Inflammatory Breast Cancer: What Should Be the Locoregional Treatment after Primary Chemotherapy?

Purpose: The aim of this retrospective, mono-centric, study was to assess the benefit of breast surgery for inflammatory breast cancer (IBC).Patients and methods:From January 1st 1985 and December 31st 1999; out of 13180 patients diagnosed at the Institut Curie with non metastatic breast cancer, 280 (2%) were treated with curative intent for IBC with primary chemotherapy followed by either exclusive radiotherapy (118 patients, 51%) or surgery with or without radiotherapy (114 patients, 49%). Median follow-up of 11 years.Results:The two groups were comparable apart from a higher rate of tumors smaller than 70mm (43% vs 33%, p=0.003), a higher rate of clinical stage N2 (15% vs 5%, p=0.04) and fewer histopathologic grade 3 tumors (46% vs 61%, p<0.05) in the no-surgery group.The addition of surgery was associated with a significant improvement in locoregional disease control (p=0.04). At 5 years locoregional free interval was 79% in the surgery group vs 66 % in the exclusive radiotherapy group and at 10 years: 78 % vs 59 % respectively.In the univariate analysis, in addition to the absence of surgery (p=0.04), other prognostic factors associated with higher locoregional recurrence rates were: high clinical nodal stage (p=0.009), high histological nodal status (p=0.02) and the absence of taxanes in the neoadjuvant chemotherapy regimen (p=0.02). In the multivariate analysis, only the clinical N2 stage was associated with a higher rate of locoregional recurrences. There were no significant difference in overall survival (52% at 5 years, 38% at 10 years, p=0.32) or disease-free interval (at 5 years 32%, at 10 years 6%,p=0.35).Factors associated in univariate analyses with a decreased overall survival were age over 50 years, the absence of achievement of a clinical response ≥ 50%, absence of hormone receptors and the absence of taxanes in the neoadjuvant chemotherapy regimen.In multivariate analysis, only the absence of hormone receptors and either complete or partial clinical tumor response remained significant.Factors associated in univariate analyses with a higher rate of disease recurrences were the absence of achievement of a clinical response ≥ 50%, absence of hormone receptors and the absence of taxanes in the neoadjuvant chemotherapy regimen.In multivariate analysis, only the absence of hormone receptors and of clinical tumor response remained significant. Late toxicities were not significantly different between the two treatment groups except for a higher rate of fibrosis in the no-surgery group (p<0.0001), and more lymphedema in the surgery group (p=0.002).Conclusion:This study seems to confirm that the addition of breast surgery to radiotherapy should contribute to increase local control after induction chemotherapy. IBC, despite combined modality treatment, continues to suffer from dismal prognosis and efforts must be made to improve overall survival.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5120.

Single Circulating Tumor Cell Detection and Overall Survival in Non Metastatic Breast Cancer

Background: Circulation of cancer cells in the blood is a necessary step of hematogeneous metastasis while circulating tumor cells (CTC) have been reported to have a low metastatic efficiency in preclinical animal models. After a median follow-up of 18 months, we previously reported that CTC detection influences the distant metastasis-free survival (DMFS) in non-metastatic breast cancer (BC) patients (pts) treated by neoadjuvant chemotherapy (NACT) in a multicenter prospective trial. Updated results are presented here, focusing on overall survival (OS) and predictors of metastatic relapse.Methods: In 115 localized BC pts, CTC were prospectively screened (CellSearch) before and after NACT (REMAGUS02). We analyzed their outcome after a median follow-up of 36 months.Results: At baseline, 23% of pts were CTC-positive, but only 10% had more than 1 CTC per 7.5ml of blood. At an individual level, CTC detection before chemotherapy, used as a test to predict metastatic relapse, exhibited a global accuracy of 77%, higher than that of tumor grade (54%), tumor size (57%), lymph node invasion (40%), triple negative phenotype (76%) and pathological complete response (27%). Multivariate analyses for OS and DMFS showed that CTC detection before chemotherapy was a strong independent prognostic factor for both DMFS (p=0.01, RR=5.0, 95%CI[1.4-17]) and OS (p=0.007, RR=9, 95%CI[1.8-45]), along with tumor size and triple-negative phenotype, while post-chemotherapy CTC detection had a lower significance for both endpoints (p=0.07 and p=0.09 respectively).Conclusion: Biologically, the metastatic efficiency of CTC could be higher than previously thought. Clinically, besides confirming our previously reported results, this study shows that CTC detection may become the main prognostic factor in BC pts treated with NACT. Implementing this technique in everyday management might help to identify high-risk pts in whom innovative strategies should be investigated.Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis.ISRCTN10059974

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3017.

Do Transcriptomic Markers Provide Significant and Stable Information in Addition to Standard Markers, for the Prediction of Pathological Complete Response in Breast Cancer?

Background: The aim of this study was to investigate and quantify the contribution of transcriptomic markers, in addition to strong predictors such as oestrogen receptor status, to the prediction of pathological complete response (pCR) in locally advanced breast cancer.Patients: The RNA profiles were analyzed using U133 plus 2.0 Affymetrix. We included 189 patients out of 340 patients entered in a neoadjuvant chemotherapy trial for large operable and locally advanced breast cancer. After four cycles of epirubicin–cyclophosphamide, patients were randomly allocated to four cycles of docetaxel with or without celecoxib for patients with HER2-negative tumors, and docetaxel with or without trastuzumab for patients with HER2-positive tumors, respectively. Proportions of pCR in each group were equal to 0.12, 0.16, 0.15 and 0.24 respectively. Patients who received trastuzumab (N=36) were discard from our example, in order to deal with similar proportions of pCR.Methods: The whole sample was divided into a training set (N=81) and a validation set (N=72). Using the training set, two predictive models were built using multivariate logistic regression models. In the first model (M1), usual clinical and biological significant markers were included. In the second model (M2), in addition to the significant parameters of M1, significant transcriptomic variables were included. Diagnostics of both predictive models were assessed on the validation set through sensitivity and specificity estimates. Simulations were performed to investigate stability of model M2.Results: In M1, oestrogen receptor status and tumor size were found to have a strong predictive role in the prediction of pCR. In addition to these classical markers, genes belonging to biological pathways involved in proliferation and microtubule stabilization appeared to have a strong role in the prediction of pCR (model M2). Validation of M1 on the validation set provided 70% of sensitivity and 86% of specificity. Validation of M2 on the validation set yielded to a better sensitivity of 80% and a specificity of 81%. Using simulations, we showed that several different predictive models M2 yielded to similar performances on the validation set. Conclusion: Our study showed that transcriptomic markers provided significant information in addition to usual biological markers for the prediction of pCR. In addition, predictive model with both usual and transcriptomic markers may lead in an improvement of the classification performances. However, as illustrated by simulations, predictive models with both classical and transcriptomic markers are not exclusive. The contribution of transcriptomic data for the prediction of pCR is straightforward, but finding a stable predictive model remains a great challenge.Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis.ISRCTN10059974

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2035.

Distant Metastasis Free Survival (DMFS) in Breast Cancer Patients with Micrometastases (pN1mi) in the Sentinel Lymph Node (SLN): Results in 582 Positive-SLN Patients in a Single Institution

Background:The risk of developing distant metastases (DM) in pN1mi and isolated tumor cells (pN0i+) patients remains under question. Does occult axillary node metastases is an additional factor for using an adjuvant systemic therapy (AST) in early breast cancer ?Patients and Methods:Among 2695 patients operated on from 2000 to 2006 for SLN, 582 patients had a positive SNB: 307 were pN1, 154 pN1mi and 121 pN0i+ (6th AJCC-classification). All patients underwent an immediate or delayed Axillary Lymph Node Dissection (ALND). We report the results for DMFS [median follow-up of 56 months (2-105)].We used Kaplan-Meier method and Cox regression for multivariate analysis.Results:ALND were positive in pN1, pN1mi and pN0i+ patients respectively in 127 (41,3%), 20 (13%) and 14 (11.6%) of these patients. On univariate and multivariate analysis, positive ALND, mitotic index, pathologic tumor size were significantly related to the DMFS; on multivariate analysis, the type of axillary lymph node metastases was an additional significative factor. There was not relationship between pN0i+ and the development of DM. Surprisingly, patients with pN1mi had a 2.8 higher risk for developing DM than pN1 patients. pN1 patients receive more AST than pN1mi (75% and 22%), however AST was not prognostic (p=0.49).Conclusion:In our series, patients with pN1mi were associated with a worse prognosis related to DMFS compared to pN1. Use of AST and/or biological primary tumor characteristics could explain this paradoxical result. Longer follow-up and larger series are needed to determine the prognostic significance of axillary occult metastases.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 308.

Is Exclusive Radiotherapy an Option for Early Breast Cancers with Complete Clinical Response after Neoadjuvant Chemotherapy?

Purpose: To determine whether exclusive radiotherapy (ERT) could be an option after complete clinical response (cCR) to neoadjuvant chemotherapy (NCT) for early breast cancers (EBC).Patients and methods: Between 1985 and 1999, 1477 patients received NCT for EBC considered to be too large for primary conservative surgery. Of 165 patients with cCR, 65 were treated by breast surgery (with radiotherapy) and 100 by ERT.Results: The two groups were comparable in terms of baseline characteristics, except for larger initial tumor sizes in the ERT group. There were no significant differences in overall, disease-free and metastasis-free survivals. Five-year and 10-year overall survivals were 91% and 77% in the no surgery group and 82% and 79% in the surgery group, respectively (p = 0.9). However, a non-significant trend towards higher locoregional recurrence rates (LRR) was observed in the no surgery group (31% vs. 17% at 10 years; p = 0.06). In patients with complete responses on mammography and/or ultrasound, LRR were not significantly different (p = 0.45, 10-year LRR: 21% in surgery vs. 26% in ERT). No significant differences were observed in terms of the rate of cutaneous, cardiac or pulmonary toxicities.Conclusion: Omission of breast surgery in patients who achieved cCR to NCT was not associated with an increased risk of distant metastases or death. However a trend towards an increased risk of locoregional recurrence was observed in the ERT group. Imaging modalities appear to be essential to monitor chemotherapy response and possibly select patients in whom ERT can be proposed.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4108.

A Multicenter Randomized Phase II Study of Sequential Epirubicin/Cyclophosphamide Followed by Docetaxel with or without Celecoxib or Trastuzumab According to HER2 Status, as Primary Chemotherapy for Localized Invasive Breast Cancer Patient

Purpose: To assess anti tumor activity of sequential epirubicin/cyclophosphamide followed by docetaxel with the randomized addition of celecoxib In Her2-ve patients or trastuzumab in Her2+ve patients versus no additional treatment, in terms of pathological complete response (pCR), defined as absence of residual invasive breast carcinoma and of nodal involvement.Patients and methods: 340 patients with stage II and III breast adenocarcinoma, with tumors ineligible for breast conservative surgery received 8 sequential 3 weekly cycles with epirubicin (75mg/m2)-cyclophosphamide (750mg/m2) for 4 cycles followed by docetaxel (100 mg/m2) for 4 cycles. According to HER2 status (IHC + FISH) they were randomized to receive together with docetaxel, in HER2 negative group (220 patients) celecoxib 800 mg/day during cycles 5-8 or no additional treatment and in HER2 positive group (120 patients) trastuzumab (8mg/kg then 6mg/kg) infused together with docetaxel or no additional treatment. All patients except eight with HER2+ tumor received adjuvant trastuzumab for a cumulative duration of 12 months.Results: In the HER2 negative group, pCR (grade 1 and 2 of Chevallier's classification) was observed in 11.5% and 13% of patients treated without and with neoadjuvant Celecoxib respectively. In the HER2+ group, pCR rate reached 26% in those having received neoadjuvant trastuzumab versus 19% in the others. There was no cardiac toxicity and no toxic death. Triple negative breast cancers experience the highest pCR rate of 30%.Conclusion: It is the first report on the effect of the addition of celecoxib to chemotherapy in neoadjuvant setting in breast cancer, showing that celecoxib does not improve the pCR rate. Addition of trastuzumab does, yet not to the extent reported with a protracted co-administration before surgery. Expression of hormonal receptors appears to be the major prognosticator for pCR. Molecular studies of gene expression profiling should allow improving such prediction.Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis.ISRCTN10059974

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5054.

Heterogeneous Amplification of HER2 Is a Rare but Clinically Significant Event in Invasive Ductal Carcinoma

BackgroundWe have recently shown that pT1ab HER2 positive tumors carry a poor prognosis, which may be alleviated by trastuzumab (T) based therapy (Rodrigues et al, ASCO 2009). We had also reported that heterogeneous expression of HER2 (hetHER2) may be associated with a poor outcome depending on the HER2 overexpressing subclone (Cottu et al, Ann Oncol 2007). Meanwhile, ASCO/CAP guidelines have questioned the minimum valid score for HER2 expression (Moeder et al, J Clin Oncol 2007; Wolff et al, J Clin Oncol 2007). We describe here the characteristics and outcome of a series of patients with hetHER2 disease.Patients and methodsHER2 status is routinely assessed in our institution in advanced breast cancer patients since 1999, and in early patients since 2002. Out of 1300 HER2 positive cases, we have been able to identify 12 pts with heterogeneous expression of HER2 in the primary tumor (<1%). HetHER2 was defined as more than 5% and less than 59% of infiltrating cells overexpressing HER2 with an intense and complete membrane staining, and /or with a FISH ratio ≥ 2.2. Confirmation was obtained by FISH in 8 patients. Detailed pathological analysis, clinical characteristics and outcome were obtained.ResultsMedian age at diagnosis was 45 years (31-64). All pts received adequate locoregional therapy according to institutional guidelines. Pathological characteristics of the primary tumors are depicted in the table.Pathological Characteristics pT1pT2pT3Tumor Size (n)633 n/ n evaluable%ER+11/1292PR+5/1242HER2 FISH+8/1080vascular emboli5/862.5 pN0pNmi/i+pN+pN (n)624 I / lowII / intermediateIII / highGrade (Elston Ellis)255Mitotic Index327 All patients had infiltrating ductal carcinoma, two of them bearing also a ductal carcinoma in situ component. Most ER+ tumors had a faint staining, observed in less than 50% of tumor cells. In 1 pt with a node-positive tumor, the same pattern of heterogeneous overexpression of EHR2 was observed in the primary tumor and in the lymph nodes. Chemotherapy was given to 9 patients (75%), hormonal treatment to 6 pts (50%) and T was added to chemotherapy in 3 pts. With a median follow-up of 69 months (0-200), 6 pts have relapsed, none of them having received T based therapy. Median time to relapse was 46 mths (14-151). Initial sites of relapses were axillary lymph nodes (1), mediastinal lymph nodes (1), skin (1), liver (2) and ipsilateral relapse (1). No brain metastases were recorded. HER2 status was obtained in four relapses and was considered either negative (Skin), or highly overexpressed (liver) or heterogeneous (ipsilateral and axillary lymph node relapses). None of the 3 T treated pts has relapsed so far, but their follow up is still under 6 months.ConclusionsMore than half of the tumors exhibited at least 1 poor prognosis feature beyond HER2 overexpression. In the line of the recent reanalysis of the NCCTG9831 adjuvant T trial which has suggested that T may be beneficial to hetHER2 patients (Sukov et al, ASCO 2009), our data support the evidence of a poor prognosis of hetHER2 disease, which may be similar to the prognosis of the “real” HER2 3+ and amplified disease. Prospective evaluation of anti HER2 based therapy in this subset of patients is clearly warranted.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6034.

Transcriptomic Profiles and Circulating Tumor Cell Detection in Primary Breast Cancer

Background: We have previously demonstrated that circulating tumor cells (CTC) detection by the CellSearch system is strongly associated with metastatic outcome in non-metastatic breast cancer (BC) treated by neoadjuvant chemotherapy (NACT) [Pierga, Clin Cancer Res 2008]. Transcriptomic analysis of primary tumors may uncover molecular phenotypes associated with CTC detection.Methods: Both CTC detection in blood at diagnosis and transcriptomic analysis of the primary tumor have been performed prospectively in 58 non-metastatic BC patients (pts) treated by NACT in a phase II trial (REMAGUS02). We searched for an association between CTC detection and (i) intrinsic molecular subtypes, (ii) stemness signature, (iii) other published signatures, and (iv) expression of molecular markers involved in CTC detection. CTC-associated genes were also studied (v).Results: (i) CTC detection was not statistically associated with an intrinsic molecular subtype: 29% in basal-like (n=5/17pts), 33% in HER2+ (3/9pts), 13% in luminal A (2/13pts), 20% in luminal B (2/10pts) and 29% in normal-like (2/7pts) BC. (ii) No association was found between CTC detection and the stemness signature. (iv) CTC detection was also not related to the “stemness profile”; it was independent of EpCAM, CK8 and CK18 transcriptomic expression. Other results (iii, v) will be disclosed at the meeting.Conclusion: Our study is the first to compare tumor gene expression profiles and blood dissemination of cancer cells in early BC pts. In these pts, CTC detection by the CellSearch system does not depend on intrinsic molecular subtypes, contrary to a published report based on in vitro-grown cells lines [Sieuwerts, J Natl Cancer Inst 2009]. Being independent from molecular prognostic factors, CTC detection is likely to play a critical role in early BC management.Supported by PHRC AOM/2OO2/02117, Pfizer inc., Roche, sanofi-aventis.ISRCTN10059974

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3005.

Outcome of HER2-Positive (HER2+) Metastatic Breast Cancer Patients (MBC) Treated with Trastuzumab (T): An Institutional Based Review

Background: HER2+ status is associated with poor prognosis, high incidence of visceral and brain metastasis. However the addition of trastuzumab to chemotherapy (CT) significantly improves survival in early and advanced breast cancer. The purpose of this retrospective study was to explore the pattern of outcome in a cohort of MBC patients treated with T-based chemotherapy in a single institution. T was approved in Europe in 2000 and in 2001 all pts had access to T according HER2+ status. Methods: Women with de novo or recurrent breast cancer treated with trastuzumab at Institut Curie between 2001 and 2006 with HER2+ status (IHC 3+ or FISH +) were identified from the Institut Curie database. Disease was classified in two groups: patients who received T upfront and those who received T after one or several CT regimens. Overall survival (OS) was defined as the time from the date of the first metastasis to the date of death or last follow-up and was estimated using the Kaplan-Meier product method. Results: The final analysis included 244 patients. Median age was 53.4 yrs (29-80). Median time from primary and first metastasis was 22 mths (0-238). Visceral metastasis were present in 153 pts (63%) and 125 pts (51%) presented multiple sites. One hundred pts (42%) developed brain metastasis during the course of disease. One hundred and sixty five pts (68%) received T as first line, 79 pts (32%) after a median of one line of CT (median 1, range 1-5). One hundred and twenty four pts (52%) received more than 3 regimens. The median overall survival was 53 mths (4-113), similar in both groups. However there is a major bias: pts with very aggressive disease not treated upfront with T not have not been offered delayed T and don't appear in the analyzed population. Patients who developed brain metastasis had a median survival of 41 mths (11-90). Complete characteristics of pts will be presented. Conclusions: The introduction of T has altered the natural history of HER2+disease. Even outside a clinical trial, our results show that the addition of T to CT improves the prognosis of MBC patients with HER2+ disease. Prolongation of T after progression with other CT appears beneficial, even in pts with a high disease burden. The high incidence of brain metastases remains an issue in such a population.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5107.

Circulating Endothelial Cells (CEC) as an Early Surrogate Marker and Circulating Tumor Cells (CTC) as a Prognostic Factor in Metastatic Breast Cancer (MBC) Patients Treated First-Line with Bevacizumab (Bv) and Chemotherapy (CT): A French Sub-Study of the Phase IIIb International Multicentre MO19391 Trial

Background: Detection of circulating tumor cells (CTC) is an independent prognostic factor in MBC. A decrease of CTC during treatment is associated with a better outcome (Cristofanilli, NEJM 2004). The antiangiogenic agent Bv, in combination with CT, (i) improves progression free survival (PFS) of first line treatments, (ii) may modify tumor cell intravasation and CTC count, and (iii) may change CEC levels. We therefore investigated whether CTC and CEC counts could be early surrogate markers of time to progression (TTP) in MBC patients receiving a highly active anti-tumor treatment (HAATT) comprising taxanes combined with Bv.Methods: Eligible patients received Bv (10mg/kg q2w or 15mg/kg q3w) combined with a taxane–based CT or non-anthracycline CT, until disease progression, unacceptable toxicity or withdrawal. For patients participating in the sub-study, CTC and CEC were measured in 7.5ml of blood at baseline and after cycle 2 or 3 of treatment. Analysis was performed using the CellSearch™ System, combining EpCAM immunomagnetic selection (IMS) followed by anti-cytokeratin (A45B/B3) staining for CTC and CD146 IMS and CD105 staining for CEC. VEGF-A constitutional polymorphisms from blood (2578C>A, -1498T>C, -634G>C, 936C>T) were also analyzed in the same patients. CTC and CEC counts at baseline and changes during treatment were correlated with TTP.Results: Sixty-seven patients were included. There was no correlation between CTC, CEC levels and VEGF-A polymorphisms. At baseline, using the threshold of 5 CTC/7.5 ml which was previously defined with standard CT: (i) CTC positivity (54% of patients) was associated with elevated LDH (p=0.04), elevated CA15.3 (p<0.001) and high tumor burden (>3 metastatic sites) (p=0.03); (ii) CTC was a significant prognostic marker for TTP at a threshold of 3 CTC/7.5 ml (p<0.05) and not at 5 CTC/7.5 ml (p=0.09). Baseline CEC levels (median:17, range [1-769]) were associated with age ≥45y (p=0.01), with elevated LDH (p<0.01) and not with TTP at any threshold. In our series, changes of CTC count during treatment was not a surrogate for TTP, with any of the model tested (threshold-based or relative decrease in %). However, changes of CEC count during treatment was significantly associated with TTP, at the threshold of 20 (p<0.001).Conclusion: Our study is the first to monitor both CTC and CEC levels in the era of HAATT comprising an antiangiogenic agent combined with standard CT. We observed that previously reported CTC thresholds may be modified by antiangiogenic therapy, whereas changes in CEC levels are a promising early surrogate marker for TTP under HAATT.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6087.

Microfluidic device for circulating tumor cell sorting, characterization, and culture

11068

Background: Circulating tumor cell (CTC) analysis is a promising approach to further characterize the tumor biology and the metastatic process, but has immediate clinical applications such as early predictive markers of response to chemotherapy. However, the devices that are used currently for CTC detection have a poor sensitivity. Microfluidic techniques offer new exciting perspectives in the field of cell sorting for CTC analysis. Methods: We propose here a new microfluidic system and strategy allowing the sorting of cells, their study by confoncal fluorescent microscopy and/or their subsequent culture. The core of our system is a self-organized array of superparamagnetic particles in a microchannel, allowing for the formation of a perfectly periodic and robust array. The superparamagnetic particles are coated with specific antibodies against surface antigens, in order to capture cells according to specific biomarkers. This original cell-separation microchip was integrated into a fully automated platform combining state-of-the-art microfluidic technologies, microvalves and nanofluidic pneumatic pumps. Results: Using B and T lymphocytes mixtures as a model biological system, the capture yield was better than 90%, and the specificity better than 97%. Captured cells were fully viable and were cultured in situ in the magnetic array. In clinics, immunophenotyping of circulating malignant B cells was performed using fluorescent confocal microscopy, and was successfully compared to flow cytometry data for each sample. Results on breast cancer cells will be presented at the meeting. Conclusions: This new system is a promising approach for efficient CTC sorting, analysis and culture in a completely integrated manner.

No significant financial relationships to disclose.

Safety and efficacy of first-line bevacizumab (B) plus chemotherapy (CT) for locally recurrent or metastatic breast cancer (LR/mBC): Analysis of MO19391 according to CT

1033

Background: Combination of B with first-line paclitaxel (TP) or docetaxel (TD) significantly improves PFS vs taxane alone in pts with LR/mBC. The open-label, multicenter MO19391 trial further assessed safety and efficacy of first-line B plus a taxane in >2,000 pts in routine clinical practice. Methods: Eligible pts had HER2- negative LR/mBC (or HER2-positive LR/mBC progressing after trastuzumab-containing therapy), ECOG PS 0–2, no prior CT for LR/mBC and no evidence of CNS metastases. Pts received B 10mg/kg q2w or 15mg/kg q3w plus the physician's choice of taxane (TP or TD alone or with another CT) or other non-anthracycline CT according to physician's standard of care. Treatment was continued until disease progression, unacceptable toxicity, or refusal. The primary endpoint was safety (NCI CTCAE v3.0); secondary endpoints included TTP, OS, and safety in pts developing CNS metastases. Results: From Sept 2006 to June 2008, 2,027 pts from 37 countries were enrolled. Median follow-up is 7.4 months. CT included a taxane (alone or with CT) in ∼75% of pts. Non-taxane agents included capecitabine (X) and vinorelbine (V). In the overall population, median age was 54 years (range 21–93), 70% were ER and/or PgR positive, and 32% had disease-free interval (DFI) ≤24 months. Baseline characteristics were broadly similar across subgroups. However, the X monotherapy subgroup included fewer pts with >3 metastatic lesions and more with a DFI ≤24 months and/or triple-negative disease compared with other subgroups. Safety and efficacy results grouped by CT are shown below. OS data are still immature (85% of pts alive at this analysis). Conclusions: In this large phase IV study, safety and efficacy of B plus TP or TD was similar to results of E2100 and AVADO. Variations in toxicities were consistent with the known profiles of each CT and no new safety signals for B were observed. The lowest incidences of serious Aes were seen with B plus TP or X. TTP was shorter with X and non-taxane combinations. Such findings are potentially attributable to small pt numbers and differences in baseline characteristics. These results show that B can be safely and effectively combined with a wide range of commonly used CT regimens as first-line therapy for mBC.

[Table: see text]

[Table: see text]

Tolerability and efficacy of first-line bevacizumab (B) plus chemotherapy (CT) in elderly patients with advanced breast cancer (aBC): Subpopulation analysis of the MO19391 study

1032

Background: Limited data exist on the efficacy and safety of biological agents in elderly patients with aBC. This is essentially due to the lack of studies specifically targeting the older population and to strict inclusion criteria in clinical trials. B significantly improved the efficacy of 1st-line taxane therapy in two large, randomized phase III trials, E2100 and AVADO. Methods: In study MO19391, 1st-line B 10mg/kg q2w or 15mg/kg q3w + CT (primarily but not exclusively taxane monotherapy) was investigated in a broader, large aBC patient population, with the aim of understanding safety and efficacy in patients seen in routine clinical practice, including elderly patients. Results: A total of 2,027 patients were enrolled. Median age was 54 years (range 21–93); 359 patients (17.7%) were aged ≥65 years and 169 (8.3%) were ≥70 years. Baseline characteristics and safety and efficacy results according to age are shown below (Table). Conclusions: Treatment with B is feasible in elderly patients. Hypertension was the only grade 3 B-related side effect reported more frequently in the older than in the younger cohort. Efficacy was similar in the two subgroups. These results suggest that the combination of B with 1st-line CT shows a similar therapeutic index regardless of age. Data on compliance according to the different CT regimens, the impact of comorbidities on safety, and analyses in the subgroup of patients ≥70 years will be presented.

[Table: see text]

[Table: see text]

Efficacy and safety of bevacizumab (BEV)-based combination regimens in patients with metastatic colorectal cancer (mCRC): Randomized phase II study of BEV + FOLFIRI versus BEV + XELIRI (FNCLCC ACCORD 13/0503 study)

4086

Background: The combination of BEV and chemotherapy is highly effective in patients with mCRC and improves response rate, progression-free survival and overall survival compared with chemotherapy alone. This randomized non-comparative phase II trial evaluated the efficacy and safety of BEV in combination with either XELIRI or FOLFIRI as first-line therapy for mCRC. Methods: Patients were eligible for inclusion in this study if they had histologically proven measurable mCRC, were aged 18–75 years, and had an ECOG performance status (PS) of 0–2. Patients were treated with 8 cycles of XELIRI (irinotecan 200 mg/m2 on Day 1 and capecitabine 1000 mg/m2 bid on Days 1–14) + BEV 7.5 mg/kg on Day 1, every 3 weeks or 12 cycles of FOLFIRI (irinotecan 200 mg/m2 on Day 1 + 5-fluorouracil (5-FU) 400 mg/m2 + folinic acid 400 mg/m2 on day 1 followed by 5-FU 2400 mg/m2 via 46-h infusion) + BEV 5 mg/kg on day 1, every 2 weeks. BEV was continued to disease progression. Patients aged ≥65 years received a lower daily dose of capecitabine (800 mg/m2 bid). The primary endpoint was crude progression-free survival (PFS) at 6 months. Results: In total, 145 patients were entered in the study between March 2006 and January 2008; 72 patients received BEV + XELIRI and 73 patients received BEV + FOLFIRI (male 64%/48%; median age 61/61 years; 35/36% aged >65 years). Preliminary results from the first 6 months of follow-up are reported here. A total of 491/783 cycles was administered, 63%/67% receiving at least the initially planned number of cycles (8 cycles for BEV + XELIRI and 12 for BEV + FOLFIRI). Main results are given in the table . Conclusions: This randomized non-comparative study has shown that BEV + XELIRI and BEV + FOLFIRI are similarly effective treatments for patients with mCRC, with manageable toxicity profiles. Results with updated follow-up will be presented at the Meeting.

[Table: see text]

[Table: see text]

A retrospective study of parameters influencing survival after surgical resection of lung metastases of bone and soft tissue sarcomas

10541

Background: Due to the high rate of isolated lung metastases of sarcomas, a multidisciplinary approach combining chemotherapy with pulmonary metastasectomy (PM) is helpful to achieve R0 resection and try to increase progression free survival (PFS) and overall survival (OS). The aim of this retrospective study is to describe the clinical and tumor features of 70 consecutive operated patients and to identify the factors influencing survival. Methods: 70 patients undergoing PM at Foch Hospital or CCML between 1995 and 2006 were identified, with follow-up (FU) for a minimum of 3 years after last PM. Statview program has been used to create survival curves, Cox proportional hazard model for multivariate analysis. Results: 64 patients had grade II/III sarcomas of mainly lower limb origin.15 patients had synchronous lung metastases, 35 showed bilateral lesions (mean number of 4, mean size of 12 mm). No patient had extrapulmonary disease at the time of PM. 51% were primary bone sarcomas (24 osteo, 9 Ewing, 3 chondro) and 49 % were soft tissue sarcomas (including 12 synovial, 9 leio). The primary tumor treatment consisted in conservative surgery in 58 patients (83%). 49 patients received neo and/or adjuvant chemotherapy, 22 patients had postoperative radiotherapy. All patients underwent PM: 1 pneumonectomy, 15 lobectomy and 54 wedge resection. 21 patients required bilateral PM. The resection margins were classified R0/R1/R2 in 54/16/0 patients, R0 was confirmed in 44 by CT scan in a month after PM. With a median FU from diagnosis of 7.7 years, the median OS for all patients reached 59 months, and the median survival after metastasectomy (OSPM) 31 months. The 5-year OS and OSPM rates were 77% and 59% respectively. The mean PFS was 20 months. 25 patients underwent subsequent PM for recurrent lung metastases, 30 are still alive. On univariate analysis, primary high grade, DFI>24 months, number of metastases>3 and largest diameter>25 mm were significant negative factors for OS. Multivariate analysis confirmed the importance of high grade, DFI, and size of metastases for OS. R0 was associated with prolonged PFS after PM. Conclusions: Accurate patient selection and technical aspects of PM are related to optimal R0 rate. DFI may be a surrogate marker for tumor biology.

No significant financial relationships to disclose.

Circulating endothelial cell (CEC) monitoring in metastatic colorectal cancer (mCRC) patients (pts) treated with first-line bevacizumab (BEV)-based combination regimens: Results of the randomized phase II FNCLCC-ACCORD 13/0503 trial

4071

Background: There is no validated biomarker to predict the efficacy of BEV, an anti-VEGF monoclonal antibody. Rare cell subpopulations such as CEC are good candidates. Methods: Pts with mCRC, aged 18–75 yrs, ECOG performance status (PS) 0–2, and no prior palliative chemotherapy were randomized to either BEV (5 mg/kg) + FOLFIRI every 2 weeks (arm A, 12 cycles) or BEV (7,5 mg/kg) + XELIRI every 3 weeks (arm B, 8 cycles). BEV was continued until disease progression [PD]. The primary endpoint was crude 6-month progression-free survival (PFS) rate. In consenting pts, CEC (CD45-CD31+CD146+7- amino-actinomycin- cells) were measured at baseline (Day [D]1, before treatment), D8, and at the end of cycle 1 (D15 or 22) in 1-mL whole blood by four-color flow cytometry according to a method we established previously (J Immunol Methods 2008). Results were correlated to pts’ characteristics and primary endpoint (Wilcoxon's, Fisher's, and trend tests). Results: From 03/06 to 01/08, we enrolled 145 pts (male, 56%; median age, 61 yrs; PS 0–1, 91%; number of metastatic sites [1/2/>2], 45/48/8%). Pts with at least one CEC measurement (n=99; arm A, 51; arm B, 48) did not differ from the 46 other pts regarding sex, age, PS, and number of metastatic sites. Baseline CEC levels (n=97; median, 16/mL) were higher in PS 1–2 pts (n=42) than in PS 0 pts (n=55) (17 vs. 12/mL, p=0.02) (age, sex, number of metastatic sites: NS) and in pts with PD (n=17) than in pts with non- PD (n=80) at 6 months (30 vs. 15/mL, p=0.004). CEC levels were higher at the end of cycle 1 in the PD group (n=17) than in the non-PD group (n=74) (34 vs. 14/mL, p=0.01). The 6-month PFS rate varied from 0% to 32% in the 4 groups defined by baseline and end-of-cycle- 1 CEC values (cutoff: baseline median) (trend test, p=0.006) ( table ). Conclusions: Baseline and end-of-cycle-1 CEC levels may predict tumor control in patients with mCRC starting first-line BEV + chemotherapy.

[Table: see text]

[Table: see text]

Bone marrow disseminated tumor cells, loco-regional and adjuvant treatment are prognostic factors for loco-regional relapses in early breast cancers

Abstract #307

Purpose: To study in early breast cancer (BC) patients (pts) if bone marrow (BM) disseminated tumor cells (DTC) are associated with a specific loco-regional dissemination of cancer cells, according to the radiotherapy fields and to the pattern of loco-regional relapses.
 Patient and methods: BM aspirates were prospectively screened for cytokeratin positive (CK+) cells at primary treatment in stage I-III BC pts. Local recurrence (LR) was defined as recurrence of the breast or chest wall; Regional recurrence (RR) was defined as lymph node recurrence after loco-regional treatment. Irradiation fields, BM DTC status, clinical and pathological variables of the pts were correlated with loco-regional relapse-free survival (LRRFS).
 Results: BM DTC were detected in 94 out of 621 pts (15%) and were not associated with the axillary lymph node status and other prognostic factors. After a median follow-up of 56 months, 18 pts (2,9%) experienced loco-regional relapses: 15 LR occurred in the RT fields whereas 2 LR and 1 RR were out. 8 of the 18 relapsing pts (44%) were DTC positive (8 LR in the RT fields). BM DTC detection was the only prognostic factor for LRRFS (p=0.0005, OR=5.2 [2.0-13.1]) in multivariate analysis. In BM DTC positive patients, longer LRRFS were observed in those who were given adjuvant hormonal therapy (p=0.03) and RT on supra-clavicular (SCN) and internal mammary (IMN) nodes (p=0.055) (multivariate analysis).
 Conclusions: BM DTC strongly influence loco-regional relapse in early BC patients. Our data support the hypothesis of a different lymphatic spread of BM DTC positive BC and of a possible re-seeding of BM DTC to the breast. Survival analyses suggest that BM DTC positive patients take advantage of adjuvant hormone therapy but also of adjuvant SCN and IMN irradiation. This observation could be one explanation of the influence of systemic treatment on locoregional relapse and of radiotherapy on distant metastatic dissemination.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 307.

Do isolated cells (pN0i+) in the sentinel lymph node change the post-operative management in breast cancer?

Abstract #206

Background: immunohistochemical (IHC) analysis of the sentinel lymph node (SLN) allows detection of occult metastases not routinely diagnosed by conventional techniques. There is, however, no consensus concerning the post-operative management of those patients with IHC-positive (pN0i+) nodes: should one re-operate, change the medical treatment or alter the irradiation fields?
 Patients and methods: 2692 patients with early invasive breast cancer underwent conservative treatment with SLN biopsy between 2000 and 2006. SLN were evaluated with frozen section followed by serial-section HES and IHC if HES showed no tumour cells. Lymph node staging followed the accepted pTNM classification: pN0, pN0i+ (≤ 0.2mm, IHC+), pNmi (0.2-2mm) and pN1a (> 2mm). In 1506 patients with T1pN0 tumours : 143 were pN0i+, that is 10%. We compared the post-operative management of pN0 patients, who had no completion axillary dissection (CAD), to those pN0i+ who did. All positive SLNs underwent CAD according to our institutional protocol.
 Results: 15 of 143 (10.5%) pN0i+ patients showed metastases in their CAD; a single node in 10 cases, 2-3 in 4 and > 3 in one patient. Univariate analysis showed chemo- and hormono-therapy to be more frequently administered in pN0i+ (24.5% vs. 77.6%) compared to pN0 (9.1% vs. 55.8%) patients; p < 0.0001. Irrespective of the result of CAD, pN0i+ patients had significant modifications in their fields of lymphatic irradiation at the internal mammary (43.6% vs. 23.5%), supra-clavicular (40.9% vs. 21.5%) and sub-clavicular (13.5% vs. 3.7%) areas; p < 0.0001. Other predictive factors showed a similar pattern including age < 50 years (31.5% vs. 18.6%), tumour size bigger (1.51cm vs. 1.16 cm) and lymphovascular invasion (27.5% vs. 11.6%); p < 0,0001. After multivariate analysis, the sole decisive factor for chemotherapy between the two groups was the presence of nodal metastasis in CAD. The duration of this study is, however, insufficient to comment on the long-term implications for pN0i+ patients.
 Discussion: immunohistochemistry alone plays a decisive role in favour of chemotherapy in N+ supplementary AD in only 10% of pN0i+ (15/143) patients. However, this concerns only 1% (15/1506) of those undergoing IHC so may have significant resource implications and other factors were found to be more influential. Moreover, pN0i+ patients underwent additional lymphatic irradiation, to all 3 fields, more frequently.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 206.

Identification of three-genomic regions prognostic signature in small node-negative breast carcinomas

Abstract #1081

Background: The purpose of this study was to identify a genomic signature of early metastatic recurrence, in order to predict accurately breast carcinomas clinical outcome and to select patients with node negative and small tumor size (<3cm) who would benefit from adjuvant chemotherapy.
 Patients and methods: Using genome-wide BAC-PAC Genomic Comparative Hybridization (CGH) array (1kb), we analyzed a training set of 78 patients. All patients had invasive ductal carcinomas and were initially treated by surgery and radiotherapy, without chemotherapy. The validation was performed on an independent test set of 90 patients. The training and tests sets were composed of respectively 53 and 58 patients disease-free survivors at 60 months (good prognosis group), and by 25 and 32 patients with distant metastatic recurrence before 48 months (poor prognosis group). In the training set, a signature was established as a logistic multivariate model of regions containing contiguous BAC clones with statistically different ratios and median frequencies of gains and losses between the poor and the good prognosis groups. This signature was then validated using the independent test set to evaluate its accuracy to classify T0T1T2N0 patients according to their outcome.
 Results: The training test identified a prognostic signature defined by 3 genomic regions, located on the 2p (38.3 to 40.9Mb), 3p (32 to 80.3Mb), and 8q (78.8 to 128.9Mb) chromosomes. In the test set, 90% of patients of favourable outcome were ER +ve and 88% were PR +ve, compared to 62% and 55% in the poor outcome group, respectively. In the test set, our signature was highly informative to identify patients that developed distant metastases before 48 months: the rate of patients well classified was 0.74, CI (95%): [0.64; 0.83], with a specificity of 95%, CI (95%): [86%; 99%]. On Kaplan-Meier analysis, the poor-prognosis genomic signature group of patients had a RR of 3.5 of metastatic relapse (log rank test p<0.001).
 Conclusions: Our signature, validated on an independent series of small T0T1T2N0 and on a majority of ER/PR positive tumors, may provide a robust and accurate tool to identify, in addition to classical parameters, patients who would benefit from adjuvant medical treatments. The comparison of this genomic signature with RNA based signatures and clinico-pathological parameters, is currently being investigated.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1081.

Phase I of high dose (HD) temozolomide (TMZ) with peripheral blood stem cell support (PBSCS) rescue in recurrent high grade glioma (HGG)

12518

Background: Despite improvements obtained with frontline treatments prognosis of recurrent HGG still remains dismal. HD chemotherapy (CT) suggested a dose-effect relationship in lymphoma and germ cell tumors. HD of TMZ could be a promising way to overcome resistance of HGG to standard schedule of CT Methods: This phase I had as principal objective to determine the Maximal Tolerated Dose (MTD) of HD of TMZ with PBSCS rescue in patients with recurrent HGG under 60 year. The MTD was defined as dose level which 50% of patients (pts) treated experienced a DLT (Dose Limiting Toxicity).The dose escalation was planned for eight dose levels from 300 to 650mg/m2/day over 5 days with CSP reinfusion at D7 according to the Modified Continual Reassessment Method (MCRM). Treatment was administered for one cycle. Results: Eighteen eligible pts were treated with HD of TMZ, all had received prior radiotherapy, 11 pts previous CT. Overall HD TMZ was well tolerated for the 7 evaluated dose levels. The MTD was not yet reached. Not dose limiting toxicities were reported in 12 pts: grade 2: fatigue (6pts), cephalalgia (3pts), nausea (3pts) , skin eruption (2pts), mucositis, FUO, vomiting, diarrhea, zoster, dental abcess, lung infection, septicemia, hepatic. grade 3 bilirubinemia, grade 4 neutropenia (13pts) and thrombocytopenia (4pts). Dose Limiting Toxicities were reported in 2 pts, gr3 cytolysis at level 3 (400mg/m2/day ) 1pt and gr 3 arthritis at level 7 (600mg/m2) 1pt respectively . Main hematological toxicities were gr 4 neutropenia in 13 pts median duration was 8 days, 4 pts had gr4 thrombocytopenia lasting 5 days. All patients were evaluable for tumor response, 2 partial responses were observed at 550 and 600mg/m2 level, 5 pts had a stabilization and a disease progression was reported in 11 patients. Conclusions: This interim analysis demonstrated that HD of TMZ with CSP reinfusion is feasible and well tolerated in patients with recurrent HGG. Nevertheless limited activity reported could be related to a less depletion of O6 alkylguanine transferase with HD than with a protracted schedule. Accrual is still ongoing.

No significant financial relationships to disclose.

[Cerebral metastases: radiotherapy and chemotherapy]

Brain metastases are common events in adult patients with solid tumors. The choice of the optimal therapy is still challenging and controversial. Whole brain radiotherapy (WBRT) is a standard practice in most patients with an excellent palliative effect. Boost to gross disease has also been advocated without a clear benefit. Moreover following extended irradiation, a substantial proportion of the long term survivors (>6 months), will present documented cognitive impairments. Patients with favorable prognostic factors can benefit from more aggressive therapy: local resection, mono or multifractionated irradiation with or without radiosensitizing agents, stereotactic radiotherapy, brachytherapy. Although brain metastases of solid tumors occur in the presence of progressive widespread disease, chemotherapy has played a limited role in their treatment. Poor drug penetration across the normal blood-brain barrier of chemotherapy agents is not a limiting factor because of the neovascularization in the tumor. The few prospective studies that have addressed this issue, especially in lung and breast tumors, are reviewed.