (FECMP) or CMF/EC. In premenopausal patients, CMF was superior to CMF/EC in terms of disease-free survival (DFS) (65% vs 45%, P = 0.0149) and survival (72.3% vs 50.2%, P = 0.0220) whereas, for N > or = 4 patients, differences between FECMP and CMF/EC did not achieve statistical significance (DFS 35% vs 26.2%; survival 50% vs 38.1%, P = NS). For post-menopausal patients, FEC was superior to CMF/EC in DFS (58.6% vs 36.8%, P = 0.0215) and survival (66.2% vs 46%, P = 0.0155). In post-menopausal patients with N > 4, differences favouring CMF/EC were significant in DFS (40.4% vs 22%, P = 0.0371) but not in survival (47.4% vs 32.2%, P = 0.1185). Alternating regimens did not offer better results in premenopausal and post-menopausal N1-3 patients. Results regarding post-menopausal N > 4 women require further confirmation.

Impact of delay to treatment upon survival in 1067 patients with breast-cancer

The medical records of 1067 patients with breast cancer were reviewed to evaluate the influence of delay between first symptom and first treatment upon survival. Three delay intervals were considered: <3 months; 3-6 months and >6 months. At a follow-up of 120 months, survival analyses identified a statistically significant difference (p=0.029) favoring patients with <3 months delay in the whole cohort, and in the group of women aged 50 or older (p=0.001). No differences were found when survival according to delay was considered within each clinical stage. A Cox multivariate analysis revealed that performance status, stage, age and menopausal status were significant predictors of survival for the whole group of patients. However, delay was an independent prognostic factor in patients with age greater-than-or-equal-to 50. In summary, 38/1067 patients (3.1%) could have been adversely affected by a >3 months delay between first symptom and first treatment. Better survival rate for patients with a short delay would obey to a greater number of patients in favorable stages and a higher proportion of women aged 50 or older in this group.

Treatment of pain and other symptoms in cancer patients: patterns in a North American and a South American hospital

The charts of 200 consecutive patients with cancer pain admitted to a major teaching hospital in Edmonton, Canada (n = 100) and in Buenos Aires, Argentina (n = 100) were reviewed to assess the differences between North American (NA) and South American (SA) facilities in patterns of treatment of pain and other symptoms. Criteria for eligibility and methods were identical in both hospitals. Characteristics of patients (age, sex, primary tumor, reason for admission) and attending staff were similar between both hospitals. Mean daily equivalent doses of parenteral morphine (mg) were 44 +/- 26 and 9 +/- 10 in NA and SA, respectively (p less than 0.001). Patients in NA, received narcotics every 4 hr and on a regular basis more frequently than in SA. The types of narcotics and the use of adjuvant drugs were significantly different between NA and SA. Nonpharmacologic treatments, antiemetics, and laxatives were more frequently used in NA. These results suggest that there are significant differences in symptomatic management of advanced cancer between institutions in NA and SA.

Relation between delay and survival in 596 patients with breast cancer

To evaluate the influence of delay between first symptom and first treatment upon survival the medical records of 596 patients with breast cancer were reviewed. The following intervals were considered: less than 3 months; 3-6 months and greater than 6 months. Patients in the less than 3 months delay group had a better distribution by clinical stages and a 10-year survival rate higher than those in the longer delay groups (p = 0.034). However, within each stage no statistically significant difference in survival according to delay was observed. A Cox multivariate analysis revealed that performance status and stage of disease were independent predictors of survival, but not delay. Assuming the best prognosis for patients with clinical stages I and II and less than 3 months delay, the group with longer delay times had 15 deaths over what would have been predicted. This adverse effect was observed almost exclusively among patients over age 50 (14/15).

Action of oral methylprednisolone in terminal cancer patients: a prospective randomized double-blind study

A 14-day, randomized, double-blind crossover trial was carried out comparing an oral glucocorticoid, methylprednisolone (MP), against placebo for the relief of pain and other symptoms in 40 terminally ill cancer patients. After the 14-day, double-blind phase was completed, all patients were given MP for 20 days. The daily dose of MP was 32 mg, and end points of the study were pain, psychiatric status, appetite, nutritional status, daily activity, and performance. Mean intensity of pain (visual analogue, 0-100 +/- SD) was 36.8 +/- 14 after MP treatment and 57.7 +/- 15 after placebo (P less than 0.01). Following the 14-day, double-blind phase, appetite and daily activity increased in 24 of 31 patients (77%) and in 21 of 31 patients (68%) with MP, respectively; depression and analgesic consumption decreased in 22 of 31 patients (71%) and in 16 of 28 patients (57%) with MP, respectively. MP was preferred over placebo by 23 of the 31 patients (74%), and, in 22 of the 31 cases (71%), the investigator chose MP over placebo. No serious toxicity was found at the dose of MP used. It is concluded that MP increases the comfort of terminally ill cancer patients.

Syndromes in workers exposed to trimellitic anhydride. A longitudinal clinical and immunologic study

A longitudinal study of workers involved in the manufacture of trimellitic anhydride has been in progress since 1977. Trimellitic anhydride is a low-molecular-weight, reactive chemical used in the manufacture of plastics. Initial studies done in 1976 defined three syndromes due to inhalation of trimellitic anhydride: asthma-rhinitis, a late respiratory systemic syndrome, and an irritant response. Also, serologic techniques were developed to measure total antibody and IgE antibody to trimellityl human serum albumin. From 1977 to 1981, 64 workers were assessed. Six workers presented with asthma-rhinitis, high levels of IgE antibody, and skin test reactivity to trimellityl human serum albumin; five workers developed the late respiratory systemic syndrome; and one worker had both immunologic syndromes. These serologic measurements detected or were predictive of an immunologic respiratory illness and were useful in monitoring workers involved in the manufacture of trimellitic anhydride.

Detection of modifications in the tail of capacitated guinea pig sperm using lectins

The surfaces of uncapacitated, capacitated, and trypsinized guinea pig sperm have been compared using 10 lectins. A previously described assay was used to assess the degree and pattern of agglutination induced by each lectin. Our method of evaluating the agglutination pattern was significantly improved by observing assay plates with an inverted phase contrast microscope at 200 X 320 X magnification rather than with a dissecting microscope. Following in vitro capacitation or trypsinization, the agglutinability of sperm by SBA, DBA, and WGA increased, and the agglutination pattern induced by SBA, DBA, WGA, and RCA120 changed to a predominantly reticular form. These changes did not occur when sperm were incubated in Ham's F-10, a control medium which does not support capacitation. Since binding of these lectins is inhibited by N-acetyl-D-galactosamine (SBA, DBA), D-galactose (SBA, RCA120, DBA), or N-acetyl-D-glucosamine (WGA), we conclude that surface receptors containing these residues are affected by capacitation. By examining assay plates with an inverted phase contrast microscope, we were able to show that the change in the agglutination pattern for all four lectins was due to an increase in agglutinability of the principal piece of the flagellum. It is suggested that the modification of the principal piece detected by this lectin assay may be important in the development of activated motility. Results further show that capacitation and trypsin treatment affect the sperm surface in a similar manner, and are thus consistent with the idea that a trypsin-like enzyme may modify the sperm during capacitation.

Quantitation and new antigenic determinant specificity of antibodies induced by inhalation of trimellitic anhydride in man

We have studied the immune response of chemical workers who are exposed to trimellitic anhydride (TMA), a biologically reactive anhydride used in the manufacture of plastics. Serum antibody activity to TMA haptenized human serum albumin (TM-HSA) was measured in workers with three clinically defined respiratory tract syndromes; asthma-rhinitis, a late respiratory systemic syndrome (LRSS), and an irritant syndrome. IgE antibody binding of ¹²⁵I TM-HSA was quantitated by polystyrene tube radioimmunoassay and total serum antibody binding of ¹²⁵I-TM-HSA by an ammonium sulfate technique. IgE antibody activity ranged from 2 to 55 ng TM-HSA bound per milliliter and was associated with the asthma-rhinitis syndrome. Total serum antibody activity ranged from 0.4 to 56 <i>μ</i>g TM-HSA bound per milliliter and was associated with either the asthma-rhinitis syndrome or LRSS. Antibody specificity for TM-HSA was determined by inhibition studies using sodium trimellitate (NaTM) and a variety of TM substituted carriers. The hapten, NaTM, was an extremely poor inhibitor of IgE or total antibody binding of TM-HSA. The other TMA haptenized carriers were either noninhibitory or had to be added in milligram quantities to effect any inhibition as contrasted with complete inhibition achieved by microgram quantities of TM-HSA. These specificity studies indicate that the inhalation of TMA results in an antibody response with specificity for unique new antigenic determinants (NAD) which arise from the coupling of TMA with autologous respiratory tract proteins.

Human antihapten antibodies in trimellitic anhydride inhalation reactions. Immunoglobulin classes of anti-trimellitic anhydride antibodies and hapten inhibition studies

Inhalational exposure to trimellitic anhydride (TMA) produces an immediate-type asthmatic or a late respiratory systemic syndrome in certain workers after a latent period of work exposure. TMA has been found to react with proteins to produce a hapten-protein complex (trimellitate [TM] protein) or become hydrolyzed in aqueous, alkaline solutions to produce a salt, NaTM. Using a solid-phase radioimmunoassay technique, antibodies of different Ig classes were detected against TM-protein conjugates. IgE antibody was detected in three of five workers with asthma. IgG and IgA antibodies were detected in most exposed workers but higher levels of antibody were found in symptomatic workers even after long periods without direct TMA exposure. IgM antibody activity against TM-human serum albumin (TM-HSA) was detected but did not differentiate symptomatic from asymptomatic workers. NaTM served as a hapten for study because it does not react with proteins to form a hapten-protein complex as TMA does. The NaTM only partially inhibited IgG antibody activity against TM-HSA and much smaller amounts of TM-HSA than of NaTM were required to neutralize IgG antibody. A similar result was found with TM-ovalbumin. The latter results suggest that some IgG antibody is directed against a TM-protein moiety, probably a TM-amino acid determinant. In contrast to IgG, marked inhibition by NaTM of IgA and IgM antibody against TM-HSA was found in the sera studied.