Prognostic value of EndoPredict test in patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative primary breast cancer screened for the randomized, double-blind, phase III UNIRAD trial

BACKGROUND

The purpose of this study was to evaluate the prognostic value of the multigene EndoPredict test in prospectively collected data of patients screened for the randomized, double-blind, phase III UNIRAD trial, which evaluated the addition of everolimus to adjuvant endocrine therapy in high-risk, hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer.

PATIENTS AND METHODS

Patients were classified into low or high risk according to the EPclin score, consisting of a 12-gene molecular score combined with tumor size and nodal status. Association of the EPclin score with disease-free survival (DFS) and distant metastasis-free survival (DMFS) was evaluated using Kaplan-Meier estimates. The independent prognostic added value of EPclin score was tested in a multivariate Cox model after adjusting on tumor characteristics.

RESULTS

EndoPredict test results were available for 768 patients: 663 patients classified as EPclin high risk (EPCH) and 105 patients as EPclin low risk (EPCL). Median follow-up was 70 months (range 1-172 months). For the 429 EPCH randomized patients, there was no significant difference in DFS between treatment arms. The 60-month relapse rate for patients in the EPCL and EPCH groups was 0% and 7%, respectively. Hazard ratio (HR) supposing continuous EPclin score was 1.87 [95% confidence interval (CI) 1.4-2.5, P < 0.0001]. This prognostic effect remained significant when assessed in a Cox model adjusting on tumor size, number of positive nodes and tumor grade (HR 1.52, 95% CI 1.09-2.13, P = 0.0141). The 60-month DMFS for patients in the EPCL and EPCH groups was 100% and 94%, respectively (adjusted HR 8.10, 95% CI 1.1-59.1, P < 0.0001).

CONCLUSIONS

The results confirm the value of EPclin score as an independent prognostic parameter in node-positive, hormone receptor-positive, HER2-negative early breast cancer patients receiving standard adjuvant treatment. EPclin score can be used to identify patients at higher risk of recurrence who may warrant additional systemic treatments.

Abstract P5-17-05: Outcome of triple negative inflammatory breast cancer (TNIBC) treated with dose-dense dose intense neoadjuvant chemotherapy (NAC), prognostic impact of post NAC lymphovascular invasion and tumor infiltrating lymphocytes (TIL)

Background

Inflammatory breast cancers (IBC) particularly triple negative (TN) subtype have poor prognosis. There are few series reporting IBC outcome according to their immunohistochemical profile. We have already shown the efficiency of dose dense dose intense chemotherapy in triple negative breast cancer (1). We report a series of TNIBC treated with dose dense anthracycline cyclophosphamide followed with taxane and analyzed the correlation between pathological complete response (pCR), pre and post NAC TIL, post NAC LVI and disease free survival (DFS).

Methods

Between January 2010 and December 2016, all patients with TNIBC seen at breast cancer disease center, St Louis hospital, Paris, France, were treated with neoadjuvant dose dense dose intense Cyclophophamide (1.2g/m2 d1) - Epirubicin (75mg/m2 d1) q2w (SIM regimen) followed with 12 injections of paclitaxel (80 mg/m2) qw or 4 injections of docetaxel (100 mg/m2) q3w. All patients have histologically proven TN tumors and no evidence of metastases assessed by initial FDG PET Scanner. Mastectomy and axillary clearance was performed after chemotherapy. pCR was defined as no residual invasive tumor in breast and lymph nodes. TIL and lymphovascular invasion were evaluated pre and post NAC by 2 independent anatomopathologists dedicated to breast cancer. Delta TILS was defined as the difference between post chemotherapy and pre chemotherapy TIL.

Results

Thirty TNIBC pts were treated, 28 underwent surgery and 2 progressed during chemotherapy. Median follow-up was 39 months (8 – 86). 9/30 patients (30%) achieved pCR. Median disease free survival (DFS) was 41 months (2 – 86). Median TIL infiltration at diagnosis was 11% (0-60) and dropped to 1% after chemotherapy (0 – 80). Median delta TIL was - 9% (-50% – +40%). TIL increase after chemotherapy was associated with a decrease of DFS (14 months vs not reached ; p = 0,0009). LVI was present on surgical specimens in 12 cases (12/30, 43%; 12/21 non pCR pts 57 %). Presence of LVI after chemotherapy was significantly associated with a decrease of DFS in the whole population (21 months vs not reached ; p = 0.008) and no significantly among the patients without pCR (23 months vs not reached; p = 0.07).

Conclusion

To the best of our knowledge, it is the best pCR rate reported in TNIBC (2). We showed in this retrospective series of 30 TNIBC that dose dense dose intense chemotherapy is efficient in this population. Presence of lymphovascular invasion and TIL after neoadjuvant chemotherapy in TNIBC are strong prognostic factors associated with DFS. Systematic determination of post NAC TIL and LIV could be a surrogate to propose adjuvant treatment after NAC in TNIBC.

References

1. Giacchetti S, et al. Long-term survival of advanced triple-negative breast cancers with a dose-intense cyclophosphamide/anthracycline neoadjuvant regimen. Br J Cancer. 2014;110:1413.

2. Masuda H, Brewer TM, Liu DD, Iwamoto T, Shen Y, Hsu L, et al. Long-term treatment efficacy in primary inflammatory breast cancer by hormonal receptor- and HER2-defined subtypes. Ann Oncol. 2014;25:384–91.

Citation Format: Campedel L, Binasker A, Blanc-Durand P, Becourt S, Ledoux F, Cuvier C, Gardnair C, Teixeira L, de Roquancourt A, Espie M, Giacchetti S. Outcome of triple negative inflammatory breast cancer (TNIBC) treated with dose-dense dose intense neoadjuvant chemotherapy (NAC), prognostic impact of post NAC lymphovascular invasion and tumor infiltrating lymphocytes (TIL) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-17-05.

Surgical resection versus systemic therapy for breast cancer liver metastases: Results of a European case matched comparison

BACKGROUND

Resection of breast cancer liver metastases (BCLM) combined with systemic treatment is increasingly accepted but not offered as therapeutic option. New evidence of the additional value of surgery in these patients is scarce while prognoses without surgery remains poor.

PATIENTS AND METHODS

For this case matched analysis, all nationally registered patients with BCLM confined to the liver in the Netherlands (systemic group; N = 523) were selected and compared with patients who received systemic treatment and underwent hepatectomy (resection group; N = 139) at a hepatobiliary centre in France. Matching was based on age, decade when diagnosed, interval to metastases, maximum metastases size, single or multiple tumours, chemotherapy, hormonal or targeted therapy after diagnosis. Based on published guidelines, palliative systemic treatment strategies are similar in both European countries.

RESULTS

Between 1983 and 2013, 3894 patients were screened for inclusion. Overall median follow-up was 80 months (95% CI 70-90 months). The median, 3- and 5-year overall survival of the whole population was 19 months, 29% and 19%, respectively. The resection and systemic group had median survival of 73 vs. 13 months (P < 0.001), respectively. Three and 5-year survival was 18% and 10% for the systemic group and 75% and 54% for the resection group, respectively. After matching, the resection group had a median overall survival of 82 months with a 3- and 5-year overall survival of 81% and 69%, respectively, compared with a median overall survival of 31 months in the systemic group with a 3- and 5-year overall survival of 32% and 24%, respectively (HR 0.28, 95% CI 0.15-0.52; P < 0.001).

CONCLUSIONS

For patients with BCLM, liver resection combined with systemic treatment results in improved overall survival compared to systemic treatment alone. Liver resection should be considered in selected cases.

Abstract P6-12-18: CANTOCHEM: Analysis of chemotherapy practice and early side effects in the 6090 first patients from the prospective CANTO cohort

Background

There is no large prospective trial assessing mid-term adverse effects of adjuvant chemotherapy. In order to address this question, we developed CANTO (CANcer TOxicities - NCT01993498 - http://etudecanto.org/), a prospective trial dedicated to the quantification of side effects after treatment for patients with early breast cancer and to develop predictors of such toxicities. The aim of this presentation is to assess chemotherapy (CT) practice and to report toxicities that persist 3-6 months after CT.

Methods

CANTO is a prospective study enrolling newly diagnosed invasive cT0-cT3, cN0-3, M0 breast cancer patients (pts) of 26 French comprehensive cancer centers. The study has included 10 500 patients at the time of submission. Pts are assessed at diagnosis, 3-6, 12, 36, 48 and 60 months after treatment completion. CANTO collects &gt;100 items related to toxicities. In the current study, we focus on the first set of data available from the trial (1st database lock, n=6090). We here assess CT practice and toxicities at 3 months.

Results

Information about (neo)adjuvant CT (NACT/ACT) is available in 5805 pts (96%). Median age at diagnosis was 57y (22-93). Pts had HR+/HER2-, HER2+ or triple negative (TN) tumors in 74%, 15% and 11% of cases. Ki67 was assessed in 70%, and genomic tests in 1% of pts, respectively.

Overall, 3074 pts (53%) received CT, either adjuvant (ACT: 76%) or neoadjuvant (NACT: 24%). ACT/NACT pts (84%) received a sequential anthracyclines–taxanes based 6 courses CT schedule. CT was administered in 44.7%, 87.2% and 92.3% of HR+/HER2+/TN tumors, respectively. ACT was administered in 73.2% of pT2+ pts (vs 36.0% in pT0-1 – p&lt;.001)) and in 74.7% in pN1+pts (vs 36.7% in pN0 – p&lt;.001)). After NACT, pts had yPT0 (32.3%) and/or ypN0 (64.6%) for an overall 28.9% pCR rate.

We focus here on clinically most relevant patient reported symptoms at 3 m (any grade).

side effects at 3m no CT (%)CT (%)p valuePain76.682.1&lt;.001Neurological symptom4768.7&lt;.001GI symptom34.342.1&lt;.001CV sympton8.110.20.011

Pain complaint was recorded in 3596 pts (97.2% of pts with available data), with a median value of 4 on the VAS (range 1-10). In ACT/NACT pts, muscle and joint pain were predominant. Neurological symptoms were seen in 3024 pts (59%), the most frequent pertaining to cognitive disorder (attention trouble, CT: 61.2% vs noCT: 56% - p=.06) and peripheral neuropathy (overall 31%). Paresthesias and sensory neuropathy were much more frequent in CT vs noCT pts: respectively 37.3% vs 20.3% and 25.7% vs 12.8% (both p&lt;.001). Of note, pts receiving paclitaxel had more peripheral neuropathy (92.3% vs 69% in docetaxel pts – p=.07). Diarrhea was the most frequent GI symptom post CT: 44.5% vs 33.2%, p&lt; 0.001. CV symptoms (NOS) were slightly more frequent after CT.

Conclusions

In this real life, prospective cohort, CT is frequently prescribed and appears in good compliance with current guidelines. Overall, symptoms burden at treatment completion is strikingly high, and much higher in pts receiving CT. A special attention should be given to pain and neurological symptoms. Dedicated questionnaires and sub-studies will explore in depth these side effects. Extended analyses of CT practice and toxicities will be presented.

Citation Format: Cottu PH, Amar Y, Pistilli B, Bonsang-Kitzis H, Lesur A, Lerebours F, Vanlemmens L, Tredan O, Levy C, Jouannaud C, Fournier M, Soulie P, Rigal O, Giacchetti S, Arnaud A, Arsene O, Savignoni A, Mesleard C, Andre F, Arveux P. CANTOCHEM: Analysis of chemotherapy practice and early side effects in the 6090 first patients from the prospective CANTO cohort [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 P6-12-18.

Abstract PD1-06: Comparison of mutational landscapes of primary breast cancer and first metastatic relapse: Results from the ESOPE study

Background

Genomic profile of breast cancer metastases (M) may differ from that of the primary tumor (PT). In a multicenter prospective study (ESOPE, NCT 01956552) including 130 patients with biopsies of the first metastatic deposit, we have shown that luminal breast cancers are the most prone to phenotypical subtype changes (Comte et al, ASCO 2016#550). We report here the first results of a comparative PT/M targeted next generation sequencing (NGS) mutational analysis.

Methods

Of 130 patients, 117 paired PT/M samples obtained before any treatment were available for analysis. Targeted Sequencing was done using Illumina Hiseq2500 technology with a custom made 95 breast cancer associated genes panel. Sequence data were aligned to the human reference genome (hg19) using Bowtie2 algorithm. Median depth was 607X and 87% of targets achieved 100X depth. SNVs and indels were called using GATK UnifiedGenotyper. We retained COSMIC confirmed non synonymous, exonic/splice variants and observed at a frequency lower than 0,1% in population. Further confirmation of detected variants was performed with comparison to public databases (cbioportal, tumorportal), and potential pathogenicity was evaluated with 4 different public algorithms. We present here the results obtained from the first 35 matched PT/M samples (liver mets 68%), focusing analysis on 40 genes including PIK3CA (20 genes), ER (6 genes) and MAPK (11 genes) pathways, RUNX1, CDH1 and TP53 genes.

Results

Patients characteristics are representative of patients with first line metastatic breast cancer (Comte et al, ASCO 2016#550). Among the 40 genes analyzed in the 70 samples, we detected 134 somatic mutations (70 in PT and 64 in M) including 15 indels and 119 SNV. Among these 134 mutations there were 74 different mutations (66SNV and 8 indels) classified pathogenic for 26 and of unknown pathogenicity for 48 of them. We detected at least 1 mutation in 31 PT and in 28 M. Median numbers of mutations were 1 in PT (range 1-9) and 1 in M (range1-22) samples (p=0.295, Wilcoxon rank sum test). Top ten mutated genes in PT included PIK3CA, TP53, NCOR1, NF1, GATA3, CDH1, ERBB3, PTEN, HRAS, INPP4B. In M samples, the 10 top genes were PIK3CA, TP53, ERBB3, AKT3, CDH1, ERBB4, GATA3, INPP4B, MET, MTOR. Only 3 ESR1 mutations were detected, including 1 PT/M pair and 1 M. Beyond highly shared PIK3CA and TP53 mutations, overall crude PT/M discordance rate was 31%. Analysis by histological subtypes showed PT and M specific mutational profiles, suggesting a role in ERB gene family (notably ERBB3) and MAPK driven pathways in early metastatic progression. Specific metastatic site analysis suggested enrichment in MAPK pathway mutations in liver metastases when compared to other sites. Variant allelic fractions were globally not significantly different between PT and M samples.

Conclusion

In this prospective multicenter series of systematic biopsies of first metastases, we report a targeted mutational analysis of matched PT and M samples not modified by previous therapy exposure. Early analyses suggest specific genotypical changes according to tumor subtype and/or metastatic site. Extended and updated results will be reported at the meeting.

Citation Format: Cottu PH, Boulai A, Callens C, Baulande S, Legoix-Ne P, Bernard V, Vincent-Salomon A, Benhamo V, Brain EGC, Chemlali W, Campone M, Bachelot TD, Giacchetti S, Bonneterre J, Bidard F-C, Servois V, Comte A, Belin L, Sigal B, Bièche I. Comparison of mutational landscapes of primary breast cancer and first metastatic relapse: Results from the ESOPE study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD1-06.

Abstract P1-14-08: Prediction of pathological response (pCR) to neoadjuvant dose dense and intense cyclophosphamide and anthracycline in a prospective series of triple negative locally advanced breast cancers (TNLABC)

Background: Stage II-III TNBC retains a poor outcome despite high chemosensitivity. Patients (pts) with pCR after neoadjuvant chemotherapy have a good prognosis whereas non-responding pts have a 25-40% risk of distant relapse at 5 years. pCR is thus a major goal in TNBC. We previously reported that TNLABC benefit the most of dose dense dose intense cyclophosphamide (C)-epirubicin (E) (S.Giacchetti; BJC, 2014)

Aim: To confirm these results prospectively and analyze the predictive factors of response to high dose chemotherapy in TNBC.

Patients and methods: From january 2009 to april 2015 non inflammatory TNLABC received high dose C (1200 mg/m2 d1 qw 2) with E (75 mg/m2/ d1 qw2) for 6 cycles. The pts had a breast biopsy with frozen tissue. We performed molecular studies: qRT-PCR for AR, FOXA1, PI3K and FASAY technic for p53 mutation.The percentage of stromal Tumor-infiltrating lymphocytes (TILs) was also evaluated by two independent pathologists and assessed as a continuous variable. A18F-FDG PET/CT was performed initially and after 2 courses of chemotherapy and the metabolic answer assessed as a variation of the tumor uptake (ΔSUVmax). We report here the pathological complete response (pCR) (absence of infiltrative carcinomas in the breast and in the lymph nodes) and the factors associated with pCR.

Results: The characteristics of the 74 pts are listed in table 1. The median age is 48 years old, 48 pts (65.8%) are premenopausal and 79% did not have any family history of breast cancers. TIL was divided in 3 groups &lt; 10 % (26 pts, 40 %); 10-50 % (30 pts, 46 %) &gt; 50% (9 pts, 14 %). Pathological response was assessed in 66 pts, one pt progressed during chemotherapy and 6 pts did not undergo surgery yet. 28 pts were in pCR (42.4 %). With a median follow up of 25 months, 13 pts (17.8 %) progressed and 8 (11%) died.

Table 1: Patients characteristics and pCR according to tumor features and metabolic responseCharacteristicsNumber of pts (%)N of pts evaluated for pCRpCR (%)OR [IC 95%]p-valueTumor size T2363519 (54)10.04T337319 (29)0.34 [0.12 ; 0.96]Nodal status N0363315 (46)10.62N1/N2/N3 24/11/33313 (39)0.78 [0.29 ; 2.07]Histological grade: 2660 (0) 0.04*3676028 (47)TILs &lt;10 %26 (40)2510 (40)10.02610-50 %30 (46)267 (27)0.55 [0.17 ; 1.80]≥ 509 (14)9 7 (78)5.25 [0.90 ; 30.62]P53 Mutated54 (89)5121 (41)10.43WT7 (12)53 (60)2.14 [0.33; 13.96]AR Negative43 (83)4318 (42)10.46Positive 9 (17)95 (56)1.74 [0.41 ; 7.38]FOXA1 Negative40 (77)4015 (38)10.08Positive 12 (23)128 (60) 3.33 [0.86 ; 12.99]Molecular Apocrine8 (17)85 (63)10.19TN38 (83)3814 (37)0.35 [0.07 ; 1.69]PI3K Non mutated44 (88)4419 (43)10.75Mutated6 (12)63 (50)1.31 [0.24 ; 7.26]SUVmax at 2 courses0.0001&lt; 70 %27 (53)221 (5)1≥ 70 %24 (47)2318 (78)79.2 [8.48 ; 739.82]* Measured with a Fisher Test

Tumor size, tumor grade, percentage of TILs, the change in 18F-fluorodeoxyglucose tumor uptake (ΔSUVmax) were significantly associated with pCR at univariate analysis. Only one factor remained significant at multivariate analysis, the ΔSUVmax, OR: 0.04 [0.007- 0.27], p = 0.0008.

Conclusion: In this prospective phase III trial we confirm the efficacy of a dose dense EC in TNBC. The metabolic response evaluated with 18 F-FDG PET/CT is a strong and reliable predictor of pCR and could allow an early change of treatment for the non responders. A clinical trial is planned to test this strategy.

Citation Format: Giacchetti S, De Roquancourt A, Groheux D, Piron P, Lehmann-che J, Cuvier C, Resche-rigon M, Albiter M, Roche B, Frank S, Hamy A-S, Teixeira L, Marty M, Lalloum M, Espié M. Prediction of pathological response (pCR) to neoadjuvant dose dense and intense cyclophosphamide and anthracycline in a prospective series of triple negative locally advanced breast cancers (TNLABC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-14-08.

Abstract P1-14-09: Long term survival of locally advanced breast cancers (LABC) treated with neoadjuvant treatment, results of a multicenter randomised phase II study (Remagus 02 trial)

Backgound : The primary analysis of the REMAGUS-02 multicenter randomized phase II trial demonstrated that celecoxib did not improve pCR rates in pts with HER2-negative localized invasive breast cancer (BC), whereas trastuzumab increased pCR rates in HER2-positive ones [Pierga BCRT 2010]. We report here the long-term follow-up results of this trial for disease free survival (DFS) and overall survival (OS).

Patients and methods: From May 2004 to October 2007, 340 stage II-III BC patients were randomly assigned to receive 4 cycles (c) of epirubicin–cyclophosphamide q 3 w followed by 4 c of docetaxel q 3 w +/- trastuzumab in HER2 positive pts (120 pts) or +/- celecoxib in HER2 negative pts (n=220). From September 2005, all pts with HER2 positive BC received adjuvant T for a total of 18 c (n=106). Patients with hormone receptors (HR) positive tumor received adjuvant endocrine treatment according to menopausal status

Results: With a median follow up of nearly 8 years (94.4 months, 20-127m), 112 relapses and 75 deaths have been observed (median DFS and OS not reached). Eight years DFS and OS were respectively 63 % [57%-71%] and 75 % [70%-81%] in HER2 negative group; and 75% [67%-83%] and 82 % [74%-90%] in HER2 positive group. DFS was significantly higher in HER+ pts than in HER2-(HR: 0.64 [0.42-0.99], p=0.042), whereas OS did not differ significantly (HR: 0.67, [0.41-1.11], p=0.123).

In the overall population, progesterone receptor (PgR) positivity was associated with a better DFS (p=0.012) and OS (p&lt;0.001) as compared to ER+/PgR- (DFS: HR=2.07 [1.27-3.39]; OS: HR=2.53 [1.3-4.92]) and ER-/PR-; DFS: HR=1.56 [0.98-2.46]; OS: HR: 3.34 [1.87 – 5.97]. In the ER-/PR- group, DFS reached a "plateau" after three years follow-up, while the annual risk of relapse remained constant in the ER+/PR- subgroup.

In the HER2- subgroup, no effect of neoadjuvant celocoxib was observed on survival, neither in intention to treat (ITT) nor in per protocol analyses. In the multivariate analysis clinical stage (T3/T4 versus T2, HR: 1.92 [1.209 - 3.05], p=0.006), PgR status (positive versus negative HR : 0.52, [0.32-0.84], p=0.007) and pCR (yes vs no, HR : 0.213 [0.066-0.687], p=0.01) were significant predictors of DFS.

In the HER2+ subgroup, neoadjuvant versus adjuvant trastuzumab was not significantly associated with DFS, neither in the ITT, nor in the per protocol analysis.

Conclusion: Celecoxib was not associated with pCR or survival benefit when added to conventional neoadjuvant CT in Her2-negative BC pts. Lack of PgR expression is a major prognostic factor for survival. Neoadjuvant versus adjuvant trastuzumab increased pCR rates but did not change significantly DFS and OS of HER2 positive BC pts.

Citation Format: Giacchetti S, Hamy-Petit A-S, Delaloge S, Brain E, Berger F, Mathieu M-C, de Cremoux P, Bertheau P, Guinebretière J-M, Saghatchian M, Tembo O, Marty M, Pierga J-Y. Long term survival of locally advanced breast cancers (LABC) treated with neoadjuvant treatment, results of a multicenter randomised phase II study (Remagus 02 trial). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-14-09.

[New targeted therapies in breast cancer]

Trastuzumab improves care of patients with HER2+ breast cancer and allows a major gain in terms of survival. T-DM1 and pertuzumab are two new treatments, which give very encouraging results in metastatic breast cancer. Their place in neo-adjuvant and adjuvant setting still remains to be defined. Bevacizumab have its place in metastatic breast cancer. In adjuvant setting, results are disappointing and in neo-adjuvant setting, we need more studies on subgroups, which can benefit more. Development of the PARP inhibitors was slowed down by recent negative results in metastatic breast cancer but studies continue with more targeted patient's. Finally, everolimus, inhibitor of mTOR, allows to by pass the hormono-resistance in metastatic phase. Its toxicity must be taken into account in particular in adjuvant setting.

Long-term survival of advanced triple-negative breast cancers with a dose-intense cyclophosphamide/anthracycline neoadjuvant regimen

BACKGROUND

Triple-negative (TN) breast cancers exhibit major initial responses to neoadjuvant chemotherapy, but generally have a poor outcome. Because of the lack of validated drug targets, chemotherapy remains an important therapeutic tool in these cancers.

METHODS

We report the survival of two consecutive series of 267 locally advanced breast cancers (LABC) treated with two different neoadjuvant regimens, either a dose-dense and dose-intense cyclophosphamide-anthracycline (AC) association (historically called SIM) or a conventional sequential association of cyclophosphamide and anthracycline, followed by taxanes (EC-T). We compared pathological responses and survival rates of these two groups and studied their association with tumours features.

RESULTS

Although the two regimens showed equivalent pathological complete response (pCR) in the whole population (16 and 12%), the SIM regimen yielded a non-statistically higher pCR rate than EC-T (48% vs 24%, P=0.087) in TN tumours. In the SIM protocol, DFS was statistically higher for TN than for non-TN patients (P=0.019), although we showed that the TN status was associated with an increased initial risk of recurrence in both regimens. This effect gradually decreased and after 2 years, TN was associated with a significantly decreased likelihood of relapse in SIM-treated LABC (hazard ratio (HR)=0.25 (95% CI: 0.07-0.86), P=0.028).

CONCLUSIONS

AC dose intensification treatment is associated with a very favourable long-term survival rate in TN breast cancers. These observations call for a prospective assessment of such dose-intense AC-based regimens in locally advanced TN tumours.

Contraception after breast cancer: a retrospective review of the practice among French gynecologists in the 2000's

PURPOSE OF INVESTIGATION

To describe the French practices regarding contraception after breast cancer in the 2000's.

MATERIALS AND METHODS

A total of 2,500 forms were sent to gynecologists practicing in France. Inclusion criteria were premenopausal patients who had a history of breast cancer and who had been prescribed contraception after diagnosis. Between June 1, 2002 and January 1, 2003, 197 evaluable responses were retrieved.

RESULTS

The median age of the sample was 38.5 years. The most commonly used form of contraception was an intrauterine device (n = 144, 73.1%). Hormonal contraception was prescribed for 42 patients (21.3%), and other methods were used in 29 patients (14.7%) (Condoms n = 14, tubal sterilization n = 7, and others n = 8). Recurrence occurred in 27 patients (13%); 2.9% in the progestin group, 16.3% in the IUD group, and 14.8% with the other methods).

CONCLUSIONS

It is necessary to evaluate current contraception practices after breast cancer to evaluate the efficacy and safety of contraception in these patients.

Abstract P6-12-13: Synchronous metastases are highly prevalent in HER2 positive inflammatory breast carcinomas evaluated by 18F-FDG PET/CT

Background: Inflammatory breast carcinomas have poor prognosis even in the absence of evident synchronous metastases. 18F-FDG PET/CT is not recommended in initial staging but could improve the sensibility of synchronous metastases detection and the management of the patients.

Objective: To assess factors associated with synchronous metastases in inflammatory breast carcinomas when evaluated by 18F-FDG PET/CT.

Methods: Since 2006, initial staging of locally advanced breast carcinomas in our center consisted of 18F-FDG PET/CT in addition to standard laboratory and radiological tests. We reviewed data of patients with inflammatory breast carcinomas treated from 2006 to 2013 who had an initial evaluable18F-FDG PET/CT. Fisher's exact test and logistic model were used to assess factors associated with synchronous metastases. Overall survival was estimated with the method of Kaplan-Meier.

Results: Among 353 locally advanced breast carcinomas seen at the breast disease unit, hospital Saint Louis from 04/2006 to 04/2013, we identified 40 inflammatory breast carcinomas. Initial 18F-FDG PET/CT was available for review in 32 inflammatory breast carcinomas. Median age was 57 years (range 38-78), 39% had pre-menopausal status (n = 12), clinical node involvement was found in 87.5% (n = 28). Histological features on biopsy were: ductal invasive carcinoma 91% (n = 29), SBR grade III 72% (n = 23), negative hormonal receptor 75% (n = 24), positive HER2 37.5% (n = 12), triple negative 44% (n = 14). Synchronous metastases were found in 41% of inflammatory breast carcinomas (n = 13), bone (n = 7), liver (n = 6) and mediastinum (n = 4). Synchronous metastases seemed more common in HER2 positive than in HER2 negative inflammatory breast carcinomas (58% vs 30%, p = 0.15). In multivariate analysis, no factor was associated with synchronous metastases. All patients with inflammatory breast carcinomas received neoadjuvant chemotherapy with sequential anthracycline and taxane (16 patients), dose-dense anthracycline and alkylating agent (8 patients), taxane with or without bevacizumab (7 patients) and anthracycline in 1 patient. Trastuzumab was given in all HER2 positive inflammatory breast carcinomas. Clinical response to neoadjuvant chemotherapy was complete in 16.5% (n = 5), partial in 67% (n = 20), stable or progressive in 16.5% (n = 5) and missing for 1 patient. One patient died before response assessment. Thirty patients (94%) underwent radical mastectomy with axillary node dissection. Pathologic complete response in breast and nodes was found in 27.5% (n = 8). Axillary node invasion was found in 45% (n = 13). All positive hormonal receptors patients received endocrine therapy after surgery. With a median follow-up of 33 months, 10 patients died. Median overall survival was 38.8 months (95%CI: 30.3-NA) with no difference between HER2 positive and HER2 negative patients.

Conclusion: Synchronous metastases are common in inflammatory breast carcinomas especially in case of HER2 positive tumors. Complete initial staging with 18F-FDG PET/CT could be useful to detect synchronous metastases mainly in bone and liver and thus allowed to adapt further treatment.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-12-13.

HER2-overexpressing breast cancer: FDG uptake after two cycles of chemotherapy predicts the outcome of neoadjuvant treatment

Background:

Pathologic complete response (pCR) to neoadjuvant treatment (NAT) is associated with improved survival of patients with HER2+ breast cancer. We investigated the ability of interim positron emission tomography (PET) regarding early prediction of pathology outcomes.

Methods:

During 61 months, consecutive patients with locally advanced or large HER2+ breast cancer patients without distant metastases were included. All patients received NAT with four cycles of epirubicin+cyclophosphamide, followed by four cycles of docetaxel+trastuzumab. ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG)-PET/computed tomography (CT) was performed at baseline (PET₁) and after two cycles of chemotherapy (PET₂). Maximum standardised uptake values were measured in the primary tumour as well as in the axillary lymph nodes. The correlation between pathologic response and SUV parameters (SUV_max at PET₁, PET₂ and ΔSUV_max) was examined with the t-test. The predictive performance regarding the identification of non-responders was evaluated using receiver operating characteristics (ROC) analysis.

Results:

Thirty women were prospectively included and 60 PET/CT examination performed. At baseline, 22 patients had PET+ axilla and in nine of them ¹⁸F-FDG uptake was higher than in the primary tumour. At surgery, 14 patients (47%) showed residual tumour (non-pCR), whereas 16 (53%) reached pCR. Best prediction was obtained when considering the absolute residual SUV_max value at PET₂ (AUC=0.91) vs 0.67 for SUV_max at PET₁ and 0.86 for ΔSUV_max. The risk of non-pCR was 92.3% in patients with any site of residual uptake >3 at PET₂, no matter whether in breast or axilla, vs 11.8% in patients with uptake ⩽3 (P=0.0001). The sensitivity, specificity, PPV, NPV and overall accuracy of this cutoff were, respectively: 85.7%, 93.8%, 92.3%, 88.2% and 90%.

Conclusion:

The level of residual ¹⁸F-FDG uptake after two cycles of chemotherapy predicts residual disease at completion of NAT with chemotherapy+trastuzumab with high accuracy. Because many innovative therapeutic strategies are now available (e.g., addition of a second HER2-directed therapy or an antiangiogenic), early prediction of poor response is critical.

Abstract P2-01-04: Long term independent prognostic impact of circulating tumor cells detected before neoadjuvant chemotherapy in non-metastatic breast cancer: 70 months analysis of the REMAGUS02 study

Background: Circulating tumor cells (CTCs) isolated by CellSearch® from peripheral blood of metastatic breast patients have been shown as strong independent prognostic factor for progression-free and overall survival. With this technique, the REMAGUS02 prospective multicentric study was the first to report that CTC detection (≥1CTC/7.5ml) before and/or after neoadjuvant chemotherapy was independently associated with distant metastasis-free survival (DMFS, 18 months follow-up, Pierga CCR 2008) and with overall survival (OS, 36 months follow-up, Bidard Ann Oncol 2010).

Patients and Methods: In 115 non-metastatic patients diagnosed with large operable or locally advanced breast cancer, we prospectively detected CTC using the CellSearch system before and after neoadjuvant chemotherapy in the REMAGUS02 trial (Pierga, BCRT 2010). For this report, survival analyses were performed at a median follow-up of 70 months.

Results: After a median follow-up of 70 months, 20 distant metastatic relapses and 14 deaths have been observed among the 115 patients included. CTC detection before chemotherapy (in 23% of patients) is an independent prognostic factor for both DMFS [p = 0.03, relative risk (RR)=3.2] and OS [p = 0.05, RR = 3.7] in multivariate analyses, together with triple negative tumor status. At long-term, CTC detection after chemotherapy (17%) had no clear prognostic significance (p = 0.15 and 0.22, respectively). Complete pathological response as well as tumour size and all other variables tested did not appear as predictive in this model.

Conclusions: Baseline CTC detection is a new independent prognostic factor in the neoadjuvant setting, and is, in this trial, superior to pathological tumor response to predict the survival of non-metastatic breast cancer patients. We confirm therefore our previous results reported with shorter follow-up.

Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis. ISRCTN10059974

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-01-04.

Abstract P1-14-03: Overall survival results of a multicenter randomized phase II study in locally advanced breast cancer patients treated with or without neoadjuvant Trastuzumab for HER2 positive tumor (Remagus 02 trial)

Background: Trastuzumab is indicated in neoadjuvant setting in locally advanced HER2 positive breast cancer patients (Gianni L. Lancet 2010). There is no data on the impact of the use of neoadjuvant Trastuzumab (T) compared to adjuvant T on survival.

Patients and methods: From May 2004 to October 2007, 341 stage II-III breast cancer patients were included in a phase II randomized trial and received 4 cycles (c) of epirubicin (75 mg/m2 d1)–cyclophosphamide (750 mg/m2 d1) q 3 w followed by 4 (c) of docetaxel (100 mg/m2 d1) q 3 w. Pts with HER2+++ tumor (120 pts) were randomized to receive or not neoadjuvant T combined with docetaxel. From September 2005, all pts with HER2+cancer received adjuvant T for a total of 18 c (106 pts). All pts with hormone receptors positive tumor received hormonal treatment according to menopausal status (Pierga et al BCRT 2010). We report here overall survival (OS) and disease free survival (DFS) data at 5 year and associated prognostic factors.

Results: At a median follow up of 49 months, the median DFS was not reached for the whole population and was statistically superior for the HER2 positive cancer patients treated with chemotherapy plus neoadjuvant T compared to the other groups, p = 0.018. The median OS is not reached for the whole population and is statistically higher in HER2 positive tumor group compared to HER2 negative group (p = 0.00077). For 106 HER2 positive breast cancer patients who had received one year of complete trastuzumab treatment, there was no significant difference in OS and DFS between pts who started T in neoadjuvant setting versus in adjuvant setting. DFS and OS were not significantly influenced by pathological Complete Response rate (pCR) (respectively, p = 0.22 and p = 0.56). At multivariate analysis including 6 factors (age, tumor size, clinical lymph node, ER, PgR), factors which influenced OS were tumor size (p = 0.03) and ER expression (p = 0.06) and for DFS, clinical lymph node status (p = 0.049) and PgR expression (p = 0.046).

Conclusion: pCR is not a surrogate of survival in the HER2+subgroup. HER2 positive breast cancer pts receiving trastuzumab have a significant higher OS than those with HER2 negative tumors. OS and DFS do not seem to differ between the neoadjuvant T group and the T adjuvant group.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-03.

Abstract P3-06-04: Role of pMAPkinase, pAKT, p27 & IGF-IR as predictive markers of response to trastuzumab in patients with HER2-positive invasive breast cancer treated with neoadjuvant chemotherapy + trastuzumab in the REMAGUS02 trial

Background: Predicting a benefit from trastuzumab in patients with HER2+ breast cancer remains an important goal. Possible mechanisms of resistance include altered receptor antibody interaction, Akt and MAPK pathways, and loss of p27. The objective of this study was to determine the correlation between pMAPkinase (pMAPK), pAKT, p27, IGF-IR protein expression and the benefit of trastuzumab for patients randomized to chemotherapy (CT) alone and CT with trastuzumab.

Patients and methods: From May 2004 to October 2007, 120 patients with stage II and III HER2+ breast carcinomas were enrolled in a phase II trial of neoadjuvant chemotherapy (CT) with epirubicin-cyclophosphamide (4 courses) followed by docetaxel ± trastuzumab (T) (4 courses). A complete pathological response (pCR) was defined by the absence of residual invasive carcinoma in the breast and axillary lymph nodes. A tissue microarray was constructed from paraffin-embedded tumor samples collected prior to neoadjuvant chemotherapy. Patients' tumours were scored HER2 3+ immunohistochemically (IHC) or 2+ IHC with HER2 amplification by FISH. Immunohistochemical analysis of pMAPK, pAKT, p27 and IGF-IR was performed on tumor tissue microarrays before CT. The H-score (intensity × %) was evaluated. Specimens were classified as exhibiting high or low expression based on a median value as the cut-off point for each marker. A logistic regression model, including the marker and its interaction with treatment, was used to analyse the markers predictive of a treatment effect on the pCR. The independent predictive value was analysed in a multivariate logistic regression adjusting on the lymph node and ER status.

Results: 117/120 (97.5%) patients had sufficient tumor for the analysis. The pCR rate was 19% in the CT arm and 25% in the CT+T arm. The median H-score was: pMAPK = 28, pAKT= 25, p27= 50 and IGF-IR = 15. No significant difference was observed in the pCR rate between the two arms according to pAKT, p27, IGF-IR expression. The pCR rate was higher in CT+T compared to CT alone in patients with high pMAPK expression (OR = 4.7 (0.9–24.2); interaction p = 0.03). No difference was observed in the pCR rate in patients with low pMAPK expression (OR = 0.5 (0.1–1.8).

Conclusions: In HER2-positive breast cancers, pMAPK expression evaluated by IHC was significantly associated with a pathological response in the arm with neoadjuvant trastuzumab. High pMAPK expression could be a predictive marker of response to trastuzumab in a CT +T regimen.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-06-04.

Abstract P4-13-03: Hormone replacement therapy, is there an increased risk of in situ breast cancer ? data from a french cohort

Background: Use of hormone replacement therapy (HRT) has been associated with an increased risk of breast cancer. Few studies focus on correlation between HRT and in situ breast cancer A large cohort study, the Million Women Study (Reeves GK et al. Lancet Oncol. 2006) have shown that the use of HRT has been associated with an increased incidence of in situ breast cancer (RR = 1, 55, IC=1, 4–1,72, p = 0,03).

Purpose: We investigated the association between HRT use and duration and in situ breast cancer incidence from a data base of infraclinic breast lesions.

Materials & Methods: From 2007 to 2011, 2708 patients (pts) with a non palpable breast lesion were referred to our breast disease unit for exploration (Saint Louis Hospital, Paris). Radiological abnormalities were screened by mammography and/or breast ultrasound, and/or MRI. Out of 2708 pts, 1668 had a biopsy. All biopsies were seen by an anatomopathologist dedicated to breast. Here, we focus on the 1017 postmenopausal women (61%).

Results: Biopsies revaled invasive breast cancers in 222 pts (22%), in situ breast cancers in 164 pts (16%) [10 lobular in situ carcinoma and 154 ductal in situ carcinoma], high risk breast lesions in 103 pts (10%) and benign breast lesions in 528 patients (52%). Characteristics of the 164 patients with in situ breast cancer: median age 62 [IQR: 57 to 68], at least one pregnancy (mean number of pregnancies per woman, 1.6) 75,6%, family history of breast cancer:30,2%. Among these 164 patients, 42.6 % had used an oral contraceptive and 53% of them a HRT, with a mean duration of use of 7 years.

The HRT use was not significantly associated with in situ breast cancer (p = 0.66) as well as the duration of HRT.

Abstract P1-14-18: Overall survival results of a multicenter randomized phase II study in locally advanced breast cancer patients treated with or without celecoxib for HER2 negative tumor (Remagus 02 trial)

Background: Cox 2 is frequently over expressed in breast cancers. Celecoxib is a COX-2 inhibitor with anti angiogenic and pro-apoptotic activities. There are few data of anti-COX2 treatment in breast cancers. and no data on the impact of neoadjuvant anti COX 2 agent on survival.

Patients and methods/: From May 2004 to October 2007, 340 stage II-III breast cancer patients were included in a phase II randomized trial and received 4 cycles (c) of epirubicin (75 mg/m2)–cyclophosphamide (750 mg/m2) q 3 w followed by 4 (c) of docetaxel (100 mg/m2) q 3 w. Pts with HER2 negative tumors (220 pts) were randomized to receive or not neoadjuvant celecoxib (200 mg bid) combined with docetaxel. All pts with hormone receptors positive tumor received hormonal treatment according to menopausal status (Pierga et al BCRT 2010). We report here overall survival (OS) and disease free survival (DFS) data and prognostic factors analyses at 5 years.

Results/: At a median follow up of 49 months, the median DFS and OS are not reached for the whole population and none of them is significantly different between pts who received celecoxib or who did not (p = respectively 0.62 and 0.36). Celecoxib had no impact either on clinical and pathological complete response rate (pCR). DFS is significantly higher in patients who achieved pCR as compared to those who did not (p = 0.017; RR = 0.21 [0.051–0.88], whereas OS is borderline significant [p = 0.07; RR = 0.19 (0.026–1.4)]. Patients with triple negative (TN) tumors (78 pts) achieved worst DFS (p = 0.02) and OS (p &lt;0.001) than non triple negative ones despite their higher pCR rate, 29.5 % [95 % CI 19;7-40;9 %] vs 11.4 % in all the other subgroups. At multivariate analysis including 7 factors [tumor size, clinical lymph node, grade (1 vs. 2and 3), pCR, ER, PR, TN], factors which influenced OS and DFS were pCR (p = 0.034 & 0.013 and PgR expression (p = 0.046 & 0.01).

Conclusion/: Celecoxib had no influence on pCR, DFS or OS. Despite higher pCR rate triple negative breast cancer patients' subgroup remains with the poorest outcome.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-18.

Sex moderates circadian chemotherapy effects on survival of patients with metastatic colorectal cancer: a meta-analysis

BACKGROUND

Molecular circadian clocks can modify cancer chemotherapy effects, with a possible moderation according to sex differences. We investigated whether sex determine the optimal delivery schedule of chemotherapy for metastatic colorectal cancer.

PATIENTS AND METHODS

A meta-analysis was performed using individual data from three international Phase III trials comparing 5-fluorouracil, leucovorin and oxaliplatin administered in chronomodulated (chronoFLO) or conventional (CONV) infusions. The data from 345 females and 497 males were updated at 9 years. The main end point was survival.

RESULTS

Overall survival was improved in males on chronoFLO when compared with CONV (P = 0.009), with respective median values of 20.8 (95% CL, 18.7 to 22.9) and 17.5 months (16.1 to 18.8). Conversely, median survival was 16.6 months (13.9 to 19.3) on chronoFLO and 18.4 months (16.6 to 20.2) on CONV in females (P = 0.012). The sex versus schedule interaction was a strong predictive factor of optimal treatment schedule, with a hazard ratio of 1.59 (1.30 to 1.75) for overall survival (P = 0.002) in multivariate analysis.

CONCLUSIONS

Males lived significantly longer on chronomodulated chemotherapy rather than on conventional chemotherapy. The current chronoFLO schedule deserves prospective assessment as a safe and more effective first-line treatment option than conventional delivery for male patients.

P2-09-11: Role of 18FDG-PET/CT in the Staging of Large Primary Operable Breast Cancer

Background: Prospective evaluation of the role of 18FDG-PET/CT in patients with large primary operable breast cancer.

Material and Methods: During 56 months, consecutive patients with large (&gt;2cm) breast cancer and clinical stage IIA/IIB/IIIA (based on clinical examination, mammography, breast MRI and ultrasonography) underwent 18FDG-PET/CT. The nuclear physician was blind to the results of any other procedure (bone scan, chest X-ray, liver ultrasound, or thoraco-abdominal CT scan). Results: Out of the 131 examined patients, 36 had clinical stage IIA (34 T2 N0, 2 T1 N1), 48 stage IIB (20 T3 N0, 28 T2 N1), and 47 stage IIIA (29 T3 N1, 9 T2 N2, 9 T3 N2). 18FDG-PET/CT modified staging for 5.6% of stage IIA patients, for 14.6% of stage IIB patients, and for 27.6% of stage IIIA patients. However, within stage IIIA, the yield was specifically high among the 18 patients with N2 disease (56% stage modification). When considering stage IIB and primary operable IIIA (T3 N1) together, the yield of 18FDG-PET/CT was 13% (10/77); extra-axillary regional lymph nodes were detected in 5 and distant metastases in 7 patients. In this series, 18FDG-PET/CT outperformed bone scan with only 1 misclassification versus 8 for bone scan (p=0.036).

Discussion: 18FDG-PET/CT provided useful information in 13% of patients with T3 N0 / T2 N1 / T3 N1 disease. The yield was more modest in patients with T2 N0 disease. The very high yield in the case of lymph nodes classified N2 demonstrates that stage IIIA comprises two quite distinct groups of patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-09-11.

Chemotherapy-induced neutropenia association with survival in metastatic colorectal cancer (MCC): Schedule dependency

454

Background: Circadian clocks control cellular proliferation and drug metabolism over 24 h. However, circadian chronomodulated chemotherapy with 5-fluorouracil, leucovorin and oxaliplatin (chronoFLO4) offered no survival benefit as compared to the non-time stipulated FOLFOX2 in an international randomized trial involving patients (pts) with previously untreated MCC (EORTC05963). We hypothesized that treatment near maximum tolerated dose could disrupt circadian clocks thus impairing the efficacy of chronoFLO4 but not of FOLFOX2.

Methods: Pts with available data (N=556) were categorized into three subgroups according to the worst grade of neutropenia experienced during treatment. Distinct multivariate models were constructed for each treatment schedule.

Results: Neutropenia (all grades) occurred in 39% of the pts on chronoFLO4 as compared to 67% of those on FOLFOX2 (p< 0.0001), with G3-4 being encountered in 7% and 25%, respectively (p< 0.0001). In both schedules, neutropenia was more frequent and more severe in women than in men (p<0.04).The occurrence (but not the severity) of neutropenia was significantly associated with improved objective response rate, progression-free and overall survival in pts on FOLFOX2 (p< 0.0001), confirming previous results by others. In pts on chronoFLO4, the occurrence of neutropenia was not associated with any efficacy advantage (p=0.36), and worst survival was observed in pts developing severe neutropenia.

Conclusions: Neutropenia was more frequent and severe in women than in men, and on FOLFOX2 than on chronoFLO4. Neutropenia was positively correlated with survival in pts on FOLFOX2 supporting intra-patient dose escalation to achieve toxicity for conventional chemotherapy. No survival prolongation was found in pts with neutropenia on chronoFLO4. Thus, reaching maximum tolerated dose was unnecessary to achieve optimal effectiveness of circadian-timed therapy, and should even be avoided.

[Table: see text]

No significant financial relationships to disclose.

Abstract P1-17-03: Comparison of Long Term Outcome of Locally Advanced and Inflammatory Breast Cancers Treated with Dose Dense Neoadjuvant Chemotherapy

Background: Inflammatory breast cancers (IBC) have a worse prognosis than locally advanced breast cancer (LABC) (KW Hance, JNCI 2005; 97:966-75). We report a series of LABC and IBC treated with dose dense anthracycline and cyclophosphamide and report the correlation between phenotypic features, pathological complete response (pCR) and disease free survival (DFS).

Materials and methods: Between 1990 and 2003, 196 patients (pts) with LABC (105 pts) and IBC (91 pts) treated at St Louis hospital received

6 cycles (c) of dose dense Cyclophophamid (1.2g/m2 d1)-Epirubicin (E) (75mg/m2d1) q2w (SIM regimen). 133 patients had frozen biopsy allowing p53 determination. Surgery was done after chemotherapy. pCR was defined as no residual invasive tumor in breast and lymph nodes.

Results: Median follow-up was 110 months. IBC were more often ER negative than LABC(52 % vs 34%), more often triple negative (33 % vs 22 %) and more often TP53 mutations .(60% vs 39 %).

pCR in breast and lymph nodes was identical in LABC (17 pts,16%) and in IBC (14 pts, 16 %).

Table I Pathological response and factors associated with pCR

Negative ER and presence of TP53 mutations were strong predictive factors of chemotherapy efficacy in LABC and less in IBCS. histologically grade 3 was not predictive in IBC.

Median disease free survival (DFS) was higher in LABC [103 months (m)] than in IBC (54 m), p=.031. Median Overall survival (OS) was not reached in LABC and was of 134 m in IBC (p = .015). A significant effect of ER status on DFS was found in LABC and IBC. When adjusting for ER, IBC still had a significantly shorter DFS (HR 1.64, 95%CI 1.12 to 2.39, P=.011). Similar results were found for OS. For TP 53, a significant interaction was found with LABC/IBC (p=0.017) with a risk for mutated patients in LABC (p=0.004) and a slight and nonsignificant increased risk in IBC patients (p=0.62).

Estimated disease free survival at 15 years

Conclusion: High risk patients treated with dose dense cyclophosphamide and anthracyclin have very long survival rate. Negativity of ER and p53 mutations are strong predictive factors of good outcome in LABC but less in IBC. This approach in ER-LABC should be prospectively studied..

Abstract P2-09-26: Circadian Clock Genes in Primary Breast Cancer: Strong Predictors of Pathologic Response on Neoadjuvant Chemotherapy

Background: Circadian clocks involve 15 specific genes, which control cell cycle, apoptosis, DNA repair and metabolism. Circadian disruption is associated with both an increased risk of breast cancer, and poor survival in patients (pts) with metastatic cancer (IARC#98; Innominato et al. Cancer Res 2009).

Objective: to provide first evidence of clinical relevance of clock genes expression for the therapeutic sensitivity of primary breast cancer. Method: Affymetrix Hgu133plus2 microarrays data were derived from 189 primary breast cancers. All the pts had non metastatic disease and were registered in multicenter Phase II trial of neoadjuvant chemotherapy with epirubicin-cyclophosphamide (4 courses) then docetaxel ± herceptin (4 courses). In this study, negative hormonal receptor status and limited tumor size predicted for pathological complete response rate (pCR) (Pierga JY, et al Breast Cancer Res Treat. 2010).The expression data of 15 core clock genes, within the whole tumor transcriptome, were related both to tumor mitotic index (MI) and estrogen receptors (ESR1), and to chemotherapy-induced pCR. Statistical validation involved T-test statistics, with corrections for multiple testing.

Results:

In the tumor biopsy obtained before treatment onset, both Per2 and Cry2 expressions correlated positively with ESR1 (r≥0.43; P&lt;0.001) and inversely with (MI (r≤−0.28; P&lt;0.007). In addition, a positive correlation was found for Dec 1 with ESR1 (r=0.65, P&lt;0.001). The mean expressions of Per2, Cry2 and Dec 1 before chemotherapy were lower in the 32 pts who subsequently achieved pathologic complete response (pCR) as compared to the 157 who did not (P&lt;0.001). No other clock gene expression was significantly related to pCR. The odds ratio confirmed the decreased chance of achieving pCR with increased expression of clock genes Per2, Cry2 or Dec1.

Clock gene expression and pCR

Conclusion: Low expressions of three core genes in the negative loop of the molecular circadian clock strongly predicted for the induction of a pathologic complete response of primary breast cancer with neoadjuvant chemotherapy. While circadian clock disruption seems to constitute a poor prognostic factor in cancer patients, our data suggest that the downregulation of core circadian genes in tumors significantly enhances susceptibility to chemotherapy.

Abstract P6-09-06: Oral Contraceptive Use and Overall Breast Disease Risk: Cross Sectional Retrospective Study

Background: Oral contraception (OC) is one of the most widely used means for birth control in the world. In several studies, OC has been associated with a slightly increased risk of breast cancer in current user, and with a decreased risk of benign disease. Little is known about atypical high risk lesions. Our goal was to investigate whether OC use was a risk factor or a protective factor for benign, high risk or malignant breast lesions. Material and methods : From 2001 to 2007, all non-palpable breast lesions referred to biopsy or cytology in Saint Louis hospital were prospectively registered. Demographic and clinical data including oral contraceptive pill use extent were reported. We defined benign lesions (fibroadenoma, blunt duct adenosis, fibrocystic changes, epithelial hyperplasia, others), high risk lesions (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ and malignant lesions (ductal carcinoma in situ, invasive ductal or lobular carcinoma). The aim was to analyse the correlation between the duration of OC use and the occurrence of the breast disease classified by histology groups. Patients with previous history of benign breast disease or malignancy were excluded.

Results: The analysis was performed on 1329 breast lesions. The breakdown of the lesions were as follows: 819 benign lesions (fibroadenoma n=155, blunt duct adenosis n=169, fibrocystic disease n=194, epithelial hyperplasia n=132, others n=170), 104 high risk lesions (atypical ductal hyperplasia n=54, atypical lobular hyperplasia n=29, lobular carcinoma in situ n=21), and 406 malignant lesions (ductal carcinoma in situ n=158, invasive ductal or lobular carcinoma n=248). The duration of oral contraception use was not significantly associated with the occurrence of benign, high risk or malignant breast disease. When focusing on benign lesion subtypes, no association was observed either. Older age was significantly correlated to the occurrence of atypia or carcinoma. Significant difference existed in the median age of apparition 55 y.o and 57 y.o respectively, versus 53 y.o for benign lesion (p&lt; 0,0001), as well as menopausal status at diagnosis (57.7% and 68.3%, respectively, versus 53% for benign lesion) (p&lt; 0,0001).

Conclusion: In this cross sectional retrospective study, the duration of OC use was not associated with differential occurrence of benign, high risk and malignant breast lesion. Although a lack of statistical power may be invoked to explain the results, we are called to believe that the magnitude of an effect of OC use is small, if ever it exists.

Results [Table 1]

Abstract P6-05-06: Clinical Presentation of Molecular Apocrine Subgroup of Breast Cancer: A Rather Aggressive Group of Tumor

Background: Estrogen receptor negative (ER-) breast cancer represents 30% of breast cancers. This heterogeneous group comprises at least the basal and HER2+ subgroups. Recent data, as well as our own, has observed that the HER2+ subtype is highly heterogeneous. Several teams have identified a new “apocrine” molecular subgroup of cancer, characterized by androgen receptor (AR) expresion in an ER-context. Here, we have retrospectively identified, based on a transcriptionnal signature, these apocrine molecular tumours and described their clinical presentation and evolution.

Material and Methods:

We retrospectively identified 60 patients treated in St Louis Hospital (Paris) from 1995 to 2008 and presenting the signature of the molecular apocrine subgroup (ERA-, AR+, FOXA1+) by Q-RT-PCR.

Results:

Mean age at diagnosis was 53,5 y.o. Tumours size were T2 or more in 78% cases. Histological types were ductal invasive with intraductal component (n=22), histological apocrine (n=3), and paget disease (n=4). Tumor grade was 3 in 68%, and 2 in 21%, with lymphovascular invasion in 37%. Excluding patients receiving neo-adjuvant chemotherapy, lymph node status was negative in 41%, and positive in 52% (1 to 3, 32%, more than 4N+, 20%). By immunohistochemistry 97.4% were PR-and 58.72% overexpressed HER2.

Surgery was conservative in 46%, and 48% patients underwent mastectomy. Sixteen patients received neoadjuvant chemotherapy (27%), 41 received adjuvant chemotherapy (68%), 16 received hormonal therapy (27%), and

16 received trastuzumab (27%). With a median follow up of 60 months, 34 events (local recurrence n=9, contralateral n=3, distant metastasis n=22), and 13 deaths occurred. Median disease free survival was 48 months.

Discussion:

In this cohort of apocrine molecular carcinomas, tumor phenotypes appears to be rather aggressive, with a high proportion of poor prognosis factors (grade SBR3, lymphovascular invasion, node involvement), and are generally well-correlated to a poor clinical outcome in this population that received heterogeneous treatments. Further data are needed to precisely characterise this particular breast cancer subtype, notably patients who are not eligible to Herceptin-based regimen.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-05-06.

Abstract P1-11-14: Neoadjuvant Chemotherapy in Lobular and Ductal Carcinoma: Comparison of Clinical, Pathological Response Rates and Survival

Introduction: Neoadjuvant chemotherapy is a standard of care in locally advanced breast carcinomas. The major purpose of neoadjuvant chemotherapy is breast conserving surgery. Advantages in survival have only been shown in patients undergoing achieving pathological complete response (pCR). Lobular carcinomas seem less chemosensitive than ductal carcinomas to neoadjuvant chemotherapy (NCT).

Purpose: To compare the clinical and pathological response rate and the outcome of lobular (ILC) versus ductal (IDC) invasive breast carcinomas after NCT.

Patients and methods: Between 1985 and 2010, 385 patients with locally advanced and/or inflammatory breast carcinomas from Saint Louis hospital received neoadjuvant chemotherapy. Forty-four (11, 4%) ILC and 341 (88, 6%) IDC were diagnosed by surgical or core needle biopsy before CT. All patients received anthracyclines based CT,181 (47%) additionally received a taxane (four cycles of epirubicin 75 mg/m2 and cyclophosphamide 750 mg/m2 then four cycles of taxotere 100mg/m2 or six cycles of a dose dense regimen of 75 mg/m2 epirubicin and 1200mg/m2 cyclophosphamide, every 14 days),and underwent breast surgical excision (lumpectomy or mastectomy) and axillary node dissection.Clinical response was defined by the lack of palpable tumor in the breast before surgery.Pathological complete response was defined by no residual invasive tumor in breast. Radiotherapy and hormonotherapy were delivered to patients, when appliable.

Results: Clinical response to NCT was higher for ILC (27, 3%) than IDC (13,4%). ILC with clinical response tended to have higher histological grade 2 (91,6 % versus 30,4% for IDC),more estrogens receptors (RE) positivity (91,6% vs 45,6%), p53 wild type (66,6% vs 30,4%) and HER2- negative tumors (91,6% vs 76%) Pathologic response (pCR) rate was lower for ILC than for IDC (2, 7% vs 9, 3%). Only one ILC (grade 2, RE+, HER2 negative, p53 wild type) underwent pCR. Thirty two (9, 3%) IDC haved pCR: 15,6% haved histological grade 2, 15,6% RE positivity,9,3% p53 wild type, 62,5% HER2 negative. Thirteen percent of ILD and 9 % of ILC haved breast conservating surgery .At a median follow up of 60 months, ILC patients tended to have longer overall survival (55% vs 48%) and recurrence free survival (44% vs 36,8%) than IDC.

Conclusions: ILC was characterized by better clinical response rates but lower pathologic response and breast conservating surgery rates .Despite the low pCR rate, patients with ILC tended to have better outcomes than did patients with IDC. Pathological complete response to NCT in ILC did not seem to have prognostic significance. Further data are warranted to help clarify the characteristics genomics and proteomics of ILC which explains this better outcome.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-11-14.

Single Circulating Tumor Cell Detection and Overall Survival in Non Metastatic Breast Cancer

Background: Circulation of cancer cells in the blood is a necessary step of hematogeneous metastasis while circulating tumor cells (CTC) have been reported to have a low metastatic efficiency in preclinical animal models. After a median follow-up of 18 months, we previously reported that CTC detection influences the distant metastasis-free survival (DMFS) in non-metastatic breast cancer (BC) patients (pts) treated by neoadjuvant chemotherapy (NACT) in a multicenter prospective trial. Updated results are presented here, focusing on overall survival (OS) and predictors of metastatic relapse.Methods: In 115 localized BC pts, CTC were prospectively screened (CellSearch) before and after NACT (REMAGUS02). We analyzed their outcome after a median follow-up of 36 months.Results: At baseline, 23% of pts were CTC-positive, but only 10% had more than 1 CTC per 7.5ml of blood. At an individual level, CTC detection before chemotherapy, used as a test to predict metastatic relapse, exhibited a global accuracy of 77%, higher than that of tumor grade (54%), tumor size (57%), lymph node invasion (40%), triple negative phenotype (76%) and pathological complete response (27%). Multivariate analyses for OS and DMFS showed that CTC detection before chemotherapy was a strong independent prognostic factor for both DMFS (p=0.01, RR=5.0, 95%CI[1.4-17]) and OS (p=0.007, RR=9, 95%CI[1.8-45]), along with tumor size and triple-negative phenotype, while post-chemotherapy CTC detection had a lower significance for both endpoints (p=0.07 and p=0.09 respectively).Conclusion: Biologically, the metastatic efficiency of CTC could be higher than previously thought. Clinically, besides confirming our previously reported results, this study shows that CTC detection may become the main prognostic factor in BC pts treated with NACT. Implementing this technique in everyday management might help to identify high-risk pts in whom innovative strategies should be investigated.Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis.ISRCTN10059974

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3017.

Correlation between 18F Fluorodeoxyglucose (FDG) Uptake and Tumor Characteristics in Locally Advanced Breast Cancers

Background: This study analysed the correlation between [18F]fluorodeoxyglucose (FDG) uptake, assessed by positron emission tomography (PET), and prognostic factors in locally advanced breast cancersMaterial and Methods: All locally advanced breast cancers seen at Saint Louis hospital and treated with neo-adjuvant chemotherapy (NAC) have a FDG PET after core needle biopsy and before chemotherapy. We correlated the tumor characteristics: T-stage, histological grade, estrogen and progesterone receptors, c-erbB2 over-expression (immuno-histochemistry determination) and P53 (determinate on frozen biopsies by the FASAYmethod) to FDG standardized uptake value (SUV max). The statistics tests used are student test (comparison of 2 means) and kendall correlation.Results: From June 2006 to April 2009, 91 patients with locally advanced breast tumors have both PET scan and frozen tissue before NAC. Median age at diagnosis is 48 (26-81) and 45 % are post menopausal.Conclusion: This study indicates that FDG-PET uptake is correlated with the phenotype of breast tumours. Over-expression of c-erbB2 does not influence FDG uptake. Triple negative tumours and p53 mutated tumors have a high initial SUV which can reflect their aggressiveness and their chemotherapy sensitivity. The knowledge of SUV uptake according to tumor characteristics allows a better understanding of the role of FDG-PET in the prediction of neoadjuvant chemotherapy response.Patients characteristicsPtes characteristicsNumber of patients (%)Tumor size: T2/T3/T438 (41)/32 (35)/21(23)Lymph nodes N0/N1/N232 (35)/46 (50.5)/13 (14 )Invasive ductal carcinoma/invasive lobular carcinoma/miscellaneous82 (90 )/5 (5 )/3 (3)Histological grade/ 1/2/37 (7 )/49 (54)/35 (38)ER + / ER-58 (64 )/33 (36)PR+ /PR-35 (38) /56 (61)C-erbB2 +++15 (16 )Triple negative22 (24 )P53 ( 64 ptes) mutated/wild type32 (50)/32 (50) 

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5010.

The Role of FDG PET for Early Prediction of Response after Two Cycles of Epirubicin + Cyclophosphamide Neoadjuvant Chemotherapy in Breast Cancer

Background: Previous studies showed a possible role of Fluorodeoxyglucose Positron Emission Tomography (FDG PET) in monitoring response to neoadjuvant chemotherapy (NACT) in breast cancer patients. Most studies, however, mixed various chemotherapy protocols. We assessed the ability of FDG PET to predict response after two cycles of epirubicin + cyclophosphamide (EC) and compared it with histopathological response as determined by the Sataloff scale after completion of chemotherapy.Material and Methods: From 07/2007 to 05/2009, 54 patients seen at Saint Louis hospital underwent FDG PET at baseline and after the second cycle of NACT. We present data for the first 22 consecutive patients for whom pathology data are available. Standard chemotherapy treatment was four cycles of epirubicin + cyclophosphamide followed by four cycles of docetaxel. The study was performed according to the guidelines of the institutional ethical committee. The standardized uptake value (SUVmax) of FDG was measured with a PET-CT instrument at baseline and after the second cycle of chemotherapy. The change in SUV was expressed as Δ SUVmax (%) = 100 X (2nd cycle SUVmax - baseline SUVmax)/baseline SUVmax. A Δ SUVmax cutoff value of -45% was used to differentiate metabolic responders and non-responders. Histopathological response was assessed on fresh surgical specimens (mastectomy or lumpectomy) by an experienced pathologist and graded according to the scale established by Sataloff: total or near-total therapeutic effect (grade A), more than 50% therapeutic effect but less than total or near-total effect (grade B), less than 50% therapeutic effect but visible effect (grade C), or no therapeutic effect (grade D). For the analysis, grades A and B were considered as histopathological responders and grades C and D were as non-responders.Results: Initial T-stage was T2 in 12 cases, T3 in 6 cases and T4 in 4 cases. There were 21 cases of invasive ductal carcinoma and 1 case of invasive lobular carcinoma. Mean SUVmax in initial PET was 7.22 (ranges from 2.7 to 18.5) and mean SUVmax after 2 cycles of chemotherapy was 4.77 (1.4-15.3). Breast-conserving surgery was performed in 12 patients and mastectomy in 10 patients. Nine (41%) of 22 patients were classified as histopathologic responders and 13 (59%) as non-responders. PET after two cycles of NACT revealed 9 patients (41%) as responders and 13 (59%) as non-responders. Among 9 metabolic responders, 7 were true positive, and 2 were false positive. Among 13 metabolic non-responders, 11 were true negative, and 2 were false negative. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of FDG PET after two cycles of NACT were 78%, 85%, 78%, 85% and 82% respectively.Discussion: NACT has proved useful in stage II and III breast cancer, to reduce tumour volume, increasing the chance of breast-conserving surgery. In order to minimize adverse effects of NACT, non-responders must be identified as early as possible. Our preliminary results on a small series of patients show that FDG PET can differentiate responders from non-responders with good accuracy after two cycles of neoadjuvant chemotherapy with EC.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5009.

A Multicenter Randomized Phase II Study of Sequential Epirubicin/Cyclophosphamide Followed by Docetaxel with or without Celecoxib or Trastuzumab According to HER2 Status, as Primary Chemotherapy for Localized Invasive Breast Cancer Patient

Purpose: To assess anti tumor activity of sequential epirubicin/cyclophosphamide followed by docetaxel with the randomized addition of celecoxib In Her2-ve patients or trastuzumab in Her2+ve patients versus no additional treatment, in terms of pathological complete response (pCR), defined as absence of residual invasive breast carcinoma and of nodal involvement.Patients and methods: 340 patients with stage II and III breast adenocarcinoma, with tumors ineligible for breast conservative surgery received 8 sequential 3 weekly cycles with epirubicin (75mg/m2)-cyclophosphamide (750mg/m2) for 4 cycles followed by docetaxel (100 mg/m2) for 4 cycles. According to HER2 status (IHC + FISH) they were randomized to receive together with docetaxel, in HER2 negative group (220 patients) celecoxib 800 mg/day during cycles 5-8 or no additional treatment and in HER2 positive group (120 patients) trastuzumab (8mg/kg then 6mg/kg) infused together with docetaxel or no additional treatment. All patients except eight with HER2+ tumor received adjuvant trastuzumab for a cumulative duration of 12 months.Results: In the HER2 negative group, pCR (grade 1 and 2 of Chevallier's classification) was observed in 11.5% and 13% of patients treated without and with neoadjuvant Celecoxib respectively. In the HER2+ group, pCR rate reached 26% in those having received neoadjuvant trastuzumab versus 19% in the others. There was no cardiac toxicity and no toxic death. Triple negative breast cancers experience the highest pCR rate of 30%.Conclusion: It is the first report on the effect of the addition of celecoxib to chemotherapy in neoadjuvant setting in breast cancer, showing that celecoxib does not improve the pCR rate. Addition of trastuzumab does, yet not to the extent reported with a protracted co-administration before surgery. Expression of hormonal receptors appears to be the major prognosticator for pCR. Molecular studies of gene expression profiling should allow improving such prediction.Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis.ISRCTN10059974

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5054.

Nonpalpable Breast Lesions in a Breast Care Unit: Prospective Analysis on 2708 Consecutive Cases

Background: Breast cancer screening increases the detection of nonpalpable breast lesions, These lesions raise specific concerns, involving radiological imaging, biopsy techniques, and pathological analysis. The objective of the study is to evaluate the management of nonpalpable breast lesions in a breast disease unit.Material and Methods: From 2001 to 2007, 2708 nonpalpable breast lesions were prospectively evaluated by a multidisciplinary team. Radiologic lesions were detected by mammography alone (71,5%), ultrasonography (27,90%), MRI (0,20%). All lesions were classified according to the BI RADS classification. Three hundred and nine (309) core needle biopsies were performed, 807 vacuum assisted biopsies, and 521 open breast biopsies. The pathologic results were correlated with surgery, rebiopsy or long-term imaging follow up.Results: The pathologic results showed 33 % of malignant lesions (DCIS, invasive carcinoma), 9 % of high risk lesions (atypical ductal or lobular hyperplasia, lobular carcinoma in situ) and 58 % of benign lesions. The prevalence of cancer as a function of BI-RADS was: BI-RADS 0 : 2,6% (4/152), BI-RADS 2: 0% (0/55), BI-RADS 3: 2,3% (17/740), BI-RADS 4: 23,4% (352/1502) et BI-RADS 5 : 78,7% (185/235). Twelve of 152 (7,9 %) high risk lesions were upgraded to malignant lesions and 34/211 DCIS (16,1%) were upgraded to invasive carcinoma after surgery. Diagnostic performance rates exhibited the following results: agreement rate=96,6%, sensibility=96,2%, overall underestimation rate=12,6%, and false-negative rate=1,6%.Table 1: Diagnostic performance of core needle biopsy, vacuum assisted biopsy, open breast biopsy core needle biopsy%vacuum assisted biopsy%open breast biopsy%Totaln=309 807 521 1637Pathologic results       benign21970,9%48960,6%23444,9%942 (57,5%)High risk82,6%728,9%6813,1%148 (9,0%)malignant8226,5%24630,5%21942,0%547 (33,4%)Diagnostic performance       sensibility80/8297,6%228/24593,1%217/21999,1%525/546 (96,2%)agreement304/30998,4%762/80794,4%515/52198,8%1581/1637 (96,6%)high risk underestimate1/616,7%10/7713,0%1/691,4%12/152 (7,9%)DCIS underestimate3/650,0%27/12421,8%4/814,9%34/211 (16,1%)overall underestimate rate4/1330,8%37/20118,4%5/1503,3%46/364 (12,6%)false negative rate1/821,2%7/2462,8%1/2190,5%9/547 (1,6%) After vacuum assisted biopsy, one-step surgery was performed in 82,9% and after core needle biopsy in 68,4%.Conclusion: This kind of quality evaluation in community practice should be encouraged. Management of those lesions continuously evolves with the widespread of RMI and new biopsy techniques. Efforts should be made in exploring imaging-pathologic discrepancies, and in identifying predictive factors of invasion on biopsies. We currently perform a focused analysis on lesions that required two surgical steps despite a prior biopsy, in order to point out new ways to improve our practices.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6020.

Meta-analysis of gender effect for first-line chronomodulated 5-fluorouracil-leucovorin-oxaliplatin (ChronoFLO) compared with FOLFOX or constant infusion (conventional delivery, CONV) against metastatic colorectal cancer (MCC) in three international controlled phase III randomized trials (RT)

4112

Background: Gender predicted for the most effective schedule in a RT of ChronoFLO vs CONV against MCC: overall survival (OS) was significantly increased in men on chronoFLO vs FOLFOX, whereas the reverse was found in women (Giacchetti, JCO 2006). Methods: To assess the relevance of gender for patient (pt) outcome, meta-analysis was performed on individual pt data (IPD) from 3 RT in 845 MCC pts treated with chronoFLO vs CONV (346 F, 499 M at 36 centers in 1990–2002)(Lévi, JNCI 1994; Lancet 1997). Data bases were merged and updated at 9 y after inclusion of the 1st pt. Main prognostic factors were comparable in each RT according to gender and treatment arm (median age: 61y; PS=0, 46% pts; liver M, 85% pts; liver involvement >25%, 41% pts; lung M, 37% pts; CEA>10, 56% pts). Results: No significant difference was found according to delivery schedule or gender in the whole population for Response Rate (RR), Progression-Free Survival (PFS) and OS. However, men on chronoFLO had highest RR, longest PFS and OS. PFS and OS were highest in women on CONV ( Table ). The rate of complete macroscopic resections of liver metastases (R0+R1) was 12.5% in men on chronoFLO vs 7.8–8.5% in men on CONV or in women on either schedule. A complete histologic response of liver metastases was documented in 2.1% of the men on chronoFLO vs 0–1.1% in the other groups. The relative risk of an earlier death in men vs women was 0.76 [95% CL, 0.91 to 0.94] on chronoFLO and 1.24 [0.99 to 1.56] on CONV. Conclusions: This IPD meta-analysis of 3 RT in MCC with a minimum follow up of 5 years confirms that men benefit from chronoFLO as compared to CONV delivery, with regard to long term outcome and medico-surgical strategy. ChronoFLO should be preferred to conventional oxaliplatin-5-FU-LV schedules in men with MCC. Support: ARTBC Internationale, P. Brousse Hospital, Villejuif, France.

[Table: see text]

No significant financial relationships to disclose.

p53 mutations to predict efficacy of alkylating-containing regimen: a metaanalysis of four different clinical trials

Abstract #6064

Background. The predictive value of p53 mutations for efficacy of anthracycline-based chemotherapy is matter of controversy. Inconsistencies among studies could be related to the heterogeneous use of alkylating agents in combination with anthracyclines in different studies. We examined the predictive value of p53 mutations in four different series of breast cancer patients treated with preoperative anthracycline-based chemotherapy including different doses of cyclophosphamide (C).&#x2028; Patients and Methods. All patients had stage II-III breast cancer and received anthracycline-containing chemotherapies. A total of 352 patients were included in four different clinical studies : 65 patients with estrogen receptor (ER)-negative cancers treated with single agent epirubicine (E) (100 mg/m2/3w x 4) in the TOP trial (R1), 52 patients treated with FAC (500 mg/m2 C, 5-FU and 50 mg/m2 doxorubicin/3w x 6) (R2), 96 patients treated with EC-T (75mg/m2 E and 750 mg/m2 C/3w x 4 followed by 100mg/m2 docetaxel/3w x 4) (R3) and 139 patients treated with dose-dense EC (1200mg/m2 C and 75 mg/m2 E/2w x 6) (R4). Before therapy, p53 status was determined in all tumors by yeast functional complementation (FASAY) assay. After chemotherapy, all patients underwent surgery. Pathologic complete response (pCR) was defined as no residual invasive tumour cells in breast and lymph nodes.&#x2028; Results. P53 mutations were more frequently observed in the 128 ER-neg compared to ER-pos cancers (78% vs 29.4%). In p53 mutated tumours, the pCR rate increased with the dose-intensity of C. Conversely, in p53 wild type tumours, pCR rates decreased.&#x2028; &#x2028; Focusing on ER-neg, p53 mutated tumors, the pCR rates rose from 11%, 6%, 32% to 52% in R1, R2, R3 and R4 groups. The R1 and R4 regimen, differing only in C dose intensity, showed marked differences in pCR in ERneg tumors.&#x2028; &#x2028; Conclusions: Increasing doses of C do not seem to improve pCR rates in P53 wild type tumours, raising the possibility of antagonism with anthracycline in this group. On the other hand, in ER-neg, p53 mutant tumors, inclusion of dose-intense C seems to significantly increase pCR rates.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6064.

Hepatic artery triplet chemotherapy for liver metastases from colorectal cancer

14554

Background: Chronomodulated (Chrono) irinotecan (I), 5-fluorouracil (F), leucovorin and oxaliplatin (O) offered sustained tumor control in CRC patients (pts) failing several chemo (Gholam et al. The Oncologist 2006). The relevance of Chrono IFO as hepatic artery infusion (HAI) for long term outcome was investigated in CRC pts with liver metastases. Methods: 32 heavily pretreated non hospitalized CRC pts received 5-day (d) q21 d courses (c) with d1 I (160 mg/m2 from 2 to 8 am, peak at 5 am) and d2–5 F (600 mg/m2/d from 10 pm to 10 am, peak at 4 am) and O (20 mg/m2/d from 10 am to 10 pm, peak at 4 pm). Intravenous cetuximab was also given to 3 pts. 172 courses (c) were given (median, 5; 1–15) using a multichannel pump (Mélodie, Aguettant, F). Toxicity was assessed q21 d and response q3 c with CT scan. Results: Prior chemo lines 1/2/3/4+: 3/5/10/14 pts; WHO Performance Status 0/1/2/3: 14/11/6/1 pts; median age: 63 years (32–73); liver only: 25 pts; liver and lung: 7 pts. Treatment was withdrawn for thrombosis (7 pts, 21%) and/or Grade (G) 3 abdominal pain (4 pts ). G3–4 diarrhea occurred in 6 pts (12%). G3–4 leucopenia, anemia and thrombocytopenia were respectively found in 5, 2 and 1 pt. G3 sensory neuropathy occurred in 3 pts with similar G at baseline. 3 pts displayed alopecia. Of 29 pts with measurable lesions, disease progressed in 12 pts (exclusively outside the liver for 4 pts) and was controlled in 17 pts (58%), including 10 objective responses - 34% [95% C.L. 13.4 to 50.6]. Partial hepatectomy was performed in 4 pts with measurable disease (14%): R0 (3 PR) and R1 (1 SD). Median Progression free survival (months, m) is 5 m [1.9 to 8.0] and median survival is 18.4 m [9.9 to 26.9], with 6 pts alive at 2.9 to 63 m. Conclusions: Triplet chronoHAI is safe in heavily pretreated pts and achieves consistent activity against CRC liver metastases despite prior failure on the same 3 drugs. The combination of systemic cetuximab with triplet HAI is feasible and could prevent extra hepatic dissemination, a hypothesis to be soon tested in a prospective European trial. Supported by ARTBC, Hôpital P. Brousse, Villejuif, France.

No significant financial relationships to disclose.

Triple-negative phenotype is a strong predictor of sensitivity to epirubicin-cyclophosphamide (EC) then docetaxel (D) (ECD) primary chemotherapy (PCT) for localized breast cancer

21128

Background: Molecular markers (GEP, p53 mutations,) could overcome usual predictors (size, pathology, Hormone receptors, HER2) in identifying patients (pts) experiencing complete pathological response (pCR) with anthracyclin based chemotherapy (Clin.Cancer Res., 2004, 10 6789). We aimed at validating and refining these finding in pts treated with ECD. Methods: From 05/2004 to 04/2006 170 pts not amenable to Breast Conserving Therapy and/or with high evolutive potential were randomly allocated to EC (75/750mg/sqm)x4 then D (100 mg/sqm)x 4 (with or without celecoxib in HER2-ve or trastuzumab (T) in HER2+ve. The primary endpoint - absence of residual invasive breast carcinoma and of nodal involvement (pCR)- was to be correlated with usual predictors , phenotype, GEP and p53 mutations assessed from core biopsies. pCR ranged from 13 to 14% in the arms without T thus without suggestion of a difference between these arms. pCR in the 30 HER2+ve pts having received ECD + T was 30% (NS). Results in 135 fully evaluable pts not allocated to T and having undergone secondary surgery are analyzed. Results: Main predictors and related pCR are shown in the table below Results of ongoing molecular analysis will be reported. Conclusions: Expression of ER appears to be the major prognosticator for ECD induced pCR. Triple negative breast cancers experience the highest pCR rate (p< 0.0001) (chi2 test with Yates correction). Molecular studies to be presented will show if GEP and/or p53 mutations could allow to improve such prediction.

[Table: see text]

No significant financial relationships to disclose.