Abstract GS5-03: Lifestyle Intervention and Effect on Disease-free Survival in Early Breast Cancer Pts: Interim Analysis from the Randomized SUCCESS C Study

Background:

Recent trials have provided evidence that obesity and a low level of physical activity are not only associated with a higher risk of developing breast cancer, but also with an increased risk for recurrence and reduced survival in breast cancer patients (pts). The SUCCESS C study is the first randomized Phase III trial to evaluate the effect of an intensive lifestyle intervention program, focusing on both physical activity and healthy diet following adjuvant chemotherapy on disease-free survival in women with early breast cancer.

Methods:

SUCCESS C is a German multicenter, 2×2 factorial design, randomized phase III study comparing disease-free survival (DFS) in pts with HER2-negative early breast cancer treated with either 3 cycles of epirubicine, fluorouracil, cyclophosphamide chemotherapy followed by 3 cycles of docetaxel (FEC-D) or 6 cycles of docetaxel-cyclophosphamide (DC). The second randomization compares DFS in pts with a body mass index (BMI) of 24—40 kg/m2 receiving either a telephone-based individualized lifestyle intervention (LI) program aiming at moderate weight loss for 2 years (LI arm) or general recommendations for a healthy lifestyle alone (non-LI arm). DFS according to lifestyle intervention was analyzed using both univariable cox regressions and multivariable cox regressions adjusted for age (years, continuous), BMI (kg/m2, continuous), menopausal status (premenopausal, postmenopausal), tumor size (pT1, pT2, pT3/pT4), nodal stage (pN0, pN1, pN2, pN3), hormone receptor status (positive, negative), grading (G1, G2, G3), histological type (ductal, lobular, other) and chemotherapy randomization (FEC-D, DC). Median follow-up was 64.2 months.

Results:

Overall, 2292 of the 3643 pts recruited for the SUCCESS C study were randomized for the lifestyle intervention program (1146 pts in both the non-LI arm and the LI arm). The Intention-to-treat analysis revealed no difference in DFS between the two treatment arms (LI vs. non-LI) in univariable analysis (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.76 — 1.28, p = 0.922) and in adjusted multivariable cox regression (HR 0.91, 95% CI 0.70 — 1.18, p = 0.48). At the 2-year follow up, pts in the LI arm lost on average 1.0 kg weight compared to the start of the LI program, while pts in the non-LI arm gained on average 0.95 kg (p < 0.001). Overall, 1477 pts completed the 2-year LI program (non-LI arm: 80.7%, 925 of 1146 pts; LI arm: 48.2%, 552 of 1146 pts; p < 0.001). Pts that completed the 2-year LI program had a significant better DFS than non-completers (HR 0.35, 95% CI 0.27 — 0.45, p < 0.001). Among completers, pts in the LI arm had a significantly better DFS than pts in the non-LI arm both in univariable analysis (HR 0.53, 95% CI 0.35 — 0.82, p = 0.004) and in adjusted multivariable cox regression (HR 0.51, 95% CI 0.33 — 0.78, p = 0.002).

Conclusions:

This explorative and non-planned interim analysis indicates that the completion of a systematic telephone life style intervention program may positively impact patient outcome in early breast cancer.

Citation Format: Janni W, Rack BK, Friedl TW, Müller V, Lorenz R, Rezai M, Tesch H, Heinrich G, Andergassen U, Harbeck N, Schochter F, De Gregorio A, Tzschaschel M, Huober J, Hepp P, Fehm TN, Schneeweiss A, Lichtenegger W, Blohmer J, Hauner D, Beckmann MW, Häberle L, Fasching PA, Hauner H. Lifestyle Intervention and Effect on Disease-free Survival in Early Breast Cancer Pts: Interim Analysis from the Randomized SUCCESS C Study [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 GS5-03.

The HER2 phenotype of circulating tumor cells in HER2-positive early breast cancer: A translational research project of a prospective randomized phase III trial

Background

HER2 is one of the predominant therapeutic targets in breast cancer. The metastatic selection process may lead to discrepancies between the HER2 status of the primary tumor and circulating tumor cells (CTCs). This study analyzed the HER2 status of CTCs in patients with HER2-positive primary breast cancer at the time of diagnosis. Aim of the study was to assess potential discordance of HER2 status between primary tumor and CTCs, as this may have important implications for the use of HER2-targeted therapy.

Methods

The number and HER2 status of CTCs out of 30ml peripheral blood were assessed in 642 patients using the CellSearch System (Janssen Diagnostics, USA). The cutoff for CTC positivity was the presence of at least 1 CTC, and the cutoff for HER2 positivity of CTCs was the presence of at least 1 CTC with a strong HER2 staining.

Results

258 (40.2%) of the 642 patients were positive for CTCs (median 2; range 1–1,689). 149 (57.8%) of these 258 patients had at least 1 CTC with strong HER2 staining. The presence of HER2-positive CTCs was not associated with tumor size (p = 0.335), histopathological grading (p = 0.976), hormone receptor status (ER: p = 0.626, PR: p = 0.263) or axillary lymph node involvement (p = 0.430). Overall, 83 (32.2%) of the CTC-positive patients exclusively had CTCs with strong HER2 staining, whereas 31 (12.0%) had only CTCs with negative HER2 staining. Within-sample variation in the HER2 status of CTCs was found in 86 (57.8%) of the 149 patients with more than 1 CTC.

Conclusion

This study demonstrated that discordance between the HER2 expression of CTCs and that of the primary tumor frequently occurs in early breast cancer. Future follow-up evaluation will assess whether this discrepancy may contribute to trastuzumab resistance.

Abstract P1-01-03: Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial

Background: The presence of circulating tumor cells (CTCs) before chemotherapy is known to be associated with reduced disease free survival (DFS) and overall survival (OS) in early breast cancer (EBC). In addition, recent findings suggest that CTCs persisting after adjuvant chemotherapy indicate poor prognosis. In an explorative analysis of the SUCCESS A trial, we evaluated the prognostic relevance of changes in CTC counts during the course of adjuvant chemotherapy across molecular subtypes to assess whether the prognostic role of persisting CTCs varies according to tumor biology.

Methods: The SUCCESS A trial is a phase III study, where patients with high-risk EBC (stage pN1-3 or pT2-4 or grade 3 or age ≤ 35 or hormone-receptor negative) were randomized to adjuvant chemotherapy with 3 cycles of epirubicin-fluorouracil-cyclophosphamide followed by either 3 cycles of docetaxel or 3 cycles of gemcitabine-docetaxel. CTC enumeration was performed before and after chemotherapy using the FDA-approved CellSearch® System (Janssen Diagnostics, LLC), and CTC positivity was defined as ≥ 1 CTC in 23 ml blood. Molecular subtypes were defined as luminal A like (hormone-receptor positive, grading 1 or 2), luminal B like (hormone-receptor positive, grading 3), triple-negative or HER2-positive. Patient outcome in terms of DFS and OS was analyzed using univariate log-rank tests and Cox regression models (median follow-up time 65.2 months).

Results: Data on both molecular subtypes and CTC status before and after chemotherapy were available for 1485 (39.6%) of 3754 patients randomized. This cohort contained 577 (38.9%) luminal A like, 236 (15.9%) luminal B like, 379 (25.5%) HER2-positive and 293 (19.7%) triple negative tumors. Overall, 917 (61.8%) patients were CTC negative before and after chemotherapy (neg/neg), 260 (17.5%) patients had a negative CTC status before and a positive CTC status after chemotherapy (neg/pos), 229 (15.4%) patients converted from positive to negative CTC status (pos/neg), and 79 (5.3%) patients were positive for CTCs at both time points (pos/pos). There were significant differences in DFS and OS among these four groups in patients with luminal A like tumors (log rank test, both p < 0.003) and patients with luminal B like tumors (log rank test, both p < 0.001). In both patients with luminal A like or luminal B like tumors, persistently CTC positive patients had the worst outcome (relative to persistently CTC-negative patients) in terms of DFS and OS. In contrast to luminal-like tumors, no significant differences with regard to DFS or OS were found among the four groups (neg/neg, neg/pos, pos/neg, pos/pos) in patients with HER2-positive or triple-negative tumors (log rank test, all p > 0.13).

Conclusion: The presence of CTCs both before and after adjuvant chemotherapy was associated with poor survival in luminal A like and luminal B like tumors, but not in HER2-positive or triple-negative tumors. Further research is needed to evaluate the effect of chemotherapy on CTC prevalence in different molecular subtypes of EBC.

Citation Format: Tzschaschel MLJ, Rack B, Andergassen U, Friedl TWP, Schneeweiss A, Mueller V, Tanja F, Pantel K, Gade J, Lorenz R, Rezai M, Tesch H, Soeling U, Polasik A, Alunni-Fabbroni M, Trapp EK, Mahner S, Schindlbeck C, Lichtenegger W, Beckmann MW, Fasching PA, Janni W. Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial [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 P1-01-03.

Hormone Therapy and its Effect on the Prognosis in Breast Cancer Patients

Introduction: Use of hormone therapy (HT) has declined dramatically in recent years. Some studies have reported that HT use before a diagnosis of breast cancer (BC) may be a prognostic factor in postmenopausal patients. This study aimed to examine the prognostic relevance of HT use before BC diagnosis. Methods: Four BC cohort studies in Germany were pooled, and 4492 postmenopausal patients with HT use data were identified. Patient data and tumor characteristics were compared between users and nonusers, along with overall survival (OS), distant metastasis-free survival (DMFS), and local recurrence-free survival (LRFS). Cox proportional hazards models were stratified by study center and adjusted for age at diagnosis, tumor stage, grading, nodal status, and hormone receptors. Results: Women with HT use before the diagnosis of BC were more likely to have a lower tumor stage, to be estrogen receptor-negative, and to have a lower grading. With regard to prognosis there were effects seen for OS, DMFS and LRFS, specifically in the subgroup of women with a positive hormone receptor. In these subgroups, BC patients had a better prognosis with previous HT use. Conclusions: HT use before a diagnosis of BC is associated with a more favorable prognosis in women with a positive hormone receptor status. It may be recommended that the prognostic factor HT should be documented and analyzed as a confounder for prognosis in studies of postmenopausal hormone-responsive breast cancers.

Circulating tumor cells versus objective response assessment predicting survival in metastatic castration-resistant prostate cancer patients treated with docetaxel chemotherapy

PURPOSE

Circulating tumor cell (CTC) counts might display a superior prognostic value for overall survival (OS) compared to objective response criteria (OR) in metastatic castration-resistant prostate cancer (mCRPC) patients.

METHODS

CTCs were detected using the CellSearch™ System out of 122 samples during docetaxel chemotherapy (75 mg/m(2)) at baseline (q0) and after 1 (q1), 4 (q4) and 10 (q10) cycles, in mCRPC patients (n = 33). OR was evaluated by morphologic RECIST and clinical criteria after 4 (q4) and 10 (q10) cycles.

RESULTS

For OS, analyses revealed a significant prognostic value for categorical (<5 vs. ≥5) CTC counts (q0, p = 0.005; q1, p = 0.001; q4, p < 0.001; q10, p = 0.002), RECIST (q4, p < 0.001; q10, p = 0.02) and clinical criteria (q4, p < 0.001; q10, p = 0.02). Concordance of CTC counts with OR revealed a sensitivity of 83.3-87.5 % and a specificity of 68.0-76.5 % with complementary discriminatory power for OS. Comparing CTC counts with concomitant OR at q4 in multivariate analyses, an independent prognostic value for OS was found for CTC counts (HR 3.3; p = 0.02) similar to clinical (HR 4.9; p = 0.02) and radiologic response (HR 3.4; p = 0.051). Comparing the predictive value for death, early post-treatment CTC counts at q1 demonstrated significant accuracy with an area under the curve of 79.5 % (p = 0.004) similar to CTC counts at q4 (76.7 %; p = 0.009). Radiologic and clinical response at q4 displayed accuracy similar to early CTC counts at q1 (72.2 %; p = 0.03 and 75.0 %; p = 0.02) despite low sensitivities.

CONCLUSIONS

CTC counts appear to be an earlier and more sensitive predictor for survival and treatment response than current OR approaches and may provide complementary information toward individualized treatment strategies.

Detection and characterisation of disseminated tumour cells in bone marrow of breast cancer patients by immunostaining of Her-2 and MUC-1 in combination with Thomsen-Friedenreich (CD176)

Disseminated tumour cells (DTCs) in the bone marrow derive from many primary tumours, such as breast cancer. Their mere existence hints to present or future metastasis and implicates a worse prognosis for the patient. DTCs may possess different characteristics in comparison to the primary tumour due to events like Epithelial-Mesenchymal-Transition. Therefore, these cells might be able to survive chemotherapy and cause relapses of the disease at a later point. We aimed to detect and further characterise DTCs by an immunostaining approach with three different antigen markers (Her-2, MUC-1 and TF, also known as CD 176). For that reason, bone marrow of 41 breast cancer patients was obtained during surgery; DTCs were enriched by density gradient centrifugation and cytospins were prepared. After fixation, immunofluorescent double-stainings were carried out with antibodies against CD176 in combination with HER-2 or MUC-1. Cells co-expressing two antigens were found in all staining combinations (Her-2 and CD176: 46.14%; MUC-1 and CD176: 18.15% of all cases). Cells that stained for a single antigen only were also found (Her-2: 36.86%; MUC-1: 34.45%; CD176: 29.65% of all cases). Significant correlations between the stainings of all markers could be shown (p<0,001). In conclusion, Thomsen-Friedenreich Antigen (TF, CD176) is a promising marker in combination with the established marker Her-2 and other markers like MUC-1. These results may serve as a basis for future DTC detection routines and help to individualize medical treatment, reducing side effects and increasing the efficiency of the therapy.

Abstract P3-12-09: The prevalence and quantity of circulating tumor cells (CTCs) after adjuvant chemotherapy with and without anthracyclines in patients with HER2-negative early breast cancer (EBC)

Background: The use of anthracycline based chemotherapy in early breast cancer (EBC) patients has been well established. However, adverse effects like cardiotoxicity and efficacy in certain subgroups continue to be subjects of discussion. Based on data suggesting a limited benefit of anthracyclines in HER2-negative patients, the German SUCCESS C study randomly assigned patients with EBC to be treated with either anthracycline-containing or anthracycline-free chemotherapy. Since the prognostic value of CTCs in EBC has already been demonstrated in several trials, we compared the prevalence of CTCs after the completion of chemotherapy between both treatment arms.

Methods: The SUCCESS C trial was a randomized, open-label, Phase III study comparing disease free survival (DFS) in patients with HER2-negative EBC. Treatments were either 3 cycles epirubicin, 5-fluorouracil and cyclophosphamide followed by 3 cycles of docetaxel (FEC–DOC), or 6 cycles of an anthracycline-free regimen with docetaxel and cyclophosphamide (DOC-C). The CTC status at chemotherapy cycle 6 was prospectively evaluated using the FDA-approved CellSearch System (Veridex, USA).

Results: Data on CTC status after chemotherapy are available for 1757 patients. Overall, CTCs were found in 220 (12.5%) patients (median 1, range 1 – 18 CTCs). One CTC was detected in 123 (55.9%), two CTCs in 53 (24.1%), three to five CTCs in 37 (16.8%), and more than five CTCs in 7 (3.2%) of these patients. Univariate analyses revealed that CTC prevalence was not significantly associated with tumor size (pT1, pT2, pT3, pT4), nodal stage (pN0, pN1, pN2, pN3), grading (G1, G2, G3), histological type (invasive ductal, invasive lobular, other), estrogen-receptor status, or progesterone-receptor status (Chi-square tests, all p &gt; 0.1). There was no significant difference with respect to the prevalence of CTCs after chemotherapy between the two treatment arms (Chi-square test, p = 0.23), as CTCs were detected in 11.6% (103 out of 889) of patients treated with the anthracycline-containing chemotherapy regimen and in 13.5% (117 out of 868) of patients treated with the anthracycline-free chemotherapy regimen. In addition, there was no significant difference between the two treatment arms with regard to the number of CTCs detected after chemotherapy in CTC-positive patients (FEC-DOC: median = 1, range 1 – 18; DOC-C: median = 1, range 1 – 8; Mann-Whitney U test, p = 0.30).

Conclusions: The comparable prevalence and number of CTCs after the completion of chemotherapy may indicate that anthracycline-free chemotherapy is not inferior to anthracycline-containing chemotherapy in this study. This however, has to be confirmed by survival analyses, which will be available in 2014.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-12-09.

Abstract P1-04-06: Discordance of the ER- and HER2-status on disseminated tumor cells compared to the primary tumor in patients with early breast cancer

Background: Differences in ER- and HER2-expression on metastases compared to the primary tumor (PT) are a known phenomenon and may have clinical implications in respect of targeted systemic treatment approaches. The aim of this study was to evaluate both ER- and HER2-status on disseminated tumor cells (DTCs) in the bone marrow (BM) of patients (pts) with early breast cancer (EBC) and to compare these with the corresponding PT.

Methods: BM aspirates were obtained at the time of first surgery. After Ficoll enrichment for mononuclear cells two cytospins with 106 BM cells were evaluated for ER-, HER2- and cytokeratin (CK) -expressions simultaneously by immunocytochemistry using a triple fluorescence staining method with antibodies directed against human ER (secondly labeled with Cy3, red), HER2 (Coumarin-AMCA, blue) and CK (DyLight488, green). The manual analysis was conducted using a computerized fluorescence microscope (Axioskop, Zeiss, Germany). Criteria for CK- and HER2-positivity were the ring-like appearance of the respective membrane stainings and for ER-expression a nuclear staining. Only pts with the detection of CK positive cells (DTC+) and known ER- and HER2-status of the PT (n = 54) were selected for this analysis.

Results: The median number of DTCs was 13 (range 1-95; total number of DTCs detected: 1082). 40 (74%) of the pts had at least one ER-positive (pos) DTC, 24 (44%) at least one HER2-pos DTC, 14 (26%) at least one ER-pos/HER2-pos DTC, and 50 (93%) at least one ER-negative/HER2-negative (neg) DTC, while 10 (19%) pts had only ER-neg/HER2-neg DTCs.

The concordance rate between ER-status on DTCs and PT was 74%. Pts with an ER-pos PT were significantly more likely to have at least one ER-pos DTC (34 out of 42) than pts with an ER-neg PT (6 out of 12; Chi-square test, χ2 = 4.66, p = 0.031). 39 (93%) of the 42 pts with ER-pos PT had at least 1 ER-neg DTC.

The concordance rate between HER2-status on DTCs and PT was 52%. The probability of having at least one HER2-pos DTC was not related to the HER2-status of the PT (Chi-square test, χ2 = 0.34, p = 0.56). 22 (46%) of the 48 pts with a HER2-neg PT had at least one HER2-pos DTC. All of the 6 pts with a HER2-pos PT had at least one HER2-neg DTC.

7 out of 10 pts with a triple-neg PT had at least one DTC pos for ER, HER2 or both. Further the heterogeneity of the ER- and HER2-expression on DTCs compared to the PT for different DTC counts was evaluated. We detected all possible combinations of ER- and HER2-experssion on DTCs regardless of the respective status of the PT.

Conclusions: Our study confirms that the ER- and/or HER2-status on DTCs may differ compared to the PT. This discordance could be especially important for pts with a triple-neg PT and ER-pos or HER2-pos DTCs, since they might respond favorably to an endocrine or HER2-targeted therapy. On the other hand, the presence of ER-neg or HER2-neg DTCs in pts with ER-pos or HER2-pos PT might explain some of the failures of adjuvant endocrine or HER2 targeted therapy.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-04-06.

Participation in the SUCCESS-A Trial Improves Intensity and Quality of Care for Patients with Primary Breast Cancer

The SUCCESS-A trial is a prospective, multicenter, phase III clinical trial for high-risk primary breast cancer. It compares disease-free survival after randomization in patients treated with fluorouracil, epirubicin and cyclophosphamide followed by 3 cycles of docetaxel (FEC-D) with that of patients treated with 3 cycles of FEC followed by 3 cycles of gemcitabine and docetaxel (FEC-DG). After a second randomization patients were treated with zoledronate for 2 or 5 years. A total of 251 centers took part in the trial and 3754 patients were recruited over a period of 18 months which ended in March 2007. In a questionnaire-based survey we investigated the impact of enrollment in the trial on patient care, the choice of chemotherapy protocol and access to current oncologic information as well as overall satisfaction in the respective centers. Analysis of the 78 questionnaires returned showed that 40 % of the centers had never previously enrolled patients with these indications in clinical studies. Prior to participating in the study, 4 % of the centers prescribed CMF or other protocols in patients with high-primary breast cancer risk, 46 % administered anthracycline-based chemotherapy and 50 % gave taxane-based chemotherapy. Around half of the participating centers noted that intensity of care and overall quality of care became even better and that access to breast cancer-specific information improved through participation in the trial. After their experience with the SUCCESS-A trial, all of the centers stated that they were prepared to enroll patients in clinical phase III trials again in the future. These data indicate that both patients and physicians benefit from clinical trials, as enrollment improves treatment strategies and individual patient care, irrespective of study endpoints.

Abstract P2-01-02: Circulating Tumor Cells (CTC) may Express HER2/neu in Patients With Early HER2/neu Negative Breast Cancer – Results of the German SUCCESS C Trial

Background: There is growing evidence that the HER2/neu-status of distant metastases or minimal residual disease in blood and bone marrow may differ from the primary tumor in patients with breast cancer. The HER2/neu-status of CTCs was prospectively evaluated in patients with HER2/neu negative primary breast cancer randomized into the German multicenter SUCCESS C study.

Methods: The SUCCESS C trial is a randomized Phase III study comparing FEC-Docetaxel (FEC-Doc) vs. Docetaxel-Cyclophosphamid (DC) as well as 2 years of a lifestyle-intervention in patients with early, HER2/neu negative, node positive or high-risk node negative primary breast cancer.

As part of the translational research program, 23ml peripheral blood were drawn after adjuvant chemotherapy. In 505 samples, the prevalence of CTCs and their HER2/neu-status were assessed using the CellSearch System (Veridex, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labelled with anti-CK8/18/19 and anti-CD45 antibodies. A fluorescein conjugate antibody with anti-CK-Fluorescein Isothiocyanate (FITC) was used for HER2/neu phenotyping. The cut-off for CTC-positivity was ≥ 1 CTC and for HER2/neu ≥ 1 CTC with strong HER2/neu-staining (+++).

Results: 26,9% of pts (n = 136) were positive for CTCs (mean 1.78; range 1–7; median = 1). The number of detected CTC was distributed as follows: 1 CTC (n = 76; 55.9%), 2 CTCs (n = 35; 25.7%), 3 CTCs (n = 13; 9.6%), 4 CTCs (n = 7; 5.2%) and ≥ 5 CTCs (n = 5; 3.7%). HER2/neu staning of CTCs was not detectable or weak in 26.5% (n = 36) and 4.4% (n = 6) of CTC positive patients respectively and therefore categorized as HER2/neu negative. In 32.4% of the CTC-positive patients (n = 44), we detected moderate and in 36.8% (n = 50) strong HER2/neu-staining of ≥ 1 CTC per sample. No association was found between CTCs or the HER2/neu-status of CTCs with tumor size, histopathological grading, hormone receptor status or axillary lymph node involvement.

Conclusions: The data of this trial confirm previous findings that patients with HER2/neu negative primary breast cancer can show HER2/neu positive minimal residual disease. These results underline the importance of frequent HER2/neu determination during follow up and disease progression. Survival data within the Success C trial will give further insight into the tumor biology of HER2/neu negative disease.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-01-02.

Abstract P4-13-11: Prognostic factors in young breast cancer patients over time – a 40 year longitudinal analysis

Background: In younger patients (pts) breast cancer (BC) is associated with a worse prognosis compared to older pts. Only few data are available presenting the development of prognostic factors regarding a period of several decades. This 40 year (y) longitudinal comparison of the main prognostic factors was performed to investigate differences in younger women with primary BC in contrast to older women over time.

Patients and Methods: In this retrospective analysis a consecutive pts cohort of 4010 pts was analyzed. Pts were documented and treated for primary invasive breast cancer between 1963 and 2003 at two University Hospitals in Germany. To be eligible, pts were required to have identified tumor characteristics, including TNM-status. Pts with carcinoma in situ or distant metastases were excluded. The cohort was divided in two age groups, ≤40y and &gt;40y. Furthermore to reveal trends and changes over the duration of 41 years the period of analysis was split into 3 time frames: 1963–1976, 1977–1989 and 1990–2003. We analyzed the main prognostic factors for BC including tumor size, grading, nodal status and HR-status in longitudinal comparison regarding the three time frames, respectively. During 1963–77 HR-status was determined in just 12.6% of pts. Thus, this time frame was excluded in the analysis of HR-status.

Results: In 41 yrs, 747 (18.6%) pts were treated between 1963–76, 1722 pts (42.9%) in 1977–89 and 1541 pts (38.4%) in 1990–2003. Overall 358 pts were ≤40y and 3652 pts were over the age of 40.

A significant reduction of tumor size (metric assessment) at primary diagnosis was observed for both age groups (pts≤40y: p = 0.012; pts&gt;40y: p &lt; 0.0001) with no difference between the time frames, respectively (1963–76: p = 0.289; 1977–89: p = 0.647; 1990–2003: p = 0.937).

The number of node-positive pts significantly decreased in pts &gt;40 y (p = 0.001) whereas no difference could be seen in pts aged ≤40 y (p = 0.991).

In both age groups the number of G2/3 tumors increased over the yrs (pts≤40y: p = 0.001; pts&gt;40y: p &lt; 0.0001). Between 1963–76 more G1-tumors were diagnosed in younger pts (p = 0.041) whereas in the two following periods significantly more G2/3 tumors (p = 0.001; p = 0.002) were observed in this group.

In young pts, 54.2% were HR-negative in 1977–89 and 47.6% in 1990–2003 (p = 0.323). In pts &gt;40y 38.4% and 21.7% were HR-negative, respectively (p &lt; 0.0001). Comparing the age groups, significantly more pts were HR-negative in the young patient group (p = 0.001 (1977–89) and p &lt; 0.0001 (1990–2003)).

Conclusions: Concerning the large period of 40yrs, technical improvement and increasing awareness for BC are reasons for decreasing tumor size at the time of primary diagnosis. However, the rate of node-positive pts in the young patient group remained stable. Furthermore, the high percentage of HR-negative pts and the increasing number of pts with unfavorable tumor grade demonstrate more aggressive tumor types in younger pts. These data confirm the need to improve screening tools to early identify young women with the risk to develop breast cancer, and for personalized treatment approaches in these patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-11.

Abstract P2-01-11: Detection and characterization of circulating and disseminated tumour cells in blood and bone marrow of breast cancer patients by two different biochemical methods

Background: The main reason for breast cancer associated death are remote metastases, that are due to cells, that dissolve from the primary tumour, and are found in blood (circulating tumour cells, CTCs) and bone marrow (disseminated tumour cells, DTCs). The detection of these cells in breast cancer patients is mostly linked to a worse prognosis.

We present an immunohistochemical staining method for the detection of DTCs from bone marrow by using the cancer-associated Thomsen-Friedenreich antigen (TF) in combination with Her-2, and stem cell markers (Muc-1, ALDH1A1), and a highly sensitive RT-PCR based approach for CTC-detection from peripheral blood of adjuvant breast cancer patients using the established cytokeratin markers CK8, 18 and 19.

Materials and Methods: 20ml blood and 2–3ml of bone marrow were withdrawn from 20 respectively 40 primary breast cancer patients during surgery. For this investigation we used only samples of patients with at least one CTC already detected with the FDA approved VERIDEX CellSearch System.

RT PCR investigations blood samples from healthy donors were taken and used as control group.

For both methods an enrichment of mononuclear cell fraction, containing DTCs and CTCs, was carried out by density gradient centrifugation.

For immunohistochemical staining cells were spun down on coverslips fixed and stained with antibodies against Thomsen-Friedenreich-Antigen and Her-2, MUC1 or ALDH1A1.

For Real-Time PCR RNA was isolated from the cell pellet obtained by density gradient centrifugation, reversely transcribed to cDNA and RT-PCR was run with Taq-Man Primers against Cytokeratin (CK) 8, 18 and 19. The housekeeping gene 18S was used as internal reference.

Results: For the staining of Her-2 and TF, 78,01% of all samples showed at least one stained cell. The biggest subgroup within these samples was the double stained one with 46,14%.

In the other two experimental settings respectively the biggest cohorts were only single stained with TF (47,4% for TF-MUC1) or ALDH1A1 (59,65% for TF-ALDH1A1).

Within the PCR trials, the investigation between the negative control group and adjuvant breast cancer blood samples showed significant correlations for the expressions of CK8 (p &lt; 0,047) and CK18 (p &lt; 0,041). CK19 showed borderline significance (P &lt; 0,057) of correlation.

Conclusion: The immunostaining-combination of diverse cell surface antigens for detection and characterization of DTCs, especially the TF antigen, in combination with Her-2, Muc-1 and ALDH1A1 is an excellent way to detect DTC's in bone marrow due to its significant correlations (p &lt; 0.001).

The verification of CTC's by using RT-PCR is possible by using epithelial marker genes like the cytokeratins, especially CK8 and 18.

Both methods can be a step towards modern personalized medicine and lead to new ways of early tumour detection. Additionally an improved tumour characterization might ease the decision on specific medical treatment (eg against Her-2).

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-01-11.

P1-07-24: Quantitative and Immunohistochemical Detection of Breast Cancer Cells in Blood Samples

Background Disseminated tumor cells (DTCs) in bone marrow and circulating tumor cells (CTCs) in blood are found in patients with epithelial carcinomas (breast cancer) and are often correlated with poor prognosis of the disease. In current models circulating tumor cells (CTCs) dissolved from the primary tumor are thought to be responsible for the occurrence of metastases. However, the detection of CTCs is still a technical challenge. In this study, two methods for tumor cell detection of patients’ samples are presented (Real-Time-PCR and immunohisto-chemical staining). Both are simple and known methods with a high sensitivity and a spread marker panel.

Materials and Methods For the implementation of both methods, different breast cancer cell lines have been used (Cama-1, MCF-7; ZR-75-1). For Real-Time-PCR, blood samples of a healthy donors were spiked with different cell counts (0, 10, 100, 1000, 10.000 and 100.000) per ml blood sample. Total RNA was isolated from the samples, reversely transcribed into cDNA and used for TaqMan Real-Time-PCR reaction with probes against CK8, 18 and 19, while 18S was used as reference. Relative Quantification Curves were drawn by Microsoft™ Excel®. For immunohistochemical staining, cytospins were prepared from spiked blood samples, fixed with acetone, air dried and stained with antibodies against Her2- and Thomsen-Friedenreich-Antigen (CD176). In a second staining step fluorescently labelled secondary antibodies were applied. Nuclei were counterstained with DAPI, TF-Antigen was stained by Cy2 and Her2-Antigen by Cy3. The staining was controlled and documented by an epifluorescence microscope.

Results The curve of Relative Quantification for MCF-7 and ZR-75-1 cells shows an increasing slope starting from 1000 cells. For the Cama-1 cell line this trend is already seen from 10–100 cells. In ZR-75-1 all three genes analysed reveal this trend, whereas in Cama-1 and MCF-7 cells a strong increase in Relative Quantification is especially seen for CK8 and 18. In the immunohistochemical staining, the cells were considered as tumour cells if they showed staining with the antibody-combinations used. Stained cells were counted and recovery rates were determined. For ZR-75-1, 17 of 30 cells which were spiked in the blood samples were recovered. For MCF-7, 18 cells were found in average, and for Cama-1 23 cells were located per slide. The recovery rates calculated from these numbers are 56,6% and 60,0% for ZR-75-1 and MCF-7, for Cama-1 the recovery rate reaches 76,6%.

Conclusion It seems that Cama-1 cells are a better model than MCF-7 and ZR-75-1 for Real-Time PCR quantification of mamma carcinoma tumor cells in blood samples. MCF-7 and ZR-75-1 cells tend to react more likely immunologically with blood cells of the donor (agglutination between blood cells and cancer cells). The Cama-1 cell line shows also advantages in the detection of tumor cells using immunohistochemical staining. Therefore it will be necessary to test both methods on patient samples to proof their benefit.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-24.

Prognostic relevance of disseminated tumor cells in the bone marrow of patients with primary breast cancer--results of a standardized follow-up

BACKGROUND

The prognostic significance of disseminated tumor cells from bone marrow (BM-DTCs) of breast cancer patients has been demonstrated previously. In this study, data of a standardized long term follow-up of 829 patients with examination of BM-DTCs at primary diagnosis are presented.

PATIENTS AND METHODS

BM aspiration and immunocytochemical examination of DTCs was performed according to a standardized protocol. Follow-up data of all patients were adjusted with the cancer registries of southern Bavaria.

RESULTS

A total of 268 patients (32%) had BM-DTCs with a median of 2 (1-1223)/2 x 10⁶ cells. Positive BM findings correlated with tumor size (p=0.032), but not with other histopathological parameters. After a median follow-up of 73 months, BM-DTCs were highly relevant for the development of distant metastases (p=0.006) and, beneath standard histological parameters, reduced overall survival (p=0.038).

CONCLUSION

These results confirm the prognostic relevance of the detection of BM-DTCs. Newer methods, such as detection of circulating tumor cells in blood, will have to demonstrate comparable prognostic information in the future.

Abstract PD04-08: Circulating tumor cells (CTC) in peripheral blood of breast cancer patients two years after adjuvant chemotherapy depending on endocrine treatment — The German SUCCESS-Trial

Background: The prognostic significance of CTC in metastatic, as well as in primary breast cancer has been demonstrated (Rack et al., ASCO 2010). The optimal endocrine treatment strategy for postmenopausal patients (pts) with hormone sensitive breast cancer remains unclear.We analyzed the prevalence of CTC two years after primary diagnosis in patients with tamoxifen or anastrozole treatment.

Methods: As part of the translational research project of the German SUCCESS-trial, we analyzed 23ml of peripheral blood from 307 N+ and high risk N-postmenopausal pts with hormone sensitive breast cancer two years after adjuvant taxane based chemotherapy and with tamoxifen or anastrozole treatment. The presence of CTCs was assessed with the CellSearchSystem (Veridex, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labelled with anti-cytokeratin (8,18,19) and anti-CD45 antibodies to distinguish between epithelial cells and leukocytes. Standard within the study was early switch treatment (tamoxifen for 2 years, followed by anastrozle), while pts with contraindications against tamoxifen were allowed to receive anastrozole up-front.

Results: In 10.1% of pts (n=31) &gt;1 CTC was detected after the completion of chemotherapy (range 2-33), while 7.8% (n=24) presented with &gt;1 CTC (range 2-99) two years after completion of chemotherapy. The median age in the tamoxifen group was 59.9 years and 59.8 in the anastrozole group. In the tamoxifen group, 33.0% of the pts had a pT1 tumor, 5.3% G1 grading and 21.6% of the pts were node negative. In the anastrozole group, 30.0% of the pts had a pT1 tumor, 7.5% G1 grading and 22.5% of the pts were node negative, respectively. None of these differences were statistically significant. After the completion of chemotherapy, 9.7% of the pts were CTC positive in the tamoxifen group (range number of cells: 2-33) and 11.3% in the anastrozole group (range of cells: 2-24), p=0.69. Two years after primary diagnosis, 7.9% of the pts were CTC positive in the tamoxifen group (range number of cells:2-99) and 7.5% in the anastrozole group (range cells: 2-5), p=0.90. Actuarial disease free and overall survival will be presented at the meeting.

Conclusions: The prognostic relevance of CTC in peripheral blood of early breast cancer patients both before and after chemotherapy has been demonstrated. The presented data will add information on the monitoring potential of CTC during adjuvant endocrine treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD04-08.