miRNA signatures of prognostic significance in single hormone receptor-positive breast cancer

e12544

Background: Single hormone receptor-positive breast cancer – ER+/PgR– and ER–/PR+, is a distinct entity with vastly undiscovered biology. This study aimed at exploring miRNA profiles of primary tumors of single hormone receptor-positive phenotype and their association with overall survival (OS). Methods: The study group comprised 32 breast cancer patients, collected at 3 Polish centers, with single hormone receptor-positive phenotype, including 14 ER+/PgR– and 18 ER–/PR+ cases, thoroughly characterized for ER (clones: 1D5, EP1 and SP1) and PgR (clone: 636) expression. Expression of 798 miRNAs was profiled using nCounter Human v3 miRNA Expression Assay (NanoString) in each primary tumor sample (FFPE), data available at NCBI GEO (GSE155362). Normalized miRNAs counts were analyzed for the association with OS. Gene targets of miRNAs showing prognostic significance were identified using miRNET 2.0, while their annotation with Gene Ontology Biological Processes was determined with DAVID Bioinformatics Resources 6.8 tool. The results were validated using MINDACT trial dataset [Cardoso et al. 2016]: single hormone receptor-positive (central assessment) cases of ductal histology (including 392 ER+/PgR– and 15 ER–/PR+ cases) where analysed for the prognostic value of gene expression of the identified miRNAs targets. Results: In our cohort, 7 miRNAs showed an association with OS (log-rank test): positive for four: hsa-miR-25-3p (p=0.013), hsa-miR-150-5p (p=0.015), hsa-miR-148a-3p (p=0.038) and hsa-miR-497-5p (p=0.044); and negative for three: hsa-miR-517c-3p (p=0.017), hsa-miR-4284 (p=0.018) and hsa-miR-301a-5p (p=0.029). According to miRNET 2.0, the 4 and 3 prognostic miRNAs have 3801 and 544 gene targets, respectively. The genes targeted by positively associated miRNAs were involved in transcription regulation, vesicle-mediated transport and protein stabilization, while the targets of negatively associated miRNAs were related with mRNA polyadenylation, DNA replication and regulation of DNA-templated transcription. Next, genes targeted by most of miRNAs from either group were identified: 11 targets of positive miRNAs (CANX, CBX5, HIPK1, PDE4DIP, PPM1A, REL, SETD5, SP1, XYLT2, ZMAT3, ZNF460) and 6 targets of negative miRNAs (ARL10, DNAJC28, MTHFD1L, PRPF6, RHOF, TSPAN6). The genes were tested for the association with OS in single hormone receptor-positive subgroup of the MINDACT cohort, with the following significant findings in multivariate analysis including N stage and Ki67 status: PDE4DIP (HR=2.84, p=0.011), CBX5 (HR=2.08, p=0.026) and PRPF6 (HR=0.44, p=0.045). Conclusions: This study identifies 7 miRNAs and their gene targets with a potential prognostic significance in single hormone receptor-positive breast cancer. Thus, several miRNA-mRNA axes merit further investigation both at molecular level and in a separate patient cohort to validate their clinical utility.

EPIK-B5: A phase III, randomized study of alpelisib (ALP) plus fulvestrant (FUL) in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-), PIK3CA-mutated advanced breast cancer (ABC) progressing on/after an aromatase inhibitor (AI) with a cyclin-dependent kinase 4/6 inhibitor (CDK4/6i)

TPS1109

Background: Endocrine therapy (ET) + CDK4/6i is standard of care for HR+, HER2− ABC; however, CDK4/6i resistance, in which the phosphatidylinositol-3-kinase (PI3K) pathway has a key role, remains challenging. Progression-free survival (PFS) for ≥ 2nd-line ET monotherapy post CDK4/6i is poor; prognosis may be worse in patients with a PI3KCA mutation. ALP (PI3K-α selective inhibitor and degrader) + FUL is approved by the European Medicines Agency (EMA) for HR+, HER2–, PIK3CA-mutated ABC after ET monotherapy. Outside the EMA, ALP + FUL approval includes post-CDK4/6i use. ALP + FUL has shown clinical activity and consistent safety in a small subpopulation in SOLAR-1 with prior CDK4/6i treatment (n = 9) and in BYLieve Cohort A (CDK4/6i + AI as immediate prior treatment; n = 121). The EPIK-B5 study aims to confirm the efficacy and safety of ALP + FUL in a larger population with HR+, HER2–, PIK3CA-mutated ABC with prior CDK4/6i + AI treatment. Methods: EPIK-B5 is a Phase III, randomized (1:1), double-blind, placebo-controlled study assessing the efficacy and safety of ALP (300 mg/d orally starting Cycle 1 Day 1 [C1D1]) + FUL (500 mg intramuscularly on C1D1 and C1D15, and D1 of subsequent cycles) in patients (N ≈ 234) with HR+, HER2–, PIK3CA-mutated ABC progressing on/after CDK4/6i + AI. Patients randomized to placebo + FUL can cross over to ALP + FUL after progression. Randomization is stratified by presence of lung and/or liver metastasis and prior CDK4/6i setting. Adult men or postmenopausal women with confirmed HR+, HER2–, PIK3CA-mutated ABC and ≥ 1 measurable lesion are eligible. The primary endpoint is PFS per blinded independent review committee assessment. Secondary endpoints include overall survival, overall response and clinical benefit rates, duration of and time to response, PFS by PIK3CA-mutation status in circulating tumor DNA, PFS on next-line treatment, time to definitive deterioration of ECOG status, quality of life (QoL), and safety and tolerability. Exploratory endpoints include biomarker analyses, additional QoL endpoints, and time to subsequent chemotherapy. Recruitment is ongoing, with enrollment planned over 2 years in 18 countries; completion of primary data collection is anticipated in 2026. Clinical trial information: NCT05038735; EUDRACT2021-001966-39.

OlympiA: A phase III, multicenter, randomized, placebo-controlled trial of adjuvant olaparib after (neo)adjuvant chemotherapy in patients with germline BRCA1/2 mutations and high-risk HER2-negative early breast cancer

LBA1

Background: PARP inhibitors (PARPi) target cancers with homologous recombination repair defects by synthetic lethality. The PARPi olaparib (OL) is licensed for metastatic HER2-negative breast cancer with BRCA1/2 germline mutation (gBRCAm). Despite (neo)adjuvant chemotherapy ([N]ACT), recurrence rates in patients (pts) with gBRCAm early breast cancer (EBC) can be high. Novel adjuvant treatments are needed. Methods: OlympiA (NCT02032823), a randomized, double-blind, phase III study, enrolled pts with gBRCAm and HER2-negative (TNBC or hormone-receptor+ [HR+]) high-risk EBC after primary local treatment and ACT/NACT. Eligible pts with TNBC had ≥pT2 or ≥pN1 disease prior to ACT or non-pCR after NACT; those with HR+ BC had ≥4 positive nodes prior to ACT or non-pCR and CPS&EG score ≥3 after NACT. Pts were randomized 1:1 to 1 year of continuous oral OL (300 mg BID) or placebo (PL). Endocrine therapy and bisphosphonates were allowed. The primary endpoint was invasive disease-free survival (IDFS) in the ITT population. Secondary endpoints included distant DFS (DDFS), overall survival (OS) and safety. Safety analysis included adverse events of special interest (AESI) (myelodysplastic syndrome/ acute myeloid leukemia, new primary malignancy, pneumonitis). Per protocol IDMC interim analysis (IA) review was triggered at 165 IDFS events in the first 900 pts, with superiority boundaries based on a hierarchical multiple testing procedure: P < 0.005 for IDFS, followed by P < 0.005 for DDFS and p<0.01 for OS. Results: 1836 pts were enrolled between 06/14–05/19; 49.9% had ACT, 50.1% NACT. Baseline demographics and tumor characteristics were balanced between arms. 82.2% had TNBC; 26.5% received a platinum agent. The IDMC recommended data unblinding as IA showed a significant benefit of OL vs PL for IDFS (hazard ratio [HR] 0.58; 99.5% CI 0.41, 0.82; P < 0.0001) at 2.5 yrs median follow-up. IDFS events occurred in 106/921 and 178/915 pts assigned to OL and PL, respectively. 3-yr IDFS was 85.9% vs 77.1% (diff. 8.8%; 95% CI 4.5%, 13.0%). DDFS was significantly improved with OL (HR 0.57; 99.5% CI 0.39, 0.83; P< 0.0001); 3-yr DDFS was 87.5% vs 80.4% (diff. 7.1%; 95% CI 3.0%, 11.1%). OS was greater for OL than PL but was not statistically significant at IA (HR 0.68; 99.0% CI 0.44, 1.05; P = 0.024); 3-yr OS% 92.0% vs 88.3% (diff. 3.7%; 95% CI 0.3%, 7.1%). Median intended OL exposure was 94.8%. AEs were consistent with the label. G3+ AEs in >1% of OL pts were; anemia (8.7%), neutropenia (4.8%), leukopenia (3.0%), fatigue (1.8%), and lymphocytopenia (1.2%). SAEs and AESI were not increased by OL, SAE 8.7% vs 8.4% and AESI 3.3% vs 5.1%, OL vs PL respectively. Conclusions: Adjuvant OL following ACT or NACT significantly improved IDFS and DDFS with acceptable toxicity in pts with gBRCAm and high-risk HER2-negative EBC. Clinical trial information: NCT02032823.

The requirements of a specialist breast centre

This article is an update of the requirements of a specialist breast centre, produced by EUSOMA and endorsed by ECCO as part of Essential Requirements for Quality Cancer Care (ERQCC) programme, and ESMO. To meet aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this article, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

ER-/PgR+ breast cancer is a separate entity characterized by distinct phenotype: Comprehensive reevaluation of cases from Polish and Hungarian centers

e12554

Background: ER negative (-)/PgR positive (+) breast cancer (BC) is very uncommon and questioned by many experts. We comprehensively reevaluated ER-/PgR+ BCs in the large cohort from Polish and Hungarian centers. Methods: FFPE blocks from 105 ER-/PgR+ tumors (45 breast biopsies and 64 post-operative samples from tumors not exposed to systemic therapy) were collected from 10 Polish and 3 Hungarian centers. In 60 cases available original slides with ER/PgR staining underwent reevaluation by 3 pathologists (MK, RP, WB) for ER and PgR expression by ASCO/CAP criteria. Subsequently, all samples were stained with 3 antibodies against ER (Dako monoclonal (MC) mouse anti-ERα, clone 1D5; Dako MC rabbit anti-ERα, clone EP1; VENTANA Roche MC rabbit anti-ERα, clone SP1), and PgR (Dako MC mouse anti-PgR, clone 636). If available, > 1 tissue block was used (av. 2.04 blocks/case, range 1-6). In 5 cases ESR1/PGR/ERBB2/MKi67 mRNA was measured by the Xpert® Breast Cancer STRAT4 (Cepheid, Sunnyvale, CA, USA). Results: 13 cases were excluded from immunohistochemical steps of the study due to insufficient amount of tissue and 8 - due to misdiagnosis after ER/PgR reevaluation of original slides. After re-staining, 42 cases (41.5%) retained the original phenotype, in 34 (33.67%) the ER status was corrected to ER+, and 16 (15.84%) tumors were ER/PgR-double-negative. The general agreement between anti-ER clones was moderate (Fleiss’ κ = 0.54). There were 56 ER- and 16 ER+ cases across all three assays. Five cases showed ER positivity with 2 antibodies (either SP1/EP1 or SP1/1D5), 5 tumors reacted exclusively with SP1 clone, and 2 - with 1D5 clone. Xpert Breast Cancer STRAT4 confirmed the ER-/PgR+ phenotype in 4 of 5 analyzed cases. The confirmed ER-/PgR+ BCs were characterized by lower percentage of PgR+ cells (median 5%) than BCs reclassified to ER+ (median 70%) (p = 0.022) and higher Ki67 expression than ER+ cases (median 54.5% vs 25%, respectively; p = 0.003). 39 (92.85%) ER-/PgR+ BCs presented with grade 3. Besides “conventional” high-grade cancers, we identified two distinct morphologies of ER-/PgR+ BC: resembling apocrine carcinoma (n = 5, 11.9%) and carcinoma with central acellular zone (n = 4, 9.5%). Conclusions: ER-/PgR+ BCs confirmed in the current study were defined by high-grade histology, high proliferation index and low percentage of PgR+ cells. We postulate ER-/PgR+ BC is a real albeit rare entity, and its diagnosis should be made cautiously, utilizing retesting with an alternative tissue block and anti-ER antibody.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with early breast cancer: a KSMO-ESMO initiative endorsed by CSCO, ISMPO, JSMO, MOS, SSO and TOS

In view of the planned new edition of the most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of primary breast cancer published in 2015, it was decided at the ESMO Asia Meeting in November 2018, by both the ESMO and the Korean Society of Medical Oncology (KSMO), to convene a special face-to-face guidelines meeting in 2019 in Seoul. The aim was to adapt the latest ESMO 2019 guidelines to take into account the ethnic and geographical differences associated with the treatment of early breast cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with early breast cancer representing the oncology societies of Korea (KSMO), China (CSCO), India (ISMPO) Japan (JSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices, and the drug availability and reimbursement situations, in the individual participating Asian countries.

Abstract OT3-05-04: A randomized, open-label, multi-center phase IV study evaluating palbociclib plus endocrine treatment versus a chemotherapy-based treatment strategy in patients with hormone receptor-positive, HER2-negative metastatic breast cancer in a real world setting (PADMA)

Background:

Although endocrine therapy (ET) is recommended as first-line therapy for hormone receptor (HR)-positive, HER2-negative metastatic breast cancer (MBC) up to 50% of patients receive chemotherapy in this setting. Meanwhile new targeted treatment options for combination with ET have been developed and endocrine-based therapy with the CDK4/6 inhibitor Palbociclib (P) improves the progression free survival (PFS) of ET alone by about 50%. So far, there is no data comparing chemotherapy with or without maintenance ET and ET in combination with P as first-line therapy. Patients included in clinical trials are often criticized not to mirror the general breast cancer population and every-day clinical practice due to rigid inclusion and exclusion criteria, limited number of treatment options, strict monitoring intervals and study assessments.

Methods:

PADMA trial is a so called low intervention trial with no rigid inclusion and exclusion criteria, and study assessments.Patients with first-line HR+/HER2- MBC who are candidate for mono-chemotherapy will be eligible to receive either P plus ET per label or mono-chemotherapy per investigator´s choice with or without maintenance ET (1:1 randomization). Primary objective is to compare the time-to-treatment failure (TTF) for patients randomized to receive the mono-chemotherapy treatment strategy versus those randomized to receive P and ET. TTF is defined as time from randomization to discontinuation of treatment due to disease progression, treatment toxicity, patient's preference, or death. Main secondary objectives are progression free survival, overall survival at 36 months, amongst other time to event endpoints as well as toxicity and compliance. All patients receive a specific mobile device (PADMA-Phone) and a validated wearable device (ActiWatch) in order to collect data regarding sleep and activity levels, patient well-being and health care utilization (number and duration of phone calls, and patient visits to investigator site) for assessment of daily monitoring treatment impact (DMTI).

Results:

Overall, 360 patients will be accrued to show an improved TTF for P in combination with ET compared to mono-chemotherapy of investigator´s choice with or without maintenance ET. Recruitment will start in QIII/2017 and is planned for approximately 18 months in 100 sites in Germany, Spain, Poland, Italy, France, UK and Canada.

Conclusions:

The aim of PADMA is to demonstrate that an endocrine-based strategy consisting of ET plus P is superior to a chemotherapy-based strategy as first-line therapy in women with HR+/HER2- MBC in a real world setting. Assessment of patient-reported outcome, health care utilization, and sleep and activity levels will deliver important information on the differences between endocrine-based and chemotherapy-based treatment.

Citation Format: Loibl S, Barinoff J, Seiler S, Decker T, Denkert C, Hardy-Bessard A-C, Senkus-Konefka E, Cognetti F, Palmieri C, Gelmon K, Luebbe K, Furlanetto J, Mueller V, Mundhenke C, Schmidt M, von Minckwitz G, Uhlig M, Burchardi N, Thill M. A randomized, open-label, multi-center phase IV study evaluating palbociclib plus endocrine treatment versus a chemotherapy-based treatment strategy in patients with hormone receptor-positive, HER2-negative metastatic breast cancer in a real world setting (PADMA) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-05-04.

Vinflunine-gemcitabine versus vinflunine-carboplatin as first-line chemotherapy in cisplatin-unfit patients with advanced urothelial carcinoma: results of an international randomized phase II trial (JASINT1)

This randomized phase II study examined the use of vinflunine in combination with gemcitabine or carboplatin as first-line chemotherapy in cisplatin-ineligible patients with advanced urothelial carcinoma. Both doublets were feasible and offered a similar 77% disease control rate. Response rate (44%), overall survival (14 months) and less haematological toxicity favoured vinflunine–gemcitabine.

Background

There is no standard first-line chemotherapy for advanced urothelial carcinoma (aUC) in cisplatin-ineligible (cisplatin-unfit) patients. The study assessed the efficacy and tolerability profile of two vinflunine-based cytotoxic regimens in this setting.

Patients and methods

Patients with aUC a creatinine clearance (CrCl) of <60 but ≥30 ml/min, performance status 0 or 1 and no prior chemotherapy for advanced disease were randomized (1 : 1). They received vinflunine 250 or 280 mg/m² (based on baseline CrCl) on day 1, plus either gemcitabine [750 mg/m² escalated to 1000 mg/m² in cycle 2 if no toxicity grade (G) ≥2 on days 1 and 8 (VG) or plus carboplatin area under the curve 4.5 day 1 (VC) every 21 days]. To detect a 22% improvement in each arm compared with H0 (41%) in the primary end point, disease control rate (DCR = complete response + partial response + stable disease), 31 assessable patients per arm were required (α = 5%, β = 20%).

Results

Sixty-nine patients were enrolled (34 VG, 35 VC). Less G3/4 haematological adverse events (AEs) were reported with VG: neutropaenia was seen in 38% (versus 68% with VC) and febrile neutropaenia in 3% (versus 14% with VC) of patients. No major differences were observed for non-haematological AEs. DCR was 77% in both groups; overall response rate (ORR) was 44.1% versus 28.6%, with a median progression-free survival of 5.9 versus 6.1 months and median OS of 14.0 versus 12.8 months with VG and VC, respectively.

Conclusion

Both vinflunine-based doublets offer a similar DCR, ORR and OS. The better haematological tolerance favours the VG combination, which warrants further study.

ClinicalTrials.gov protocol identifier

NCT 01599013.

International guidelines for management of metastatic breast cancer: combination vs sequential single-agent chemotherapy

Compared with treatment options for early-stage breast cancer, few data exist regarding the optimal use of chemotherapy for metastatic breast cancer (MBC). The choice of using a combination of cytotoxic chemotherapies vs sequential single agents is controversial. At the 6th European Breast Cancer Conference, the European School of Oncology Metastatic Breast Cancer Task Force convened an open debate on the relative benefits of combination vs sequential therapy. Based on the available data, the Task Force recommends sequential monotherapy as the preferred choice in advanced disease, in the absence of rapid clinical progression, life-threatening visceral metastases, or the need for rapid symptom and/or disease control. Patient- and disease-related factors should be used to choose between combination and sequential single-agent chemotherapy for MBC. Additional research is needed to determine the impact of therapy on patient-rated quality of life and to identify predictive factors that can be used to guide therapy.

A breast international group survey of young breast cancer patients' attitudes towards the risk of loss of fertility related to adjuvant therapies. EORTC protocol 10002 – BIG 3-98

Abstract #3106

Objectives: Under the auspices of the Breast International Group (BIG), the European Organization for Research and Treatment of Cancer (EORTC) conducted a survey with the International Breast Cancer Study Group (IBCSG) and German Breast Group (GBG) of breast cancer (BC) patients (pts) aged 35 years or less at the moment of BC diagnosis. The primary objective of our survey was to evaluate the attitude of BC pts towards the risk of sterility related to anti-cancer treatments.&#x2028; Patients and methods: Four hundred premenopausal, early stage BC pts participated in this survey after signing the informed consent, and 389 were evaluable. Patients completed a short, previously pilot-tested questionnaire, translated into 15 languages broadly following EORTC translation procedures.&#x2028; Results: 228 pts (59%) wanted to have children in the future, but 158 (41%) did not, with 57 (36%) of these women stating they were afraid the cancer would return, and as such they would not like to have children. The wish to have children in the future was more frequently expressed by those women who had no children (84% of these pts against 43% of patients with children). Thirty-two (8%) women stated they would not undergo chemotherapy, and this was dependent on whether they already had children or not. Of the 355 pts (91%) who agreed they would have chemotherapy even knowing that this may reduce their chance of having children in the future, 113 (32%) would accept treatment even if there were only 1-5% extra chance of being cured. However, 169 (48%) would accept chemotherapy only if the extra chance of being cured exceeded 20%. Ninety-one (26%) women who would undergo chemotherapy would accept only the minimal risk of sterility of 0-25%, while 171 (48%) would accept as high as 76-100% risk of sterility. The maximum risk of sterility that would be accepted by BC patients is clearly influenced by their already having children.&#x2028; Conclusion: Our international survey provides key evidence of young, early breast cancer patients' attitudes towards infertility related to breast cancer treatments. While obviously women are primarily interested in being cured, they are also highly concerned about the loss of fertility.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3106.

Estimating the magnitude of trastuzumab effects within patient subgroups in the HERA trial

BACKGROUND

Trastuzumab (Herceptin(R)) improves disease-free survival (DFS) and overall survival for patients with human epidermal growth factor receptor 2 (HER2)-positive early breast cancer. We aimed to assess the magnitude of its clinical benefit for subpopulations defined by nodal and steroid hormone receptor status using data from the Herceptin Adjuvant (HERA) study.

PATIENTS AND METHODS

HERA is an international multicenter randomized trial comparing 1 or 2 years of trastuzumab treatment with observation after standard chemotherapy in women with HER2-positive breast cancer. In total, 1703 women randomized to 1-year trastuzumab and 1698 women randomized to observation were included in these analyses. Median follow-up was 23.5 months. The primary endpoint was DFS.

RESULTS

The overall hazard ratio (HR) for trastuzumab versus observation was 0.64 [95% confidence interval (CI) 0.54-0.76; P < 0.0001], ranging from 0.46 to 0.82 for subgroups. Estimated improvement in 3-year DFS in subgroups ranged from +11.3% to +0.6%. Patients with the best prognosis (those with node-negative disease and tumors 1.1-2.0 cm) had benefit similar to the overall cohort (HR 0.53, 95% CI 0.26-1.07; 3-year DFS improvement +4.6%, 95% CI -4.0% to 13.2%).

CONCLUSIONS

Adjuvant trastuzumab therapy reduces the risk of relapse similarly across subgroups defined by nodal status and steroid hormone receptor status, even those at relatively low risk for relapse.

Parallel-opposed fields versus four fields, and two- versus three-dimensional radiotherapy planning in thin patients with gynecological malignancies

Conformal radiotherapy constitutes the standard management of pelvic malignancies, yet its role in thin patients remains debatable. This study compares dose distribution for 2D and 3D treatment techniques for cobalt (60Co) and high energy photons from linear accelerator (LA) in cervical and endometrial cancer patients with antero-posterior diameter of less than 20 cm. CT-based 3D treatment planning and 2D simulation were performed in 10 patients. Particular techniques were compared in terms of treatment portal areas, coverage of planning target volume (PTV) and sparing of critical organs. For 60Co beams, PTV was not covered adequately with 2D fields in nine patients and with conformal fields in seven. For LA, PTV was not adequately covered with 2D two-field and 2D four-field ("box") technique in three and one patients, respectively. Mean bladder dose was comparable for all plans. Both 2D "box" and 3D "box" technique spared additional portion of the rectum volume included in 95% isodose, compared to two-field plan. 3D treatment planning better protected the small intestine. Use of multiple field techniques and 3D planning allows for some improvement of PTV coverage and normal tissue sparing, although the magnitude of this benefit must be weighted against savings of time and labour related to use of simpler treatment techniques.

BRCA1 and BRCA2 point mutations and large rearrangements in breast and ovarian cancer families in Northern Poland

Sixty-four Polish families with a history of breast and/or ovarian cancer were screened for mutations in the BRCA1/2 genes using a combination of denaturing high performance liquid chromatography (DHPLC) and sequencing. Two thirds (43/64; 67%) of the families were found to carry deleterious mutations, of which the most frequent were BRCA1 5382insC (n=22/43; 51%) and Cys61Gly (n=9/43; 20%). Two other recurrent mutations were BRCA1 185delAG (n=3) and 3819del5 (n=4), together accounting for 16% of the 43 mutation-positive cases. We also found three novel mutations (BRCA1 2991del5, BRCA2 6238ins2del21 and 8876delC) which combined with findings from our earlier study of 60 Northern Polish families. Moreover, screening of 43 BRCA1/2 negative families for the presence of large rearrangements by multiplex ligation-dependent probe amplification (MLPA) resulted in the finding of two additional BRCA1 mutations: a deletion of exons 1A, 1B and 2, and a deletion of exons 17-19, both present in single families. We conclude that the Polish population has a diverse mutation spectrum influenced by strong founder effects. However, families with strong breast/ovarian cancer history who are negative for these common mutations should be offered a complete BRCA gene screening, including MLPA analysis.

Cardiovascular effects of breast cancer radiotherapy

Cardiac toxicity has been implicated as the primary reason for excess non-breast cancer mortality in early breast cancer radiotherapy studies. Refinements in radiotherapy techniques have allowed for a considerable reduction of this risk in the majority of breast cancer patients. Recent large population-based studies confirmed an increase of cardiovascular death risk in patients irradiated for cancer of the left breast and in individuals exposed to relatively low (hitherto believed to be of no cardiovascular disease risk) doses of radiation, such as atomic bomb survivors or patients treated for various benign conditions. The issue of potential radiation-related cardiac damage may also be assuming a new significance due to the widespread use of other cardiotoxic agents, such as anthracyclines, paclitaxel and trastuzumab. The aim of this review is to summarize and critically analyze the available evidence on the impact of ionizing radiation on the cardiovascular system, with special attention to recent data demonstrating previously unrecognized adverse effects. This review discusses the pathology of radiation-related cardiovascular disease, its clinical presentation, risk factors and methods of assessment, as well as technical developments minimizing cardiac exposure. Epidemiological data are presented on the incidence of radiation-induced heart disease and cardiovascular mortality in various populations of patients irradiated for breast cancer and in individuals exposed to low radiation doses. Additionally, non-cardiac radiation-related vascular morbidity and mortality in breast cancer patients are addressed.

Gene copy numbers of HER family in breast cancer

10544

Background: Most clinicopathological analyses of HER alterations in breast cancer were limited to single HER family members. Since the activation of certain HER receptors is possible only as a result of their dimerization, determining the alterations of all four HER genes may be more relevant. The aim of the study was to estimate the frequency of disorders in all four HER genes, and to determine their correlation with the clinical and histological features in breast cancer patients. Methods: Gene copy number (GCN) of ERBB oncogenes was analyzed with double differential PCR (ddPCR) in a consecutive series of 225 breast cancer patients. Statistical analysis was performed with a set of nonparametric tests. Results: Amplifications of HER1, HER2, HER3 and HER4 were detected in 15%, 26%, 10% and 15% of cases respectively, and deletions in 31%, 2%, 2% and 7% cases respectively. Abnormal GCN of at least one, and at least two oncogenes was found in 65% and 31% of the tumors, respectively. Average GCNs of all HER oncogenes significantly correlated with each other. These correlations were particularly high for HER2/HER3, HER2/HER4 and HER3/HER4 (all p<10-8), and were much stronger in N(+) compared to N(-) tumors. HER1 deletions were associated with the lack of progesterone receptor (p=0.03), whereas HER3 and HER4 amplifications were more common in well differentiated tumors (p=0.03 and 0.047 respectively). At univariate analysis disease-free survival (DFS) and overall survival (OS) were related with T and N stage, and HER1 amplification. The multivariate analysis showed that DFS was influenced by T, N and HER1 amplification, whereas OS by T, N and tumor grade. Conclusions: Our results indicate a key role of HER heterodimers in tumor progression and confirm that HER2 is the preferred partner for other HER oncogenes in this process. Deletions of HER1 were associated with unfavourable characteristics, whereas HER3 and HER4 amplifications may be linked with less aggressive phenotypes.

No significant financial relationships to disclose.

[Late recurrence of malignant tumours 20 years after diagnosis and treatment]

Late recurrence of malignant tumours is very rare phenomenon. Seven cases of late recurrent malignancy (melanoma--2 cases, clear cell renal cancer, stomach sarcoma, breast cancer, basal cell carcinoma, ovarian cancer) after 20-32 (average 22.3) years from diagnosis and treatment were described. The histopathological examination results of primary and recurrent tumours were identical. Six patients died at the age from 40 to 89 (mean 66.8) years. The survival of patients after recurrence was from 4 to 11 (mean 7.3) months.

Changes in lateral dimensions of irradiated volume and their impact on the accuracy of dose delivery during radiotherapy for head and neck cancer

BACKGROUND AND PURPOSE

To assess changes in lateral dimensions of irradiated volume during head and neck cancer radiotherapy and to determine their impact on the accuracy of dose delivery.

PATIENTS AND METHODS

Lateral dimensions of irradiated volumes were measured in five predefined points prior to treatment and then bi-weekly. For each measurement, midline dose was calculated and verified using in vivo dosimetry. Early radiation reactions, patient weight changes and the need to modify radiotherapy accessories were also recorded. The study included 33 head and neck cancer patients irradiated using parallel opposed megavoltage fields.

RESULTS

Body mass changes during radiotherapy ranged from -18 to +4 kg (median -5). Lateral dimension changes >5 mm (range -37 to +16) occurred in 32 patients (97%). For axis measurements, the degree of lateral dimension changes were correlated with treatment field size (P = 0.022) and degree of mucositis (P = 0.017). Axis doses calculated for changed dimensions varied from those prescribed by -2.5 to +6% (median +2%). Differences larger than 5% were present in 4.8% of calculations. In 17 patients (52%), radiotherapy accessories had to be modified during treatment. The need to modify radiotherapy accessories correlated with larger treatment portals (P = 0.004), more weight loss during treatment (P = 0.01) and higher initial N stage (P = 0.04).

CONCLUSIONS

Changes of irradiated volume lateral dimensions during head and neck cancer radiotherapy may lead to considerable dose delivery inaccuracies. Watchful monitoring, corrections to calculated dose when changes observed are significant and radiotherapy accessories modification during the course of treatment are strongly recommended.

Complications of Breast-cancer Radiotherapy

Although the beneficial effect of postoperative radiotherapy for breast cancer is well documented, this treatment may be related to a number of complications, which may affect patient quality of life and possibly survival. Among significant long-term irradiation sequelae are cardiac and lung damage, lymphoedema, brachial plexopathy, impaired shoulder mobility and second malignancies. The risk of these complications, particularly high with old, suboptimal irradiation techniques, has decreased with the introduction of modern technologies. In this paper, we review the contemporary knowledge on the toxicity of breast-cancer radiotherapy and discuss possible preventive measures.

Intraocular malignant teratoid medulloepithelioma in an adult: clinicopathological case report and review of the literature

PURPOSE

To report a case of intraocular medulloepithelioma, an embryonal tumour with extremely rare presentation in adults.

METHOD

The case of a 44-year-old man with intraocular malignant teratoid medulloepithelioma, primarily diagnosed as intraocular teratoma, is described and the literature on this subject is reviewed.

RESULTS

The patient presented with progressive proptosis caused by a tumour in the left eyeball. He had a 28-year history of loss of vision in the left eye. Histopathological examination of the enucleated eye demonstrated an intraocular teratoma. No adjuvant treatment was given. Six months later the patient presented with massive progression in the left orbit and intracranial invasion. Cisplatin-based chemotherapy was administered, but discontinued after two cycles due to poor tolerance and lack of response. At subsequent pathology review, a final diagnosis of malignant teratoid medulloepithelioma was made. Salvage radiotherapy (60 Gy in 30 fractions) resulted in partial response of the intracranial lesion. However, the patient died 6 months later due to intracranial tumour progression.

CONCLUSION

Medulloepithelioma should be considered in the differential diagnosis of intraocular tumours in adults, especially in the case of coexisting, long-standing ocular symptoms. In some cases this disease is very aggressive.

A prospective, randomised study to compare two palliative radiotherapy schedules for non-small-cell lung cancer (NSCLC)

A prospective randomised study compared two palliative radiotherapy schedules for inoperable symptomatic non-small-cell lung cancer (NSCLC). After stratification, 100 patients were randomly assigned to 20 Gy/5 fractions (fr)/5 days (arm A) or 16 Gy/2 fr/day 1 and 8 (arm B). There were 90 men and 10 women aged 47–81 years (mean 66), performance status 1–4 (median 2). The major clinical characteristics and incidence and degree of initial disease-related symptoms were similar in both groups. Treatment effects were assessed using patient's chart, doctor's scoring of symptomatic change and chest X-ray. Study end points included degree and duration of symptomatic relief, treatment side effects, objective response rates and overall survival. A total of 55 patients were assigned to arm A and 45 to arm B. In all, 98 patients received assigned treatment, whereas two patients died before its termination. Treatment tolerance was good and did not differ between study arms. No significant differences between study arms were observed in the degree of relief of all analysed symptoms. Overall survival time differed significantly in favour of arm B (median 8.0 vs 5.3 months; P=0.016). Both irradiation schedules provided comparable, effective palliation of tumour-related symptoms. The improved overall survival and treatment convenience of 2-fraction schedule suggest its usefulness in the routine management of symptomatic inoperable NSCLC.

Radiotherapy for breast cancer in patients undergoing breast reconstruction or augmentation

Due to increasing indications for postmastectomy radiotherapy and a growing demand for breast reconstruction or augmentation, increasing numbers of patients are currently being exposed to both these treatments. In view of the wide range of available techniques for breast reconstruction, either prosthetic or autologous, and their various sequencing in relation to radiotherapy, physicians can be faced with numerous clinical situations requiring comprehensive knowledge of the topic. This review discusses physical, radiobiological and clinical aspects of combining breast reconstruction and radiotherapy. The available data indicate the feasibility of such combinations, although at the expense of increased risk of complications and less satisfactory cosmesis. Of the two methods of breast reconstruction: using autologous tissue or prosthesis, the former seems to provide better cosmesis and a lower risk of complications in conjunction with radiotherapy. To minimize the risk of unfavourable outcome, the techniques and timing of both breast reconstruction and radiotherapy should be given meticulous attention.

The effects of tamoxifen on the female genital tract

Tamoxifen is an effective and relatively non-toxic compound used in palliative and adjuvant treatment of breast cancer. More recently its preventive role in breast cancer has also been demonstrated. However, tamoxifen use is related to some increase in the risk of endometrial cancer and to a significant rise in the incidence of benign endometrial pathologies. The activity of tamoxifen against breast cancer is mainly achieved by blocking the oestrogen receptor, whereas the effect of this compound on the female genital tract is mostly related to its agonistic properties. Despite numerous studies no effective methods of tamoxifen-user surveillance have been developed and currently no active screening for endometrial cancer, apart from yearly gynaecological examination, is recommended in these patients. In other parts of the genital tract, tamoxifen increases the risk of some benign conditions and may cause difficulties in the interpretation of cervical smears. Further studies are warranted to develop more effective surveillance and methods decreasing the detrimental effects of tamoxifen on the female genital tract.

[Efficacy and feasibility evaluation in long term pamidronate treatment of bone metastases]

The aim of our study was to evaluate the efficacy and feasibility of long-term pamidronate treatment.

MATERIAL AND METHODS

Thirty-six patients (pts) undergoing long-term (> 9 months) pamidronate treatment for bone metastases of breast cancer (30 pts), prostate cancer (3), multiple myeloma (2) and renal carcinoma (1) were retrospectively analyzed. The indication for pamidronate treatment were appearance of bone metastases (21 pts), progression of bone lesions (13) or intolerance of clodronate (2). Pamidronate was administered as an intravenous infusion, most commonly at a dose of 90 mg monthly. Skeletal complications including pathologic fractures, the need for palliative radiotherapy or bone surgery, spinal cord compression and hypercalcemia as well as occurrence of new bone or visceral lesions were assessed. The use of analgesics and subjective bone pain relief were used to evaluate the analgetic effect of pamidronate therapy. Adverse events of pamidronate treatment were noted.

RESULTS

Patients received a median of 15 pamidronate infusions (range 9-35). Complete pain control was observed in 7 pts (19%), partial in 21 (58%) and stabilization in 8 (22%). Mean time to maximal effect was 5 months (range 0-17). There were 5 cases (14%) of fever and 6 cases (17%) of flu-like syndrome after pamidronate administration. New bone lesions appeared in 16 pts (44%) after a median of 12 months (range 1-28). Other skeletal complications included pathologic fractures (9 pts, 25%) and hypercalcemia (2 pts, 5.6%); 13 pts (36%) required radiotherapy. Symptomatic progression occurred in 27 pts (75%), with a median progression-free time of 14 months (range 5-35) from the beginning of pamidronate treatment.

CONCLUSIONS

Long-term treatment with pamidronate in patients with bone metastases is well tolerated and effective in decreasing bone pain, thus maintaining considerably high quality of life.

[Results of surgical treatment of vulvar cancer]

OBJECTIVES

Vulvar cancer is a relatively rare genital malignancy. The mainstay of it's treatment is surgery.

DESIGN

A retrospective study of vulvar cancer patients treated between 1967 and 1995 at Department of Gynaecology, Medical University of Gdańsk.

MATERIALS AND METHODS

The type and outcome of surgical treatment was studied in 162 consecutive patients.

RESULTS

The surgery was limited to the vulva in 24% cases and in the reaming 76% of patients removed were also regional lymph nodes. Median survived of the whole group was 105 months and actuarial 5-year survival-60%.

CONCLUSIONS

The results of treatment of vulvar cancer in presented series correspond well with the literature data.

Influence of brachytherapy applicators geometry on dose distribution in cervical cancer

AIM

Although the relationship between the dose delivered to adjacent organs (urinary bladder and rectum) and the frequency and severity of treatment complications has been reported in many series, the factors influencing pelvic dose distribution are not well defined. The aim of the study was to assess retrospectively the influence of the size of cervical cancer brachytherapy applicators (ovoids and uterine tandems) on pelvic dose distribution and the impact of various therapy-dependent factors on patient anatomy and on dose distribution in particular applications.

PATIENTS AND METHOD

The subject of this study were 356 cervical cancer patients treated with Selectron LDR as a part of their radical radiotherapy. Analysed factors included preceding external beam radiotherapy (EBRT) or brachytherapy applications, use of general anaesthesia for application and the system of pellet loading.

RESULTS

Significant correlation was found between the size of applicators and doses to bladder, rectum and points B: larger vaginal applicators produced lower dose in bladder and rectum and higher dose in point B (all p < 0.0001), longer uterine tandems produced lower dose in rectum and higher dose in point B (both p < 0.0001). Significant decrease in the frequency of use of large applicators (ovoids: p < 0.0001, tandems: p = 0.055) and worsening of dose distribution, i.e. higher doses to critical organs (respectively: bladder p = 0.0012, rectum p = 0.02) and lower point B dose (p = 0.0001) were observed at consecutive brachytherapy applications. Similar situation occurred in patients, who received EBRT prior to brachytherapy (ovoids: p < 0.001, tandem: p = 0.04, bladder dose: p = 0.009, rectal dose: p = 0.073, point B dose: p = 0.059). Vaginal applicators were larger (p = 0.026) and the dose distribution was better (bladder: p = 0.023, rectum: p = 0.002, point B: p = 0.0001) in patients who had their insertions performed under general anaesthesia. The comparison of 2 consecutively used systems of pellet loading revealed more favourable dose distribution: lower dose for bladder (p = 0.014) and higher dose for point B (p < 0.0001) for the system, which utilised more sources in ovoids and in the distal part of the uterine tandem, in spite of more frequent use of smaller applicators in this group of patients. In multivariate analysis ovoid size was related to preceding external beam radiotherapy (p = 0.025). Uterine tandem length was dependent on the number of preceding intracavitary applications (p < 0.001) and preceding external beam radiotherapy (p = 0.007). Bladder dose was related to preceding brachytherapy (p = 0.011) and the pattern of pellet loading (p = 0.031). Rectal dose was dependent only on the use of general anaesthesia during application (p = 0.001) and point B dose was dependent on the pattern of pellet loading (p < 0.001) and marginally-on the use of preceding external beam radiotherapy (p = 0.06).

CONCLUSIONS

The results of this study allow for identification of treatment-related factors determining pelvic dose distribution in cervical cancer brachytherapy and may potentially enable optimisation of this distribution in particular clinical situation.

Patient-related factors determining geometry of intracavitary applicators and pelvic dose distribution during cervical cancer brachytherapy

PURPOSE

The aim of this study was to assess retrospectively the influence of the size of cervical cancer brachytherapy applicators (ovoids and uterine tandems) on pelvic dose distribution and to analyze the impact of various patient- and disease-related factors on applicators' geometry and on dose distribution in particular applications.

METHODS AND MATERIALS

The subject of this study were 356 cervical cancer patients treated with Selectron LDR as a part of their radical radiotherapy. Analyzed factors included patient age, weight, number of vaginal deliveries, and disease stage.

RESULTS

The use of larger vaginal applicators resulted in lower bladder and rectum doses and in higher point B doses (all p < 0.0001); longer uterine tandems produced lower rectum doses and higher point B doses (both p < 0.0001). Increasing patient age and disease stage resulted in a decreased frequency of use of large ovoids (both p < 0.0001) and of long tandems (age: p = 0.0069, stage: p = 0.004). As a result, higher doses to bladder (age: p < 0.0001, stage: p = 0.017) and rectum (age: p = 0.037, stage: p = 0.011) were observed. Increasing age also resulted in lower point B doses (p < 0.0001). Increasing patient weight correlated with less frequent use of long tandems (p = 0.0015) and with higher bladder doses (p = 0.04). Higher number of vaginal deliveries was related to the increase in the use of long tandems (p = 0.002); in patients who had had at least one vaginal delivery, point B doses were significantly higher (p = 0.0059). In multivariate analysis ovoid size and uterine tandem length were dependent on patient age (respectively: p < 0.001 and p = 0.001), disease stage (respectively: p = 0.003 and p = 0.008) and on the number of vaginal deliveries (respectively: p = 0.07 and p = 0.008). Doses to critical organs and to points B were dependent on patient age (respectively: p < 0.001, p = 0.011, and p < 0.001) and on disease stage (respectively: p < 0.001, p = 0.004, and p = 0.048).

CONCLUSION

The results of this study allow for identification of some patient- and disease-related factors influencing pelvic dose distribution in cervical cancer brachytherapy. This potentially may enable optimization of the dose distribution in particular clinical situations.

[Small cell tumor of the uterine neck]

Small cell cervical cancer is a rare, but important for its distinct biological properties and clinical behaviour, neoplasm. It is both morphologically, and clinically aggressive, in many aspects resembling small cell lung cancer. This paper discusses the present knowledge about biology and treatment of this rare malignancy.

[Alveolar rhabdomyosarcoma of the uterine cervix]

A rare case of cervical alveolar rhabdomyosarcoma in a 45-year old female is presented. The removal of the tumour was performed in two stage-procedure, due to its large dimensions: first the bulk of the tumour was removed per vaginam, proceeding afterwards to a radical hysterectomy. Metastases were detected in pelvic lymph nodes. The patient was given postoperative radiotherapy, but a dissemination of the tumour was found at the termination of the treatment and the patent died 3.5 months after surgery.