Tumor-infiltrating lymphocytes in HER2-positive breast cancer treated with neoadjuvant chemotherapy and dual HER2-blockade

Tumor-infiltrating lymphocytes (TILs) have been associated with outcomes in HER2-positive breast cancer patients treated with neoadjuvant chemotherapy and trastuzumab. However, it remains unclear if TILs could be a prognostic and/or predictive biomarker in the context of dual HER2-targeting treatment. In this study, we evaluated the association between TILs and pathological response (pCR) and invasive-disease free survival (IDFS) in 389 patients with stage II-III HER2 positive breast cancer who received neoadjuvant anthracycline-containing or anthracycline-free chemotherapy combined with trastuzumab and pertuzumab in the TRAIN-2 trial. Although no significant association was seen between TILs and pCR, patients with TIL scores ≥60% demonstrated an excellent 3-year IDFS of 100% (95% CI 100-100), regardless of hormone receptor status, nodal stage and attainment of pCR. Additionally, in patients with hormone receptor positive disease, TILs as a continuous variable showed a trend to a positive association with pCR (adjusted Odds Ratio per 10% increase in TILs 1.15, 95% CI 0.99-1.34, p = 0.070) and IDFS (adjusted Hazard Ratio per 10% increase in TILs 0.71, 95% CI 0.50-1.01, p = 0.058). We found no interactions between TILs and anthracycline treatment. Our results suggest that high TIL scores might be able to identify stage II-III HER2-positive breast cancer patients with a favorable prognosis.

Adjuvant dose-dense doxorubicin-cyclophosphamide versus docetaxel-doxorubicin-cyclophosphamide for high-risk breast cancer: First results of the randomised MATADOR trial (BOOG 2004-04)

BACKGROUND

Dose-dense administration of chemotherapy and the addition of taxanes to anthracycline-based adjuvant chemotherapy have improved breast cancer survival substantially. However, clinical trials directly comparing the additive value of taxanes with dose-dense anthracycline-based chemotherapy are lacking.

PATIENTS AND METHODS

In the multicentre, randomised, biomarker discovery Microarray Analysis in breast cancer to Tailor Adjuvant Drugs Or Regimens (MATADOR) trial, patients with pT1-3, pN0-3 breast cancer were randomised (1:1) between six adjuvant cycles of doxorubicin 60 mg/m² and cyclophosphamide 600 mg/m² every 2 weeks (ddAC) and six cycles of docetaxel 75 mg/m², doxorubicin 50 mg/m² and cyclophosphamide 500 mg/m² every 3 weeks (TAC). The primary objective was to discover a predictive gene expression profile for ddAC and TAC benefit. Here we report the preplanned secondary end-point recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Between 2004 and 2012, 664 patients were randomised. At 5 years, RFS was 87% (95% confidence interval [CI] 83%-91%) in the ddAC-treated patients and 88% (84-92%) in the TAC-treated subgroup (hazard ratio [HR] 0.89, 95% CI 0.62-1.28, P = 0.53). OS at 5 years was 93% (90%-96%) in the ddAC-treated and 94% (91%-97%) in the TAC-treated patients (HR 0.89, 95% CI 0.57-1.39, P = 0.61). Anaemia was more frequent in ddAC-treated patients (62/327 patients [18.9%] versus 15/319 patients [4.7%], P < 0.001) and diarrhoea (21 [6.4%] versus 53 [16.6%], P<0.001) and peripheral neuropathy (15 [4.6%] versus 46 [14.4%], P < 0.001) were observed more often in TAC-treated patients.

CONCLUSIONS

With a median follow-up of 7 years, no significant differences in RFS and OS were observed between six adjuvant cycles of ddAC and TAC in high-risk breast cancer patients.

TRIAL REGISTRATION NUMBERS

ISRCTN61893718 and BOOG 2004-04.

Vitamin D (25-0H D3) status and pathological response to neoadjuvant chemotherapy in stage II/III breast cancer: Data from the NEOZOTAC trial (BOOG 10-01)

BACKGROUND

Serum levels of 25-OH vitamin D3 (vitamin D) have been shown to be prognostic for disease-free survival in patients with breast cancer. We investigated the predictive value of these levels for pathological response after neoadjuvant chemotherapy in patients with breast cancer taking part in the NEOZOTAC phase-III trial. Additionally, the effect of chemotherapy on vitamin D levels was studied.

MATERIALS AND METHODS

Serum vitamin D was measured at baseline and before the last cycle of chemotherapy. The relationship between these measurements and clinical outcome, as defined by pathological complete response in breast and lymph nodes (pCR) was examined.

RESULTS

Baseline and end of treatment vitamin D data were available in 169 and 91 patients, respectively. Median baseline vitamin D values were 58.0 nmol/L. In patients treated with chemotherapy only, serum vitamin D levels decreased during neoadjuvant chemotherapy (median decrease of 16 nmol/L, P = 0.003). The prevalence of vitamin D levels < 50 nmol/L increased from 38.3% at baseline to 55.9% after chemotherapy. In the total population, baseline and end of therapy vitamin D levels were not related to pathological response. No associations were found between pCR and vitamin D level changes.

CONCLUSION

The significant decrease in vitamin D post-neoadjuvant chemotherapy suggests that vitamin D levels should be monitored and in case of decrease of vitamin D levels, correction may be beneficial for skeletal health and possibly breast cancer outcome.

Abstract P3-06-50: Thyroid function is associated with the response to neoadjuvant chemotherapy in breast cancer patients: Results from the NEOZOTAC trial on behalf of the Dutch Breast Cancer Research Group (BOOG 2010-01)

Background: Thyroid hormones, regulators of metabolism and development in healthy tissue, stimulate tumor growth in vitro and are associated with breast cancer risk. We investigated the effect of chemotherapy on thyroid function and the extent to which it can predict the pathological response in patients with HER2 negative stage II/III breast cancer taking part in the NEOZOTAC phase III trial, randomizing between 6 cycles of neoadjuvant TAC chemotherapy with or without additional zoledronic acid. Moreover, we examined the impact of thyroid function on chemotherapy toxicity.

Methods: Serum samples of 38 of the 105 patients who participated in the side study of the NEOZOTAC trial were available for analyses. Serum free thyroxin (fT4) and thyroid stimulating hormone (TSH) levels were measured at baseline and compared with fT4 and TSH levels before the 2nd and 6th chemotherapy cycle. FT4 and TSH levels were also compared between subjects with and without pathological complete response (pCR). The relation between toxicity, per side effect of any CTC grade, and the variation in fT4 and TSH levels during chemotherapy was tested.

Results: Serum samples at baseline, before the 2nd chemotherapy cycle and at end of treatment were available for 31, 30 and 21 patients, respectively. In the total population, the mean baseline fT4 level was 16,0pmol/L and the mean TSH level 1,11mU/L. There were no differences between subjects solely treated with TAC chemotherapy and subjects treated with zoledronic acid as an adjunct to TAC with respect to the mean fT4 and TSH at each time point. Baseline TSH levels tended to be higher in patients who achieved pCR (p=0.035 univariate analysis and p=0.074 multivariate analysis) (Table 1). During 6 cycles of chemotherapy, fT4 levels decreased (p&lt;0.000) and TSH levels increased significantly (p=0.019). Interestingly, the decrease of fT4 was significantly greater in patients without nausea, vomiting or sensory neuropathy, than in patients with those side effects (p=0.037, p=0.043 and p=0.050 respectively).

CharacteristicUnivariate analysisMultivariate analysis OR95%CIP valueOR95%CIP valueN stage: N0 vs. N+0.330.03-3.640.368T stage: &lt;5cm vs. &gt;5cm0.330.03-3.630.333ER receptor: Pos vs. Neg2.560.20-33.10.473fT40.780.43-1.420.4170.660.33-1.290.581TSH3.241.09-9.700.03517.30.76-3910.074Table 1. Univariate and multivariate logistic regression models of baseline characteristics and TSH and fT4 predictive of pCR.

Conclusion: TSH levels at baseline were higher in breast cancer patients with pCR. Chemotherapy blunts thyroid function, and a large decline of fT4 was associated with less side effects. These data suggest that thyroid hormones may interact with chemotherapy to modulate treatment (side-) effects in patients with breast cancer.

Citation Format: S de Groot, A Charehbili, L GM Janssen, E M Dijkgraaf, V THBM Smit, L W Kessels, A van Bochove, H WM van Laarhoven, E Meershoek-Klein Kranenbarg, A E van Leeuwen-Stok, G J Liefers, C JH van de Velde, J WR Nortier, J JM van der Hoeven, H Pijl, J R Kroep. Thyroid function is associated with the response to neoadjuvant chemotherapy in breast cancer patients: Results from the NEOZOTAC trial on behalf of the Dutch Breast Cancer Research Group (BOOG 2010-01) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-06-50.

Accuracy of MRI for treatment response assessment after taxane- and anthracycline-based neoadjuvant chemotherapy in HER2-negative breast cancer

BACKGROUND

Studies suggest that MRI is an accurate means for assessing tumor size after neoadjuvant chemotherapy (NAC). However, accuracy might be dependent on the receptor status of tumors. MRI accuracy for response assessment after homogenous NAC in a relative large group of patients with stage II/III HER2-negative breast cancer has not been reported before.

METHODS

250 patients from 26 hospitals received NAC (docetaxel, adriamycin and cyclophosphamide) in the context of the NEOZOTAC trial. MRI was done after 3 cycles and post-NAC. Imaging (RECIST 1.1) and pathological (Miller and Payne) responses were recorded. Accuracy measures were calculated and MRI and pathologically assessed tumor sizes were correlated. Tumor size over- and underestimation were quantified.

RESULTS

Accuracy of MRI for determining pathological complete response (pCR) was 76%. The ROC-curve of MRI response and pCR had an area under the curve value of 0.63 (95% C.I. 0.52-0.74). The correlation coefficient of MRI and histopathological tumor measurements was 0.46 (p < 0.001). Correlations were different for ER-positive (r = 0.40, p < 0.001) and ER-negative (r = 0.76, p < 0.001) breast tumors. MRI under- and overestimated the tumor size in 47% and 40% of all patients. In cases of substantial tumor size underestimation (>2 cm), surgical margins were more often tumor positive compared to the rest of the patients (33% vs.12%, p = 0.005).

CONCLUSION

MRI measurements correlated moderately with tumor size on the surgical specimen. Only in ER-negative breast tumors, MRI tumor sizes correlated sufficiently with residual tumor size on the pathological specimen. Therefore, post-NAC MRI should be interpreted with caution.

A randomized phase III study comparing pegylated liposomal doxorubicin with capecitabine as first-line chemotherapy in elderly patients with metastatic breast cancer: results of the OMEGA study of the Dutch Breast Cancer Research Group BOOG

BACKGROUND

Prospective data on chemotherapy for elderly patients with metastatic breast cancer (MBC) remain scarce. We compared the efficacy and safety of first-line chemotherapy with pegylated liposomal doxorubicin (PLD) versus capecitabine in MBC patients aged ≥65 years in a multicentre, phase III trial.

PATIENTS AND METHODS

Patients were randomized to six cycles of PLD (45 mg/m(2) every 4 weeks) or eight cycles of capecitabine (1000 mg/m(2) twice daily, day 1-14 every 3 weeks).

RESULTS

The study enrolled 78 of the planned 154 patients and was closed prematurely due to slow accrual and supply problems of PLD. Many included patients were aged ≥75 years (54%) and vulnerable (≥1 geriatric condition: 71%). The median dose intensity was 85% for PLD and 84% for capecitabine, respectively. In both arms, the majority of patients completed at least 12 weeks of treatment (PLD 73%; capecitabine 74%). After a median follow-up of 39 months, 77 patients had progressed and 62 patients had died of MBC. Median progression-free survival was 5.6 versus 7.7 months (P = 0.11) for PLD and capecitabine, respectively. Median overall survival was 13.8 months for PLD and 16.8 months for capecitabine (P = 0.59). Both treatments were feasible, grade 3 toxicities consisting of fatigue (both arms: 13%), hand-foot syndrome (PLD: 10%; capecitabine: 16%), stomatitis (PLD: 10%; capecitabine: 3%), exanthema (PLD: 5%) and diarrhoea (PLD: 3%; capecitabine: 5%). Only 1 of 10 patients aged ≥80 years completed chemotherapy, while 3 and 6 patients discontinued treatment due to toxicity or progressive disease, respectively.

CONCLUSION

Both PLD and capecitabine demonstrated comparable efficacy and acceptable tolerance as first-line single-agent chemotherapy in elderly patients with MBC, even in vulnerable patients or patients aged ≥75 years. However, patients aged ≥80 years were unlikely to complete chemotherapy successfully.

CLINICAL TRIAL NUMBERS

EudraCT 2006-002046-10; ISRCTN 11114726; CKTO 2006-09; BOOG 2006-02.

Addition of zoledronic acid to neoadjuvant chemotherapy does not enhance tumor response in patients with HER2-negative stage II/III breast cancer: the NEOZOTAC trial (BOOG 2010-01)

BACKGROUND

The role of zoledronic acid (ZA) when added to the neoadjuvant treatment of breast cancer (BC) in enhancing the clinical and pathological response of tumors is unclear. The effect of ZA on the antitumor effect of neoadjuvant chemotherapy has not prospectively been studied before.

PATIENTS AND METHODS

NEOZOTAC is a national, multicenter, randomized study comparing the efficacy of TAC (docetaxel, adriamycin and cyclophosphamide i.v.) followed by granulocyte colony-stimulating factor on day 2 with or without ZA 4 mg i.v. q 3 weeks inpatients withstage II/III, HER2-negative BC. We present data on the pathological complete response (pCR in breast and axilla), on clinical response using MRI, and toxicity. Post hoc subgroup analyses were undertaken to address the predictive value of menopausal status.

RESULTS

Addition of ZA to chemotherapy did not improve pCR rates (13.2% for TAC+ZA versus 13.3% for TAC). Postmenopausal women (N = 96) had a numerical benefit from ZA treatment (pCR 14.0% for TAC+ZA versus 8.7% for TAC, P = 0.42). Clinical objective response did not differ between treatment arms (72.9% versus 73.7%). There was no difference in grade III/IV toxicity between treatment arms.

CONCLUSIONS

Addition of ZA to neoadjuvant chemotherapy did not improve pathological or clinical response to chemotherapy. Further investigations are warranted in postmenopausal women with BC, since this subgroup might benefit from ZA treatment.

Baseline comprehensive geriatric assessment is associated with toxicity and survival in elderly metastatic breast cancer patients receiving single-agent chemotherapy: results from the OMEGA study of the Dutch breast cancer trialists' group

AIM

To evaluate the association between baseline comprehensive geriatric assessment (CGA) or the Groningen Frailty Indicator (GFI) and toxicity in elderly metastatic breast cancer (MBC) patients treated with first-line palliative chemotherapy.

PATIENTS AND METHODS

MBC patients (≥65 years) were randomized between pegylated liposomal doxorubicine or capecitabine. CGA included instrumental activities of daily living (IADL), cognition using the mini-mental state examination (MMSE), mood using the geriatric depression scale (GDS), comorbidity using the Charlson index, polypharmacy and nutritional status using the body mass index. Frailty on CGA was defined as one or more of the following: IADL ≤ 13, MMSE ≤ 23, GDS ≥ 5, BMI ≤ 20, ≥5 medications or Charlson ≥2. The cut-off for frailty on the GFI was ≥4.

RESULTS

Of the randomized 78 patients (median age 75.5 years, range 65.8-86.8 years), 73 were evaluable for CGA; 52 (71%) had one or more geriatric conditions. Grade 3-4 chemotherapy-related toxicity was experienced by 19% of patients without geriatric conditions compared to 56% of patients with two geriatric conditions and 80% of those with three or more (p = 0.002). Polypharmacy was the only individual factor significantly associated with toxicity (p = 0.001). GFI had a sensitivity of 69% and a specificity of 76% for frailty on CGA, and was not significantly associated with survival or toxicity.

CONCLUSION

In this study of elderly patients with MBC, the number of geriatric conditions correlated with grade 3-4 chemotherapy-related toxicity. Therefore, in elderly patients for whom chemotherapy is being considered, a CGA could be a useful addition to the decision-making process.

Effect of modulation of the transferrin receptor on gallium-67 uptake and cytotoxicity in lymphoma cell lines

Gallium-67 is a radionuclide that accumulates in haematological malignancies and is used for diagnostic purposes. Uptake of 67Ga into the cell occurs via the transferrin receptor, which is differentially expressed during the various cell cycle phases. With the aim of selectively increasing 67Ga uptake, we studied whether the transferrin receptor (TfR) expression could be modulated in the U937 and U715 lymphoma cell lines by cytostatic drugs inducing cell cycle phase accumulation. We tested clinically relevant drugs such as 1-beta-D-arabinofuranosylcytosine (Ara-C), hydroxyurea and methotrexate. Cytotoxicity was determined by testing the clonogenic capacity of the lymphoma cell lines. All three drugs induced an increase in S-phase content, TfR expression and 67Ga uptake in U937 and U715 single cells. The combinations of drugs and 67Ga resulted in an additive effect on the clonogenic capacity. In U937 spheroids, cultured by the fibrin clot technique, we found an accumulation in the S-phase too as well as an increase of the transferrin receptor expression after Ara-C preincubation. As in single cells 67Ga uptake was increased without synergistic effects on the clonogenic capacity. In conclusion, priming with drugs induces increased transferrin receptor expression and 67Ga uptake. Inhibition of clonogenic capacity was additive rather than synergistic.

Radiotoxic effect and dosimetry of 67GA in multicellular spheroids as compared to single cells of the lymphoma cell line U715

PURPOSE

The purpose of the present study was to investigate if there were differences between U715 spheroids and single cells in the radiotoxic effect of 67Ga on cell growth and clonogenic capacity in vitro and to generate dosimetric approaches for the multicellular tumor model.

METHODS AND MATERIALS

Human lymphoma U715 cells were cultured in vitro as single cells and multicellular spheroids, grown with the use of a combination of fibrin clot technique, spinner flasks, and liquid-overlay culture. Cells were incubated with 2.96-8.88 MBq/ml 67Gallium for 4 days. Spheroids were dispersed to single cells by treatment with plasmin. Residual proliferative and clonogenic capacity after 67Ga incubation were assayed using the MTT-test and clonogenic test, respectively. Autoradiography was performed with 1 microm sections and Ilford L4 liquid photographic emulsion. Dosimetric approaches were made, based on the MIRD-approach.

RESULTS

During 67Ga incubation proliferation was inhibited. The residual proliferative or clonogenic capacity was inhibited by 8.88 MBq/ml for 39 and 88%, respectively. For single cells with 6.66 MBq/ml these inhibitions were 64 and 96%, respectively. Autoradiography showed an homogeneous distribution of 67Ga in spheroids and single cells. In single cells a 2.1-3.5 times higher 67Ga uptake/cell than in spheroids produced an equitoxic effect. The uptake parameters were implemented in new dosimetric approaches and showed that the efficacy of intracellular 67Ga was two times higher in spheroid clusters than in single cells due to energy deposition of internal conversion electrons within the cell clusters with a mean diameter size of nine cells. Both for proliferative and clonogenic capacity the exponential survival curves were superimposed.

CONCLUSIONS

With the new approaches made in our dosimetric model the discrepancy found between 67Ga accumulation and radiotoxic effect in spheroids as compared to single cells can be explained by additional effects of the crossfire of internal conversion electrons within clusters of about nine cells in diameter in spheroids. Only twice as much 67Ga was needed to reach equitoxic absorbed doses in spheroids than was needed in single cells. Such might be important for the use of 67Ga treatment of small metastasis of malignant lymphoma.

Gallium 67 in the human lymphoid cell line U-715: uptake, cytotoxicity and intracellular localization

The selective uptake of the Auger- and internal conversion electrons emitting radionuclide 67Ga in malignant tumours may have therapeutic potential. We studied several factors which might affect the uptake and radiotoxicity of 67Ga in the human lymphoma cell line U-715. The 67Ga uptake was dependent on transferrin in a dose-dependent manner. The highest 67Ga uptake was found in the presence of 50 micrograms/ml purified human transferrin. Serum components other than transferrin negatively influenced the 67Ga uptake. Cells were adapted to a serum-free medium in which cells could be maintained for months and without factors disturbing 67Ga uptake. We demonstrated that there was a positive correlation between cell viability and 67Ga uptake (r = 0.97). Preculturing of cells in iron- and transferrin-deficient medium prior to 67Ga uptake led to upregulation of the transferrin receptor and a three-fold increase of 67Ga uptake. Uptake in these cells could be blocked by 72% by anti-transferrin-receptor monoclonal antibodies. Autoradiography of U-715 cells after 67Ga incubation showed intracellular 67Ga both in the cytoplasm and nucleus. Cell fractionation of 67Ga-loaded cells showed 27% of 67Ga present in the nuclei. Culturing of cells for 4 days in the presence of 3 MBq/ml 67Ga resulted in a 45% decrease of cell proliferation. The clonogenic capacity was diminished by 91%. In conclusion, we have demonstrated that 67Ga uptake is a transferrin-receptor-dependent mechanism of vital cells, and that after uptake 67Ga enters the cytosol and nucleus and has a strong cytotoxic effect on clonogenic capacity.