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Moldoveanu D, Hoskin TL, Day CN, Schulze AK, Goetz MP, Boughey JC. Nodal pCR and overall survival following neoadjuvant chemotherapy for node positive ER+/Her2- breast cancer. Breast Cancer Res Treat 2024; 203:419-428. [PMID: 37878154 DOI: 10.1007/s10549-023-07152-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/29/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE The role of neoadjuvant chemotherapy (NAC) in node-positive (N+) ER+/HER2- breast cancer (BC) is debated, given low total pathologic complete response (pCR) rates. However, the rate and impact of nodal pCR is unknown. We sought to evaluate nodal pCR rates and the impact on overall survival (OS). Further, we sought to validate the association between nodal pCR with age and Ki67. METHODS We queried the National Cancer Database for cN + ER+/HER2- BC patients treated with NAC and surgery. Data from 2010 to 2018 were used to evaluate nodal pCR and OS, with multivariable Cox proportional hazards modeling for OS, as well as Ki67 for the years 2018-2019. RESULTS From 2010 to 2018, we identified 19,611 cN + ER+/HER2- BC patients treated with NAC. While total pCR occurred in only 7.4%, nodal pCR rates were nearly double (14.3%). Nodal pCR (+/- breast pCR) was seen in 21.7% and associated with 5-year OS rate of 86.1% (95% CI: 84.9-87.4%) versus 77.1% (95% CI: 76.3-77.9%) in patients without nodal pCR (p < 0.001). On multivariable analysis, nodal pCR had better OS (adjusted HR 0.57, 95% CI 0.52-0.63, p < 0.001) across all age groups. Of 2,444 patients with available Ki67, those with age < 50 and Ki67 ≥ 20% had the highest nodal pCR at 31.6%. CONCLUSION In cN + ER+/HER2- BC treated with NAC, nodal pCR is common, associated with age and Ki67, and prognostic for OS. These data strongly suggest that for cN + patients, eradication of nodal disease is critical for OS, and total pCR may not be the optimal measure of NAC benefit.
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Affiliation(s)
- Dan Moldoveanu
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tanya L Hoskin
- Department of Quantitative Health Sciences , Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Quantitative Health Sciences , Mayo Clinic, Rochester, MN, USA
| | - Amy K Schulze
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Matthew P Goetz
- Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Abstract
The selective estrogen receptor (ER) modulator, tamoxifen, is the only endocrine agent with approvals for both the prevention and treatment of premenopausal and postmenopausal estrogen-receptor positive breast cancer as well as for the treatment of male breast cancer. Endoxifen, a secondary metabolite resulting from CYP2D6-dependent biotransformation of the primary tamoxifen metabolite, N-desmethyltamoxifen (NDT), is a more potent antiestrogen than either NDT or the parent drug, tamoxifen. However, endoxifen's antitumor effects may be related to additional molecular mechanisms of action, apart from its effects on ER. In phase 1/2 clinical studies, the efficacy of Z-endoxifen, the active isomer of endoxifen, was evaluated in patients with endocrine-refractory metastatic breast cancer as well as in patients with gynecologic, desmoid, and hormone-receptor positive solid tumors, and demonstrated substantial oral bioavailability and promising antitumor activity. Apart from its potent anticancer effects, Z-endoxifen appears to result in similar or even greater bone agonistic effects while resulting in little or no endometrial proliferative effects compared with tamoxifen. In this review, we summarize the preclinical and clinical studies evaluating endoxifen in the context of breast and other solid tumors, the potential benefits of endoxifen in bone, as well as its emerging role as an antimanic agent in bipolar disorder. In total, the summarized body of literature provides compelling arguments for the ongoing development of Z-endoxifen as a novel drug for multiple indications.
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Affiliation(s)
| | - Joel M Reid
- Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
| | - John R Hawse
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN 55905, USA
| | - Matthew P Goetz
- Correspondence: Matthew P. Goetz, MD, Department of Medical Oncology and Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Jayaraman S, Hou X, Kuffel MJ, Suman VJ, Hoskin TL, Reinicke KE, Monroe DG, Kalari KR, Tang X, Zeldenrust MA, Cheng J, Bruinsma ES, Buhrow SA, McGovern RM, Safgren SL, Walden CA, Carter JM, Reid JM, Ingle JN, Ames MM, Hawse JR, Goetz MP. Antitumor activity of Z-endoxifen in aromatase inhibitor-sensitive and aromatase inhibitor-resistant estrogen receptor-positive breast cancer. Breast Cancer Res 2020; 22:51. [PMID: 32430040 PMCID: PMC7238733 DOI: 10.1186/s13058-020-01286-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 05/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The tamoxifen metabolite, Z-endoxifen, demonstrated promising antitumor activity in endocrine-resistant estrogen receptor-positive (ER+) breast cancer. We compared the antitumor activity of Z-endoxifen with tamoxifen and letrozole in the letrozole-sensitive MCF7 aromatase expressing model (MCF7AC1), as well as with tamoxifen, fulvestrant, exemestane, and exemestane plus everolimus in a letrozole-resistant MCF7 model (MCF7LR). METHODS MCF7AC1 tumor-bearing mice were randomized to control (no drug), letrozole (10 μg/day), tamoxifen (500 μg/day), or Z-endoxifen (25 and 75 mg/kg). Treatment in the letrozole arm was continued until resistance developed. MCF7LR tumor-bearing mice were then randomized to Z-endoxifen (50 mg/kg) or tamoxifen for 4 weeks and tumors harvested for microarray and immunohistochemistry analysis. The antitumor activity of Z-endoxifen in the MCF7LR tumors was further compared in a second in vivo study with exemestane, exemestane plus everolimus, and fulvestrant. RESULTS In the MCF7AC1 tumors, both Z-endoxifen doses were significantly superior to control and tamoxifen in reducing tumor volumes at 4 weeks. Additionally, the 75 mg/kg Z-endoxifen dose was additionally superior to letrozole. Prolonged letrozole exposure resulted in resistance at 25 weeks. In MCF7LR tumor-bearing mice, Z-endoxifen significantly reduced tumor volumes compared to tamoxifen, letrozole, and exemestane, with no significant differences compared to exemestane plus everolimus and fulvestrant. Additionally, compared to tamoxifen, Z-endoxifen markedly inhibited ERα target genes, Ki67 and Akt expression in vivo. CONCLUSION In endocrine-sensitive and letrozole-resistant breast tumors, Z-endoxifen results in robust antitumor and antiestrogenic activity compared to tamoxifen and aromatase inhibitor monotherapy. These data support the ongoing development of Z-endoxifen.
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Affiliation(s)
| | - Xiaonan Hou
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Mary J Kuffel
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Vera J Suman
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - David G Monroe
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Krishna R Kalari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Xiaojia Tang
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Jingfei Cheng
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth S Bruinsma
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Chad A Walden
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Jodi M Carter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Joel M Reid
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - James N Ingle
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - John R Hawse
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Matthew P Goetz
- Department of Oncology, Mayo Clinic, Rochester, MN, USA.
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA.
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