Abstract P3-03-18: Invasive lobular carcinoma does not fit to axillary lymph node management according to NCCN guideline influenced by ACOSOG Z0011 criteria

[Introduction] Surgery for breast cancer (BC) became less invasion, from radical mastectomy to modified or breast conserving surgery (BCS). Axillary lymph node (ALN) management for cN0 also became less, from ALN dissection (ALND) to sentinel lymph node (SLN) biopsy. In some cases, management without ALND is allowed even if ALN macro-metastasis exist.

[Background] ALND for SLN metastasis positive case is useful for local control, staging and decision making for post-operative treatment. Since the ACOSOG Z0011 trial (Z11) result was reported, however, the necessity of ALND, even if SLN metastasis, became less. In the NCCN guideline (NCCN), strongly influenced by Z11, for cN0 BC with SLN metastasis, operations without ALND are allowed in cases of T1 or T2, the number of metastatic ALN 1 or 2, BCS with whole breast radiation and no-neoadjuvant therapy. This does not mean ALND was abolished but the position of ALND changed, from the perspective that over invasive procedure must be prohibited with appropriate pre-operative and intra-operative diagnosis. If there are some discordance between clinical and pathological diagnosis of tumor size or ALN metastasis, however, the criteria for axillary operation by NCCN will not be recommended. We have major two types of invasive carcinoma, ductal (IDC) and lobular (ILC). Z11 or NCCN did not describe about these two phenotypes. We compared these at the point of suitable axillary management.

[Subjects] Out of 1320 invasive BC (IDC; 1212, ILC; 108) cases in our hospital from January 2008 to January 2018, 1210 cases (IDC; 1113, ILC; 97) with T1/T2 and cN0 were reviewed in two points, the judgment of the competence for BCS was appropriate or not, and cN0 reflected the condition for the omission of ALND (ALN metastasis within 2) or not.

[Results] The difference of diameter between cT and pT; dT (=pT-cT) were measured significantly larger in ILC (0.68±1.97cm) than IDC (0.01±1.08cm)(p<0.01, t-test) with the wide scattering. We can make proper evaluation for the cT of IDC, but underestimate for ILC. The conversion rate from cN0 to pN1 was significantly higher in ILC (33/97; 34.0%) than IDC (238/1113; 21.4%)(p<0.01, χ2 test). In addition, the cases with 3 or more ALN metastasis, this means ALND is necessary, was observed with significantly higher frequent in ILC (13/97; 13.4%) than IDC (74/1113; 7.1%)(p=0.02, χ2 test). Clinical evaluation for ALN in ILC was difficult and inaccurate.

[Discussion] Commonly, ILC makes diffuse spread into the breast tissue. This feature will make it difficult to evaluate the clinical appropriate tumor size. Because of not only underestimation but wide scattering, the diagnosis for safety BCS may not be guaranteed in ILC. For ALN, cN0 did not reflect adequately the condition of omission for ALND in ILC compared with IDC. ILC patients with SLN metastasis have to be performed ALND at higher risk. These facts will mean that ILC does not fit to ALN management according to NCCN. Few guidelines separate ILC from IDC for the axillary management. The validation of clinical trials for ALND should be done in histological subtype as well as intrinsic again. Clinically, we must observe carefully in cases of ILC without ALND according to Z11.

Citation Format: Miyamoto T, Fujisawa T, Morishita A, Yanagita Y, Fujii T-A. Invasive lobular carcinoma does not fit to axillary lymph node management according to NCCN guideline influenced by ACOSOG Z0011 criteria [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 P3-03-18.

Efficacy and safety of trastuzumab, lapatinib, and paclitaxel neoadjuvant treatment with or without prolonged exposure to anti-HER2 therapy, and with or without hormone therapy for HER2-positive primary breast cancer: a randomised, five-arm, multicentre, open-label phase II trial

Background

Dual blockade of HER2 promises increased pathological complete response (pCR) rate compared with single blockade in the presence of chemotherapy for HER2-positive (+) primary breast cancer. Many questions remain regarding optimal duration of treatment and combination impact of endocrine therapy for luminal HER2 disease.

Methods

We designed a randomised phase II, five-arm study to evaluate the efficacy and safety of lapatinib and trastuzumab (6 weeks) followed by lapatinib and trastuzumab plus weekly paclitaxel (12 weeks) with/without prolongation of anti-HER2 therapy prior to chemotherapy (18 vs. 6 weeks), and with/without endocrine therapy in patients with HER2+ and/or oestrogen receptor (ER)+ disease. The primary endpoint was comprehensive pCR (CpCR) rate. Among the secondary endpoints, pCR (yT0-isyN0) rate, safety, and clinical response were evaluated.

Results

In total, 215 patients were enrolled; 212 were included in the full analysis set (median age 53.0 years; tumour size = T2, 65%; and tumour spread = N0, 55%). CpCR was achieved in 101 (47.9%) patients and was significantly higher in ER− patients than in ER+ patients (ER− 63.0%, ER+ 36.1%; P = 0.0034). pCR with pN0 was achieved in 42.2% of patients (ER− 57.6%, ER+ 30.3%). No significant difference was observed in pCR rate between prolonged exposure groups and standard groups. Better clinical response outcomes were obtained in the prolongation phase of the anti-HER2 therapy. No surplus was detected in pCR rate by adding endocrine treatment. No major safety concern was recognised by prolonging the anti-HER2 treatment or adding endocrine therapy.

Conclusions

This study confirmed the therapeutic impact of lapatinib, trastuzumab, and paclitaxel therapy for each ER− and ER+ subgroup of HER2+ patients. Development of further strategies and tools is required, particularly for luminal HER2 disease.

Electronic supplementary material

The online version of this article (10.1007/s12282-018-0839-7) contains supplementary material, which is available to authorized users.

Abstract P3-07-38: Increment of neutrophil/lymphocyte ratio (NLR) can be one of the useful predictive markers for the metastatic breast cancer (MBC) with first line hormonal therapy (HT)

[Introduction] Cancer microenvironment formed by the immune and inflammatory cells is noticed to be one of the factors for tumor growth, invasion or metastasis. To figure out the systemic inflammatory environment, the neutrophil / lymphocyte ratio (NLR) is a useful method and a simple indicator. We have some reports that NLR can predict the prognosis in many malignancies, including breast cancer, as I reported in SABCS 2014, however, NLR cannot be a predictive marker in major cancers, because the usage with anti-cancer agents will make NLR status out of order. In hormonal receptor positive metastatic breast cancer (HR+ve MBC), we choice hormonal therapy (HT) for the first line, mainly. HTs have little influence for NLR, therefore, the change of NLR, increment or decrement, can reflect the systemic inflammatory status and be a useful predictive marker for the HR+ve MBC with HTs.

[Purpose] I define dNLR as the difference between NLR at the 2-3 months after HT and before HT. To evaluate the dNLR affects the Overall Survival (OS) and Progression Free Survival (PFS) of the patients of MBC or not.

[Patients] From 2003 to 2013, we have 299 MBC patients in our hospital. Out of them, 134 patients had HTs as first line, included 18 Stage4 patients at the first visit. Median Disease free survival (DFS) is 1497-day, the median OS after the recurrence is 1472-day. Average value of the NLR before HT is 2.62. The reasons of MBC are bone metastases (mets), pleural and pulmonary mets, liver mets, lymph node mets, central nervous system (CNS) mets, unresectable metastatic chest wall recurrence, or other.

[Results] By univariate analysis, DFS < 1000 (p<0.01) and liver mets (p<0.05) made a contribution to poor OS. dNLR>=0.5 (p<0.05), liver mets (p<0.05) and 2 or more organs involvements (p < 0.05) made a contribution to poor PFS. With multivariate analysis, for OS, only DFS < 1000 was an independent prognostic factor. And for PFS, only dNLR>=0.5 was an independent predictive factor. Poor OS factors by univariate analysis had no influence for PFS as well as poor PFS factors did not reflect the OS.

[Discussion] The dNLR was a predictive marker for HR+ve MBC which we can easily and simply examine by blood sample. Now we cannot reveal the relationship with dNLR and OS, however, this fact suggests that we can decide to stop the first line HT and select the second line therapy using with not only images or tumor makers but also dNLR. This can certainly contribute for good OS. It remains some questions between dNLR and other examinations, for example, which can detect the patient status earlier and more accurate? First, we need to accumulate further retrospective cases and plan the prospective study to make sure of the adequate treatment divided by dNLR.

[Conclusion] The dNLR>=0.5 is one of the independent predictive markers for HR+ve MBC with first line HT.

Citation Format: Miyamoto T, Fujisawa T, Morishita A, Yanagita Y, Kuwano H. Increment of neutrophil/lymphocyte ratio (NLR) can be one of the useful predictive markers for the metastatic breast cancer (MBC) with first line hormonal therapy (HT). [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 P3-07-38.

Survival of HER2-positive primary breast cancer patients treated by neoadjuvant chemotherapy plus trastuzumab: a multicenter retrospective observational study (JBCRG-C03 study)

We investigated the disease-free survival (DFS) of HER2-positive primary breast cancer patients treated with neoadjuvant chemotherapy plus trastuzumab, as well as predictive factors for DFS and pathologic response. Data from 829 female patients treated between 2001 and 2010 were collected from 38 institutions in Japan. Predictive factors were evaluated using multivariate analyses. The 3-year DFS rate was 87 % [95 % confidence interval (CI) 85-90]. The pathologic complete response (pCR: ypT0/is + ypN0) rate was 51 %. The pCR rate was higher in the ER/PgR-negative patients than in the ER/PgR-positive patients (64 vs. 36 %, P < 0.001). Patients with pCR showed a higher DFS rate than patients without pCR (93 vs. 82 %, P < 0.001). Multivariate analysis revealed three independent predictors for poorer DFS: advanced nodal stage [hazard ratio (HR) 2.63, 95 % CI 1.36-5.21, P = 0.004 for cN2-3 vs. cN0], histological/nuclear grade 3 (HR 1.81, 95 % CI 1.15-2.91, P = 0.011), and non-pCR (HR 1.98, 95 % CI 1.22-3.24, P = 0.005). In the ER/PgR-negative dataset, non-pCR (HR 2.63, 95 % CI 1.43-4.90, P = 0.002) and clinical tumor stage (HR 2.20, 95 % CI 1.16-4.20, P = 0.017 for cT3-4 vs. cT1-2) were independent predictors for DFS, and in the ER/PgR-positive dataset, histological grade of 3 (HR 3.09, 95 % CI 1.48-6.62, P = 0.003), clinical nodal stage (HR 4.26, 95 % CI 1.53-13.14, P = 0.005 for cN2-3 vs. cN0), and young age (HR 2.40, 95 % CI 1.12-4.94, P = 0.026 for ≤40 vs. >40) were negative predictors for DFS. Strict pCR (ypT0 + ypN0) was an independent predictor for DFS in both the ER/PgR-negative and -positive datasets (HR 2.66, 95 % CI 1.31-5.97, P = 0.006 and HR 3.86, 95 % CI 1.13-24.21, P = 0.029, respectively). These results may help assure a more accurate prognosis and personalized treatment for HER2-positive breast cancer patients.

Abstract P3-12-03: Adjuvant capecitabine in breast cancer patients with pathologic residual disease after neoadjuvant chemotherapy: First safety analysis of CREATE-X (JBCRG-04)

Background

Patients (pts) without pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) have a poor prognosis compared with pts achieving a pCR with NAC. It is not clear whether further systemic chemotherapy is beneficial for pts with no pCR. CREATE-X (UMIN000000843) is an ongoing collaborative Korean (KRN)/Japanese (JPN) prospective multicenter open-label randomized phase III trial evaluating this clinical question using capecitabine (X) in pts with no pCR after NAC. We report first safety results, focusing on hand-foot syndrome (HFS), the timing of radiotherapy (RT) and hormone therapy (HT), and differences between KRN and JPN pts.

Methods

Pts with residual invasive cancer after anthracycline- and/or taxane-containing NAC were randomized to standard post-surgical treatment (RT, HT as appropriate) with or without 8 cycles of X (1250 mg/m2 bid, days 1–14 q3w). RT was given before or after X. Pts with hormone receptor (HR)-positive disease received HT either with or after X, according to each center's prespecified standard practice. After evaluation of the tolerability of 6 cycles of X in the first 50 pts, the independent data monitoring committee recommended extending X to 8 cycles.

Results

Between Feb 2007 and Jul 2012, 910 pts were enrolled (304 in Korea, 606 in Japan). At the time of data cut-off (May 20, 2013), data were available from 866 pts. Median age was 48 years in both arms. In the investigational arm, RT was given before X in 260 pts and after X in 33 pts; 73 pts received prophylactic vitamin B6 (VB6). In HR-positive pts HT was given with X in 200 pts and after X in 24 pts. The relative dose intensity of X was 85.7% in JPN pts and 95.2% in KRN pts. Grade (G) 3/4 neutropenia, HFS (G3 only), fatigue, and diarrhea were significantly (p&lt;0.05) more common with X than no X. G3 HFS occurred in 11.1% of pts receiving X, and was significantly more common in JPN vs KRN pts (p = 0.016). No significant difference in HFS was observed between pts who received vs did not receive VB6 (p = 0.392). G3/4 alanine aminotransferase (ALT) abnormalities were significantly more common in pts receiving RT after vs before X (p&lt;0.001) and in pts receiving HT after vs concurrently with X (p&lt;0.001).

 n/N(%) Investigational armControl arm (n = 430)(n = 436)HR status Positive275/430(64)275/436(63)Negative141/430(33)143/436(33)Unknown14/430(3)18/436(4)G 3/4 toxicity Neutropenia36/385(9)5/326(2)Fatigue6/426(1)0/417(0)Diarrhea12/426(3)1/417(&lt;1)HFS(G3)47/424(11)0 JPN40/296(14)0 KRN7/128(5)0 VB66/73(8)- No VB641/351(12)-ALT abnormality10/409(2)3/391(&lt;1) with RT8/285(3)1/280(&lt;1) X → RT8/31(26)- RT → X0/254(0)- without RT2/124(2)2/111(2) with HT2/214(1)1/267(&lt;1) X + HT0/190(0)- X → HT2/24(8)- wothout HT8/195(4)2/124(2)

Conclusions

Addition of 8 cycles of X to standard adjuvant therapy is feasible and tolerable, resulting in a modest yet acceptable increase in toxicities. The timing of RT and HT administration relative to X influenced the incidence of adverse events. HFS was more common in JPN than KRN pts, although further investigation of the potential cause of this difference is required. These findings should be interpreted in light of efficacy data, expected in 2015.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-12-03.

Abstract P6-06-20: Predictive factors for pathologic complete response and disease-free survival after neoadjuvant chemotherapy with trastuzumab: A multicenter retrospective observational study in patients with HER2-positive primary breast cancer (JBCRG-C03 study)

BACKGROUND:

Addition of trastuzumab to neoadjuvant chemotherapy (NAC) improved pathologic complete response (pCR) rate in HER2-positive breast cancer. Although recent trials have shown favorable prognosis with NAC plus trastuzumab, clinicopathological factors to predict the outcome have not been fully understood. The aim of this study was to investigate the survival after NAC with trastuzumab and to explore the predictive factors.

PATIENTS AND METHODS:

This is a multicenter retrospective observational study. Patients with HER2-positive primary breast cancer treated with NAC plus trastuzumab from 2001 to 2010 were identified from the institutional database. Primary end point was disease-free survival (DFS). pCR was defined as ypT0/is+ypN0. Kaplan-Meier method was used to estimate DFS. Logistic regression and proportional hazard analysis were used to identify clinicopathological factors to predict pCR and DFS, respectively.

RESULTS:

733 patients were included in the analysis (whole dataset). 425 were ER/PgR-negative (HR- dataset) and 306 were ER/PgR-positive (HR+ dataset). Radiation therapy was performed in 90% of lumpectomy and 31% of mastectomy. Hormonal therapy was performed in 84% of HR+ dataset. pCR rate was 45% in whole dataset, 60% in HR- dataset, and 34% in HR+ dataset. Table 1 showed the result of multivariate analysis for pCR in whole dataset. When HR+ and HR- dataset were analyzed separately, no definitive predictors for pCR were identified in multivariate analysis. Although the patients with pCR showed a significantly favorable prognosis than those without pCR at 3 years DFS, in whole dataset (93% vs 83%, p&lt;0.0001) and HR- dataset (94% vs 80%, p&lt;0.0001), there was no significant difference in HR+ dataset (89% vs 86%, p = 0.10). Different predictors were selected for DFS when multivariate analysis was conducted separately between HR- and HR+ dataset (Table 2).

CONCLUSIONS:

In this observational study, we clarified predictors for pCR and DFS in HER2-positive patients treated with neoadjuvant trastuzumab containing therapy based on tumor subtype. Our results may help us to predict the prognosis more precisely and to simulate the disease course.

Table 1) Multivariate logistic regression analysis for pCR in whole datasetFactorsOR95%CIp-valuePost- vs Pre-menopause1.50(1.05-2.15)0.026*cT1-2 vs cT3-41.72(1.16-2.59)0.008*ER/PgR-negative vs ER/PgR-positive3.32(2.30-4.82)&lt;0.0001*Grade 3 vs 1-21.28(0.89-1.84)0.183

Table 2) Multivariate proportional hazard analysis for DFSFactors†HR95%CIp-valueWhole dataset   Pre- vs Post-menopause1.61(1.04-2.52)0.033*cN2-3 vs cN03.06(1.58-6.24)0.001*cN1 vs cN02.26(1.23-4.41)0.007*Grade 3 vs 1-21.87(1.20-2.97)0.006*non-pCR vs pCR1.90(1.18-3.13)0.008*HR- dataset   Pre- vs Post-menopause1.70(1.01-2.85)0.046*cT3-4 vs cT1-21.86(1.09-3.17)0.024*non-pCR vs pCR3.28(1.90-5.87)&lt;0.0001*HR+ dataset   cN2-3 vs cN05.01(1.79-16.19)0.002*cN1 vs cN03.50(1.40-10.61)0.006*Grade 3 vs 1-22.95(1.52-5.87)0.001*†Only factors with statistical significance

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-20.

Abstract P3-14-05: Randomized phase II study of preoperative docetaxel and cyclophosphamide-containing chemotherapy for luminal-type breast cancer

Background: We compared and evaluated three 6-cycle, docetaxel and cyclophosphamide (TC)-containing chemotherapy regimens in a multicenter randomized phase II study. The main aim was to investigate whether anthracyclines are needed or can be omitted, and whether the order of chemotherapy is important, for treating luminal-type breast cancer.

Methods: We recruited patients (pts) with ER-positive, HER2-negative breast cancer aged 20–70 years, and histo-pathologically invasive breast cancer (T1c-3, N0-1, M0), T≤7cm. Pts were randomized to 3 groups for the following treatments: 6 cycles of TC; 3 cycles of 5-FU/epirubicin/cyclophosphamide (FEC) followed by 3 cycles of TC (FEC-TC); and 3 cycles of TC followed by 3 cycles of FEC (TC-FEC). TC treatment consisted of administration of docetaxel at 75 mg/m2 and cyclophosphamide at 600 mg/m2 once every 3 weeks. FEC treatment consisted of administration of 5-FU at 500 mg/m2, epirubicin at 100 mg/m2, and cyclophosphamide at 500 mg/m2 once every 3 weeks. We aimed to enroll 65 pts per group based on an expected pCR rate among regimens of adding 10% at a threshold of 9%. The primary endpoint was pathological complete response (pCR) rate. Secondary endpoints were overall response rate (ORR), breast conservation rate and safety.

Results: A total of 195 pts (median age, 49.5 years (range, 26–69); median tumor size, 32.8 mm (range, 9–82); 91 pts with N(+) (51%)) were enrolled and randomized as follows: FEC-TC (n = 65), TC-FEC (n = 63), and TC group (n = 67). There were no differences in backgrounds among groups. Both the intention-to-treat population and the safety analysis set included 65, 63 and 65 pts in these groups, respectively. The 6-cycle treatment completion rates were 96.9%, 96.8% and 84.6%, respectively. pCR, defined as yT0/isyN0, was achieved by 9.2% of pts in the FEC-TC group, 8.1% in the TC-FEC group, and 15.9% in the TC group (p = 0.321). A quasi pCR in breast (yT0/is and near pCR) was achieved by 13.9%, 14.5%, and 17.5%, respectively. These responses did not differ among the 3 groups. ORRs, assessed by MRI or CT, were 75.8% (CR: 12.9%), 75% (CR: 5%), and 82.2% (CR: 17.9%) in the FEC-TC, TC-FEC and TC groups, respectively. Breast conservation rates were 50.8%, 45.2%, and 73.0%, respectively.Adverse events of Grade≥3 were observed in 20.0%, 27.0%, and 20.3% of pts in the FEC-TC, TC-FEC, and TC groups, respectively, with no significant differences. Febrile neutropenia was observed in 17.2%, 21.0%, and 11.3%, respectively, but in most cases it was managed sufficiently on an outpatient basis. Of 28, 27 and 23 pts in these groups in whom mastectomy was planned, 9 (32%), 5 (19%), and 10 (44%) were successfully converted to undergo breast-conserving surgery. Of 37, 35 and 40 pts in the FEC-TC, TC-FEC and TC groups in whom breast-conserving surgery was planned, 13 (35%), 12 (34%), and 4 (10%) underwent mastectomy.

Conclusion: Six cycles of TC had therapeutic effects and safety equivalent to FEC-TC and TC-FEC. The 3 treatment groups showed similar pCR rates, although the breast conservation rate was significantly higher in the TC group than in the other 2 groups. It may be possible to conduct preoperative chemotherapy for pts with ER-positive breast cancer without using an anthracycline.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-05.

P3-14-10: Early Predictive Value of Non-Responder to Docetaxel in Neoadjuvant Chemotherapy in Breast Cancer Using 18F- FDG-PET

Background; Clinical response is determined after several cycles of chemotherapy by changes in tumor size in imaging procedures including ultrasound, MRI or CT. The aim of this prospective study was to early detect non-responder to docetaxel (DTX) in neoadjuvant chemotherapy using 18F- FDG-PET in patients with breast cancer. Method; 41 patients were eligible for this study. 37 were assessable (4 were not eligible or not evaluable) with Invasive carcinoma (T1:10%, T2: 83%). All 37 patients were treated with 4 cycles of docetaxel (75mg per square meter) followed by 4 cycles of FEC(cyclophosphamide/epirubicin/fluorouracil: 500/75/500 mg per square meter) before surgery. 18F-FDG-PET response rate was evaluated between before and after the first cycle of DTX. 18F-FDG-PET images were analyzed by standardized uptake value, SUVmax. Clinical response is determined by reduction rate in tumor size with MRI (RECIST criteria) between before the first cycle and after the fourth cycle of DTX. Pathological response evaluated by core needle biopsy after the fourth cycle of DTX.

Result; 18F-FDG-PET response rate after the first cycle of DTX showed correlation with tumor size reduction rate with MRI image after the fourth cycle of DTX (r=0.746)(P &lt;.001). 0 out of 8 patients (0%) revealed cPR with MRI changes in SUV decrease less than 18% (p &lt;.001). 8 out of 13 patients (62%) showed cPR (cCR = 0) with MRI in SUV decrease over 19 to 44% (P &lt;.001). 9 out of 16 patients (56%) were cPR, and 7 out of them (44%) showed cCR with MRI in SUV decrease over 45% (P &lt;.001).

Conclusion; Changes of 18F-FDG SUVs in tumors were statistically significantly different between responding and nonresponding (P &lt;.001). SUV decrease less than 18% after the first cycle indicated potential failure to DTX in neoadjuvant chemotherapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-10.

Abstract P1-12-03: The STAGE Study: A Phase III Comparison of Anastrozole Plus Goserelin with Tamoxifen Plus Goserelin as Pre-Operative Treatments in Premenopausal Breast Cancer Patients

Background: Although superior antitumor activity of anastrozole over tamoxifen has been well established in postmenopausal breast cancer patients, it still remains to be examined whether or not anastrozole is superior to tamoxifen in premenopausal breast cancer patients whose ovarian function is suppressed by goserelin to postmenopausal levels. The aim of this study was to compare anastrozole plus goserelin versus tamoxifen plus goserelin as pre-operative treatment for premenopausal Japanese women with breast cancer.

Methods: Phase III, randomized, double-blind, parallel-group, multi-center study (D539BC00001). Premenopausal patients (pts) with ER-positive and HER2-negative breast cancer and with operable and measurable lesions (T [2-5 cm], N0, M0) were randomized 1:1 to receive a goserelin 3.6 mg depot injection once monthly plus either anastrozole 1 mg (A+G) or tamoxifen 20 mg (T+G) p.o. once daily. Treatment continued for 24 weeks prior to surgery or until any other criterion for discontinuation was met. Concomitant chemotherapy was not permitted during the pre-operative period. The primary objective was to assess the best overall tumor response (either a complete response [CR] or a partial response [PR]), according to modified RECIST criteria. Tumor size was measured by caliper and ultrasound every 4 weeks and by magnetic resonance imaging/computed tomography (MRI/CT) every 12 weeks. Tolerability (adverse events [AEs], laboratory tests, vital signs, WHO performance status) was assessed as a secondary objective. AEs were evaluated according to CTCAE v3.0.

Results: In total, 197 pts were randomized (A+G: 98, T+G: 99) and 185 pts completed the 24-week pre-operative treatment period and went on to receive breast surgery. The remaining 12 pts discontinued study treatment due to disease progression (A+G: 1; T+G: 5), voluntary discontinuation (A+G: 2; T+G: 3) and AE (T+G: 1). Pt demographics were generally well balanced. Median duration of exposure was similar for A+G (171 days) and T+G (170 days); treatment compliance was 99% for both. A+G led to a statistically significantly higher overall response rate compared with T+G, by caliper as well as by ultrasound and MRI/CT.

The safety profiles were consistent with the known safety profile of anastrozole, tamoxifen and goserelin. The incidence of AEs was similar

for A+G (88.8%) vs T+G (85.7%); most AEs were mild or moderate (CTC grade 1 or 2). The most common AEs were hot flash (A+G: 52.0%; T+G: 53.1%) and arthralgia (A+G: 35.7%; T+G: 20.4%). Conclusion: This study has demonstrated that the A+G combination has a superior benefit-risk profile compared with T+G as pre-operative treatment in Japanese premenopausal women with ER-positive breast cancer.

Integrated analysis of efficacy and safety of palonosetron (PALO) 0.75 mg IV for preventing chemotherapy-induced nausea and vomiting (CINV) in anthracycline and cyclophosphamide (AC/EC) combination chemotherapy in Japan: PALO Japanese breast cancer cooperative study group

Abstract #4099

Background: In the treatment of breast cancer, combination chemotherapy of AC/EC has been widely used for neoadjuvant, adjuvant chemotherapy or standard treatment of metastatic breast cancer. AC/EC frequently induces severe nausea and vomiting, that it is important to adequately prevent and control. PALO is the first novel serotonine antagonist approved for prevention of delayed nausea and vomiting in moderately emetogenic chemotherapy in US and other countries. Integrated analysis was done on the data from phase 2 and 3 trials that have been completed in Japan. The purpose of this analysis was to assess efficacy and safety of PALO for preventing CINV induced by AC/EC regimens.&#x2028; Methods: Three Japanese studies with single/repeated IV dose of PALO in pts receiving AC/EC were used. In all these studies, PALO 0.75 mg IV was administrated 30 min prior to AC/EC. Dexamethasone was administrated before AC/EC on day 1, and also on days 2-3 for the phase 3 trial. This integrated analysis assessed the efficacy and safety by difference in regimens (AC or EC), assessed the efficacy by difference in FEC (EC with 5-FU) or EC regimen and by difference in epirubicin (E) dosage in EC. Apart from the integrated analysis, efficacy of PALO in repeated cycles of chemotherapy was assessed by different regimens (AC or EC).&#x2028; Results: Total of 266 pts administrated AC/EC were evaluated for efficacy in single dose. Overall CR(CR = no emesis or rescue medication)% for PALO in acute phase was 70.7%. Overall CR% in delayed phase was 61.3%. CR% in acute and delayed phase for (a) AC (n=76) vs EC (n=190), (b) FEC (n=141) vs EC (n=49), (c) low (n=109) vs high (n=81) dosage of E (&lt;=90, &gt;90 mg/m2) in EC were as follows; (a) acute: 80.3 vs 66.8, delayed: 68.4 vs 58.4, (b) acute: 61.7 vs 81.6, delayed: 56.7 vs 63.3, (c) acute: 72.5 vs 59.3, delayed: 61.5 vs 54.3. Total of 155 pts administrated AC/EC were evaluated for efficacy of PALO in repeated cycles of chemotherapy, and similar efficacy between AC and EC was confirmed. Total of 474 pts administered AC/EC were evaluated for safety in all Japanese studies. There was no significant difference in the incidence of adverse drug reactions between AC and EC.&#x2028; Conclusion: This integrated analysis suggested that high antiemetic activity of PALO in CINV was shown for breast cancer pts receiving either AC or EC. In addition, in the FEC regimen and high dosage of E, all showed CR rate of more than 50% in both acute and delayed phases in the efficacy analysis, revealing a long lasting antiemetic activity of palonosetron.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4099.

A study on telomerase activity and prognosis in breast cancer

There are still many questions to be elucidated concerning the relationship between telomerase activity and various factors associated with cancer. Whether or not the level of telomerase activity could be a prognostic factor in breast cancer was investigated through 5-yr follow-up observation. Telomerase activity was quantified by the fluorescence-based telomeric repeat amplification protocol assay in 54 patients with breast cancer and its relationship with patient prognosis was examined. Telomerase activity was detected in 92.6% of breast cancer patients, with a median of 65.4 TPG (total product generated) (Min 0-Max 446.2). The follow-up observation for 5 yr demonstrated that among background factors examined, recurrence was the only factor that showed a significant association with the level of telomerase activity when a cutoff at 100 TPG was adopted. This suggested the possibility of 100 TPG telomerase activity being a prognostic factor for recurrence. Prospective studies will be necessary to clarify this matter.

Clinicopathological study of unilateral multiple breast cancer

BACKGROUND

The tendency for breast cancer to form multiple lesions is important to consider when planning breast-conserving surgery. However, many unknowns remain regarding the pathology and prognosis of multiple breast cancer, and therefore it is clinically significant to investigate its clinicopathological properties.

METHODS

Over the past 25 years, in the period between April 1972 and March 1997, we investigated the clinicopathological findings including the 5-year and 10-year survival rates of 66 patients treated for unilateral multiple breast cancer.

RESULTS

Of the total of 1,334 female patients with unilateral breast cancer who underwent curative surgery at our hospital, we identified 66 (5.0%) patients with unilateral multiple cancer. The incidence of such cancer has been higher in recent years. Of the 66 patients, 50 (75.8%) were premenopausal, and the remaining patients were postmenopausal, but multiple cancer among postmenopausal women is a recent phenomenon. The ER positivity rate of the main lesion in patients with multiple breast cancer was 69.2% and that of PgR was 50.0%. The 5-and 10-year overall survival rate in all 66 patients with multiple breast cancer was 90.8% and 79.7%, respectively.

CONCLUSION

In the past, multiple breast cancer was frequently identified in premenopausal women. However, the current findings indicate that its incidence among postmenopausal women has increased in recent years. In addition, prognoses were comparable for patients with multiple or solitary breast cancer, a relevant finding in the planning of breast-conserving surgery.

The seven amino acids of human RAMP2 (86) and RAMP3 (59) are critical for agonist binding to human adrenomedullin receptors

When co-expressed with a receptor activity-modifying protein (RAMP) accessory protein, calcitonin receptor-like receptor (CRLR) can function as a calcitonin gene-related peptide receptor (CRLR-RAMP1) or an adrenomedullin (AM) receptor (CRLR-RAMP2/3). Here we report on the structural domain(s) involved in selective AM binding that were examined using various RAMP chimeras and deletion mutants. Co-expression of chimeric RAMPs and CRLR in HEK293 cells revealed that residues 77-101, situated in the extracellular N-terminal domain of human RAMP2 (hRAMP2), were crucial for selective AM-evoked cAMP production. More detailed analysis showed that deletion of hRAMP2 residues 86-92 significantly attenuated high-affinity (125)I-AM binding and AM-evoked cAMP production despite full cell surface expression of the receptor heterodimer and that deletion of hRAMP3 residues 59-65 had a similar effect. There is little sequence identity between hRAMP3 residues 59-65 and hRAMP2 residues 86-92; moreover, substituting alanine for Trp(86) (Ala(87)), Met(88), Ile(89), Ser(90), Arg(91), or Pro(92) of hRAMP2 had no effect on AM-evoked cAMP production. It thus seems unlikely that any one amino acid residue is responsible for determining selective AM binding or that AM binds directly to these peptide segments. Instead these findings suggest that the respective seven-amino acid sequences confer selectivity either by directly contributing to the structure of ligand binding pocket or by allosteric modulation of the conformation of CRLR.

Molecular analysis of the h-warts/LATS1 gene in human breast cancer

Loss of heterozygosity (LOH) on chromosome 6q is often observed in breast cancer, suggesting the existence of a putative tumor suppressor. Recently, a human homolog of the Drosophila warts tumor suppressor gene, h-warts/LATS1, was identified and mapped at chromosome 6q24-25.1. Mutation analysis of the h-warts/LATS1 was performed using 25 breast cancer tissues by RT-PCR SSCP analysis. Although LOH of the h-warts/LATS1 was found in one patient, no mutations were found. Two polymorphisms were found, but neither of them caused amino acid substitutions. Further investigations are necessary to elucidate the role of the h-warts/LATS1 gene in the carcinogenesis of breast cancer.

[Weekly administration of paclitaxel for advanced or metastatic breast cancer--short-course premedications for outpatients]

A phase II trial has demonstrated that paclitaxel (210 mg/m2/3 hr) showed a 33.3% response rate among anthracycline-resistant breast cancer patients in Japan. Recently, weekly dosing of paclitaxel has been demonstrated to be a well-tolerated, feasible and effective administration schedule. Standard premedication is commonly administered prior to treatment with paclitaxel. However, this regimen requires dexamethasone administration beginning at 12 to 14 hours prior to paclitaxel, which would not be convenient for outpatients. In this study, paclitaxel was administered by 1 hour intravenous infusion at a dose of 80 mg/m2 every week. Administration was continued for 3 weeks with a 1 week rest. A short course premedication schedule consisted of dexamethasone 20 mg i.v. (diluted in 50 ml normal saline, 1 hour prior to paclitaxel), and oral diphenhydramine 50 mg, H2-antagonist and anti-emetic agent i.v. (diluted in 50 ml normal saline, 30 minutes prior to paclitaxel). A total of 14 outpatients were enrolled in the study. There were 10 partial responders and no complete responders, and the overall response rate was 71.4%. No hypersensitivity reactions were observed, and grade 3/4 leukopenia occurred in 43% (6/14). Allopecia was observed in 4 patients, and peripheral neuropathy in 1 patient (both grade 1). Weekly administration of paclitaxel is effective and well-tolerated in patients with advanced or metastatic breast cancer, with a minimum of peripheral neuropathy. In addition to the above, no hypersensitive reaction in the short course premedication schedule suggests that this administration schedule is feasible for outpatients.

[Anesthetic management of a patient with amyotrophic lateral sclerosis]

A 49-year-old male with amyotrophic lateral sclerosis (ALS) was scheduled for gastrectomy. Anesthetic management was performed under general anesthesia with sevoflurane and epidural anesthesia with lidocaine. He showed increased response to vecuronium under monitoring of neuromuscular block. But he responded favorably to anticholineesterase. He had little pain and showed no progress in neurological symptoms in the postoperative period. Neuromuscular monitoring is essential in administrating non-depolarizing neuromuscular blocking agents to patients with ALS, and epidural anesthesia may be useful for perioperative management of patients with ALS.

Gs alpha mutations in hyperfunctioning thyroid adenomas

Hyperfunctioning thyroid adenomas are benign tumors characterized by their autonomous growth and functional activity, which frequently cause clinical hyperthyroidism and show a predominant radioactive iodine uptake in the nodule. Activating mutations in the gene encoding the alpha subunit of the stimulatory G protein (Gs alpha), as well as activating mutations in the gene encoding thyrotropin receptor in hyperfunctioning thyroid adenomas, have been reported. The mutations in Gs alpha involved the replacement of either arginine 201 with cysteine or histidine, or glutamine 227 with arginine or leucine. These residues are involved in GDP/GTP binding of Gs alpha and these mutations inhibit intrinsic GTPase activity that results in constitutive activation of adenylyl cyclase. The pathophysiological roles of these mutations in the formation of hyperfunctioning thyroid adenoma have been suggested.

Primary culture of cells from hyperfunctioning thyroid adenoma with an activating mutation of G alphas

We analyzed cultured cells from hyperfunctioning thyroid adenoma and its surrounding thyroid tissue from a Japanese woman and determined the nucleotide sequences of genes encoding the alpha subunit of the stimulatory G-protein 1 (G alphas) and thyrotropin (TSH) receptor in its tumor tissue. Primary culture of cells from hyperfunctioning thyroid adenoma and its surrounding thyroid tissue revealed that cAMP production was constitutively activated while intracellular Ca2+ concentration was suppressed both at the basal level and in the response to TSH stimulation in the cells from tumor tissue compared with those from non-tumor tissue. Nucleotide sequence analysis demonstrated the somatic missense mutation at codon 201 (CGT(Arg)-CAT(His)) of G alphas gene in tumor tissue but not in its surrounding tissue. No mutation was observed in the transmembrane region of TSH receptor. These results suggest that cAMP regulatory cascade is constitutively activated while phospholipase C-Ca2+ signaling cascade is suppressed in hyperfunctioning thyroid adenoma with an activating mutation of G alphas gene in the present case.

Absence of mutations in the analysis of coding sequences of the entire transforming growth factor-beta type II receptor gene in sporadic human breast cancers

The transforming growth factor-beta (TGFbeta) binds the type II TGFbeta growth factor receptor (TGFbetaRII) to inhibit the growth of most epithelial tissues. Most human colon and gastric cancers with microsatellite instability (MI) have frameshift mutations in polynucleotide repeats within the TGFbetaRII coding region; these mutations truncate the receptor protein and disable the serine/threonine kinase to produce TGF-beta resistance. To further investigate the type, frequency and tissue distribution of TGFbetaRII gene mutations, in this study, we examined 36 sporadic breast cancers. We previously produced eight intron based primer pairs for mutational analysis of the entire coding region of the TGFbetaRII gene. Using these primers, we developed protocols for polymerase chain reaction-single strand conformational polymorphism (PCR-SSCP) analysis of PCR products from genomic DNA samples of 36 breast cancer patients and we tested them for microsatellite instability (MI) at eight microsatellite loci. One case demonstrated MI (2.8%) and we found no mutations. These and other recent data indicate that TGFbetaRII mutations are essentially confined to colon and gastric cancers with MI. The narrow spectrum of tissues containing RII mutations illustrates the complexity of genetic checkpoints in human carcinogenesis.

A new fine probe for electric cautery during endoscopic surgery

The present paper introduces a new fine probe for electric cautery (1.65 mm in diameter, 22 cm long) that can be connected to a conventional cylindrical hand-controlled cautery holder, which is monopolar and widely used in general surgery. When cautery was required, a 14-gauge intravenous catheter was inserted at an appropriate site under the guidance of a videoscope. After removing the steel inner needle, the extra tube was used as the fine surgical port for the cautery probe. The position of insertion could be altered according to the operating field. Cautery was performed by conventional methods. There was no bleeding or air leakage at the site of puncture during or after surgery. The puncture wound was closed without any sutures. Based on these results, the new fine probe for cautery can reduce the number of surgical ports required for instruments during video-assisted surgery, thus improving the ease and safety of endoscopic surgery.

An adenosine derivative cooperates with TSH and Graves' IgG to induce Ca2+ mobilization in single human thyroid cells

Digital video imaging indicated that about 80% of fura-2-loaded single human thyroid cells responded to TSH, resulting in an increase in intracellular Ca2+ concentration ([Ca2+]i). Most of the TSH-sensitive cells further responded to N6-(L-2-phenylisopropyl)-adenosine (PIA) showing a transient [Ca2+]i rise in a PIA dose-dependent manner. Addition of PIA prior to TSH administration had no effect or showed only a slight [Ca2+]i increase, but in about 80% of the cells, regardless of the response to PIA, the addition of TSH after PIA resulted in a higher transient [Ca2+]i response than that in the absence of PIA. Inactivation of Gi/G(o) by pertussis toxin (PTX) treatment markedly reduced the effect of PIA on TSH action to the level induced by PIA alone. Immunoglobulin fractions obtained from two Graves' patients with high TSAb (antibody activity measured by cAMP response) activity induced [Ca2+]i increase and cooperated with PIA. Under the same conditions, TSH-dependent cAMP accumulation was inhibited by PIA. These results suggest that adenosine Ai receptor is expressed in human thyroid cells in primary culture as well as in FRTL-5 rat thyroid cells, and that in the presence of adenosine. TSH or Graves' IgG signal tends to be directed to the Ca2+ pathway in the human thyroid.

Natural cytotoxic T cells responsible for anti-CD3-induced cytotoxicity in mice

T cells obtained from normal mouse spleen cells showed significant cytotoxic activity against Fc receptor positive tumor cells in the presence of anti-CD3 monoclonal antibody (mAb). This activity was designated as natural cytotoxic T cell (NCT) activity and compared with natural killer (NK) activity. Considerable levels of NCT activity were detected in mouse strains with both high and low NK activity. NCT cells were distributed in both lower and higher density fractions of Percoll discontinuous density gradients, while NK cells were enriched in the lower density fraction of Percoll gradients. Moreover, NCT activity was resistant to in vivo anti-asialo GM1 treatment, in contrast to NK cells. These results indicate that NCT cells, which have different characteristics from NK cells, are present in normal, nonimmunized mouse spleen cells. Unexpectedly, CD4+ T cells sorted from normal mouse spleen T cells revealed significant NCT activity, as did CD8+ T cells. It was also demonstrated that NCT cells require the LFA-1 molecule to lyse tumor cells in the presence of anti-CD3 mAb.

Cytochrome c-551 from the thermophilic bacterium PS3 grown under air-limited conditions

A small-sized c-type cytochrome, designated cytochrome c-551, was prepared from membrane fraction of the thermophilic bacterium PS3 grown under air-limited conditions by extraction with cholate, precipitation with polyethylene glycol, and successive chromatographies with DEAE-cellulose and Sephacryl S-200 in the presence of a detergent. The purified sample contained approximately 1 mol of heme c per 10,000 g protein; it showed absorption bands at 551, 522 and 416 nm upon reduction, and a Soret peak at 409 nm upon oxidation. This cytochrome showed a single band of 10 kDa on polyacrylamide gel electrophoresis with sodium dodecyl sulfate. The isoelectric point of this cytochrome c-551 was pH 4.0. Cytochrome c-551 was suggested to play an important role in the respiratory chain with a terminal oxidase cytochrome o, which is produced under air-limited conditions, since cytochrome c-551 could mediate electron transfer between cytochrome bc1(b6f) complex and cytochrome o, showing quinol oxidase activity.

Polypeptide-dependent protein kinase from bakers' yeast

The purification and properties of a protein serine kinase (PK-P) extracted with Triton X-100 from membranes of bakers' yeast are described. The enzyme is virtually inactive unless either a histone or a heat-stable polypeptide from yeast membranes and Mg2+ are added. Other divalent cations substitute for Mg2+ poorly or not at all; most of them, including Mn2+, inhibit when added in the presence of 5 mM Mg2+. The enzyme is unstable but can be stabilized by addition of 0.1% Triton X-100 and 20% glycerol. The final preparation shows, on silver-stained electrophoresis gels, two major bands (Mr 41,000 and 35,000). According to gel filtration the molecular weight of the active protein is about 75,000. Of the two subunits, only the smaller one appears to be autophosphorylated. In addition to casein, the enzyme phosphorylates several proteins including the H+-ATPase (Mr 100,000) in the yeast plasma membrane. In order to demonstrate the phosphorylation of the ATPase (up to 0.9 equivalents), exposure of the latter to an acid phosphatase was required. Other phosphorylated proteins include mRNA cap-binding protein from mammalian erythrocytes and yeast, a glucocorticoid receptor protein, and a preparation of the guanine nucleotide-binding proteins Gi and Go from brain. A partial purification of a natural activator from yeast plasma membranes is described.

High vectorial proton stoichiometry by cytochrome c oxidase from the thermophilic bacterium PS3 reconstituted in liposomes

The stoichiometry of vectorial H+ ejection, coupled to ferrocytochrome c oxidation by a three-subunit bacterial cytochrome c oxidase (EC 1.9.3.1) from the thermophilic bacterium PS3, was measured. Three methods of measuring the H+/e- ratio were applied to proteoliposomes containing a relatively small amount of PS3 cytochrome oxidase, which showed a relatively low oxidation rate and a very low H+ leakage, as follows: (a) simultaneous measurements of H+ ejection and cytochrome c oxidation upon addition of a yeast ferrocytochrome c pulse, which enable us to calculate the H+/e- ratio as H+ ejected per cytochrome c oxidized; (b) computer simulations to find out the fit for the pH meter trace by changing the H+/e- ratio and the velocity constant of leakage; and (c) two successive measurements of initial rates of H+ movement in the absence and presence of carbonyl cyanide p-trifluoromethoxyphenylhydrazone. The H+/e- ratios obtained were 1.39, the 10-s value after ferrocytochrome c addition in (a), 1.35 in (b), and 1.33 in (c). This high H+/e- stoichiometry observed, exceeding 1 and as high as 1.4, is discussed with respect to the controversy of the H+/e- ratio at the cytochrome oxidase site.

Proton pumping and oxidase activity of thermophilic cytochrome oxidase remain after its extensive proteolysis

A proton-pumping heme aa3-type cytochrome oxidase purified from the thermophilic bacterium PS3 was treated with trypsin, thermolysin, chymotrypsin, subtilisin, or pronase. The cleavage of the oxidase subunits and the effects of their cleavage on the oxidase activity and proton-pumping in reconstituted vesicles were studied. Trypsin and thermolysin cleaved some of the oxidase subunits without affecting the proton-pumping, but subtilisin and pronase cleaved all the subunits resulting in partial decrease in both activities. Chymotrypsin had an intermediate effect. Subunit II of this enzyme contains heme c which is also cleaved by proteases.

A cross-linking study of apo-low density lipoprotein

Chemical cross-linking with dimethylsuberimidate was applied to the study of apo B interactions in human serum low density lipoprotein (LDL). Since apo B is known to have a mass of 500,000 to 600,000 daltons in non-ionic detergent solutions (i.e., a dimer of apo B based on the molecular weight of 260,000 for a single peptide of apo B), the possibility was investigated that the cross-linking reagent might be used to identify the interacting site of apo B in LDL. Although extensive cross-linking was observed in our experiment most of the reaction took place not between apo B's in one LDL (intramolecular) but between apo B's of different LDL's (intermolecular). Only a small fraction of cross-linked apo B dimer was formed intramolecularly. We interpret the results as indicating that the exposed or hydrophilic regions of LDL are scattered on the surface of LDL and that the protein-protein interaction site is not accessible to dimethylsuberimidate, probably being hidden under the surface layer of LDL.